Nursing Elites

1. During a well-baby check of a 7-month-old infant, the practical nurse notes an absence of babbling. Which focused assessment should the PN implement?

• A. Visual function.
• B. Auditory function.
• C. Cognitive function.
• D. Social development.

Correct answer: B

Rationale: The absence of babbling in a 7-month-old infant is a concerning auditory development milestone. Babbling is an early stage of language development that involves making various sounds. A lack of babbling could indicate a hearing impairment or other auditory issues. Therefore, the practical nurse should focus on assessing the infant's auditory function to determine if further evaluation or intervention is necessary. Choices A, C, and D are incorrect because the absence of babbling specifically points towards a potential issue related to auditory function rather than visual, cognitive, or social development.

2. When developing a behavior modification program for an extremely aggressive 10-year-old boy, what should the nurse do first?

• A. Identify what activities, foods, and toys the child enjoys
• B. Assess the child's previous reactions to punishment
• C. Offer the child positive feedback
• D. Involve other children on the unit in describing the token system

Correct answer: A

Rationale: The first step in developing a behavior modification program for an extremely aggressive 10-year-old boy is to identify what activities, foods, and toys the child enjoys. Understanding the child's motivations is crucial in creating an effective behavior modification plan tailored to his interests and preferences, which can help in positively reinforcing desired behaviors.

3. A 14-year-old adolescent with a history of substance abuse is brought to the emergency department by the parents, who suspect that the adolescent has relapsed. What is the nurse’s priority action?

• A. Obtain a urine sample for toxicology screening
• B. Discuss treatment options with the parents
• C. Establish a therapeutic relationship with the adolescent
• D. Administer a medication to reverse the effects of the substance

Correct answer: A

Rationale: In this scenario, the nurse's priority action should be to obtain a urine sample for toxicology screening. This step is crucial in identifying the substances involved in the relapse, which will guide appropriate treatment strategies. By knowing the specific substances, healthcare providers can tailor treatment plans effectively. Establishing a therapeutic relationship and discussing treatment options come after obtaining necessary diagnostic information to ensure a comprehensive care plan. Administering a medication to reverse substance effects is not the initial priority; identification of the substances through toxicology screening should precede any treatment intervention.

4. A 2-year-old child is admitted with severe dehydration due to gastroenteritis. Which assessment finding indicates that the child's condition is improving?

• A. Decreased heart rate.
• B. Sunken fontanelle.
• C. Increased urine output.
• D. Dry mucous membranes.

Correct answer: C

Rationale: Increased urine output is a positive sign indicating that the child's hydration status is improving. It suggests that the kidneys are functioning more effectively and able to excrete urine, which is a crucial indicator of improved hydration levels in a dehydrated patient. Decreased heart rate (Choice A) can be a sign of possible shock. A sunken fontanelle (Choice B) is a sign of dehydration. Dry mucous membranes (Choice D) are also indicative of dehydration.

5. The nurse is caring for a 4-year-old child who has been diagnosed with measles. Which intervention should the nurse implement to prevent the spread of infection?

• A. Administer antipyretics as prescribed
• B. Place the child in airborne isolation
• C. Encourage fluid intake
• D. Teach the parents about hand hygiene

Correct answer: B

Rationale: Measles is an airborne infection, so placing the child in airborne isolation is crucial to prevent the spread of the virus to others. Airborne isolation precautions help contain infectious respiratory droplets and reduce the risk of transmission to healthcare workers, other patients, and visitors. Administering antipyretics, encouraging fluid intake, and teaching parents about hand hygiene are important aspects of care but do not directly address the prevention of the spread of measles, which requires airborne precautions.

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