Nursing Elites

1. An 8-year-old child diagnosed with meningitis is to undergo a lumbar puncture. What should the nurse explain is the purpose of this procedure?

• A. To measure the pressure of cerebrospinal fluid
• B. To obtain a sample of cerebrospinal fluid for analysis
• C. To relieve intracranial pressure
• D. To assess the presence of infection in the spinal fluid

Correct answer: B

Rationale: A lumbar puncture is performed to obtain a sample of cerebrospinal fluid for analysis. This fluid is then examined for signs of infection, bleeding, or other abnormalities. Measuring the pressure of cerebrospinal fluid is typically done during the procedure itself, but it is not the primary purpose of the lumbar puncture. While a lumbar puncture can indirectly help relieve intracranial pressure by removing excess cerebrospinal fluid, this is not its primary purpose. Assessing the presence of infection in the spinal fluid is part of the analysis that follows the collection of the sample, making it a secondary outcome of the procedure.

2. A nurse is assessing a 10-month-old infant. What developmental milestone should the nurse expect to observe?

• A. Crawling
• B. Sitting without support
• C. Standing with assistance
• D. Pulling to a stand

Correct answer: D

Rationale: The correct answer is D: Pulling to a stand. By 10 months of age, most infants should be able to pull themselves up to a standing position while holding onto furniture or other support. This milestone indicates good strength and coordination in the lower body. Choice A, Crawling, is typically achieved around 6-9 months of age. Choice B, Sitting without support, usually occurs around 6-8 months. Choice C, Standing with assistance, can typically be seen around 9-12 months, but pulling to a stand is a more advanced milestone expected by 10 months.

3. What are the most common signs and symptoms of leukemia related to bone marrow involvement?

• A. petechiae, infection, fatigue
• B. headache, papilledema, irritability
• C. muscle wasting, weight loss, fatigue
• D. decreased intracranial pressure, psychosis, confusion

Correct answer: A

Rationale: Petechiae, infection, and fatigue are common signs and symptoms of leukemia related to bone marrow involvement. Petechiae are small red or purple spots on the skin caused by bleeding under the skin due to low platelet counts. Infection susceptibility increases due to decreased white blood cells from compromised bone marrow function. Fatigue is a common symptom of anemia resulting from decreased red blood cell production. Choices B, C, and D are incorrect as they do not align with the typical signs and symptoms of leukemia associated with bone marrow dysfunction.

4. What is the priority nursing responsibility when a 3-year-old child in a crib has a clamped jaw and is having a tonic-clonic seizure?

• A. Apply restraints.
• B. Administer oxygen.
• C. Protect the child from self-injury.
• D. Insert a plastic airway in the child’s mouth.

Correct answer: C

Rationale: During a tonic-clonic seizure, the priority nursing responsibility is to protect the child from self-injury. Applying restraints is not recommended during a seizure as it can lead to further harm. Administering oxygen may be necessary after the seizure to support oxygenation, but it is not the priority during the seizure itself. Inserting a plastic airway is also not indicated as the jaw is clamped, and the child should not have anything placed in the mouth during a seizure. Therefore, the correct action is to ensure the child's safety by protecting them from self-injury, preventing harm from uncontrolled movements and potential falls.

5. What should be included in the teaching plan for parents of an infant diagnosed with phenylketonuria (PKU)?

• A. Mental retardation occurs if PKU is untreated.
• B. Testing for PKU is done immediately after birth.
• C. Treatment for PKU includes lifelong dietary management.
• D. PKU is transmitted by an autosomal recessive gene.

Correct answer: A

Rationale: The correct answer is A: 'Mental retardation occurs if PKU is untreated.' Phenylketonuria (PKU) is a metabolic disorder that, if left untreated with dietary management, can lead to severe mental retardation due to the accumulation of phenylalanine. It is crucial for parents to understand the potential consequences of untreated PKU to emphasize the importance of early and consistent treatment. Choice B is incorrect because testing for PKU is typically done through newborn screening shortly after birth, not immediately. Choice C is incorrect as treatment for PKU primarily involves strict dietary management that restricts phenylalanine intake, not lifelong medications. Choice D is incorrect as PKU is inherited in an autosomal recessive pattern, meaning that both parents must pass on a mutated gene for the disorder to manifest.

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