Nursing Elites

1. A child with acute gastrointestinal bleeding is admitted to the hospital. The nurse observes which sign or symptom as an early manifestation of shock?

• A. Restlessness
• B. Rapid capillary refill
• C. Increased temperature
• D. Increased blood pressure

Correct answer: A

Rationale: Restlessness is an early sign of shock due to decreased perfusion and oxygenation to the brain. This symptom requires immediate attention to prevent the progression to more severe stages of shock. Rapid capillary refill (Choice B) is not typically an early sign of shock but rather a sign of adequate perfusion. Increased temperature (Choice C) may occur in later stages of shock due to the body's response to stress. Increased blood pressure (Choice D) is not an early sign of shock; in fact, blood pressure tends to decrease in shock as a compensatory mechanism.

2. What is the appropriate method for measuring the temperature of a 2-day-old neonate?

• A. Tympanic
• B. Oral
• C. Axillary
• D. Rectal

Correct answer: C

Rationale: For a 2-day-old neonate, the most suitable method to measure temperature is the axillary method. This approach is considered safe and appropriate for neonates, minimizing the risk of injury. Tympanic temperature measurement may not be as accurate in neonates due to their small ear canals. Oral temperature measurement is not recommended for neonates as they may not be able to hold a thermometer properly in their mouths. Rectal temperature measurement is invasive and carries a higher risk of injury and should be avoided unless absolutely necessary.

3. The nurse has completed an education program on normal communication abilities in the preschool-age child. Which statement by a participant indicates a need for further education?

• A. When my child counts numbers, it is only to 10 and we are slowly working on counting higher.
• B. I am glad to know that my 4-year-old child asking so many questions is normal.
• C. Stating his name and address is too hard for my 5-year-old child; it will be another year before he can do that.
• D. My child is finally talking in a way that most of my friends can understand her speech.

Correct answer: C

Rationale: The correct answer is C. By age 5, children should be able to state their name and address. If a child cannot do this, it may indicate a developmental delay that requires further assessment. Choices A, B, and D do not indicate a need for further education as they reflect typical developmental milestones for preschool-age children, such as gradually improving counting skills, asking many questions, and improving speech clarity over time.

4. Which pediatric condition is characterized by a "string sign" on an upper GI series?

• A. Intussusception
• B. Hypertrophic pyloric stenosis
• C. Hirschsprung disease
• D. Meckel diverticulum

Correct answer: B

Rationale: The correct answer is B: Hypertrophic pyloric stenosis. The "string sign" is associated with hypertrophic pyloric stenosis, a condition where the pyloric canal is narrowed, leading to gastric outlet obstruction. Intussusception (choice A) typically presents with colicky abdominal pain and currant jelly stools. Hirschsprung disease (choice C) is characterized by the absence of ganglion cells in the distal colon. Meckel diverticulum (choice D) is a congenital outpouching of the small intestine that can present with painless rectal bleeding.

5. The parents of an 8-month-old infant voice concern to the nurse that their infant is not developing motor skills as the infant should. What question would be appropriate for the nurse to ask in determining if their fears are warranted?

• A. Does the infant move a toy back and forth from one hand to the other?
• B. Is the infant able to drink from a cup by oneself?
• C. Is the infant able to hold a pencil and scribble on paper?
• D. Does the infant place toys into a box or container and take them out?

Correct answer: A

Rationale: The correct answer is A. By 8 months, an infant should be able to transfer objects between hands, which is an important motor skill milestone. This action shows coordination and developing fine motor skills. Choices B, C, and D involve more advanced motor skills that are typically not expected at 8 months of age. Drinking from a cup, holding a pencil to scribble, and engaging in purposeful play with toys are skills that develop later in infancy.

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