Nursing Elites

1. After reinforcing information on treating a sprained ankle, what statement by the adolescent indicates to the practical nurse that further instruction is needed?

• A. Keep the leg elevated when sitting.
• B. Wrap the ankle in an elastic bandage for support.
• C. Apply warm compresses to the ankle for the first 24 hours.
• D. Put an ice pack on the ankle, alternating 30 minutes on and 30 minutes off.

Correct answer: C

Rationale: The correct answer is C. Applying warm compresses to a sprained ankle within the first 24 hours is incorrect as it can increase swelling and inflammation. Instead, cold compresses are recommended to help reduce swelling and pain. Option A, keeping the leg elevated, helps in reducing swelling. Option B, wrapping the ankle in an elastic bandage, provides support. Option D, using an ice pack in intervals, is effective in reducing swelling and pain. Therefore, the statement about applying warm compresses indicates the need for further instruction.

2. A 4-year-old child with a history of frequent ear infections is brought to the clinic by the parents who are concerned about the child’s hearing. What is the nurse’s priority action?

• A. Perform a hearing test
• B. Inspect the child’s ears for drainage
• C. Refer the child to an audiologist
• D. Ask the parents about the child’s speech development

Correct answer: B

Rationale: The nurse's priority action should be to inspect the child's ears for drainage. This immediate assessment can provide valuable information about the presence of infection or fluid accumulation, which can directly impact the child's hearing. By identifying any signs of drainage, the nurse can promptly address any current issues affecting the child's ear health and hearing abilities. Performing a hearing test (Choice A) may be necessary but should follow the initial assessment of the ears. Referring the child to an audiologist (Choice C) can be considered later based on the findings. Asking about speech development (Choice D) is important but not the immediate priority compared to assessing for current ear issues.

3. When observing a distraught mother scolding her 3-year-old son for wetting his pants in the hallway of a pediatric unit, what initial action should the nurse take?

• A. Suggest that the mother consult a pediatric nephrologist.
• B. Provide disposable training pants while calming the mother.
• C. Refer the mother to a community parent education program.
• D. Inform the mother that toilet training is slower for boys.

Correct answer: B

Rationale: In this situation, the nurse's initial action should be to provide disposable training pants to manage the immediate issue of wetting while also calming the mother. This approach addresses the current distressing situation and offers a practical solution to alleviate the mother's concerns.

4. In a hospitalized child receiving IV fluids for dehydration, what is the best indicator that the child’s dehydration is improving?

• A. The child’s urine output increases
• B. The child’s skin turgor is normal
• C. The child’s weight increases
• D. The child’s vital signs are stable

Correct answer: A

Rationale: An increase in urine output is a reliable indicator of improving dehydration in a child. It signifies that the kidneys are functioning better, helping to restore fluid balance in the body. Monitoring urine output is crucial in assessing hydration status and response to treatment. Choices B, C, and D are not the best indicators of improving dehydration. Normal skin turgor is helpful but may not change immediately with improving hydration. Weight increase may reflect retained fluids rather than improved hydration status. Stable vital signs are important but may not always indicate improving dehydration.

5. The healthcare provider is assessing an infant with diarrhea and lethargy. Which finding should the provider identify that is consistent with early dehydration?

• A. Tachycardia
• B. Bradycardia
• C. Dry mucous membranes
• D. Decreased skin turgor

Correct answer: A

Rationale: Tachycardia is a common early sign of dehydration in infants. It is important for healthcare providers to be vigilant in monitoring infants with these symptoms, as prompt intervention is crucial to prevent further complications.

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