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. A home care nurse is visiting a family for the first time. The 4-week-old infant had surgery for exstrophy of the bladder and creation of an ileal conduit soon after birth. When the nurse arrives, the mother appears tired, and the baby is crying. After an introduction, which is the most appropriate statement by the nurse?

• A. “Tell me about your daily routine.”
• B. “You look tired. Is everything all right?”
• C. “When was the last time the baby had a bottle?”
• D. “Oh, it looks like you two are having a bad day.”

Correct answer: A

Rationale: The most appropriate statement by the nurse in this scenario is to inquire about the family's daily routine. This question allows the nurse to gather information about the family dynamics, the care routine for the infant post-surgery, feeding schedules, and potential stressors. It opens the conversation in a non-intrusive manner and helps the nurse assess the family's situation to provide appropriate support. Choices B, C, and D do not address the situation effectively. Asking about the daily routine is crucial for the nurse to understand the family's needs and offer targeted assistance.

3. What is one of the most important factors that a healthcare professional must consider when parents of a toddler request to be present at a procedure occurring on the hospital unit?

• A. Type of procedure to be performed
• B. Individual assessment of the parents
• C. Whether the toddler wants the parents present
• D. Probable reaction to the toddler’s response to pain

Correct answer: B

Rationale: When parents of a toddler request to be present during a procedure, an individual assessment of the parents is crucial. This assessment helps healthcare professionals understand the parents' ability to cope with the situation, provide support to their child, and ensure a conducive environment for the procedure. Choice A is not as critical because the focus is on the parents' readiness rather than the specific procedure. Choice C, considering the toddler's desire, is important but not as crucial as assessing the parents. Choice D, anticipating the toddler's response to pain, is relevant but secondary to assessing the parents' readiness and support capabilities.

4. When explaining the occurrence of febrile seizures to a parents' class, what information should the nurse include?

• A. They may occur in minor illnesses.
• B. The cause is usually readily identified.
• C. They usually do not occur during the toddler years.
• D. The frequency of occurrence is greater in females than males.

Correct answer: A

Rationale: The correct answer is A: 'They may occur in minor illnesses.' Febrile seizures can occur even in minor illnesses, particularly in young children, and are often triggered by a rapid increase in body temperature. Choice B is incorrect because the cause of febrile seizures is not always readily identified. Choice C is incorrect as febrile seizures commonly occur in children between the ages of 6 months to 5 years, which includes the toddler years. Choice D is incorrect as febrile seizures are slightly more common in males than females.

5. A child has been admitted to the pediatric unit with a severe asthma attack. What type of acid-base imbalance should the nurse expect the child to develop?

• A. metabolic alkalosis caused by decreased acid metabolites production
• B. respiratory alkalosis caused by decreased respiratory rate and carbon dioxide retention
• C. respiratory acidosis caused by impaired respirations and increased carbonic acid formation
• D. metabolic acidosis caused by the kidneys' inability to compensate for increased carbonic acid production

Correct answer: C

Rationale: In a severe asthma attack, the child is likely to develop respiratory acidosis due to impaired respirations leading to the retention of carbon dioxide, which combines with water to form carbonic acid. This results in the pH imbalance characterized by an excess of carbonic acid. Choices A, B, and D are incorrect. Metabolic alkalosis (Choice A) is not typically associated with severe asthma attacks; respiratory alkalosis (Choice B) would involve a decrease, not an increase, in carbon dioxide levels; and metabolic acidosis (Choice D) is not the primary acid-base imbalance seen in severe asthma attacks.

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