Nursing Elites

1. An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Postoperative nursing care would include what?

• A. Monitor closely for signs of infection.
• B. Place the child with the operative side of the head up.
• C. Avoid pumping the shunt reservoir to maintain patency.
• D. Avoid maintaining a Trendelenburg position to decrease pressure on the shunt.

Correct answer: A

Rationale: Postoperative nursing care for an infant with hydrocephalus who underwent ventriculoperitoneal shunt placement includes monitoring closely for signs of infection, as infection is the greatest hazard in the postoperative period. Signs of cerebrospinal fluid infection to watch for include elevated temperature, poor feeding, vomiting, decreased responsiveness, and seizure activity. The child should be placed with the operative side of the head up to reduce pressure on the valve. The shunt reservoir should not be pumped to maintain patency, as this can disrupt its function. Maintaining a Trendelenburg position to decrease pressure on the shunt is contraindicated as it can lead to increased intracranial pressure and compromise the shunt's effectiveness.

2. Which describe the feelings and behaviors of early preschool children related to divorce? (Select all that apply.)

• A. Regressive behavior
• B. Fear of abandonment
• C. Blame themselves for the divorce
• D. All of the above

Correct answer: D

Rationale: Preschool children may exhibit regressive behavior, fear abandonment, and blame themselves for their parents' divorce due to their limited understanding of the situation.

3. The nurse is administering the first hepatitis A vaccine to an 18-month-old child. When should the child return to the clinic for the second dose of hepatitis A vaccination?

• A. After 2 months
• B. After 3 months
• C. After 4 months
• D. After 6 months

Correct answer: D

Rationale: The second dose of the hepatitis A vaccine is recommended 6 months after the first dose to ensure full immunity.

4. What procedure is most appropriate for the assessment of an abdominal circumference related to a bowel obstruction?

• A. Measuring the abdomen after feedings
• B. Marking the point of measurement with a pen
• C. Measuring the circumference at the symphysis pubis
• D. Using a new tape measure with each assessment to ensure accuracy

Correct answer: B

Rationale: Marking the point of measurement ensures consistent and accurate assessments of abdominal circumference, especially important in conditions like bowel obstruction where changes need to be monitored closely.

5. An important intervention for infants with developmental disabilities is to:

• A. Help parents realize their child will not develop further
• B. Stress the importance of early infant stimulation and intervention programs
• C. Have them institutionalized as soon as possible
• D. Have children reevaluated at 2 years of age to confirm the diagnosis

Correct answer: B

Rationale: The correct answer is B: Stress the importance of early infant stimulation and intervention programs. Early intervention programs are essential for infants with developmental disabilities as they can significantly impact the child's development and future outcomes. These programs provide necessary support and therapies to enhance the child's skills and abilities. Choice A is incorrect because it is crucial to provide hope and support to parents, emphasizing the potential for development and progress. Choice C is inappropriate and unethical as the first line of intervention. Institutionalization should only be considered in extreme cases where other options have been exhausted. Choice D is not the most crucial intervention at this stage. While reevaluation may be necessary, early intervention and support should be prioritized to maximize the child's developmental potential.

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