Nursing Elites

1. The nurse has just started assessing a young child who is febrile and appears ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. Which is the most appropriate action?

• A. Ask the parent when the neck was injured
• B. Refer for immediate medical evaluation
• C. Continue assessment to determine the cause of the neck pain
• D. Record head lag on the assessment record and continue the assessment of the child

Correct answer: B

Rationale: Opisthotonos with pain on flexion is a sign of possible meningitis or other serious neurological conditions, requiring immediate medical evaluation.

2. The nurse is assessing a 3-year-old child. Which assessment finding would the nurse identify as abnormal?

• A. Pedals tricycle without assistance
• B. Unscrews a bolt on a toy
• C. Falls when bending over to touch toes
• D. Builds a tower of 10 cubes

Correct answer: C

Rationale: The correct answer is C. Falling when bending over to touch toes could indicate a developmental delay or a balance issue that may need further assessment. Choices A, B, and D are typical developmental milestones for a 3-year-old child. Pedaling a tricycle without assistance, unscrewing a bolt on a toy, and building a tower of 10 cubes are all age-appropriate activities for a child of this age.

3. What is the appropriate placement of a tongue blade for assessment of the mouth and throat?

• A. On the lower jaw
• B. Side of the tongue
• C. Against the soft palate
• D. Center back area of the tongue

Correct answer: B

Rationale: The side of the tongue is the appropriate place for a tongue blade to avoid triggering the gag reflex during assessment of the mouth and throat.

4. What is the most common cause of acute kidney injury in children?

• A. Dehydration
• B. Glomerulonephritis
• C. Hemolytic uremic syndrome
• D. Sepsis

Correct answer: C

Rationale: Hemolytic uremic syndrome is the most common cause of acute kidney injury in children. While dehydration can lead to prerenal acute kidney injury, it is not the most common cause in children. Glomerulonephritis is a common cause of chronic kidney disease but not typically the most common cause of acute kidney injury in children. Sepsis can lead to acute kidney injury, but in children, hemolytic uremic syndrome is more prevalent.

5. The nurse is caring for a child with a urinary tract infection who is on intravenous gentamicin (Garamycin). What interventions should the nurse plan for this child with regard to this medication? (Select all that apply.)

• A. Encourage fluids.
• B. Monitor urinary output.
• C. Monitor sodium serum levels.
• D. All above

Correct answer: D

Rationale: Gentamicin is an aminoglycoside antibiotic that requires monitoring of serum peak and trough levels to avoid toxicity, particularly nephrotoxicity and ototoxicity. Encouraging fluids and monitoring urinary output are also crucial to minimize the risk of kidney damage.

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