Nursing Elites

1. 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.

2. At what point in the hospitalization of the pediatric patient should discharge planning and teaching begin?

• A. Post-operatively
• B. Right when the patient is being discharged with the parents and support members present
• C. On the morning that the patient is scheduled to go home
• D. On admission

Correct answer: D

Rationale: Discharge planning should begin on admission to ensure that all necessary teaching and preparations are completed in a timely manner. Starting discharge planning early allows for a comprehensive assessment of the patient's needs, coordination with the healthcare team, and adequate time for patient and family education. Choice A, post-operatively, is too late in the process and may lead to rushed planning. Choice B, right at discharge, may not allow enough time for thorough preparation. Choice C, on the morning of discharge, also does not provide sufficient time for effective planning and education.

3. The parents of a 2-year-old boy who had a repair of exstrophy of the bladder at birth ask when they can begin toilet training their son. The nurse replies based on what knowledge?

• A. Most boys in the United States can be toilet trained at age 3 years.
• B. Training can begin when he has sufficient bladder capacity.
• C. Additional surgery may be necessary to achieve continence.
• D. They should begin now because he will require additional time.

Correct answer: B

Rationale: Toilet training should begin when the child has sufficient bladder capacity and control, which may be delayed in children who have undergone surgical repairs for conditions like bladder exstrophy. Premature training can lead to frustration and setbacks.

4. The mother of a 6-year-old boy who has recently had surgery for the removal of his tonsils and adenoids complains that he has begun sucking his thumb again. Which defense mechanism should the nurse include when responding to the mother?

• A. Repression
• B. Regression
• C. Rationalization
• D. Fantasy

Correct answer: B

Rationale: The correct answer is B: Regression. Regression is a common defense mechanism where a child reverts to an earlier stage of development, such as thumb-sucking, to cope with stress. In this scenario, the 6-year-old boy is using thumb-sucking (a behavior typical of earlier developmental stages) as a way to deal with the stress of surgery. Repression (choice A) involves unconsciously blocking out thoughts or feelings, which is not applicable in this case. Rationalization (choice C) is a defense mechanism where illogical or unreasonable explanations are provided to justify behavior, which is not relevant here. Fantasy (choice D) refers to the use of imagination to escape from reality, which is also not the appropriate defense mechanism for the situation described.

5. The apnea monitor alarm sounds on a neonate for the third time during this shift. What is the priority action by the nurse?

• A. Provide tactile stimulation.
• B. Administer 100% oxygen.
• C. Investigate possible causes of a false alarm.
• D. Assess infant for color and presence of respirations.

Correct answer: D

Rationale: The priority action for the nurse when the apnea monitor alarm sounds on a neonate is to assess the infant for color and the presence of respirations. This initial assessment helps determine the infant's respiratory status and the need for immediate intervention. Providing tactile stimulation or administering oxygen should only be done after assessing the infant's respiratory status. Investigating possible causes of a false alarm comes after ensuring the infant's well-being through the initial assessment.

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