Nursing Elites

1. An infant is suspected of having esophageal atresia/tracheoesophageal fistula. While waiting for the pediatrician to see the infant, which action should the nurse take?

• A. Position the infant with the head of the bed slightly elevated
• B. Allow the infant to bond with the mother in her room
• C. Offer the infant breastfeeding instead of formula feeding
• D. Wrap the infant in blankets and place in a crib by the viewing window

Correct answer: A

Rationale: Positioning the infant with the head of the bed elevated helps to prevent aspiration and manage secretions until further treatment can be provided. Choice B is incorrect as the priority is ensuring the infant's safety and health, not immediate bonding. Choice C is incorrect as breastfeeding may worsen the condition. Choice D is incorrect as it does not address the potential risk of aspiration associated with esophageal atresia/tracheoesophageal fistula.

2. The nurse has just started assessing a young child who is febrile and appears ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. Which is the most appropriate action?

• A. Ask the parent when the neck was injured
• B. Refer for immediate medical evaluation
• C. Continue assessment to determine the cause of the neck pain
• D. Record head lag on the assessment record and continue the assessment of the child

Correct answer: B

Rationale: Opisthotonos with pain on flexion is a sign of possible meningitis or other serious neurological conditions, requiring immediate medical evaluation.

3. The nurse is teaching parents about high-fiber foods that can prevent constipation. What foods should the nurse include in the teaching?

• A. Oranges
• B. All are correct
• C. Lima beans
• D. Baked beans

Correct answer: B

Rationale: The correct answer is B: All are correct. High-fiber foods like oranges, lima beans, baked beans, and raisin bran cereal are effective in preventing constipation. Oranges are a good source of fiber, lima beans and baked beans are high in fiber content, and raisin bran cereal is also rich in fiber. Bananas, which are not listed but could be considered by some as a high-fiber food, are actually low in fiber and may not be as effective in preventing constipation. Therefore, the nurse should include all the options provided in the teaching to help prevent constipation effectively.

4. The predominant characteristic of the intellectual development of a child aged 2 to 7 years is egocentricity. Which of the following best describes this concept?

• A. Selfishness
• B. Unable to see another’s point of view
• C. Able to put self in another’s place
• D. Prefers to play alone

Correct answer: B

Rationale: Egocentricity in children aged 2 to 7 years means they are unable to see things from another person's perspective. This characteristic is a normal part of their cognitive development during this stage. Choice A, 'Selfishness,' is not an accurate description as egocentricity is more about a limited ability to understand others' viewpoints rather than intentional selfishness. Choice C, 'Able to put self in another’s place,' is incorrect as egocentric children struggle to do this. Choice D, 'Prefers to play alone,' is not directly related to egocentricity but may be a behavior exhibited by some children for various reasons.

5. What is the priority nursing intervention for a child with epiglottitis?

• A. Administer antibiotics
• B. Maintain airway patency
• C. Provide hydration
• D. Monitor vital signs

Correct answer: B

Rationale: The correct answer is B: Maintain airway patency. When dealing with a child with epiglottitis, the priority nursing intervention is to ensure airway patency to prevent airway obstruction, which can lead to respiratory distress or failure. Administering antibiotics (choice A) is important to treat the infection, but airway management takes precedence. Providing hydration (choice C) and monitoring vital signs (choice D) are essential aspects of care but are secondary to securing the airway in a child with epiglottitis.

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