Nursing Elites

1. Melena, the passage of black, tarry stools, suggests bleeding from which source?

• A. The perianal or rectal area
• B. The upper gastrointestinal (GI) tract
• C. The lower GI tract
• D. Hemorrhoids or anal fissures

Correct answer: B

Rationale: Melena indicates bleeding from the upper GI tract. The black, tarry appearance of the stool results from the partial digestion of blood as it passes through the intestines, typically originating from sources like the stomach or duodenum. Lower GI bleeding usually presents as bright red blood in the stool, originating from sources like the colon or rectum. Choices A, C, and D are incorrect because melena specifically points to upper GI bleeding rather than issues in the perianal/rectal area, lower GI tract, or hemorrhoids/anal fissures.

2. The nurse is performing an assessment on a 10-week-old infant. The nurse understands that the developmental characteristic of hearing at this age is which?

• A. The infant responds to his own name.
• B. The infant localizes sounds by turning his head directly to the sound.
• C. The infant turns his head to the side when sound is made at the level of the ear.
• D. The infant locates sound by turning his head to the side and then looking up or down.

Correct answer: C

Rationale: By 10 weeks, infants typically turn their heads to the side to locate the source of a sound made at ear level.

3. Which distraction technique should be used for an adolescent child during a painful procedure?

• A. Blowing bubbles
• B. Guided imagery
• C. EMLA cream
• D. Sucrose solution

Correct answer: B

Rationale: The correct answer is B: Guided imagery. Guided imagery is an effective distraction technique for adolescents as it helps them focus on positive mental images instead of the pain. This technique can be a powerful tool in managing pain and anxiety during procedures. Blowing bubbles (choice A) may be more suitable for younger children as it can engage them visually and help distract them. EMLA cream (choice C) is a topical anesthetic and not a distraction technique. Sucrose solution (choice D) is used for pain relief in infants, not typically for adolescents undergoing painful procedures.

4. What information should the nurse include when teaching an adolescent with Crohn disease (CD)?

• A. How to cope with stress and adjust to chronic illness
• B. Preparation for surgical treatment and cure of CD
• C. Nutritional guidance and prevention of constipation
• D. Prevention of spread of illness to others and principles of high-fiber diet

Correct answer: A

Rationale: Teaching about coping with stress and adjusting to chronic illness is crucial for adolescents with Crohn disease. CD is a chronic condition with no cure, so focusing on managing the disease, stress, and diet is essential for improving the adolescent's quality of life. Choice B is incorrect because Crohn disease cannot be cured surgically. Choice C is relevant but not as essential as coping with stress and chronic illness. Choice D is not a priority in teaching an adolescent with Crohn disease as it mainly focuses on preventing the spread of illness to others, which is not a significant concern with CD, and high-fiber diets may not always be suitable for individuals with this condition.

5. The nurse determines that a child's intravenous infusion has infiltrated. The infused solution is a vesicant. What is the most appropriate nursing action?

• A. Stop the infusion and apply ice.
• B. End the infusion and notify the practitioner.
• C. Slow the infusion rate and notify the practitioner.
• D. Discontinue the infusion and apply warm compresses.

Correct answer: B

Rationale: If a vesicant solution infiltrates, stopping the infusion immediately and notifying the practitioner is critical to prevent tissue damage. Cold or warm compresses should only be applied following specific medical advice based on the vesicant involved.

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