Nursing Elites

1. Superficial palpation of the abdomen is often perceived by the child as tickling. Which measure by the nurse is most likely to minimize this sensation and promote relaxation?

• A. Palpate another area simultaneously
• B. Ask the child not to laugh or move
• C. Begin with deeper palpation and gradually progress to superficial palpation
• D. Have the child help with palpation by placing his or her hand over the palpating hand

Correct answer: D

Rationale: Allowing the child to place their hand over the nurse's hand helps reduce the tickling sensation and increases the child's comfort during the examination.

2. A young mother asks if her 9-month-old can begin drinking cow’s milk instead of formula. You explain that:

• A. Cow’s milk is easier to digest than formula
• B. Breast milk or formula should be used for now because whole cow’s milk is not recommended for infants under 1 year
• C. As long as whole milk is given and not skim milk, it is okay
• D. Cow’s milk will decrease the chance of iron deficiency anemia

Correct answer: B

Rationale: Breast milk or formula should be used for now because whole cow’s milk is not recommended for infants under 1 year. Cow’s milk is not suitable for infants under 1 year of age as it lacks essential nutrients like iron and can lead to iron deficiency. Therefore, it is important to continue with breast milk or formula to ensure the baby's nutritional needs are met. Choice A is incorrect as cow’s milk is not easier to digest than formula for infants. Choice C is incorrect as the type of milk, whether whole or skim, is not the primary concern at this age. Choice D is incorrect as cow’s milk can actually increase the risk of iron deficiency anemia in infants.

3. When assessing a child with chronic renal failure, which clinical manifestations would the nurse expect to find?

• A. Uremic frost
• B. Hypotension
• C. Massive hematuria
• D. Severe metabolic acidosis

Correct answer: A

Rationale: When assessing a child with chronic renal failure, the nurse would expect to find uremic frost as a clinical manifestation. Uremic frost, a white powdery deposit of urea on the skin, occurs in severe cases of chronic renal failure due to the accumulation of urea and other waste products in the blood. Hypotension and massive hematuria are less common in chronic renal failure, while severe metabolic acidosis is typically mild to moderate and not a prominent clinical manifestation.

4. The presence of which pair of factors is a good predictor of a fluid deficit of at least 5% in an infant?

• A. Weight loss and decreased heart rate
• B. Capillary refill of less than 2 seconds and no tears
• C. Increased skin elasticity and sunken anterior fontanel
• D. Dry mucous membranes and generally ill appearance

Correct answer: D

Rationale: Dry mucous membranes and an ill appearance are good indicators of dehydration in infants, often correlating with a fluid deficit of at least 5%. Sunken fontanels and poor skin turgor are also indicative but were not options here.

5. Evidence-based practice (EBP), a decision-making model, is best described as which?

• A. Using information in textbooks to guide care
• B. Combining knowledge with clinical experience and intuition
• C. Using a professional code of ethics as a means for decision-making
• D. Gathering all evidence that applies to the child’s health and family situation

Correct answer: D

Rationale: Evidence-based practice involves gathering and integrating all relevant evidence to guide clinical decision-making, ensuring that care is based on the best available research.

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