Nursing Elites

1. A child with acetaminophen (Tylenol) poisoning has been admitted to the emergency department. What antidote does the nurse anticipate being prescribed?

• A. Carnitine (Carnitor)
• B. Fomepizole (Antizol)
• C. Deferoxamine (Desferal)
• D. N-acetylcysteine (Mucomyst)

Correct answer: D

Rationale: N-acetylcysteine is the specific antidote for acetaminophen poisoning, working by replenishing glutathione and preventing liver damage. The other options are antidotes for different types of poisoning (e.g., Fomepizole for methanol or ethylene glycol poisoning).

2. The nurse has just started assessing a young child who is febrile and appears ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. Which is the most appropriate action?

• A. Ask the parent when the neck was injured
• B. Refer for immediate medical evaluation
• C. Continue assessment to determine the cause of the neck pain
• D. Record head lag on the assessment record and continue the assessment of the child

Correct answer: B

Rationale: Opisthotonos with pain on flexion is a sign of possible meningitis or other serious neurological conditions, requiring immediate medical evaluation.

3. Two 3-year-old clients are playing together in a hospital playroom. One is working on a puzzle, while the other is stacking blocks. Which type of play is this?

• A. Cooperative play
• B. Solitary play
• C. Parallel play
• D. Associative play

Correct answer: C

Rationale: The correct answer is C, parallel play. Parallel play is observed when children play alongside each other but do not directly interact. In this scenario, each child is engaged in their own activity without engaging or influencing each other's play, which characterizes parallel play. Cooperative play (choice A) involves children playing together towards a common goal, which is not evident in the given situation. Solitary play (choice B) is when a child plays alone, unrelated to the presence of others. Associative play (choice D) involves more interaction and sharing of toys between children, which is not happening in the described play scenario.

4. A new parent, when asked by a nurse, explains that the 4-month-old infant has been nursing regularly every 3 to 4 hours and seems satisfied. However, the parent recently introduced solid food in the form of unbuttered popcorn to the infant as a supplement. What should be the primary nursing concern in this situation?

• A. Imbalanced nutrition, more than body requirements, related to introduction of a high-calorie food
• B. Risk for aspiration related to feeding the infant an inappropriate food
• C. Imbalanced nutrition, less than body requirements, related to introduction of a low-nutritive food
• D. Readiness for enhanced nutrition, related to the age of the infant

Correct answer: B

Rationale: The primary nursing concern in this situation is the risk for aspiration. Popcorn is a choking hazard for infants, as their airway is not fully developed to handle solid foods like popcorn. Choices A, C, and D are incorrect because the main focus should be on the immediate risk of aspiration due to the inappropriate solid food given to the infant, rather than on nutritional imbalances or readiness for enhanced nutrition.

5. The nurse is preparing to complete documentation on a patient's chart. Which should be included in documentation of nursing care? (Select all that apply.)

• A. Reassessments
• B. Nursing care provided
• C. Initial assessments
• D. All of the above

Correct answer: D

Rationale: Proper documentation includes reassessments, initial assessments, care provided, and the patient's response, but incident reports are typically documented separately.

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