Nursing Elites

1. The parent of a 3-month-old infant is concerned because the infant is not able to sit independently. How should the nurse respond to this parent's concern?

• A. Sitting ability and the age of first tooth eruption are not correlated.
• B. Most infants sit steadily at 4 months.
• C. Most infants sit steadily at 3 months.
• D. Most infants do not sit steadily until 6-8 months.

Correct answer: D

Rationale: The correct answer is D because sitting steadily typically occurs closer to 6-8 months of age, not 3 or 4 months. Choice A is incorrect because sitting ability and the age of first tooth eruption are not related. Choice B and C are incorrect as most infants do not sit steadily at 3 or 4 months, and it is more common for infants to achieve this milestone around 6-8 months.

2. What findings on physical assessment of a neonate would indicate the need for further evaluation?

• A. Nystagmus
• B. Epstein pearls
• C. Low-set ears
• D. Positive Babinski reflex

Correct answer: C

Rationale: Low-set ears in a neonate suggest major abnormalities and should prompt further evaluation. The correct alignment of the top of the pinnae of the ear with the outer canthus of the eye is crucial. Nystagmus, an involuntary eye movement, is common in newborns and often resolves on its own. Epstein pearls, small cysts on the hard palate, are insignificant and disappear over time. A positive Babinski reflex is normal in infants up to 1 year of age. Therefore, the presence of low-set ears is the most concerning finding that requires immediate attention.

3. What is a common sign of moderate dehydration in children?

• A. Dry mucous membranes
• B. Normal capillary refill
• C. Hyperactive bowel sounds
• D. Edema

Correct answer: A

Rationale: Dry mucous membranes are a common sign of moderate dehydration in children, indicating a loss of bodily fluids. When a child is moderately dehydrated, the mucous membranes in the mouth and nose may appear dry. This condition can occur due to various factors such as vomiting, diarrhea, or inadequate fluid intake. Normal capillary refill (choice B) is not typically associated with dehydration; it is a measure of circulatory status. Hyperactive bowel sounds (choice C) can be present in conditions like gastroenteritis but are not specific to dehydration. Edema (choice D) is the retention of fluid in the body and is not a typical sign of dehydration.

4. Where in the health history does a record of immunizations belong?

• A. History
• B. Present illness
• C. Review of systems
• D. Physical assessment

Correct answer: A

Rationale: Immunizations are part of the patient’s health history and are recorded under the history section to ensure the child is up-to-date with vaccinations.

5. After a 7-year-old with acute diarrhea has been rehydrated with oral rehydration solutions, what type of diet should the nurse recommend following rehydration?

• A. Regular diet
• B. Fruit juices
• C. High carbohydrate diet
• D. BRAT diet (bananas, rice, apples, and toast or tea)

Correct answer: A

Rationale: After rehydration, a regular diet is generally recommended to ensure proper nutrition and recovery. A regular diet includes a balanced intake of all food groups and nutrients. Fruit juices may be too high in simple sugars and lack necessary nutrients, which can exacerbate diarrhea. While a high carbohydrate diet may be beneficial in some cases, a regular diet is more comprehensive. The BRAT diet, consisting of bananas, rice, apples, and toast or tea, was previously recommended for diarrhea, but it lacks adequate protein and fat, so a regular diet is now preferred for overall better nutrition and recovery.

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