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. When teaching a group of parents in the daycare center about accident prevention, the nurse explains that young toddlers are prone to injuries from falls. When receiving feedback, the nurse identifies that more teaching is needed when one parent states, 'I will:'

• A. keep medications in a medicine cabinet.
• B. have secured gates at entrances to staircases.
• C. move our child to a regular bed by the age of three.
• D. buy shoes that fasten with Velcro rather than laces.

Correct answer: C

Rationale: The correct answer is C. Moving a child to a regular bed by the age of three can increase the risk of falls as young toddlers may not have the motor skills to safely navigate a larger bed. This indicates a need for more teaching on safety measures. Choices A, B, and D are all appropriate safety measures that can help prevent accidents and injuries in young children. Keeping medications in a medicine cabinet, having secured gates at entrances to staircases, and choosing shoes that fasten with Velcro instead of laces are all good practices to ensure a safe environment for toddlers.

3. The nurse is conducting a physical examination of a 9-month-old baby with a flat, discolored area on the skin. The nurse documents this as a:

• A. Papule
• B. Macule
• C. Vesicle
• D. Scale

Correct answer: B

Rationale: A macule is defined as a flat, discolored area on the skin that is different from surrounding tissue due to a change in color. In this case, the baby has a flat, discolored area on the skin, which fits the description of a macule. A papule is a small, raised solid bump, a vesicle is a small fluid-filled blister, and a scale is a flake of skin that is often dry and rough. Therefore, choices A, C, and D do not accurately describe the flat, discolored area on the baby's skin, making them incorrect.

4. The nurse is assisting low-income families to access health care. The nurse is aware that, in today's society, this most accurately defines the diversity of a modern family.

• A. A family consists of parents and their offspring living together.
• B. A family is whatever the child and family say it is.
• C. A family is two or more people related or unrelated who are living together.
• D. A family is two or more genetically related persons living together with separate roles.

Correct answer: B

Rationale: In today's diverse society, the concept of family has evolved beyond traditional definitions. Choice B, 'A family is whatever the child and family say it is,' reflects the contemporary understanding that families can take various forms, based on self-identification and individual perspectives. Choice A is too restrictive, as modern families may not solely consist of parents and their offspring living together. Choice C is somewhat inclusive but lacks the recognition of self-identification and diversity within families. Choice D focuses on genetic relation and roles, which may not apply to all modern family structures. Therefore, choice B is the most suitable and inclusive definition of a modern family in today's society.

5. The nurse is caring for a boy with probable intussusception. He had diarrhea before admission, but while waiting for the administration of air pressure to reduce the intussusception, he passes a normal brown stool. Which nursing action is the most appropriate?

• A. notify the practitioner
• B. measure abdominal girth
• C. auscultate for bowel sounds
• D. take vital signs, including blood pressure

Correct answer: A

Rationale: The passage of a normal brown stool in a child with intussusception could indicate spontaneous reduction of the intussusception. This change in the patient's condition is significant, requiring prompt notification of the practitioner for further evaluation and management. While measuring abdominal girth (Choice B) is important for assessing abdominal distention, it is not the priority when a potential spontaneous reduction may have occurred. Auscultating for bowel sounds (Choice C) and taking vital signs, including blood pressure (Choice D), are routine nursing assessments but do not address the immediate need to inform the practitioner of a possible change in the patient's condition that necessitates urgent attention.

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