Nursing Elites

1. A 1-month-old girl with low-set ears and severe hypotonia has been diagnosed with trisomy 18. Which nursing diagnosis would the nurse identify as most likely?

• A. Interrupted family process related to the child's diagnosis
• B. Deficient knowledge related to the genetic disorder
• C. Grieving related to the child's poor prognosis
• D. Ineffective coping related to the stress of providing care

Correct answer: C

Rationale: The most likely nursing diagnosis for a 1-month-old girl with trisomy 18, characterized by low-set ears and severe hypotonia, is 'Grieving related to the child's poor prognosis.' Trisomy 18 is associated with a poor prognosis, and families often experience grief as they come to terms with the challenges and uncertainties associated with the condition. 'Interrupted family process' may not be as relevant since the primary focus is on the child's condition. 'Deficient knowledge related to the genetic disorder' could be important but may not be the most likely initial concern, as emotional support for the family is crucial at this point. 'Ineffective coping related to the stress of providing care' is a broad diagnosis that does not specifically address the emotional response to the child's prognosis, which is the primary concern in this case.

2. A 2-week-old infant is admitted with a tentative diagnosis of a ventricular septal defect. The parents report that their baby has had difficulty feeding since coming home after birth. What should the nurse consider before responding?

• A. Feeding problems are common in neonates.
• B. Inadequate sucking is not significant unless cyanosis is present.
• C. Ineffective sucking and swallowing may be early indications of a heart defect.
• D. Many neonates retain mucus, which can interfere with feeding for several weeks.

Correct answer: C

Rationale: Ineffective sucking and swallowing can be early signs of a heart defect like a ventricular septal defect. This is crucial information for the nurse to consider as it aligns with the infant's tentative diagnosis. Choice A is too general and does not provide specific relevance to the situation. Choice B is incorrect as inadequate sucking can indeed be significant, especially in the context of a potential heart defect. Choice D is not directly related to the potential heart defect and feeding difficulties mentioned in the scenario.

3. A child with a diagnosis of bronchiolitis is admitted to the hospital. What is the most important nursing intervention?

• A. Administering bronchodilators
• B. Providing respiratory therapy
• C. Monitoring oxygen saturation
• D. Encouraging fluid intake

Correct answer: B

Rationale: The most important nursing intervention for a child with bronchiolitis is providing respiratory therapy. This intervention helps to maintain airway patency and improve breathing by assisting with mucus clearance and ventilation. Administering bronchodilators (Choice A) may be considered in some cases, but it is not the most crucial intervention for bronchiolitis. Monitoring oxygen saturation (Choice C) is important but is not as directly impactful as providing respiratory therapy. Encouraging fluid intake (Choice D) is important for hydration but does not directly address the respiratory distress associated with bronchiolitis.

4. What information should be included in the preoperative plan of care for an infant with myelomeningocele?

• A. Positioning the infant supine with a pillow under the buttocks
• B. Covering the sac with saline-soaked nonadhesive gauze
• C. Wrapping the infant snugly in a blanket
• D. Applying a diaper to prevent fecal soiling of the sac

Correct answer: B

Rationale: Covering the sac with saline-soaked nonadhesive gauze is essential in the preoperative care of an infant with myelomeningocele. This practice helps prevent infection and maintains moisture around the sac before surgery, promoting optimal healing outcomes. Positioning the infant supine with a pillow under the buttocks may be uncomfortable and unnecessary. Wrapping the infant snugly in a blanket does not address the specific care needs of the myelomeningocele. Applying a diaper over the sac can increase the risk of infection and should be avoided in this case.

5. What treatment should the nurse suggest to an adolescent with type 1 diabetes if an insulin reaction is experienced while at a basketball game?

• A. Call your parents immediately.
• B. Buy a soda and hamburger to eat.
• C. Administer insulin as soon as possible.
• D. Leave the arena and rest until the symptoms subside.

Correct answer: B

Rationale: When an adolescent with type 1 diabetes experiences an insulin reaction, it is essential to quickly raise their blood sugar levels. Buying a soda and a hamburger to eat is the best choice in this situation as it provides a fast-acting source of sugar to counteract hypoglycemia. Calling parents immediately may cause a delay in receiving appropriate treatment. Administering insulin would further lower blood sugar levels, worsening the situation. Leaving the arena and resting would not address the immediate need to raise blood sugar levels.

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