Nursing Elites

1. A parent brings their 2-year-old son in for a well visit. The nurse assesses his growth since the last appointment. Which finding should concern the nurse?

• A. Prominent abdomen
• B. Forward curve of the spine in the sacral area
• C. Increase in height of 5 inches in the past year
• D. Total weight gain of 15 lb in the past year

Correct answer: D

Rationale: The correct answer is D. A total weight gain of 15 lb in one year for a 2-year-old is excessive and may indicate an underlying issue such as a metabolic disorder or overfeeding. This rapid weight gain can put the child at risk for health problems. Choices A, B, and C are not typically concerning findings in a 2-year-old. A prominent abdomen can be normal at this age due to a toddler's slightly protruding belly, a forward curve of the spine at the sacral area is a typical finding in young children, and an increase in height of 5 inches in a year is within the expected range of growth for a 2-year-old.

2. What type of shock is characterized by a hypersensitivity reaction causing massive vasodilation and capillary leaks, which may occur with drug or latex allergy?

• A. Neurogenic shock
• B. Cardiogenic shock
• C. Hypovolemic shock
• D. Anaphylactic shock

Correct answer: D

Rationale: Anaphylactic shock is a severe allergic reaction that causes massive vasodilation and increased capillary permeability, leading to rapid fluid shifts and circulatory collapse if not treated promptly. Neurogenic, cardiogenic, and hypovolemic shocks have different etiologies.

3. Baby M is 5 months old. You notice that she now has the ability to grasp objects between her fingers and opposing thumb. This is known as:

• A. Parachute reflex
• B. Grasp reflex
• C. Pincer grasp
• D. Prehension

Correct answer: C

Rationale: The correct answer is C: Pincer grasp. The pincer grasp is the ability to hold objects between the thumb and another finger, typically developed around 9-12 months. At 5 months, it is early for a pincer grasp to fully develop, but the beginning of this skill can be seen as early as 5 months. Choices A and B are incorrect as the parachute reflex is a protective response to falling and the grasp reflex is an automatic response to touch. Choice D, prehension, is a general term for the act of grasping or holding objects, but it does not specifically refer to holding objects between the thumb and fingers like the pincer grasp does.

4. What intervention is contraindicated in a suspected case of appendicitis?

• A. Enemas
• B. Palpating the abdomen
• C. Administration of antibiotics
• D. Administration of antipyretics for fever

Correct answer: A

Rationale: Enemas are contraindicated in cases of suspected appendicitis because they can increase the risk of perforation. The pressure from the enema can exacerbate inflammation and potentially lead to the rupture of the appendix. Palpating the abdomen gently is essential for diagnosing appendicitis, as it helps identify the characteristic signs like rebound tenderness. Antibiotics are commonly used to treat the infection associated with appendicitis, and antipyretics are administered to manage fever, which is a common symptom of the condition. Therefore, enemas are the intervention to avoid in suspected appendicitis cases.

5. The nurse is administering activated charcoal to a preschool child with acetaminophen (Tylenol) poisoning. What potential complications from the use of activated charcoal should the nurse plan to assess for?

• A. Diarrhea
• B. Vomiting
• C. All are correct
• D. Intestinal obstruction

Correct answer: C

Rationale: Common complications of activated charcoal administration include diarrhea and vomiting. Intestinal obstruction can occur if the charcoal forms a mass in the intestines. Fluid retention is less likely and not typically a complication associated with activated charcoal.

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