Nursing Elites

1. Following an apparent febrile seizure, a 4-year-old boy is alert and crying. His skin is hot and moist. Appropriate treatment for this child includes:

• A. allowing the parents to transport the child.
• B. offering oxygen and providing transport.
• C. rapidly cooling the child in cold water.
• D. keeping the child warm and providing transport.

Correct answer: B

Rationale: After a febrile seizure, the priority is to offer oxygen and provide transport to a medical facility. Oxygen may be necessary to ensure proper oxygenation, and medical evaluation is crucial to determine the cause of the seizure and prevent recurrence. Rapidly cooling the child in cold water is not recommended as it may lead to complications such as hypothermia. Keeping the child warm is also not indicated as the skin is already hot and moist. Therefore, offering oxygen and timely transportation to a healthcare facility is the most appropriate course of action. Allowing the parents to transport the child might delay necessary medical care, and keeping the child warm can exacerbate the existing heat. Rapidly cooling the child in cold water can lead to adverse effects, making it an inappropriate choice.

2. Which of the following techniques represents the MOST appropriate method of opening the airway of an infant with no suspected neck injury?

• A. Perform the technique as you would for an older child or adult.
• B. Lift up the chin and hyperextend the neck.
• C. Gently lift the chin while maintaining slight flexion of the neck.
• D. Tilt the head back without hyperextending the neck.

Correct answer: D

Rationale: Tilting the head back without hyperextending the neck is the safest way to open an infant's airway. Hyperextending the neck can potentially cause harm to the infant, making option D the most appropriate method for opening an infant's airway without suspected neck injury.

3. An 18-month-old child presents with fever, nasal flaring, intercostal retractions, and a respiratory rate of 50 bpm. What is the most appropriate nursing diagnosis?

• A. High risk for altered body temperature (hyperthermia)
• B. Ineffective breathing pattern
• C. Ineffective individual coping
• D. Knowledge deficit

Correct answer: B

Rationale: The most appropriate nursing diagnosis for the 18-month-old child presenting with fever, nasal flaring, intercostal retractions, and a respiratory rate of 50 bpm is 'Ineffective breathing pattern.' These symptoms collectively indicate respiratory distress, which aligns with the nursing diagnosis of ineffective breathing pattern. Nasal flaring, intercostal retractions, and an increased respiratory rate are signs of respiratory distress in pediatric patients, suggesting the need for immediate intervention to address the underlying breathing difficulties.

4. In growing children, growth hormone deficiency results in short stature and very slow growth rates. Short stature may result from which of the following?

• A. Anterior pituitary gland hypofunction
• B. Posterior pituitary gland hyperfunction
• C. Parathyroid gland hyperfunction
• D. Thyroid gland hyperfunction

Correct answer: A

Rationale: Short stature in growing children can result from anterior pituitary gland hypofunction, which leads to growth hormone deficiency. The anterior pituitary gland plays a crucial role in stimulating the release of growth hormone, and when it is underactive (hypofunction), insufficient growth hormone is produced, resulting in short stature and slow growth rates.

5. A 3-year-old female has had severe diarrhea and vomiting for 4 days. She is now unresponsive with rapid, shallow respirations and thready radial pulses. Her heart rate is 160 beats/min, and her oxygen saturation is 88%. You should:

• A. Ventilate her with a bag-valve mask.
• B. Start chest compressions.
• C. Administer high-flow oxygen via a non-rebreathing mask.
• D. Place her in the recovery position.

Correct answer: A

Rationale: In a pediatric patient presenting with unresponsiveness, rapid, shallow respirations, thready pulses, high heart rate, and low oxygen saturation, the priority is to ensure adequate oxygenation. Ventilating the child with a bag-valve mask is crucial in this scenario to support her breathing and improve oxygenation, as indicated by her low oxygen saturation and respiratory distress. Starting chest compressions is not indicated as the child has a pulse. Administering high-flow oxygen via a non-rebreathing mask may not be as effective as providing positive pressure ventilation with a bag-valve mask in this situation. Placing her in the recovery position is not appropriate when the child is unresponsive and in respiratory distress.

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