Nursing Elites

1. A parent receives a note from the school that a student in class has head lice. The parent calls the school nurse to ask how to check for head lice. What instructions should the nurse provide?

• A. Ask the child where it itches.
• B. Check to see if your dog has ear mites.
• C. Look along the scalp line for white dots.
• D. Observe between the fingers for red lines.

Correct answer: C

Rationale: The correct answer is to look along the scalp line for white dots (nits) when checking for head lice. White dots are indicative of head lice infestation. Itching alone, as mentioned in choice A, is not a reliable indicator of head lice. Choice B is irrelevant as it refers to checking for ear mites in a dog, not head lice in a human. Observing between the fingers for red lines, as in choice D, is not a method to check for head lice.

2. A child with a diagnosis of leukemia is receiving chemotherapy. What is the most important nursing intervention?

• A. Monitor for signs of infection
• B. Monitor for signs of bleeding
• C. Monitor for signs of dehydration
• D. Monitor for signs of pain

Correct answer: A

Rationale: The most important nursing intervention for a child with leukemia receiving chemotherapy is to monitor for signs of infection. Chemotherapy suppresses the immune system, putting the child at a higher risk of developing infections. Early detection and prompt treatment of infections are crucial to prevent complications and improve outcomes. Monitoring for signs of bleeding (choice B), dehydration (choice C), and pain (choice D) are also important aspects of care, but in this scenario, the priority is to prevent and manage infections due to the compromised immune system.

3. When evaluating the laboratory report of a 1-year-old infant’s hematocrit, a healthcare professional compares it with the expected hematocrit range for this age group. What is the hematocrit of a healthy 12-month-old infant?

• A. 19% to 32%
• B. 29% to 41%
• C. 37% to 47%
• D. 42% to 69%

Correct answer: C

Rationale: The correct answer is C: 37% to 47%. The normal hematocrit range for a 12-month-old infant is between 37% to 47%, which reflects the expected blood volume and red blood cell levels for this age. Choice A (19% to 32%) and Choice B (29% to 41%) are too low and do not encompass the typical hematocrit range for a healthy 1-year-old. Choice D (42% to 69%) is too high and falls outside the usual hematocrit values for this age group.

4. A parent tells the nurse, “My 9-month-old baby no longer has the same strong grasp that was present at birth and no longer acts startled by loud noises.” How should the nurse explain these changes in behavior?

• A. “I will check these responses before deciding how to proceed.”
• B. “Failure of these responses may be related to a developmental delay.”
• C. “Additional sensory stimulation is needed to aid in the return of these responses.”
• D. “These responses are replaced by voluntary activity at about five months of age.”

Correct answer: D

Rationale: The correct answer is D: “These responses are replaced by voluntary activity at about five months of age.” The grasp reflex and startle reflex (Moro reflex) are normal in newborns but typically disappear as the infant's nervous system matures and voluntary control develops. Choice A is incorrect because checking the responses before deciding a course of action does not address the developmental milestone related to the reflexes. Choice B is incorrect as it jumps to a conclusion of developmental delay without considering the normal developmental process. Choice C is incorrect as additional sensory stimulation is not necessary for the return of these reflexes, as they are expected to naturally diminish as part of normal development.

5. A 3-year-old child ingests a substance that may be a poison. The parent calls a neighbor who is a nurse and asks what to do. What should the nurse recommend the parent to do?

• A. Administer syrup of ipecac.
• B. Call the poison control center.
• C. Take the child to the emergency department.
• D. Give the child bread dipped in milk to absorb the poison.

Correct answer: B

Rationale: In cases of potential poisoning, immediate guidance from professionals is crucial. Administering syrup of ipecac is no longer recommended routinely due to potential risks and lack of benefit. Taking the child to the emergency department is necessary in severe cases but may not always be the immediate action needed. Giving the child bread dipped in milk is not an appropriate method to manage poisoning and could potentially worsen the situation. Therefore, the most appropriate action for the nurse to recommend is to call the poison control center for expert advice on managing the situation.

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