Nursing Elites

1. The caregiver asks why the 6-month-old infant needs to have solid foods when breast milk is such a good source of nutrition. What would be the best response by the nurse?

• A. Solid foods, especially iron-fortified cereals, are introduced to meet the infant's increased nutritional needs, including iron, which breast milk alone may not provide adequately.
• B. The extrusion reflex must be developed and feeding solid foods will help the infant to develop this reflex.
• C. Breastfeeding will become painful when the infant gets more teeth, so the infant needs to eat solid foods.
• D. By this age the infant becomes interested in trying new skills.

Correct answer: A

Rationale: The correct response is A. Solid foods, especially iron-fortified cereals, are introduced to meet the infant's increased nutritional needs, including iron, which breast milk alone may not provide adequately. Choice B is incorrect because the extrusion reflex is related to the tongue-thrust reflex, not the nutritional needs of the infant. Choice C is incorrect as breastfeeding does not become painful when the infant gets more teeth, and it is not a reason for introducing solid foods. Choice D is incorrect as the infant's interest in trying new skills is not a primary reason for introducing solid foods at this age.

2. A 4-month-old infant is discharged home after surgery for the repair of a cleft lip. What should instructions to the parents include?

• A. Provide crib toys for distraction
• B. Breast- or bottle-feeding can begin immediately
• C. Give pain medication to the infant to minimize crying
• D. Leave the infant in the crib at all times to prevent suture strain

Correct answer: C

Rationale: Pain management is essential postoperatively to reduce crying, which could place strain on the surgical site. Feeding and holding the infant are allowed, but care should be taken to avoid placing pressure on the suture line.

3. Which actions by the nurse demonstrate clinical reasoning? (Select all that apply.)

• A. All below
• B. Considering alternative actions
• C. Using formal and informal thinking to gather data
• D. Giving deliberate thought to a patient's problem

Correct answer: A

Rationale: Clinical reasoning involves deliberate and thoughtful decision-making, considering alternatives, and using both formal and informal data gathering methods to provide optimum care.

4. A 14-year-old with chronic renal failure suddenly becomes non-compliant with the medication regimen. Which nursing intervention would most likely improve compliance?

• A. Give the child a computer-animated game that presents information on the management of chronic renal failure.
• B. Set up a meeting with some older teens who have chronic renal failure and have been managing their disease effectively.
• C. Arrange for a physician to sit down and talk to the child about the risks related to noncompliance with medications.
• D. Discuss with the child’s parents that privileges, such as a cell phone, can be taken away if compliance fails to improve.

Correct answer: B

Rationale: Adolescents often seek guidance and support from their peers. Setting up a meeting with older teens who are effectively managing chronic renal failure can provide the 14-year-old with motivation, encouragement, and practical advice on how to handle their treatment regimen. This peer support can positively influence the non-compliant adolescent, making choice B the most likely intervention to improve compliance. Choices A and C may not address the peer influence aspect of adolescent behavior, while choice D focuses on punitive measures rather than addressing the underlying reasons for non-compliance.

5. A six-year-old child is admitted to the hospital with a diagnosis of urinary tract infection. Which of these factors contribute to urinary tract infections in young children?

• A. Excessive intake of carbonated beverages.
• B. Insufficient water intake to flush the kidneys.
• C. Voiding pattern of 5-6 times a day.
• D. Infrequent voiding which results in urinary stasis.

Correct answer: D

Rationale: Infrequent voiding can lead to urinary stasis, which increases the risk of urinary tract infections by allowing bacteria to multiply in the bladder. Encouraging regular voiding and proper hydration can help prevent UTIs. Choices A, B, and C are incorrect. Excessive intake of carbonated beverages may irritate the bladder but is not a direct cause of UTIs. Insufficient water intake can concentrate urine but does not necessarily lead to infections. A voiding pattern of 5-6 times a day is within the normal range and is not associated with increased UTI risk.

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