Nursing Elites

1. When caring for a 5-year-old child with a history of seizures who suddenly begins to have a tonic-clonic seizure, what should the nurse do first?

• A. Administer oxygen
• B. Insert an oral airway
• C. Turn the child to the side
• D. Start an IV line

Correct answer: C

Rationale: During a tonic-clonic seizure, the priority action is to turn the child to the side. This helps maintain an open airway and prevents aspiration of secretions or vomitus. It also helps in keeping the airway clear and promotes safety during the seizure episode. Administering oxygen, inserting an oral airway, and starting an IV line are important interventions but should follow the initial step of positioning the child to prevent airway obstruction.

2. A 3-year-old child is brought to the clinic by the parents who are concerned that the child is not yet potty trained. What is the nurse’s best response?

• A. Most children are potty trained by this age, so you should not be concerned
• B. Every child develops at their own pace. Let’s discuss some strategies to help
• C. Your child may need to be evaluated for developmental delays
• D. It’s best to force your child to use the potty to encourage training

Correct answer: B

Rationale: The correct answer is B because it is important to acknowledge that children develop at different rates. By offering support and discussing strategies for potty training, the nurse can provide the necessary guidance without causing unnecessary concern or pressure on the parents. Choice A is incorrect because it dismisses the parents' concerns. Choice C is incorrect because jumping to the conclusion of developmental delays without further assessment or discussion can cause undue anxiety. Choice D is incorrect because forcing a child to use the potty can lead to resistance and negative associations with potty training.

3. A 7-year-old child with cystic fibrosis is admitted to the hospital with a respiratory infection. The nurse is teaching the child’s parents about the importance of chest physiotherapy (CPT). Which statement by the parents indicates they need further teaching?

• A. We should perform CPT before meals.
• B. CPT will help loosen mucus in the lungs.
• C. We should perform CPT right after the child eats.
• D. CPT is an important part of our child’s treatment.

Correct answer: C

Rationale: The correct answer is C. Chest physiotherapy should not be performed right after meals to avoid inducing vomiting. It should be done before meals or at least 1 hour after for effective mucus clearance and to prevent any potential complications like vomiting. Choice A is correct as performing CPT before meals helps in loosening mucus. Choice B is also correct as CPT is indeed helpful in loosening mucus in the lungs. Choice D is correct as CPT plays a crucial role in the treatment of cystic fibrosis.

4. The mother of a 4-month-old asks the nurse for advice in preventing diaper rash. What suggestion should the nurse provide?

• A. At diaper change generously powder the baby's diaper area with talcum powder to promote dryness.
• B. Wash the diaper area every 2 hours with soap and water to help prevent skin breakdown.
• C. Use a barrier cream, such as zinc oxide, which does not have to be completely removed with each diaper change.
• D. Place a cloth diaper inside the disposable diaper for overnight periods when increased wearing time is likely.

Correct answer: C

Rationale: Using a barrier cream like zinc oxide protects the skin and helps prevent diaper rash.

5. During a well-baby check, the nurse hides a block under the baby's blanket, and the baby looks for the block. Which normal growth and development milestone is the baby developing?

• A. Separation anxiety.
• B. Associative play.
• C. Object prehension.
• D. Object permanence.

Correct answer: D

Rationale: When a baby looks for a hidden object, it demonstrates the development of object permanence. This milestone is significant as it signifies the baby's understanding that objects continue to exist even when they are not visible. It is a crucial aspect of cognitive development in infancy. Choice A, separation anxiety, refers to distress when separated from a primary caregiver and is not demonstrated in this scenario. Choice B, associative play, involves interactive play with others and is not relevant to object search. Choice C, object prehension, refers to the ability to grasp and hold objects, which is not specifically demonstrated by looking for a hidden object in this context.

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