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. What finding would the nurse expect to assess in a child with hypothyroidism?

• A. Nervousness
• B. Heat intolerance
• C. Smooth velvety skin
• D. Weight gain

Correct answer: D

Rationale: In a child with hypothyroidism, weight gain is a typical finding due to the slowed metabolism associated with the condition. This occurs because thyroid hormone levels are insufficient to regulate metabolism effectively. Choices A, B, and C are not typically associated with hypothyroidism. Nervousness is more commonly seen in conditions like hyperthyroidism, where there is an excess of thyroid hormones. Heat intolerance may be seen in hyperthyroidism as well, where the body's metabolism is increased. Smooth velvety skin is a characteristic finding in conditions like Cushing's syndrome, where there is excess cortisol production.

3. The nurse is assessing the 'resilience' of a 16-year-old boy. Which exemplifies an external protective factor that may help to promote resiliency in this child?

• A. His ability to take control of his own decisions
• B. His ability to accept his own limitations
• C. His caring relationship with members of his family
• D. His knowledge of when to continue or stop with goal achievement

Correct answer: C

Rationale: A caring relationship with family members is an external protective factor that promotes resilience. It provides emotional support, stability, and a sense of belonging, which are crucial elements in building resilience. Choices A, B, and D are more related to internal factors and individual traits rather than external factors like family relationships, which play a significant role in promoting resilience. Taking control of decisions, accepting limitations, and knowing when to stop or continue with goals are internal factors that contribute to personal resilience but do not directly represent external protective factors like family relationships.

4. A parent arrives in the emergency clinic with a 3-month-old baby who has difficulty breathing and prolonged periods of apnea. Which assessment data should alert the nurse to suspect shaken baby syndrome (SBS)?

• A. Birth occurred before 32 weeks’ gestation
• B. Lack of stridor and adventitious breath sounds
• C. Previous episodes of apnea lasting 10 to 15 seconds
• D. Retractions and use of accessory respiratory muscles

Correct answer: D

Rationale: Retractions and the use of accessory respiratory muscles are signs of respiratory distress in infants. These clinical manifestations can be associated with trauma, such as shaken baby syndrome (SBS), which can lead to severe head injuries and respiratory compromise. Birth before 32 weeks’ gestation (Choice A) is more related to prematurity complications rather than SBS. The absence of stridor and adventitious breath sounds (Choice B) may not be specific indicators of SBS. Previous episodes of apnea lasting 10 to 15 seconds (Choice C) alone may not be as concerning as the presence of retractions and use of accessory muscles in the context of a distressed infant.

5. What is an important nursing responsibility when a dysrhythmia is suspected?

• A. Order an immediate electrocardiogram
• B. Count the radial pulse every minute for five times
• C. Count the apical pulse for 1 full minute and compare the rate with the radial pulse rate
• D. Have someone else take the radial pulse simultaneously with the apical pulse

Correct answer: C

Rationale: When a dysrhythmia is suspected, it is important for nurses to count the apical pulse for a full minute and compare it with the radial pulse rate. This method helps in identifying dysrhythmias because discrepancies between the apical and radial pulse rates can indicate irregular heart rhythms. Option A is incorrect because ordering an immediate electrocardiogram may not always be feasible or necessary as a first step. Option B, counting the radial pulse multiple times, is less accurate than comparing the apical and radial pulse rates. Option D involves an unnecessary step of having another person take simultaneous pulses when the nurse can do it effectively alone.

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