Nursing Elites

1. A parent tells the nurse in the emergency department, 'My 3-year-old has had a fever for several days and has been vomiting.' After instituting ordered measures to reduce the fever, what nursing action is most important?

• A. Preventing shivering
• B. Restricting oral fluids
• C. Measuring output hourly
• D. Taking vital signs hourly

Correct answer: A

Rationale: Preventing shivering is crucial in this scenario as it can increase body temperature and counteract the effects of antipyretic measures aimed at reducing the fever. Shivering generates heat through muscle activity, which can elevate the body temperature. Restricting oral fluids (choice B) is inappropriate as maintaining hydration is vital, especially in cases of fever and vomiting. Measuring output hourly (choice C) and taking vital signs hourly (choice D) are important nursing actions but not the most critical in this case where preventing shivering takes precedence.

2. A healthcare provider is assessing a child with suspected pneumonia. What clinical manifestation is the healthcare provider likely to observe?

• A. Cough
• B. Diarrhea
• C. Rash
• D. Vomiting

Correct answer: A

Rationale: When assessing a child with suspected pneumonia, a healthcare provider is likely to observe a cough as a common clinical manifestation. Pneumonia often presents with symptoms such as cough, fever, difficulty breathing, and chest pain. Choice B, diarrhea, is not typically associated with pneumonia. Choice C, rash, is not a common clinical manifestation of pneumonia. Choice D, vomiting, is also not a typical symptom of pneumonia. Therefore, the correct answer is A: Cough.

3. You are managing a 10-month-old infant who has had severe diarrhea and vomiting for 3 days and is now showing signs of shock. You have initiated supplemental oxygen therapy and elevated the lower extremities. En route to the hospital, you note that the child's work of breathing has increased. What must you do first?

• A. Lower the extremities and reassess the child
• B. Begin positive pressure ventilations and reassess the child
• C. Place a nasopharyngeal airway and increase the oxygen flow
• D. Listen to the lungs with a stethoscope for abnormal breath sounds

Correct answer: A

Rationale: In this scenario, the infant is showing signs of shock with increased work of breathing. Lowering the extremities helps improve venous return to the heart, cardiac output, and oxygenation by reducing the pressure on the diaphragm. This action can alleviate the respiratory distress and is a critical step to take in a child with signs of shock. Beginning positive pressure ventilations (Choice B) should be considered if the infant's respiratory distress worsens despite lowering the extremities. Placing a nasopharyngeal airway and increasing oxygen flow (Choice C) may not directly address the increased work of breathing or the underlying shock condition. Listening to the lungs with a stethoscope (Choice D) may provide information on lung sounds but does not address the immediate need to improve breathing in a child with signs of shock.

4. A healthcare professional is assessing a child with suspected bacterial meningitis. What is a common clinical manifestation that the healthcare professional is likely to observe?

• A. Rash
• B. Photophobia
• C. Jaundice
• D. Kernig sign

Correct answer: D

Rationale: A common clinical manifestation of bacterial meningitis is a positive Kernig sign, indicating irritation of the meninges. Rash (Choice A) is not typically associated with bacterial meningitis. Photophobia (Choice B) can be present but is more commonly seen in viral meningitis. Jaundice (Choice C) is not a typical clinical manifestation of meningitis and is more indicative of liver dysfunction.

5. A child sitting on a chair in a playroom starts to have a tonic-clonic seizure with a clenched jaw. What is the nurse’s best initial action?

• A. Attempt to open the jaw.
• B. Place the child on the floor.
• C. Call out for assistance from staff.
• D. Place a pillow under the child’s head.

Correct answer: B

Rationale: The correct initial action during a tonic-clonic seizure is to place the child on the floor to prevent injury. This action helps protect the child from falling off the chair and provides a safer environment for the seizure to occur. Attempting to open the jaw can cause harm or injury. Calling out for assistance is important but should follow the immediate action of moving the child to the floor. Placing a pillow under the child’s head is not recommended as it may lead to airway obstruction or further injury during the seizure.

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