Nursing Elites

1. When assessing a child with suspected bacterial meningitis, what clinical manifestation is the nurse likely to observe?

• A. Photophobia
• B. High fever
• C. Rash
• D. Nasal congestion

Correct answer: B

Rationale: The correct answer is B: High fever. In bacterial meningitis, a high fever is a common clinical manifestation due to the body's inflammatory response to the infection. While photophobia (choice A) is also a common symptom in meningitis, it is not as specific as a high fever. Rash (choice C) is more commonly associated with viral infections or other conditions, rather than bacterial meningitis. Nasal congestion (choice D) is not a typical clinical manifestation of bacterial meningitis and is more commonly seen in respiratory infections. Therefore, when assessing a child with suspected bacterial meningitis, the nurse is most likely to observe a high fever as a key clinical manifestation.

2. What clinical manifestation of tetralogy of Fallot should the nurse expect when caring for children with this diagnosis?

• A. Slow respirations
• B. Clubbing of fingers
• C. Decreased RBC counts
• D. Subcutaneous hemorrhages

Correct answer: B

Rationale: Clubbing of fingers is a common manifestation in children with tetralogy of Fallot due to chronic hypoxia. Clubbing occurs as a result of long-standing decreased oxygen levels in the blood, leading to changes in the fingertips. Slow respirations (Choice A) are not typically a direct clinical manifestation of tetralogy of Fallot. While decreased RBC counts (Choice C) may occur due to chronic hypoxia, they are not a primary manifestation specific to tetralogy of Fallot. Subcutaneous hemorrhages (Choice D) are not a common clinical manifestation associated with tetralogy of Fallot.

3. A 1-week-old infant has been in the pediatric unit for 18 hours following placement of a spica cast. The nurse observes a respiratory rate of fewer than 24 breaths/min. No other changes are noted. Because the infant is apparently well, the nurse does not report or document the slow respiratory rate. Several hours later, the infant experiences severe respiratory distress and emergency care is necessary. What should be considered if legal action is taken?

• A. Most infants have slow respirations when they are uncomfortable.
• B. The respirations of young infants are irregular, so a drop in rate is unimportant.
• C. Vital signs that are outside the expected parameters are significant and should be documented.
• D. The respiratory tract of young infants is underdeveloped, and their respiratory rate is not significant.

Correct answer: C

Rationale: In this scenario, the correct answer is C. Any vital signs outside the expected range in an infant should be documented and reported, as they may indicate a developing condition that requires prompt attention. Choice A is incorrect because slow respirations in infants should not be dismissed without assessment and documentation. Choice B is incorrect because a drop in respiratory rate in this case was significant and should have been documented. Choice D is incorrect because even though infants have underdeveloped respiratory tracts, any abnormal respiratory rate should be taken seriously and documented for monitoring and intervention if necessary.

4. When picked up by a parent or the nurse, an 8-month-old infant screams and seems to be in pain. After observing this behavior, what should the nurse discuss with the parent?

• A. Accidents and the importance of accident prevention
• B. Limiting playtime with other children in the family
• C. Any other behaviors that the parent may have noticed
• D. Food and appropriate vitamins for infants

Correct answer: C

Rationale: Discussing any other observed behaviors can help identify patterns or potential issues, which is crucial for assessing the infant's overall well-being. Option A about accidents and prevention is not pertinent to the situation described. Option B regarding playtime with other children does not address the infant's behavior and potential causes. Option D about food and vitamins is not relevant to the presented scenario and the observed behavior of the infant.

5. What is an important nursing responsibility when a dysrhythmia is suspected?

• A. order an immediate electrocardiogram
• B. count the radial pulse every 1 minute for five times
• C. count the apical pulse for 1 full minute, and compare the rate with the radial pulse rate
• D. have someone else take the radial pulse simultaneously with the apical pulse

Correct answer: C

Rationale: When a dysrhythmia is suspected, an important nursing responsibility is to count the apical pulse for 1 full minute and then compare this rate with the radial pulse rate. This method helps in identifying dysrhythmias as it allows for a direct comparison of the heart's rhythm at two different pulse points. Ordering an immediate electrocardiogram (Choice A) may be necessary but should not be the first step. Counting the radial pulse multiple times (Choice B) is not as accurate as comparing rates directly. Having someone else take the radial pulse simultaneously (Choice D) may introduce errors and inconsistencies in the measurement.

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