Nursing Elites

1. When discussing the side effects of the Haemophilus influenzae (Hib) vaccine with parents, which sign should the nurse mention for an infant receiving the vaccine?

• A. Lethargy
• B. Urticaria
• C. Generalized rash
• D. Low-grade fever

Correct answer: D

Rationale: The correct answer is 'Low-grade fever.' A low-grade fever is a typical, mild side effect that can occur after the Hib vaccine is administered. It is a sign that the body's immune system is responding to the vaccine and is generally not a cause for concern. Lethargy, urticaria, and generalized rash are not commonly associated side effects of the Hib vaccine. Lethargy may be a sign of other issues, while urticaria and generalized rash are more indicative of allergic reactions rather than typical responses to the Hib vaccine.

2. A 6-year-old child comes to the school nurse reporting a sore throat, and the nurse verifies that the child has a fever and a red, inflamed throat. When a parent of the child arrives at school to take the child home, the nurse urges the parent to seek treatment. The nurse is aware that the causative agent may be beta-hemolytic streptococcus, and the illness may progress to inflamed joints and an infection in the heart. What illness is of most concern to the nurse?

• A. Tetanus
• B. Influenza
• C. Scarlet fever
• D. Rheumatic fever

Correct answer: D

Rationale: Rheumatic fever is the most concerning illness in this case. It can develop as a complication of untreated strep throat caused by beta-hemolytic streptococcus. If not properly treated, rheumatic fever can lead to serious complications such as inflamed joints and heart infections. Tetanus is caused by a toxin produced by Clostridium tetani bacteria and is not related to the symptoms described in the scenario. Influenza is a viral respiratory illness and does not typically lead to rheumatic fever. While scarlet fever is also caused by streptococcus bacteria, in this case, the symptoms described are more indicative of rheumatic fever than scarlet fever.

3. Why does a cleft lip predispose an infant to infection?

• A. Waste products accumulate along the defect.
• B. There is evidence of inadequate circulation in the defective area.
• C. Nutrition is inadequate due to ineffective feeding.
• D. Mouth breathing dries the oropharyngeal mucous membranes.

Correct answer: D

Rationale: The correct answer is D. Mouth breathing due to a cleft lip can dry the mucous membranes, making them more susceptible to infection. Choice A is incorrect because waste products do not accumulate along the defect to predispose the infant to infection. Choice B is incorrect as there is no evidence of inadequate circulation being a primary factor in infection predisposition in cleft lip cases. Choice C is incorrect because although ineffective feeding may lead to other issues, it is not the main reason for infection predisposition in infants with a cleft lip.

4. How is the diagnosis of Hirschsprung disease confirmed in a 1-month-old infant admitted to the pediatric unit?

• A. Colonoscopy
• B. Rectal biopsy
• C. Multiple saline enemas
• D. Fiberoptic nasoenteric tube

Correct answer: B

Rationale: Rectal biopsy is the definitive diagnostic procedure for Hirschsprung disease in infants. It confirms the absence of ganglion cells in the affected bowel segment, which is characteristic of Hirschsprung disease. Colonoscopy (Choice A) is not typically used for confirmation as it may not provide a definitive result. Multiple saline enemas (Choice C) are utilized in the treatment of meconium ileus, a complication of cystic fibrosis, and not in the diagnosis of Hirschsprung disease. Fiberoptic nasoenteric tube (Choice D) is not a diagnostic tool for Hirschsprung disease; it is commonly used for gastrointestinal decompression or feeding purposes but does not confirm the diagnosis.

5. A child with a diagnosis of acute glomerulonephritis is admitted to the hospital. What is the priority nursing intervention?

• A. Monitoring for hypertension
• B. Providing pain relief
• C. Restricting fluid intake
• D. Encouraging fluid intake

Correct answer: A

Rationale: The correct answer is monitoring for hypertension. Acute glomerulonephritis involves inflammation of the kidney's glomeruli, potentially leading to impaired kidney function and elevated blood pressure. Monitoring for hypertension is crucial as it is a common complication of this condition. Providing pain relief (choice B) may be necessary for comfort but is not the priority. While fluid restriction (choice C) is important in some kidney conditions, in acute glomerulonephritis, maintaining adequate hydration to support kidney function is typically recommended. Encouraging fluid intake (choice D) may exacerbate fluid overload, making it an inappropriate intervention in this scenario.

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