Nursing Elites

1. The mother of a 5-year-old boy with a myelomeningocele who has developed a sensitivity to latex is being taught by the nurse. Which response from his mother indicates a need for further teaching?

• A. He needs to wear a medical alert identification.
• B. I will need to inform his caregivers about this.
• C. A product's label always indicates if it is latex-free.
• D. He should avoid all contact with latex.

Correct answer: C

Rationale: Choice C indicates a need for further teaching because not all products are clearly labeled as latex-free. It is essential for the mother to understand that she should not solely rely on product labels to determine latex content. She should be encouraged to verify with manufacturers and consult healthcare providers for accurate information. Choices A, B, and D are correct responses. Wearing a medical alert identification, informing caregivers, and ensuring the boy avoids all contact with latex are crucial steps in managing his sensitivity to latex and preventing potential allergic reactions.

2. After an infant has had corrective surgery for hypertrophic pyloric stenosis (HPS), what should the nurse teach a parent to do immediately after a feeding to limit vomiting?

• A. Rock the infant.
• B. Place the infant in an infant seat.
• C. Place the infant flat on the right side.
• D. Keep the infant awake with sensory stimulation.

Correct answer: B

Rationale: Correct Answer: B. Placing the infant in an infant seat is essential after feeding to help keep the head elevated and reduce the risk of vomiting. This position helps prevent regurgitation of formula or milk. Rocking the infant (Choice A) is incorrect because it may exacerbate vomiting due to the movement. Placing the infant flat on the right side (Choice C) is incorrect as it does not promote proper digestion and can increase the risk of vomiting. Keeping the infant awake with sensory stimulation (Choice D) is incorrect as it does not directly address the physiological need to reduce vomiting after feeding.

3. A child with a diagnosis of nephrotic syndrome is being discharged. What dietary instructions should the nurse provide?

• A. Encourage a high-protein diet
• B. Avoid foods high in salt
• C. Encourage a low-sodium diet
• D. Encourage a low-protein diet

Correct answer: B

Rationale: For a child with nephrotic syndrome, it is important to avoid foods high in salt. This instruction helps manage symptoms and prevent complications associated with the condition. High salt intake can lead to fluid retention and worsen edema, which are common issues in nephrotic syndrome. Encouraging a low-sodium diet is crucial to maintaining fluid balance and reducing strain on the kidneys. Choices A, C, and D are incorrect because a high-protein diet can further stress the kidneys, while a low-protein diet may not be necessary unless specifically advised by the healthcare provider. Encouraging a low-sodium diet is more appropriate for managing nephrotic syndrome.

4. What is an early sign of congestive heart failure that the nurse should recognize?

• A. Tachypnea
• B. Bradycardia
• C. Inability to sweat
• D. Increased urinary output

Correct answer: A

Rationale: Tachypnea, which refers to rapid breathing, is an early sign of congestive heart failure. In heart failure, the heart's inability to pump efficiently can lead to fluid accumulation in the lungs, causing the child to breathe faster to try to compensate for the decreased oxygen exchange. Bradycardia (slow heart rate) is not typically associated with congestive heart failure; instead, it may indicate a different issue. Inability to sweat is not a common early sign of congestive heart failure. Increased urinary output is not a typical early sign of congestive heart failure; instead, it may be a sign of other conditions like diabetes or kidney issues.

5. The parents of a newborn with phenylketonuria (PKU) need help and support in adhering to specific dietary restrictions. They ask the nurse, “How long will our child have to be on this diet?” How should the nurse respond?

• A. “We are still not sure; you should discuss this with your health care provider.”
• B. “If your baby does well, foods containing protein can gradually be introduced.”
• C. “Your child needs to be on this diet at least through adolescence and into adulthood.”
• D. “This is a lifelong problem, and it is recommended that dietary restrictions must be continued.”

Correct answer: D

Rationale: The correct answer is D: “This is a lifelong problem, and it is recommended that dietary restrictions must be continued.” PKU requires a lifelong adherence to a specific diet low in phenylalanine to prevent cognitive and developmental issues. Phenylalanine buildup can lead to irreversible damage, making it crucial for individuals with PKU to maintain dietary restrictions throughout their lives. Choices A, B, and C are incorrect because they do not address the lifelong nature of dietary restrictions necessary for PKU management.

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