Nursing Elites

1. During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is which?

• A. A normal finding
• B. A sign of a possible visual defect and a need for vision screening
• C. An abnormal finding requiring referral to an ophthalmologist
• D. A sign of small hemorrhages, which usually resolve spontaneously

Correct answer: A

Rationale: A brilliant, uniform red reflex in both eyes is a normal finding, indicating that the retina is healthy and there are no significant obstructions in the visual pathway.

2. The parent asks when the soft area in the infant's head will go away. What is the best response by the nurse?

• A. The area is called the anterior fontanel (fontanelle) and typically closes anytime up to 18 months of age.
• B. The area is called a fontanel (fontanelle). They remain open to allow for rapid brain growth in the first months of life.
• C. The soft spots may stay open until your infant is 2 or 3 years old.
• D. Soft spots on the infant's head should have closed by now.

Correct answer: A

Rationale: The best response by the nurse is A, as the anterior fontanel typically closes between 12-18 months of age, allowing for brain growth during infancy. Choice B is incorrect because it does not provide a specific timeframe for the closure of the fontanel. Choice C is incorrect as it suggests a later closure timeframe than usual. Choice D is incorrect as it states that the soft spots should have closed already, which is inaccurate for a 6-month-old infant.

3. What intervention is contraindicated in a suspected case of appendicitis?

• A. Enemas
• B. Palpating the abdomen
• C. Administration of antibiotics
• D. Administration of antipyretics for fever

Correct answer: A

Rationale: Enemas are contraindicated in cases of suspected appendicitis because they can increase the risk of perforation. The pressure from the enema can exacerbate inflammation and potentially lead to the rupture of the appendix. Palpating the abdomen gently is essential for diagnosing appendicitis, as it helps identify the characteristic signs like rebound tenderness. Antibiotics are commonly used to treat the infection associated with appendicitis, and antipyretics are administered to manage fever, which is a common symptom of the condition. Therefore, enemas are the intervention to avoid in suspected appendicitis cases.

4. The parent of an 8.2-kg (18-lb) 9-month-old infant is borrowing a federally approved car seat from the clinic. The nurse should explain that the safest way to put in the car seat is what?

• A. Front facing in back seat
• B. Rear facing in back seat
• C. Front facing in front seat with air bag on passenger side
• D. Rear facing in front seat if an air bag is on the passenger side

Correct answer: B

Rationale: Infants should be placed rear-facing in the back seat until they are at least 2 years old or exceed the weight/height limit of their car seat for optimal safety.

5. A new parent, when asked by a nurse, explains that the 4-month-old infant has been nursing regularly every 3 to 4 hours and seems satisfied. However, the parent recently introduced solid food in the form of unbuttered popcorn to the infant as a supplement. What should be the primary nursing concern in this situation?

• A. Imbalanced nutrition, more than body requirements, related to introduction of a high-calorie food
• B. Risk for aspiration related to feeding the infant an inappropriate food
• C. Imbalanced nutrition, less than body requirements, related to introduction of a low-nutritive food
• D. Readiness for enhanced nutrition, related to the age of the infant

Correct answer: B

Rationale: The primary nursing concern in this situation is the risk for aspiration. Popcorn is a choking hazard for infants, as their airway is not fully developed to handle solid foods like popcorn. Choices A, C, and D are incorrect because the main focus should be on the immediate risk of aspiration due to the inappropriate solid food given to the infant, rather than on nutritional imbalances or readiness for enhanced nutrition.

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