Nursing Elites

1. A child is being assessed for suspected intussusception. What clinical manifestation is the nurse likely to observe?

• A. Projectile vomiting
• B. Currant jelly stools
• C. Abdominal distension
• D. Constipation

Correct answer: C

Rationale: The correct clinical manifestation that a nurse is likely to observe in a child with suspected intussusception is abdominal distension. Intussusception is a medical emergency where a part of the intestine folds into itself, causing obstruction. Abdominal distension is a common symptom due to the obstruction and the build-up of gases and fluids. While currant jelly stools (Choice B) are a classic sign of intussusception, they are typically seen in later stages of the condition and may not be present during the initial assessment. Projectile vomiting (Choice A) is more commonly associated with conditions like pyloric stenosis. Constipation (Choice D) is not a typical manifestation of intussusception; the condition usually presents with severe colicky abdominal pain and possible passage of blood and mucus in stools.

2. A child has coarctation of the aorta. What does the nurse expect to identify when taking the child’s vital signs?

• A. A weak radial pulse
• B. An irregular heartbeat
• C. A bounding femoral pulse
• D. An elevated radial blood pressure

Correct answer: A

Rationale: When a child has coarctation of the aorta, the nurse would expect to identify a weak radial pulse when taking the child's vital signs. Coarctation of the aorta results in a narrowing of the aorta, leading to reduced blood flow and a weakened pulse. An irregular heartbeat (Choice B) is less likely to be associated with coarctation of the aorta. Similarly, a bounding femoral pulse (Choice C) is not typically observed with this condition. An elevated radial blood pressure (Choice D) is less common as coarctation of the aorta usually causes decreased blood pressure in the lower extremities due to the aortic narrowing.

3. A child undergoes heart surgery to repair the defects associated with tetralogy of Fallot. What behavior is essential for the nurse to prevent postoperatively?

• A. Crying
• B. Coughing
• C. Straining at stool
• D. Unnecessary movement

Correct answer: C

Rationale: The correct behavior that the nurse needs to prevent postoperatively is straining at stool. Straining at stool should be avoided as it can increase intrathoracic pressure, leading to stress on the surgical site. This stress can potentially compromise the surgical repair and increase the risk of complications. Crying, coughing, and unnecessary movement, although important to monitor postoperatively, do not directly impact the surgical site as significantly as straining at stool does. Therefore, the focus should be on preventing straining at stool to ensure the best postoperative outcome for the child.

4. An infant is admitted to the neonatal intensive care unit (NICU) with exstrophy of the bladder. What covering should the nurse use to protect the exposed area?

• A. Loose diaper
• B. Dry gauze dressing
• C. Moist sterile dressing
• D. Petroleum jelly gauze pad

Correct answer: C

Rationale: A moist sterile dressing should be used to protect the exposed bladder tissue from infection and injury. Exstrophy of the bladder requires careful management to prevent complications such as infection. A loose diaper (Choice A) may not provide adequate protection or prevent infection. Dry gauze dressing (Choice B) may not be ideal as it could adhere to the exposed area and cause trauma upon removal. Petroleum jelly gauze pad (Choice D) may not be suitable as it can trap moisture and increase the risk of infection.

5. A nurse is assessing a child with suspected rotavirus infection. What clinical manifestation is the nurse likely to observe?

• A. Abdominal pain
• B. Diarrhea
• C. Constipation
• D. Vomiting

Correct answer: B

Rationale: The correct answer is B: Diarrhea. Rotavirus infection commonly presents with symptoms such as watery diarrhea, vomiting, fever, and abdominal pain. While abdominal pain and vomiting are also associated with rotavirus infection, diarrhea is a hallmark feature. Constipation is not typically seen in cases of rotavirus infection. Therefore, the most likely clinical manifestation that the nurse would observe in a child with suspected rotavirus infection is diarrhea.

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