Nursing Elites

1. 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.

2. The nurse suspects fluid overload in an infant receiving intravenous fluids. What clinical manifestation is suggestive of water intoxication?

• A. Oliguria
• B. Weight loss
• C. Irritability and seizures
• D. Muscle weakness and cardiac dysrhythmias

Correct answer: C

Rationale: Water intoxication can lead to cerebral edema, causing neurological symptoms such as irritability and seizures. Oliguria, weight loss, and muscle weakness are not typical signs of water intoxication.

3. A nurse is working with the local community on promoting physical fitness for children. The nurse encourages the community to develop programs that meet the needs of the school-aged child for physical activity, based on the understanding that this age group requires how much physical activity daily?

• A. 30 minutes
• B. 60 minutes
• C. 90 minutes
• D. 15 minutes

Correct answer: B

Rationale: The correct answer is B: 60 minutes. School-aged children require at least 60 minutes of physical activity daily according to recommendations. This level of activity helps in promoting overall health, development, and well-being. Choice A (30 minutes) is incorrect as it falls short of the recommended duration. Choice C (90 minutes) is excessive and not the standard guideline for this age group. Choice D (15 minutes) is insufficient to meet the physical activity needs of school-aged children.

4. In teaching parents about appropriate pacifier selection, the nurse should recommend which characteristic?

• A. Easily grasped handle
• B. Detachable shield for cleaning
• C. Soft, pliable material
• D. Ribbon or string to secure to clothing

Correct answer: A

Rationale: A pacifier with an easily grasped handle is safer and more convenient for the infant to use without the risk of choking hazards that detachable parts might pose.

5. When teaching a mother how to administer eye drops, where should the nurse tell her to place them?

• A. At the lacrimal duct
• B. On the sclera while the child looks to the outside
• C. In the conjunctival sac when the lower eyelid is pulled down
• D. Carefully under the eyelid while it is gently pulled upward

Correct answer: C

Rationale: Eye drops should be placed in the conjunctival sac, which allows the medication to be absorbed properly without causing irritation. Placing drops directly on the sclera or near the lacrimal duct is less effective and can cause discomfort.

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