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. 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.

3. A 4-year-old child is admitted with a diagnosis of bacterial pneumonia. What is the priority nursing intervention?

• A. Administering antipyretics
• B. Administering antibiotics
• C. Monitoring fluid intake
• D. Providing nutritional support

Correct answer: B

Rationale: The priority nursing intervention for a 4-year-old child admitted with bacterial pneumonia is administering antibiotics. Antibiotics are essential to treat the infection, prevent its spread, and avoid potential complications. Administering antipyretics (Choice A) may help reduce fever but does not address the underlying cause of pneumonia, which is bacterial in this case. Monitoring fluid intake (Choice C) is important to maintain hydration but does not directly treat the infection. Providing nutritional support (Choice D) is crucial for overall health, but the immediate priority is to address the bacterial infection with antibiotics to prevent further complications and promote recovery.

4. The nurse is caring for an infant with osteogenesis imperfecta and is providing instruction on how to reduce the risk of injury. Which response from the mother indicates a need for further teaching?

• A. I need to avoid pushing or pulling on an arm or leg.
• B. I must avoid lifting the baby from under the armpits.
• C. I should not bend an arm or leg into an awkward position.
• D. We must avoid lifting the legs by the ankles to change diapers.

Correct answer: B

Rationale: Lifting the baby from under the armpits can cause fractures in infants with osteogenesis imperfecta. The correct approach is to support the baby's body and head carefully, avoiding pressure on vulnerable areas prone to fractures. Choices A, C, and D demonstrate proper awareness of caring for an infant with osteogenesis imperfecta by emphasizing caution to prevent fractures.

5. An 8-year-old child diagnosed with meningitis is to undergo a lumbar puncture. What should the nurse explain is the purpose of this procedure?

• A. To measure the pressure of cerebrospinal fluid
• B. To obtain a sample of cerebrospinal fluid for analysis
• C. To relieve intracranial pressure
• D. To assess the presence of infection in the spinal fluid

Correct answer: B

Rationale: A lumbar puncture is performed to obtain a sample of cerebrospinal fluid for analysis. This fluid is then examined for signs of infection, bleeding, or other abnormalities. Measuring the pressure of cerebrospinal fluid is typically done during the procedure itself, but it is not the primary purpose of the lumbar puncture. While a lumbar puncture can indirectly help relieve intracranial pressure by removing excess cerebrospinal fluid, this is not its primary purpose. Assessing the presence of infection in the spinal fluid is part of the analysis that follows the collection of the sample, making it a secondary outcome of the procedure.

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