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. What findings on physical assessment of a neonate would indicate the need for further evaluation?

• A. Nystagmus
• B. Epstein pearls
• C. Low-set ears
• D. Positive Babinski reflex

Correct answer: C

Rationale: Low-set ears in a neonate suggest major abnormalities and should prompt further evaluation. The correct alignment of the top of the pinnae of the ear with the outer canthus of the eye is crucial. Nystagmus, an involuntary eye movement, is common in newborns and often resolves on its own. Epstein pearls, small cysts on the hard palate, are insignificant and disappear over time. A positive Babinski reflex is normal in infants up to 1 year of age. Therefore, the presence of low-set ears is the most concerning finding that requires immediate attention.

3. Which explains the importance of detecting strabismus in young children?

• A. Color vision deficit may result.
• B. Amblyopia, a type of blindness, may result.
• C. Epicanthal folds may develop in the affected eye
• D. Corneal light reflexes may fall symmetrically within each pupil

Correct answer: B

Rationale: Undetected strabismus can lead to amblyopia, where the brain favors one eye over the other, potentially resulting in permanent vision loss in the affected eye.

4. What urine test result is considered abnormal?

• A. pH 4.0
• B. WBC 1 or 2 cells/ml
• C. Protein level absent
• D. Specific gravity 1.020

Correct answer: A

Rationale: A urine pH of 4.0 is abnormally low, indicating possible acidosis or other metabolic conditions. WBC count of 1-2 cells/ml, absence of protein, and a specific gravity of 1.020 are within normal limits.

5. Which of the following is a hallmark sign of intussusception in children?

• A. Bilious vomiting
• B. "Currant jelly" stools
• C. Abdominal distention
• D. Constipation

Correct answer: B

Rationale: "Currant jelly" stools, consisting of mucus and blood, are characteristic of intussusception in children. It occurs due to the telescoping of a segment of the intestine into an adjacent segment, leading to obstruction and subsequent mucosal ischemia, causing the passage of bloody mucus in the stool. Bilious vomiting can be seen in other conditions like bowel obstruction, abdominal distention can be present but is not as specific, and constipation is less likely in the presentation of intussusception.

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