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 placement of a tongue blade for assessment of the mouth and throat?

• A. On the lower jaw
• B. Side of the tongue
• C. Against the soft palate
• D. Center back area of the tongue

Correct answer: B

Rationale: The side of the tongue is the appropriate place for a tongue blade to avoid triggering the gag reflex during assessment of the mouth and throat.

3. The nurse is taking a health history of an adolescent. Which best describes how the chief complaint should be determined?

• A. Request a detailed listing of symptoms.
• B. Ask the adolescent, "Why did you come here today?"
• C. Interview the parent away from the adolescent to determine the chief complaint
• D. Use what the adolescent says to determine, in correct medical terminology, what the problem is

Correct answer: B

Rationale: Asking the adolescent directly about the reason for their visit encourages open communication and helps the nurse understand the primary concern from the patient's perspective.

4. Which immunization should the nurse include in a teaching session for parents of toddler-age clients to decrease the risk for epiglottitis?

• A. Hepatitis B
• B. Polio
• C. Measles, mumps, and rubella (MMR)
• D. Hemophilus influenzae type B (Hib)

Correct answer: D

Rationale: The correct answer is D, Hemophilus influenzae type B (Hib) vaccine. Hib vaccine is crucial in preventing epiglottitis, a serious respiratory condition caused by Haemophilus influenzae type b bacteria. This vaccine is recommended for toddlers to protect them from developing epiglottitis. Choices A, B, and C are incorrect because while they are important vaccines for children, they do not specifically target the prevention of epiglottitis, unlike the Hib vaccine.

5. According to Erikson’s developmental theory, toddlers need to be encouraged to become independent to successfully complete which developmental challenge?

• A. Trust vs. mistrust
• B. Industry vs. inferiority
• C. Autonomy vs. shame and doubt
• D. Initiative vs. guilt

Correct answer: C

Rationale: The correct answer is C: Autonomy vs. shame and doubt. Erikson's developmental stage for toddlers focuses on the conflict between developing a sense of independence (autonomy) and feelings of inadequacy (shame and doubt). Encouraging toddlers to explore their environment and make choices helps them build self-confidence and independence. Choices A, B, and D are incorrect because trust vs. mistrust relates to infancy, industry vs. inferiority is associated with school-age children, and initiative vs. guilt is linked to preschoolers.

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