Nursing Elites

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

• A. Jaundice
• B. Edema
• C. Hypertension
• D. Polyuria

Correct answer: B

Rationale: Edema is a hallmark clinical manifestation of nephrotic syndrome. In nephrotic syndrome, there is increased glomerular permeability leading to the loss of proteins, particularly albumin, in the urine. This results in decreased oncotic pressure, leading to fluid shifting into the interstitial spaces and causing edema. Jaundice (Choice A) is not a typical clinical manifestation of nephrotic syndrome. Hypertension (Choice C) is more commonly associated with conditions like glomerulonephritis. Polyuria (Choice D) is not a primary symptom of nephrotic syndrome; instead, patients may have reduced urine output due to fluid retention from edema.

2. During a routine monthly examination, a 5-month-old infant is brought to the pediatric clinic. What assessment finding should alert the nurse to notify the health care provider?

• A. Temperature of 99.5°F
• B. Blood pressure of 75/48 mm Hg
• C. Heart rate of 100 beats per minute
• D. Respiratory rate of 50 breaths per minute

Correct answer: D

Rationale: A respiratory rate of 50 breaths per minute in a 5-month-old infant is considered high and may indicate respiratory distress. Infants normally have a higher respiratory rate than older children and adults, but a rate of 50 breaths per minute is above the expected range. This finding warrants immediate attention as it may be indicative of an underlying respiratory issue or distress. Choice A (Temperature of 99.5°F) is within the normal range for body temperature and does not necessarily indicate a critical issue. Choice B (Blood pressure of 75/48 mm Hg) is not typically assessed in isolation for a 5-month-old infant during a routine examination, and the values provided are not indicative of a critical condition. Choice C (Heart rate of 100 beats per minute) is within the normal range for heart rate in infants and may not be a cause for immediate concern during a routine examination.

3. When counseling a couple who suspect they could have a child with a genetic abnormality, what would be most important for the nurse to incorporate into the plan of care when working with this family?

• A. Gathering information from at least three generations
• B. Informing the family of the need for a wide range of information
• C. Maintaining the confidentiality of the information
• D. Presenting the information in a nondirective manner

Correct answer: D

Rationale: When counseling a couple about the possibility of having a child with a genetic abnormality, it is vital for the nurse to present information in a nondirective manner. This approach empowers the couple to make decisions based on their values and preferences, respecting their autonomy. Gathering information from three generations (Choice A) may not be necessary and might overwhelm the couple with unnecessary data. Informing the family about the need for a wide range of information (Choice B) is not as critical as supporting their decision-making process through a nondirective approach. While maintaining confidentiality (Choice C) is crucial, it is not the most important aspect compared to ensuring the couple can make informed choices that align with their beliefs and wishes.

4. During a primary survey of a child with partial thickness burns over the upper body areas, what action should the nurse take first?

• A. Inspect the child's skin color.
• B. Assess for a patent airway.
• C. Observe for symmetric breathing.
• D. Palpate the child's pulse.

Correct answer: B

Rationale: When managing a child with partial thickness burns over the upper body areas, the priority action during the primary survey is to assess for a patent airway. This step is crucial as burns in this region can lead to airway compromise, potentially causing rapid deterioration in the child's condition. Checking for a patent airway ensures that the child can breathe adequately, which is essential for oxygenation and ventilation. Inspecting the child's skin color (Choice A) is an important assessment but should follow ensuring a patent airway. Observing for symmetric breathing (Choice C) is relevant, but the immediate focus should be on securing the airway. Palpating the child's pulse (Choice D) is also a vital assessment, but in this scenario, the priority is to assess and maintain a clear airway to support respiratory function and oxygen delivery.

5. A nurse is reviewing the immunization schedule of an 11-month-old infant. What immunizations does the nurse expect the infant to have previously received?

• A. Pertussis, tetanus, polio, and measles
• B. Diphtheria, pertussis, tetanus, and polio
• C. Rubella, polio, tuberculosis, and pertussis
• D. Measles, mumps, rubella, and tuberculosis

Correct answer: B

Rationale: The correct answer is B: Diphtheria, pertussis, tetanus, and polio. By 11 months of age, infants should have received doses of these vaccines as part of the immunization schedule. Choice A is incorrect because measles is usually given later in the schedule. Choice C is incorrect as rubella is usually given as part of the MMR vaccine, not individually, and tuberculosis is not routinely given as a vaccine in early infancy. Choice D is incorrect because mumps is not part of the recommended vaccines at 11 months of age.

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