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 5-year-old child is admitted to the hospital with a diagnosis of bacterial meningitis. What is the priority nursing intervention?

• A. Administering antibiotics
• B. Isolating the child
• C. Monitoring vital signs
• D. Administering fluids

Correct answer: B

Rationale: The priority nursing intervention for a 5-year-old child admitted to the hospital with bacterial meningitis is to isolate the child. Isolating the child is crucial to prevent the spread of infection to others, as bacterial meningitis is highly contagious. Administering antibiotics (Choice A) is important in the treatment of bacterial meningitis, but isolating the child takes precedence to protect others. Monitoring vital signs (Choice C) and administering fluids (Choice D) are essential aspects of care for a child with meningitis but are not the priority intervention to prevent the spread of the infection.

3. When teaching the parents of a child with a diagnosis of type 1 diabetes mellitus about insulin administration, what should the nurse emphasize?

• A. Rotate injection sites
• B. Administer insulin before meals
• C. Store insulin in the refrigerator
• D. Administer insulin at bedtime

Correct answer: A

Rationale: The correct answer is to rotate injection sites. This practice helps prevent lipodystrophy, a localized loss of fat tissue that can affect insulin absorption. By rotating sites, the child can avoid developing lumps or indentations in the skin where insulin is repeatedly injected. Administering insulin before meals (choice B) may be necessary for certain types of insulin but is not the priority when teaching about insulin administration. Storing insulin in the refrigerator (choice C) is important for maintaining its potency, but it is not the primary emphasis when teaching about insulin administration. Administering insulin at bedtime (choice D) may be necessary based on the child's insulin regimen but is not the primary consideration for teaching injection techniques and site rotation.

4. During a primary survey of a child with partial thickness burns over the upper body areas, what action should the nurse take first?

• A. Inspect the child's skin color.
• B. Assess for a patent airway.
• C. Observe for symmetric breathing.
• D. Palpate the child's pulse.

Correct answer: B

Rationale: The correct answer is B: Assess for a patent airway. When dealing with a child who has sustained partial thickness burns, the priority is ensuring a patent airway due to the risk of respiratory compromise. Checking the child's skin color (choice A) may be important but is secondary to assessing the airway. While observing for symmetric breathing (choice C) is crucial, assessing the airway takes precedence in this situation. Palpating the child's pulse (choice D) is not the initial priority when managing burns and potential airway compromise.

5. In planning care for a 7-year-old boy with diabetes insipidus, what is the priority nursing diagnosis?

• A. Deficient fluid volume related to dehydration
• B. Excess fluid volume related to edema
• C. Deficient knowledge related to fluid intake regimen
• D. Imbalanced nutrition, more than body requirements related to excess weight

Correct answer: A

Rationale: The priority nursing diagnosis for a 7-year-old boy with diabetes insipidus is deficient fluid volume related to dehydration. Diabetes insipidus leads to excessive urination and fluid loss, which can result in dehydration. This diagnosis should take precedence as restoring fluid balance is crucial in managing this condition. Choices B, C, and D are less of a priority in this case. Excess fluid volume related to edema is not typically associated with diabetes insipidus. Deficient knowledge about fluid intake and imbalanced nutrition related to excess weight may be important but addressing the dehydration and fluid volume deficit is the most critical aspect in the immediate care of a child with diabetes insipidus.

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