Nursing Elites

1. The nurse is assessing a child with type 2 diabetes. The child is awake and alert with a serum glucose of 60 mg/dL. What action should the nurse take?

• A. Administer Insulin.
• B. Administer Epinephrine.
• C. Give 15 grams of carbohydrates.
• D. Give glucagon by injection.

Correct answer: C

Rationale: For a conscious child with mild hypoglycemia, giving 15 grams of fast-acting carbohydrates is the appropriate intervention. This can quickly raise blood glucose levels to prevent further complications. Administering insulin (Choice A) would further lower the glucose level, which is not suitable in this scenario. Administering epinephrine (Choice B) is not indicated for hypoglycemia. Glucagon (Choice D) is used for severe hypoglycemia with altered consciousness, not for mild cases where the child is awake and alert.

2. Which explains the importance of detecting strabismus in young children?

• A. Color vision deficit may result.
• B. Amblyopia, a type of blindness, may result.
• C. Epicanthal folds may develop in the affected eye
• D. Corneal light reflexes may fall symmetrically within each pupil

Correct answer: B

Rationale: Undetected strabismus can lead to amblyopia, where the brain favors one eye over the other, potentially resulting in permanent vision loss in the affected eye.

3. Which parental statement indicates correct understanding regarding pancreatic enzyme administration in the treatment of cystic fibrosis?

• A. “I will administer this medication 4 times a day.”
• B. “I will administer this medication twice a day.”
• C. “I will administer this medication with meals and snacks.”
• D. “I will administer this medication every 6 hours with meals.”

Correct answer: C

Rationale: The correct answer is C: "I will administer this medication with meals and snacks." Pancreatic enzymes should be administered with meals and snacks to aid in the digestion of nutrients in children with cystic fibrosis. Choices A, B, and D are incorrect because administering the medication without meals and snacks may not provide the necessary support for digestion needed in cystic fibrosis.

4. What findings on physical assessment of a neonate would indicate the need for further evaluation?

• A. Nystagmus
• B. Epstein pearls
• C. Low-set ears
• D. Positive Babinski reflex

Correct answer: C

Rationale: Low-set ears in a neonate suggest major abnormalities and should prompt further evaluation. The correct alignment of the top of the pinnae of the ear with the outer canthus of the eye is crucial. Nystagmus, an involuntary eye movement, is common in newborns and often resolves on its own. Epstein pearls, small cysts on the hard palate, are insignificant and disappear over time. A positive Babinski reflex is normal in infants up to 1 year of age. Therefore, the presence of low-set ears is the most concerning finding that requires immediate attention.

5. The nurse is caring for a child with hypernatremia. The nurse evaluates the child for which signs and symptoms of hypernatremia? (Select all that apply.)

• A. All below
• B. Lethargy
• C. Oliguria
• D. Intense thirst

Correct answer: A

Rationale: Hypernatremia typically presents with lethargy, oliguria, and intense thirst due to the body's attempt to conserve water. Apathy can also occur, but lethargy and thirst are more consistent indicators.

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