Nursing Elites

1. A healthcare provider is assessing the pain level of a three-year-old toddler. Which of the following pain assessment scales should the healthcare provider use?

• A. FACES Pain rating scale
• B. Numeric pain rating scale
• C. CRIES pain assessment scale
• D. Non-communicating children's pain checklist

Correct answer: A

Rationale: The healthcare provider should use the FACES pain rating scale for pediatric clients who are 3 years old and older. This scale allows the toddler to point to the face that depicts the current level of pain, making it a suitable choice for non-verbal or young children who may have difficulty expressing their pain verbally.

2. A parent of a child with cerebral palsy is being taught about home care by a healthcare provider. Which statement by the parent indicates an understanding of the teaching?

• A. I will perform range-of-motion exercises twice a day.
• B. I will apply a heating pad on my child's legs to reduce spasms.
• C. I will allow my child to rest in a recliner for 1 hour each day.
• D. I will use wrist splints to maintain alignment.

Correct answer: D

Rationale: Using wrist splints can help maintain alignment and prevent contractures in a child with cerebral palsy. This intervention is crucial in managing the condition and supporting the child's mobility and function.

3. When planning care for a newborn with esophageal atresia and tracheoesophageal fistula, which is the priority nursing diagnosis?

• A. Ineffective Tissue Perfusion
• B. Ineffective Infant Feeding Pattern
• C. Acute Pain
• D. Risk for Aspiration

Correct answer: D

Rationale: The priority nursing diagnosis for a newborn with esophageal atresia and tracheoesophageal fistula is 'Risk for Aspiration' because of the potential respiratory complications associated with these conditions. The newborn is at a higher risk of aspirating oral or gastric contents due to the abnormal connections between the esophagus and trachea, posing a serious threat to the airway and lungs. Addressing this risk is crucial to prevent respiratory distress and maintain the airway's patency, making it the priority nursing diagnosis in this scenario. 'Ineffective Tissue Perfusion' is not the priority as respiratory compromise takes precedence over perfusion concerns. 'Ineffective Infant Feeding Pattern' may be relevant but addressing the risk of aspiration is more critical. 'Acute Pain' is not the priority compared to the life-threatening risk of aspiration.

4. The nurse is unsuccessful in inserting a nasogastric tube for a newborn client. The nurse suspects the newborn has esophageal atresia/tracheoesophageal (EA/TE) fistula. Which nursing action is appropriate while waiting for the healthcare provider to further assess the neonate?

• A. Position the newborn in a semi-Fowler position.
• B. Allow the newborn to stay in the nursery for observation.
• C. Offer the newborn pacifier for comfort.
• D. Wrap the newborn in blankets and place in an incubator.

Correct answer: A

Rationale: Positioning the newborn in a semi-Fowler position is appropriate as it helps prevent aspiration in suspected EA/TE fistula. This position helps reduce the risk of regurgitation and aspiration of gastric contents. Placing the newborn in a semi-Fowler position promotes the drainage of secretions and reduces the risk of complications while awaiting further assessment by the healthcare provider.

5. A parent of a child with cystic fibrosis is being taught about dietary guidelines. Which statement by the parent indicates an understanding of the teaching?

• A. My child should eat a high-calorie, high-protein diet.
• B. My child should avoid eating eggs.
• C. My child should follow a low-fat, low-sodium diet.
• D. My child should follow a high-fiber, high-protein diet.

Correct answer: A

Rationale: The correct answer is A. For a child with cystic fibrosis, a high-calorie, high-protein diet is recommended to meet the increased metabolic needs associated with the condition. The protein helps with growth and repair, while the extra calories help compensate for malabsorption and increased energy requirements. Choice B is incorrect because eggs are a good source of protein and essential nutrients unless the child has a specific allergy. Choice C is incorrect as a low-fat, low-sodium diet is not typically recommended for children with cystic fibrosis who need higher calorie and fat intake. Choice D is incorrect because while a high-protein diet is beneficial, a high-fiber diet may not be suitable for a child with cystic fibrosis due to potential gastrointestinal issues.

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