Nursing Elites

1. An infant who has had diarrhea for 3 days is admitted in a lethargic state and is breathing rapidly. The parent states that the baby has been ingesting formula, although not as much as usual, and cannot understand the sudden change. What explanation should the nurse give the parent?

• A. Cellular metabolism is unstable in young children.
• B. The proportion of water in the body is less than in adults.
• C. Renal function is immature in children until they reach school age.
• D. The extracellular fluid requirement per unit of body weight is greater than in adults.

Correct answer: D

Rationale: The correct answer is D. Infants have a higher extracellular fluid requirement per unit of body weight, making them more susceptible to dehydration and electrolyte imbalances during illnesses such as diarrhea. Choice A is incorrect because cellular metabolism being unstable is not the primary explanation for the symptoms described. Choice B is incorrect as the proportion of water in the body alone does not fully explain the increased risk of dehydration in infants. Choice C is incorrect because while renal function is immature in children, it is not the most relevant factor in this scenario compared to the increased fluid requirements.

2. An order is written for an isotonic enema for a 2-year-old child. What is the maximum amount of fluid the nurse should administer without a specific order from the health care provider?

• A. 100 to 150 mL
• B. 155 to 250 mL
• C. 255 to 360 mL
• D. 365 to 500 mL

Correct answer: B

Rationale: For a 2-year-old child, the maximum recommended amount of fluid for an isotonic enema is between 155 to 250 mL to prevent overdistension and potential harm. Choice A (100 to 150 mL) is too low and may not be effective in achieving the desired outcome. Choices C (255 to 360 mL) and D (365 to 500 mL) exceed the safe range for a 2-year-old child and can lead to overdistension, electrolyte imbalance, or other complications. Therefore, the correct answer is B.

3. During the health assessment of a school-age child, on which problem would the nurse focus more attention based on the child's developmental level?

• A. Infections
• B. Poisonings
• C. Risk-taking behaviors
• D. Accidents and injuries

Correct answer: D

Rationale: During the school-age years, children are more physically active and curious, which increases their risk of accidents and injuries. This developmental stage is characterized by increased exploration and engagement in physical activities. While infections and poisonings are important health concerns, school-age children are more likely to be affected by accidents and injuries due to their active nature. Risk-taking behaviors may become more prevalent in adolescence rather than during the school-age period, making it a less likely focus for the nurse during the health assessment of a school-age child.

4. The nurse is caring for a 12-year-old boy with idiopathic thrombocytopenia. The nurse is providing discharge instructions about home care and safety recommendations to the boy and his parents. Which response indicates a need for further teaching?

• A. We should avoid aspirin and medications like ibuprofen.
• B. He can resume participation in football in 2 weeks.
• C. Swimming would be a great activity.
• D. Our son cannot take any antihistamines.

Correct answer: B

Rationale: Choice B indicates a need for further teaching because participation in contact sports like football should be avoided in children with idiopathic thrombocytopenia due to the increased risk of bleeding. Choices A, C, and D are correct. Avoiding aspirin and medications like ibuprofen helps prevent bleeding complications. Swimming is a safe physical activity that can be recommended. Antihistamines do not pose a significant risk in this case and can be used if needed.

5. During a check-up for a 5-year-old child with eczema before school starts, what will the nurse do?

• A. Change the bandage on a cut on the child’s hand.
• B. Assess the compliance with treatment regimens.
• C. Discuss systemic corticosteroid therapy.
• D. Assess the child’s fluid volume.

Correct answer: B

Rationale: Assessing compliance with treatment regimens is crucial in managing eczema effectively and preventing flare-ups. This involves ensuring that the child is following the prescribed treatment plan, which may include medication application, skincare routines, and lifestyle modifications. Changing a bandage on a cut would not be a routine part of an eczema check-up unless there was a specific wound related to eczema. Discussing systemic corticosteroid therapy may be part of the management plan for severe eczema cases but would not be the primary focus during a routine check-up. Assessing the child’s fluid volume, while important in general health assessments, is not directly related to managing eczema specifically.

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