Nursing Elites

1. When assessing a child with a possible fracture, what would be the most reliable indicator for the nurse to identify?

• A. Lack of spontaneous movement
• B. Point tenderness
• C. Bruising
• D. Inability to bear weight

Correct answer: B

Rationale: Point tenderness is the most reliable indicator of a possible fracture in a child. It refers to localized pain at a specific point, indicating a potential bone injury. Lack of spontaneous movement (Choice A) is non-specific and can be due to various reasons. Bruising (Choice C) may be present in fractures but is not as specific as point tenderness. Inability to bear weight (Choice D) can also be seen in fractures but may not always be present, making it less reliable compared to point tenderness.

2. A nurse is reviewing the immunization schedule of an 11-month-old infant. What immunizations does the nurse expect the infant to have previously received?

• A. Pertussis, tetanus, polio, and measles
• B. Diphtheria, pertussis, tetanus, and polio
• C. Rubella, polio, tuberculosis, and pertussis
• D. Measles, mumps, rubella, and tuberculosis

Correct answer: B

Rationale: The correct answer is B: Diphtheria, pertussis, tetanus, and polio. By 11 months of age, infants should have received doses of these vaccines as part of the immunization schedule. Choice A is incorrect because measles is usually given later in the schedule. Choice C is incorrect as rubella is usually given as part of the MMR vaccine, not individually, and tuberculosis is not routinely given as a vaccine in early infancy. Choice D is incorrect because mumps is not part of the recommended vaccines at 11 months of age.

3. A 6-year-old child with asthma is admitted to the hospital with an acute exacerbation. What is the priority nursing intervention?

• A. Administering a bronchodilator
• B. Administering an antihistamine
• C. Administering a corticosteroid
• D. Administering oxygen

Correct answer: A

Rationale: Administering a bronchodilator is the priority intervention for a child experiencing an acute asthma exacerbation. Bronchodilators help to dilate the airways quickly, providing immediate relief by opening up the narrowed air passages in asthma. Antihistamines are not the first-line treatment for asthma exacerbations and may not address the underlying bronchoconstriction. Corticosteroids are important for long-term control of asthma but may take longer to have an effect compared to bronchodilators. Administering oxygen is essential for hypoxemia in asthma exacerbations, but the priority is to relieve bronchoconstriction promptly with a bronchodilator.

4. A young child has coarctation of the aorta. What does the nurse expect to identify when taking the child’s vital signs?

• A. A weak radial pulse
• B. An irregular heartbeat
• C. A bounding femoral pulse
• D. An elevated radial blood pressure

Correct answer: A

Rationale: In coarctation of the aorta, there is narrowing of the aorta leading to decreased blood flow distal to the constriction. This results in a weak or delayed femoral pulse and a relatively weaker radial pulse compared to the femoral pulse. An irregular heartbeat (choice B) is not a typical finding in coarctation of the aorta. A bounding femoral pulse (choice C) would not be expected due to the decreased blood flow beyond the constriction. An elevated radial blood pressure (choice D) is not a common characteristic of coarctation of the aorta; instead, blood pressure may be higher in the upper extremities compared to the lower extremities due to the constriction.

5. What is the priority nursing intervention for a child admitted to the hospital with a diagnosis of acute glomerulonephritis?

• A. Monitoring for hypertension
• B. Providing pain relief
• C. Restricting fluid intake
• D. Encouraging fluid intake

Correct answer: A

Rationale: The priority nursing intervention for a child with acute glomerulonephritis is monitoring for hypertension. Acute glomerulonephritis involves inflammation of the kidney's glomeruli, leading to impaired kidney function. Hypertension is a common complication due to fluid retention and increased renin-angiotensin system activity. Monitoring for hypertension is crucial for early detection and management to prevent further kidney damage and complications. Providing pain relief (Choice B) may be required for discomfort but is not the priority. Restricting fluid intake (Choice C) may be necessary in some kidney diseases, but in acute glomerulonephritis, the focus is on monitoring and managing hypertension. Encouraging fluid intake (Choice D) is inappropriate as it can exacerbate fluid overload and hypertension in acute glomerulonephritis.

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