Nursing Elites

1. During a routine health assessment, the nurse notes that an 8-month-old infant has a significant head lag. Which is the most appropriate action?

• A. Recheck head control at the next visit
• B. Teach the parents appropriate exercises
• C. Schedule the child for further evaluation
• D. Refer the child for further evaluation if the anterior fontanel is still open

Correct answer: C

Rationale: Significant head lag at 8 months is concerning and warrants further evaluation, as it may indicate developmental delays or neurological issues.

2. Two 3-year-old clients are playing together in a hospital playroom. One is working on a puzzle, while the other is stacking blocks. Which type of play is this?

• A. Cooperative play
• B. Solitary play
• C. Parallel play
• D. Associative play

Correct answer: C

Rationale: The correct answer is C, parallel play. Parallel play is observed when children play alongside each other but do not directly interact. In this scenario, each child is engaged in their own activity without engaging or influencing each other's play, which characterizes parallel play. Cooperative play (choice A) involves children playing together towards a common goal, which is not evident in the given situation. Solitary play (choice B) is when a child plays alone, unrelated to the presence of others. Associative play (choice D) involves more interaction and sharing of toys between children, which is not happening in the described play scenario.

3. What laboratory finding should the nurse expect in a child with an excess of water?

• A. Decreased hematocrit
• B. High serum osmolality
• C. High urine specific gravity
• D. Increased blood urea nitrogen (BUN)

Correct answer: A

Rationale: Water excess typically leads to hemodilution, resulting in a decreased hematocrit. High serum osmolality and specific gravity would indicate dehydration, while elevated BUN could suggest renal impairment or dehydration, not fluid overload.

4. The nurse is taking a sexual history on an adolescent girl. Which is the best way to determine whether she is sexually active?

• A. Ask her, "Are you sexually active?"
• B. Ask her, "Are you having sex with anyone?"
• C. Ask her, "Are you having sex with a boyfriend?"
• D. Ask both the girl and her parent if she is sexually active

Correct answer: A

Rationale: Directly asking the adolescent if she is sexually active is the most straightforward and respectful approach, ensuring privacy and fostering trust.

5. The parent of a 2-week-old infant asks the nurse if fluoride supplements are necessary because the infant is exclusively breastfed. What is the nurse's best response?

• A. The infant needs to begin taking them now.
• B. Supplements are not needed if you drink fluoridated water.
• C. The infant may need to begin taking them at age 6 months.
• D. The infant can have infant cereal mixed with fluoridated water instead of supplements.

Correct answer: C

Rationale: Breastfed infants may need fluoride supplements starting at 6 months if they are not receiving fluoride from other sources, such as drinking water.

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