Nursing Elites

1. A mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night. Which finding is most significant in planning care for this family?

• A. The mother is a single parent and lives with her parents
• B. The mother states the baby is irritable during feedings
• C. The infant’s formula has been changed twice
• D. The diaper area shows severe skin breakdown

Correct answer: D

Rationale: Severe skin breakdown in the diaper area is a significant finding indicating a potential health issue that needs immediate attention. It may be a sign of a skin condition, such as a diaper rash, which can cause discomfort and pain for the infant. Addressing this concern promptly is crucial to prevent further complications and ensure the baby's well-being. The other choices may also be important in assessing the overall situation of the family, but in terms of immediate care for the infant, the severe skin breakdown takes priority.

2. A 10-year-old child is brought to the emergency department after falling from a bicycle and hitting their head. The nurse notes that the child is drowsy and has a headache. What is the nurse’s priority action?

• A. Perform a full neurological assessment
• B. Administer pain medication
• C. Allow the child to rest quietly
• D. Check the child's immunization status

Correct answer: A

Rationale: In a child who has fallen and hit their head, presenting with drowsiness and headache, the priority action for the nurse is to perform a full neurological assessment. This is crucial to evaluate the extent of the head injury and monitor for signs of increased intracranial pressure, which could indicate a more severe traumatic brain injury. Administering pain medication or allowing the child to rest quietly are not appropriate initial actions without first assessing the neurological status. Checking the child's immunization status is important for overall health but is not the priority in this acute situation.

3. The mother of a 4-month-old asks the nurse for advice in preventing diaper rash. What suggestion should the nurse provide?

• A. At diaper change generously powder the baby's diaper area with talcum powder to promote dryness.
• B. Wash the diaper area every 2 hours with soap and water to help prevent skin breakdown.
• C. Use a barrier cream, such as zinc oxide, which does not have to be completely removed with each diaper change.
• D. Place a cloth diaper inside the disposable diaper for overnight periods when increased wearing time is likely.

Correct answer: C

Rationale: Using a barrier cream like zinc oxide protects the skin and helps prevent diaper rash.

4. The parents of a 4-year-old child who has just been diagnosed with celiac disease are being educated by a healthcare provider. Which statement by the parents indicates a correct understanding of the condition?

• A. We can give our child small amounts of gluten occasionally
• B. We need to avoid giving our child foods containing wheat, barley, and rye
• C. We should limit our child’s intake of dairy products
• D. Our child will need to take gluten-free supplements

Correct answer: B

Rationale: Choice B is the correct answer because for individuals with celiac disease, a strict gluten-free diet is essential for managing the condition. Foods containing wheat, barley, and rye must be completely avoided to prevent adverse reactions and damage to the intestines. This dietary restriction is crucial to ensure the child's health and well-being in managing celiac disease effectively. Choices A, C, and D are incorrect because giving small amounts of gluten occasionally, limiting dairy products, or taking gluten-free supplements are not sufficient measures to manage celiac disease. Complete avoidance of gluten-containing foods is necessary to prevent complications.

5. A mother brings her 3-month-old infant to the clinic, concerned about frequent vomiting after feeding. The practical nurse (PN) suspects gastroesophageal reflux (GER). Which recommendation should the PN provide to the mother?

• A. Feed the infant in a prone position.
• B. Provide larger, less frequent feedings.
• C. Keep the infant upright for 30 minutes after feeding.
• D. Offer only formula thickened with rice cereal.

Correct answer: C

Rationale: The correct recommendation for reducing symptoms of gastroesophageal reflux (GER) in infants is to keep the infant upright for 30 minutes after feeding. This position helps prevent the backflow of stomach contents, alleviating symptoms of reflux. Placing the infant in a prone position or providing larger, less frequent feedings may worsen symptoms by increasing the likelihood of regurgitation. Offering only formula thickened with rice cereal is not the first-line intervention for GER and should not be recommended initially.

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