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 explains the importance of detecting strabismus in young children?

• A. Color vision deficit may result.
• B. Amblyopia, a type of blindness, may result.
• C. Epicanthal folds may develop in the affected eye
• D. Corneal light reflexes may fall symmetrically within each pupil

Correct answer: B

Rationale: Undetected strabismus can lead to amblyopia, where the brain favors one eye over the other, potentially resulting in permanent vision loss in the affected eye.

3. The nurse is planning an educational session with a group of school-age children. Which primary task from Erikson’s theory of psychosocial development should be addressed?

• A. Establishing trust in others
• B. Developing a sense of autonomy
• C. Developing a sense of industry
• D. Establishing a sense of identity

Correct answer: C

Rationale: In Erikson’s theory of psychosocial development, school-age children typically focus on developing a sense of industry. This stage, occurring during middle childhood, involves the desire to feel competent and productive in their skills and abilities. Choices A, B, and D are incorrect because establishing trust in others (A) is related to the first stage of Erikson's theory (trust vs. mistrust) which occurs in infancy, developing a sense of autonomy (B) is linked to the second stage (autonomy vs. shame and doubt) which occurs in early childhood, and establishing a sense of identity (D) is associated with the fifth stage (identity vs. role confusion) which occurs in adolescence.

4. The physician tells the parents of a 2-year-old that the child probably has RSV. The parents ask how the diagnosis will be confirmed. How should the nurse respond?

• A. We will swab your child's nose and send the secretions for testing.
• B. There is no specific test for RSV. The diagnosis is based on symptoms.
• C. We will send a viral culture to an outside lab for testing.
• D. There is no specific test for RSV. The diagnosis is based on symptoms.

Correct answer: A

Rationale: The correct answer is A. RSV is typically diagnosed by swabbing the nose and testing the secretions. This method helps confirm the presence of the respiratory syncytial virus. Choice B is incorrect because while symptoms are important in diagnosis, specific tests like swabbing for RSV do exist. Choice C is incorrect as sending a viral culture to an outside lab is not the primary method for diagnosing RSV. Choice D is a duplicate of choice B and is incorrect for the same reasons.

5. Ongoing fluid losses can overwhelm the child’s ability to compensate, resulting in shock. What early clinical sign precedes shock?

• A. Tachycardia
• B. Slow respirations
• C. Warm, flushed skin
• D. Decreased blood pressure

Correct answer: A

Rationale: Tachycardia is an early sign of shock as the body tries to maintain cardiac output in the face of declining circulatory volume. Blood pressure often remains normal until late in the progression, at which point decompensated shock is occurring.

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