Nursing Elites

1. The nurse is caring for a 15-year-old boy who has sustained burn injuries. The nurse observes the burn developing a purplish color with discharge and a foul odor. The nurse suspects which infection?

• A. Burn wound cellulitis.
• B. Invasive burn cellulitis.
• C. Burn impetigo.
• D. Staphylococcal scalded skin syndrome.

Correct answer: B

Rationale: The correct answer is B: Invasive burn cellulitis. Invasive burn cellulitis presents with the burn developing a dark brown, black, or purplish color with discharge and a foul odor. Burn wound cellulitis (choice A) typically involves redness, warmth, and swelling around the burn site. Burn impetigo (choice C) is a superficial infection characterized by honey-colored crusting. Staphylococcal scalded skin syndrome (choice D) is a condition caused by exotoxins from Staphylococcus aureus, leading to widespread skin peeling.

2. 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.

3. The parents of a 6-week-old infant who was born without an immune system ask a nurse why their baby is still so healthy. How should the nurse reply?

• A. Exposure to pathogens during this time can be limited.
• B. Some antibodies are produced by the infant’s colonic bacteria.
• C. Antibodies are passively received from the mother through the placenta and breast milk.
• D. Fewer antibodies are produced by the fetal thymus during the eighth and ninth months of gestation.

Correct answer: C

Rationale: The correct answer is C. Infants receive passive immunity through antibodies from the mother during pregnancy and breastfeeding, which protect them initially. Choice A is incorrect because a 6-week-old infant born without an immune system would not be able to limit exposure to pathogens effectively. Choice B is incorrect as antibodies produced by colonic bacteria are not a significant source of immunity in infants. Choice D is incorrect as the fetal thymus primarily plays a role in T cell development rather than antibody production during gestation.

4. The nurse is assessing the 'resilience' of a 16-year-old boy. Which exemplifies an external protective factor that may help to promote resiliency in this child?

• A. His ability to take control of his own decisions
• B. His ability to accept his own limitations
• C. His caring relationship with members of his family
• D. His knowledge of when to continue or stop with goal achievement

Correct answer: C

Rationale: A caring relationship with family members is an external protective factor that promotes resilience. It provides emotional support, stability, and a sense of belonging, which are crucial elements in building resilience. Choices A, B, and D are more related to internal factors and individual traits rather than external factors like family relationships, which play a significant role in promoting resilience. Taking control of decisions, accepting limitations, and knowing when to stop or continue with goals are internal factors that contribute to personal resilience but do not directly represent external protective factors like family relationships.

5. The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation would indicate pyloric stenosis?

• A. abdominal rigidity and pain on palpation
• B. rounded abdomen and hypoactive bowel sounds
• C. visible peristalsis and weight loss
• D. distention of the lower abdomen and constipation

Correct answer: C

Rationale: Visible peristalsis and weight loss are classic clinical manifestations of pyloric stenosis. The obstruction at the pyloric sphincter causes visible peristalsis as the stomach tries to push food through the narrowed opening, leading to the appearance of waves across the abdomen. Weight loss occurs due to poor feeding and frequent vomiting associated with pyloric stenosis. Choices A, B, and D are incorrect. Abdominal rigidity and pain on palpation, rounded abdomen and hypoactive bowel sounds, as well as distention of the lower abdomen and constipation are not typically seen in pyloric stenosis.

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