Nursing Elites

1. The mother of a one-month-old calls the clinic to report that the back of her infant's head is flat. How should the nurse respond?

• A. Turn the infant on the left side braced against the crib when sleeping.
• B. Prop the infant in a sitting position with a cushion when not sleeping.
• C. Place a small pillow under the infant's head while lying on the back.
• D. Position the infant on the stomach occasionally when awake and active.

Correct answer: D

Rationale: Positioning the infant on the stomach occasionally when awake and active can help prevent flat spots on the head. This position allows for more natural movement and prevents prolonged pressure on one area of the head, reducing the risk of developing a flat spot. Turning the infant on the left side braced against the crib when sleeping (choice A) is not recommended as it does not address the issue of flat spots. Propping the infant in a sitting position with a cushion when not sleeping (choice B) may increase the risk of falls and is not suitable for a one-month-old. Placing a small pillow under the infant's head while lying on the back (choice C) should be avoided due to the risk of suffocation and sudden infant death syndrome (SIDS).

2. The caregiver is caring for a 3-year-old child with a diagnosis of gastroenteritis. The child has had several episodes of vomiting and diarrhea over the past 24 hours. What is the caregiver's priority assessment?

• A. Monitor the child's weight
• B. Assess the child's hydration status
• C. Evaluate the child's nutritional intake
• D. Check the child's temperature

Correct answer: B

Rationale: The correct answer is B: Assess the child's hydration status. In children with gastroenteritis, assessing hydration status is crucial as they are at risk of dehydration due to vomiting and diarrhea. Monitoring hydration helps prevent complications and guides appropriate interventions to maintain the child's fluid balance. Monitoring the child's weight (Choice A) is not the priority in this situation compared to assessing hydration status. Evaluating nutritional intake (Choice C) is important but not the priority when the child is at risk of dehydration. Checking the child's temperature (Choice D) is relevant but not the priority over assessing hydration status in a child with gastroenteritis.

3. The nurse is assessing a 3-month-old infant who was brought to the clinic by the parents due to concerns about the infant’s feeding. The parents report that the infant has been vomiting after every feeding and has not gained any weight. What should the nurse assess first?

• A. Evaluate the infant’s feeding technique
• B. Check the infant’s hydration status
• C. Measure the infant’s abdominal circumference
• D. Review the infant’s growth chart

Correct answer: B

Rationale: Assessing hydration status is crucial in an infant who is vomiting frequently, as dehydration can quickly become a serious issue. In this scenario, the infant's inability to retain feeds and lack of weight gain may indicate a potential risk of dehydration, making it essential to prioritize checking the infant's hydration status to prevent complications. Evaluating the feeding technique (Choice A) could be important but is secondary to addressing potential dehydration. Measuring the abdominal circumference (Choice C) and reviewing the growth chart (Choice D) are not the priority in this situation where dehydration is a primary concern.

4. What response should the practical nurse (PN) provide when a school-age child asks to talk with a dying sister?

• A. Talk loudly to ensure the dying person hears and recognizes others' voices.
• B. Touch can provide a tactile presence if the dying person does not respond to words.
• C. Sitting close offers the dying person the sensation of others' presence.
• D. Although the dying person may not respond, they can still hear what is said.

Correct answer: D

Rationale: The correct response is D because it is believed that hearing is the last sense to go. Even if the dying person does not respond, speaking to them can still provide comfort. Choice A is incorrect because talking loudly is not necessary and can be distressing. Choice B is incorrect as it focuses on touch rather than the sense of hearing. Choice C is incorrect because sitting close may not necessarily help the dying person hear better.

5. The healthcare provider is caring for a 3-year-old child who is hospitalized with dehydration. The child is now receiving IV fluids and has started to produce urine. What is the best indicator that the child’s dehydration is improving?

• A. The child’s urine output has increased
• B. The child’s skin turgor is normal
• C. The child’s weight has increased
• D. The child’s vital signs are stable

Correct answer: A

Rationale: An increase in urine output is a reliable indicator that the child's hydration status is improving. Adequate urine output signifies that the kidneys are functioning properly and that the body is effectively eliminating waste and excess fluids, indicating improved hydration levels. The other options are not as direct indicators of hydration status. Skin turgor and weight changes can be influenced by various factors, and stable vital signs do not specifically reflect hydration status.

Similar Questions