Nursing Elites

1. An infant is born with anencephaly. Based on the knowledge of this diagnosis, what information does the nurse consider when interacting with the family?

• A. Many treatment options exist.
• B. Immediate surgery is necessary.
• C. The condition is incompatible with life.
• D. The child will have permanent disabilities.

Correct answer: C

Rationale: The correct answer is C: 'The condition is incompatible with life.' Anencephaly is the most serious neural tube defect where both hemispheres of the brain are absent. It is incompatible with life, as there are no medical or surgical treatment options available. While some infants with mature brain stem function can maintain vital functions for a short period, anencephaly is ultimately not survivable. Choice A is incorrect as there are no treatment options for anencephaly. Choice B is incorrect as immediate surgery is not necessary for this condition. Choice D is incorrect as an infant with anencephaly will not have permanent disabilities since the condition is not compatible with life.

2. The nurse is discussing home care with a mother whose 6-year-old child has hepatitis A. What information should the nurse include?

• A. Advise bed rest until 1 week after the icteric phase.
• B. Teach infection control measures to family members.
• C. Inform the mother that the child cannot return to school until 3 weeks after onset of jaundice.
• D. Reassure the mother that hepatitis A cannot be transmitted to other family members.

Correct answer: B

Rationale: Teaching infection control measures is crucial as Hepatitis A is highly contagious, especially in household settings. Proper hand hygiene and avoiding sharing personal items can prevent the spread of the virus within the family. Option A is incorrect because bed rest is not typically required for hepatitis A. Option C is incorrect as the child can return to school once feeling well and no longer contagious, not necessarily after a specific duration. Option D is incorrect because hepatitis A can be transmitted through contaminated food, water, or close personal contact.

3. The nurse is preparing to complete documentation on a patient's chart. Which should be included in documentation of nursing care? (Select all that apply.)

• A. Reassessments
• B. Nursing care provided
• C. Initial assessments
• D. All of the above

Correct answer: D

Rationale: Proper documentation includes reassessments, initial assessments, care provided, and the patient's response, but incident reports are typically documented separately.

4. How is masturbation in the pre-school child viewed?

• A. Abnormal behavior that needs to be dealt with immediately
• B. Disruptive to the family
• C. Normal behavior that can best be dealt with by ignoring and providing distraction
• D. Embarrassing to the parents

Correct answer: C

Rationale: Masturbation in preschool children is a normal behavior as they explore their bodies. It is best viewed as a natural part of development. Parents are often advised to ignore it and provide distractions rather than making the child feel ashamed or embarrassed. Choice A is incorrect because it is a natural behavior and not considered abnormal in this context. Choice B is incorrect as it does not necessarily disrupt the family. Choice D is incorrect as the focus should be on the child's development and well-being, not on the parents' feelings of embarrassment.

5. What is the most appropriate nursing action when intermittently gavage feeding a preterm infant?

• A. Allow formula to flow by gravity
• B. Avoid allowing the infant to suck on the tube
• C. Insert the tube through the nares instead of the mouth
• D. Apply gentle pressure to the syringe to deliver the formula

Correct answer: A

Rationale: The correct action when intermittently gavage feeding a preterm infant is to allow the formula to flow by gravity. This method helps prevent overfeeding and aspiration, which can occur if the formula is delivered too quickly under pressure. Choice B is incorrect as sucking on the tube can cause complications. Choice C is incorrect as the tube is typically inserted through the mouth. Choice D is incorrect as steady pressure can lead to rapid delivery of the formula, increasing the risk of complications.

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