Nursing Elites

1. The nurse is caring for a 2-year-old child in the postoperative period. Which pain assessment tool is most appropriate for assessing pain intensity in a 2-year-old?

• A. Poker chip tool
• B. Oucher Scale
• C. Faces Pain Rating Scale
• D. FLACC Behavioral Pain Assessment Scale

Correct answer: D

Rationale: The FLACC Behavioral Pain Assessment Scale is the most suitable tool for assessing pain in 2-year-old children postoperatively. It assesses pain by evaluating facial expression, leg movement, activity, cry, and consolability, making it effective for non-verbal children. The Poker chip tool is not appropriate for this age group. The Oucher Scale and Faces Pain Rating Scale are more suitable for older children who can self-report pain levels.

2. A child with pyloric stenosis is having excessive vomiting. The nurse should assess for what potential complication?

• A. Hyperkalemia
• B. Hyperchloremia
• C. Metabolic acidosis
• D. Metabolic alkalosis

Correct answer: D

Rationale: Excessive vomiting in pyloric stenosis leads to the loss of stomach acid (hydrochloric acid), resulting in metabolic alkalosis, not hyperkalemia, hyperchloremia, or metabolic acidosis. Metabolic alkalosis is characterized by a higher pH level in the blood due to the loss of acid and a relative increase in bicarbonate. Hyperkalemia is an elevated level of potassium in the blood and is not directly related to excessive vomiting in pyloric stenosis. Hyperchloremia is an excess of chloride in the blood, which is not typically associated with this condition. Metabolic acidosis is a condition characterized by a lower pH level in the blood, caused by an excess of acid or a loss of bicarbonate, which is not the typical complication seen in pyloric stenosis with excessive vomiting.

3. The nurse is aware that skin turgor best estimates what?

• A. Perfusion
• B. Adequate hydration
• C. Amount of body fat
• D. Amount of anemia

Correct answer: B

Rationale: Skin turgor is a quick and simple way to assess hydration status. Poor skin turgor can indicate dehydration.

4. What is most important in the management of cellulitis?

• A. Burow solution compresses
• B. Oral or parenteral antibiotics
• C. Topical application of an antibiotic
• D. Incision and drainage of severe lesions

Correct answer: B

Rationale: Oral or parenteral antibiotics are essential in treating cellulitis to eliminate the infection. Topical antibiotics are not sufficient, and incision and drainage are only for abscesses.

5. The nurse is planning to counsel family members as a group to assess the family's group dynamics. Which theoretical family model is the nurse using as a framework?

• A. Feminist theory
• B. Family stress theory
• C. Family systems theory
• D. Developmental theory

Correct answer: C

Rationale: Family systems theory views the family as an interconnected system where changes in one member affect the entire family, making it ideal for assessing group dynamics.

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