Nursing Elites

1. The infant scheduled for reduction of intussusception passes a soft-formed brown stool the day before the procedure. What intervention should the nurse implement?

• A. Instruct the parents that the infant needs to be NPO.
• B. Notify the healthcare provider of the passage of brown stool.
• C. Obtain a stool specimen for laboratory analysis.
• D. Ask the parents about recent changes in the infant's diet.

Correct answer: B

Rationale: Notifying the healthcare provider is crucial when an infant scheduled for intussusception reduction passes a soft-formed brown stool as it may indicate spontaneous reduction of the intussusception. The healthcare provider needs to be informed to assess if the procedure is still necessary or if further evaluation is required. Instructing the parents that the infant needs to be NPO (nothing by mouth) is not the immediate action required in this situation. Obtaining a stool specimen for laboratory analysis is not necessary as the soft-formed brown stool is likely a result of the intussusception spontaneously reducing. Asking about recent changes in the infant's diet is not the most appropriate action when brown stool is passed before the procedure for intussusception reduction.

2. An adolescent's mother calls the primary HCP's office to inquire about the results of her daughter's serum test that was drawn last week. Since it is the teenager's 18th birthday, how should the nurse respond to this mother's inquiry?

• A. Ask when the adolescent was last seen at the clinic
• B. Tell the mother to have the teenager call the clinic
• C. Provide the mother with the findings
• D. Explain that the information cannot be released without the 18-year-old's permission

Correct answer: D

Rationale: The correct response is to explain to the mother that the information cannot be released without the 18-year-old's permission. When an individual turns 18, they are legally considered an adult, and privacy laws mandate that their consent is required before sharing their medical information with others. It is crucial to respect the adolescent's autonomy and privacy rights. Choices A and C are incorrect because they involve disclosing the information without the individual's consent. Choice B is incorrect as it does not address the legal requirement for the adolescent's permission before sharing medical information.

3. A mother brings her 8-month-old baby boy to the clinic because he has been vomiting and having diarrhea for the last 3 days. Which assessment is most important for the nurse to make?

• A. Assess the infant's abdomen for tenderness
• B. Determine if the infant has been exposed to a virus
• C. Measure the infant’s pulse
• D. Evaluate the infant’s cry

Correct answer: C

Rationale: The most crucial assessment in this scenario is to measure the infant's pulse. Pulse measurement is essential to evaluate the severity of dehydration, which can be a significant concern in a baby experiencing vomiting and diarrhea for several days. Assessing the abdomen for tenderness may provide information on potential causes of symptoms but is not as urgent as monitoring hydration status. Determining exposure to a virus is important for infection control but does not directly address the immediate issue of dehydration. Evaluating the infant's cry, although a form of communication, does not provide critical information regarding the baby's physiological status in this situation.

4. A child is recovering from an appendectomy. The parent asks when the child can resume normal activities. What is the best response by the nurse?

• A. The child can resume normal activities as soon as they feel up to it
• B. The child should avoid strenuous activities for at least 2 weeks
• C. The child can resume normal activities after the stitches are removed
• D. The child should avoid all physical activities for the next month

Correct answer: B

Rationale: After an appendectomy, it is important for the child to avoid strenuous activities for at least 2 weeks to allow for proper healing. Resuming normal activities too soon can put unnecessary strain on the healing process and increase the risk of complications.

5. What information should the nurse provide to parents of a 3-year-old boy with Duchenne muscular dystrophy who inquire about the disease and future children?

• A. This is an inherited X-linked recessive disorder, which primarily affects male children in the family
• B. The striated muscle groups of males can be impacted by a lack of the protein dystrophin in their mothers
• C. The male infant had a viral infection that went unnoticed and untreated so muscle damage was incurred
• D. Birth trauma with a breech vaginal birth causes damage to the spinal cord, thus weakening the muscles

Correct answer: A

Rationale: Duchenne muscular dystrophy is an X-linked recessive disorder caused by mutations in the DMD gene on the X chromosome. This disorder primarily affects males because they have one X chromosome, inherited from their mothers, who may be carriers of the mutated gene. Females have two X chromosomes, providing a protective effect as the normal gene on one X chromosome can compensate for the mutated gene on the other. Therefore, the nurse should explain to the parents that Duchenne muscular dystrophy is an inherited X-linked recessive disorder, which is why their son has the disease and why there is a risk of passing it on to future sons. Choice B is incorrect as it inaccurately implies that the lack of dystrophin in mothers impacts their sons' muscle groups. Choice C is incorrect as it suggests a viral infection caused the muscle damage, which is not the case with Duchenne muscular dystrophy. Choice D is incorrect as it attributes the muscle weakness to birth trauma instead of the genetic nature of the disorder.

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