Nursing Elites

1. The healthcare provider assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/minute. Based on this finding, which action is most appropriate?

• A. Administer oxygen
• B. Document the findings
• C. Notify the healthcare provider
• D. Reassess the respiratory rate in 15 minutes

Correct answer: B

Rationale: Documenting the findings is the most appropriate action since a respiratory rate of 35 breaths per minute falls within the normal range for a 12-month-old infant. There is no immediate need for interventions such as administering oxygen or notifying the healthcare provider. Reassessing the respiratory rate in 15 minutes is unnecessary as the rate is within normal limits.

2. The word hormone is derived from the Greek 'hormao' meaning 'I excite or arouse'. Hormones communicate this effect by their unique chemical structures recognized by specific receptors on their target cells, by their patterns of secretion, and their concentrations in the general or local circulation. Which of the following is NOT a function of hormones?

• A. Producing new offspring
• B. Promoting growth and beauty
• C. Maintaining body temperature
• D. Fighting infections

Correct answer: A

Rationale: The function of producing new offspring is not attributed to hormones. Hormones primarily regulate various physiological processes in the body such as growth, metabolism, reproduction, and immune response, but they do not directly play a role in producing offspring.

3. Which of the following clinical signs would MOST suggest acute respiratory distress in a 2-month-old infant?

• A. Heart rate of 130 beats/min
• B. Respiratory rate of 30 breaths/min
• C. Abdominal breathing
• D. Grunting respirations

Correct answer: D

Rationale: Grunting respirations are a key clinical sign of acute respiratory distress in infants. Grunting is a protective mechanism where the infant exhales against a partially closed glottis to increase functional residual capacity and oxygenation. This is often seen in conditions such as respiratory distress syndrome, pneumonia, or other causes of respiratory compromise in infants. Monitoring respiratory patterns like grunting is crucial for early recognition and intervention in infants with respiratory distress. Choices A, B, and C are less specific to acute respiratory distress in infants. While an elevated heart rate and respiratory rate can be present in respiratory distress, grunting respirations are a more direct indicator of significant respiratory compromise in infants.

4. A mother reported to you that her 6-year-old child is suffering from diarrhea. Which of the following advice will you give to the mother?

• A. Breastfeeding should be continued day and night
• B. Formula milk should be stopped for 6 hours
• C. Breast milk can be given together with oral rehydration salts
• D. A and C

Correct answer: D

Rationale: When a child is suffering from diarrhea, it is essential to continue breastfeeding day and night to maintain hydration and provide necessary nutrients. Stopping formula milk for 6 hours (choice B) is not the recommended approach as it may lead to a lack of essential nutrients during this critical time. Giving breast milk together with oral rehydration salts (choice C) can help replenish lost fluids and electrolytes, making it a suitable recommendation. Therefore, advising the mother to follow both options A and C is the most appropriate approach to manage the child's condition effectively.

5. Which pain assessment tool is most appropriate for a 3-month-old hospitalized with a fractured femur?

• A. FLACC scale
• B. Poker chip tool
• C. Number scale
• D. Visual analog scale

Correct answer: A

Rationale: The FLACC scale, which stands for Face, Legs, Activity, Cry, and Consolability, is specifically designed for nonverbal patients like infants and young children. It assesses pain based on observable behaviors such as facial expressions, leg movement, activity level, cry, and the ability to be consoled. In this case, a 3-month-old infant who is unable to communicate verbally would best be assessed using the FLACC scale to determine the level of pain experienced due to a fractured femur. The Poker chip tool, Number scale, and Visual analog scale are not suitable for nonverbal infants and young children as they rely on self-reporting or cognitive abilities that are not yet developed at this age.

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