Nursing Elites

1. The nurse is preparing to feed a 10-month-old child diagnosed with failure to thrive (FTT). Which actions should the nurse plan to implement?

• A. Be persistent.
• B. Introduce new foods slowly.
• C. All are correct
• D. Maintain a calm, even temperament.

Correct answer: C

Rationale: Persistence in feeding, introducing new foods slowly, and maintaining a calm temperament are key strategies in managing FTT. A stimulating atmosphere may overwhelm the child and should be minimized during feeding times.

2. The nurse is taking vital signs on a group of assigned preschool-aged children. Which assessment finding would indicate the need for further action?

• A. Respiratory rate of 20 breaths per minute
• B. Heart rate of 89 beats per minute
• C. Heart rate of 120 beats per minute
• D. Respiratory rate of 24 breaths per minute

Correct answer: C

Rationale: A heart rate of 120 beats per minute is high for a preschool-aged child and may indicate an underlying issue that requires further assessment. A respiratory rate of 20 breaths per minute (choice A) is within the normal range for preschool children. Similarly, a heart rate of 89 beats per minute (choice B) falls within the expected range. A respiratory rate of 24 breaths per minute (choice D) is slightly elevated but may not be as concerning as a heart rate of 120 beats per minute.

3. What clinical manifestation(s) is associated with calcium depletion (hypocalcemia)?

• A. Nausea, vomiting
• B. Weakness, fatigue
• C. Muscle hypotonicity
• D. Neuromuscular irritability

Correct answer: D

Rationale: Hypocalcemia can lead to neuromuscular irritability, causing symptoms such as muscle cramps, tetany, or seizures. Other symptoms like nausea, vomiting, and weakness are less specific and can be related to various conditions.

4. Which laboratory test would be most important for the nurse to assess when caring for a toddler suspected of having cystic fibrosis?

• A. Liver enzymes
• B. Serum calcium
• C. Sweat chloride test
• D. Urine creatinine

Correct answer: C

Rationale: The sweat chloride test is the primary diagnostic test for cystic fibrosis. Cystic fibrosis is characterized by abnormal transport of chloride and sodium across epithelial cell membranes, leading to increased chloride in sweat. This test is crucial for diagnosing cystic fibrosis in suspected cases. Liver enzymes (Choice A), serum calcium (Choice B), and urine creatinine (Choice D) are not specific tests for cystic fibrosis and would not provide the necessary information for diagnosis in this case.

5. The nurse is performing an assessment on a 10-week-old infant. The nurse understands that the developmental characteristic of hearing at this age is which?

• A. The infant responds to his own name.
• B. The infant localizes sounds by turning his head directly to the sound.
• C. The infant turns his head to the side when sound is made at the level of the ear.
• D. The infant locates sound by turning his head to the side and then looking up or down.

Correct answer: C

Rationale: By 10 weeks, infants typically turn their heads to the side to locate the source of a sound made at ear level.

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