Nursing Elites

1. A teacher states to the school nurse, 'I have a student who will often just stare at me for 15 seconds after asking a question; then the student blinks and asks me to repeat the question. Should I be concerned?' Which should the nurse include in the response to the teacher?

• A. The child has a crush on the teacher.
• B. The child has increased intracranial pressure.
• C. The child may have had a head injury.
• D. The child is experiencing absence seizures.

Correct answer: D

Rationale: Staring spells that end abruptly and are followed by normal activity are indicative of absence seizures. In absence seizures, a child may exhibit staring spells, brief loss of awareness, and lack of responsiveness, which can last for a few seconds. Choice A is incorrect because the behavior described is not associated with having a crush. Choice B is incorrect as increased intracranial pressure usually presents with other symptoms. Choice C is less likely as a head injury would typically manifest with additional signs beyond just staring and blinking.

2. A 4-year-old child is admitted to the hospital secondary to dehydration. Laboratory tests indicate a high hemoglobin and hematocrit, and the serum sodium is below normal levels. Which condition does the nurse suspect based on the current data?

• A. Hypernatremia
• B. Metabolic acidosis
• C. Hypotonic dehydration
• D. Isotonic dehydration

Correct answer: C

Rationale: The correct answer is hypotonic dehydration. The combination of high hemoglobin and hematocrit with low serum sodium indicates hypotonic dehydration. In this condition, there is an excess of solutes relative to water, leading to higher red blood cell concentration (elevated hemoglobin and hematocrit) and low serum sodium levels.

3. The therapist engages a teen in a game of cards to improve his hand skills for schoolwork. Which statement best reflects this session?

• A. Playfulness as an approach
• B. Play as an occupation
• C. Play as a tool
• D. Play as a reward

Correct answer: C

Rationale: The correct answer is 'Play as a tool.' In this session, the therapist is using play as a tool to integrate therapeutic goals into a playful activity, which helps engage the teen and improve specific skills, in this case, hand skills for schoolwork.

4. A neonate with a meningomyelocele is scheduled for surgery in the morning. Which nursing action is appropriate for this neonate?

• A. Applying a diaper to prevent contamination of the sac
• B. Positioning the newborn in a side-lying position
• C. Encouraging the mother to hold the newborn because she will not be able to pick him up after surgery
• D. Positioning the newborn in a prone position

Correct answer: D

Rationale: Positioning the newborn in a prone position is appropriate for a neonate with a meningomyelocele before surgery. Placing the newborn in this position helps prevent pressure on the sac, reducing the risk of damaging it and promoting optimal surgical outcomes. Applying a diaper (choice A) may not be recommended as it can increase pressure on the sac. Positioning the newborn in a side-lying position (choice B) or encouraging the mother to hold the newborn (choice C) are not ideal actions before surgery as they do not address the specific needs of a neonate with a meningomyelocele.

5. While auscultating the lungs of an adolescent with asthma, what should the nurse identify the sound as?

• A. Biots respiration
• B. Chaney-Stokes respiration
• C. Tachypnea
• D. Bradypnea

Correct answer: C

Rationale: The nurse should identify the sound heard during auscultation as tachypnea, which is characterized by a rapid, regular breathing pattern. In the case of an adolescent with asthma, tachypnea can be indicative of increased work of breathing due to airway constriction and inflammation. Biots respiration (choice A) is characterized by an irregular pattern of breathing with periods of apnea. Chaney-Stokes respiration (choice B) is a pattern of breathing characterized by alternating periods of deep, rapid breathing followed by periods of apnea. Bradypnea (choice D) refers to an abnormally slow breathing rate, which is not typically associated with asthma exacerbation.

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