Nursing Elites

1. A new mother expresses concern about her baby's frequent hiccups. What should the nurse explain about newborn hiccups?

• A. Hiccups are a sign of respiratory distress in newborns.
• B. Hiccups indicate the baby is overeating.
• C. Hiccups are common and usually harmless in newborns.
• D. Hiccups are caused by a lack of burping.

Correct answer: C

Rationale: Newborn hiccups are common and usually harmless. They are typically caused by the baby's immature diaphragm and tend to resolve on their own. It is essential for parents to understand that hiccups in newborns are a normal phenomenon and do not necessarily indicate any underlying health issue. Choice A is incorrect because hiccups are not a sign of respiratory distress in newborns. Choice B is incorrect as hiccups do not indicate the baby is overeating. Choice D is also incorrect as hiccups are not solely caused by a lack of burping.

2. An 18-month-old child presents with fever, nasal flaring, intercostal retractions, and a respiratory rate of 50 bpm. What is the most appropriate nursing diagnosis?

• A. High risk for altered body temperature - hyperthermia
• B. Ineffective breathing pattern
• C. Ineffective individual coping
• D. Knowledge deficit

Correct answer: B

Rationale: In this case, the child is showing signs of respiratory distress, such as nasal flaring, intercostal retractions, and an increased respiratory rate. These are indicative of an ineffective breathing pattern. The child's compromised respiratory function requires immediate attention and intervention, making 'Ineffective breathing pattern' the most appropriate nursing diagnosis. Choices A, C, and D do not address the respiratory distress the child is experiencing and are not the priority in this situation.

3. How would you classify a child at two years of age who has fast breathing without chest indrawing or stridor when calm?

• A. Very severe disease
• B. Pneumonia
• C. No pneumonia
• D. Local infection

Correct answer: B

Rationale: In pediatric clinical assessment, a child at two years of age with fast breathing but without chest indrawing or stridor when calm is classified as having pneumonia. Fast breathing in this context is a key symptom used in the Integrated Management of Childhood Illness (IMCI) guidelines to diagnose pneumonia in children under five years old. The absence of chest indrawing or stridor when the child is calm helps differentiate this case from other respiratory conditions, making pneumonia the likely classification. Choices A, C, and D are incorrect. 'Very severe disease' is too broad and not specific to the symptoms described. 'No pneumonia' is also incorrect as the symptoms match the presentation of pneumonia. 'Local infection' is too vague and does not specifically address the respiratory symptoms observed.

4. In which stage do you determine if the patient has achieved the expected outcomes?

• A. Implementation
• B. Evaluation
• C. Assessment
• D. Diagnosis

Correct answer: B

Rationale: Evaluation is the correct stage in the nursing process to determine if the patient has achieved the expected outcomes. During the evaluation stage, the healthcare provider assesses the effectiveness of the care plan and decides on any necessary adjustments to reach the desired goals. Choice A, Implementation, is incorrect because this stage involves putting the care plan into action. Choice C, Assessment, is incorrect as it is the stage where data about the patient's health status is gathered. Choice D, Diagnosis, is also incorrect as it is the stage where the healthcare provider identifies the patient's health problems based on the assessment data.

5. You are caring for a 6-year-old child with a possible fractured arm and have reason to believe that the child was abused. How should you manage this situation?

• A. Inform the parents of your suspicions.
• B. Transport the child to the hospital regardless of the parents' wishes.
• C. Call the police and have the parents arrested.
• D. Advise the parents that the child needs to be transported.

Correct answer: D

Rationale: In cases where child abuse is suspected, the priority is the safety and well-being of the child. Advising the parents that the child needs to be transported for further evaluation and care is the appropriate initial step. This ensures that the child receives necessary medical attention while also addressing the suspicion of abuse through proper channels. It is essential to involve appropriate authorities and follow established procedures to protect the child and investigate any potential abuse further.

Similar Questions