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. Which describe the feelings and behaviors of early preschool children related to divorce? (Select all that apply.)

• A. Regressive behavior
• B. Fear of abandonment
• C. Blame themselves for the divorce
• D. All of the above

Correct answer: D

Rationale: Preschool children may exhibit regressive behavior, fear abandonment, and blame themselves for their parents' divorce due to their limited understanding of the situation.

3. The nurse is taking a sexual history on an adolescent girl. Which is the best way to determine whether she is sexually active?

• A. Ask her, "Are you sexually active?"
• B. Ask her, "Are you having sex with anyone?"
• C. Ask her, "Are you having sex with a boyfriend?"
• D. Ask both the girl and her parent if she is sexually active

Correct answer: A

Rationale: Directly asking the adolescent if she is sexually active is the most straightforward and respectful approach, ensuring privacy and fostering trust.

4. The nurse is caring for an adolescent who is overweight. Which of the following psychological effects of being overweight during adolescence will the nurse consider when planning care for the adolescent?

• A. Poor body image
• B. Sexual promiscuity
• C. Feelings of contempt for thin peers
• D. Lack of independence

Correct answer: A

Rationale: Adolescents who are overweight often struggle with poor body image, which can lead to low self-esteem and mental health issues. Addressing body image concerns and promoting healthy lifestyle changes are important aspects of care. Choices B, C, and D are incorrect. Sexual promiscuity is not a direct psychological effect of being overweight; feelings of contempt for thin peers are not a common or recommended psychological response; lack of independence is a broad term that does not specifically relate to the psychological effects of being overweight.

5. The nurse's approach when introducing hospital equipment to a preschooler who seems afraid should be based on which principle?

• A. The child may think the equipment is alive.
• B. Explaining the equipment will only increase the child’s fear
• C. One brief explanation will be enough to reduce the child’s fear
• D. The child is too young to understand what the equipment does

Correct answer: A

Rationale: Preschoolers may engage in magical thinking and believe inanimate objects are alive, so the nurse should explain the equipment in a way that reduces fear.

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