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 child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement first?

• A. Place the child in a quiet environment
• B. Make a list of foods that the child likes
• C. Encourage the parents to rest when possible
• D. Apply lotion to hands and feet

Correct answer: A

Rationale: The correct intervention for a child with Kawasaki disease, presenting with irritability and skin peeling, is to place the child in a quiet environment. This helps reduce environmental stimuli, calming the child and aiding in managing the symptoms associated with the disease. Choice B is incorrect as addressing food preferences is not the priority in this situation. Choice C is incorrect as the focus should be on the child's immediate needs. Choice D is incorrect as applying lotion is not the first-line intervention for Kawasaki disease symptoms.

4. A mother brings her 2-year-old son to the clinic because he has been crying and pulling on his earlobe for the past 12 hours. The child’s oral temperature is 101.2°F. Which intervention should the nurse implement?

• A. Ask the mother if the child has had a runny nose
• B. Cleanse purulent exudate from the affected ear canal
• C. Apply a topical antibiotic to the periauricle area
• D. Provide parent education to prevent recurrence

Correct answer: A

Rationale: In a child with ear pain and fever, asking about a runny nose is important to assess if the ear pain is associated with a respiratory infection, such as otitis media. This information can guide further assessment and treatment decisions. Choice B is incorrect because cleansing purulent exudate should be done by a healthcare provider, not the nurse. Choice C is incorrect as topical antibiotics should only be applied under healthcare provider's orders. Choice D is not the priority at this moment, as the immediate concern is assessing the association between the ear pain and a possible respiratory infection.

5. A 3-year-old with HIV infection is staying with a foster family who is caring for 3 other foster children in their home. When one of the children acquires pertussis, the foster mother calls the clinic and asks the nurse what she should do. Which action should the nurse take first?

• A. Remove the child with HIV from the foster home.
• B. Report the exposure of the child with HIV to the health department.
• C. Place the child with HIV in reverse isolation.
• D. Review the immunization documentation of the child with HIV.

Correct answer: D

Rationale: The priority action for the nurse is to review the immunization documentation of the child with HIV. This step ensures that the child has received the necessary vaccines to protect against pertussis and other preventable diseases. It is essential to verify the immunization status to provide appropriate care and prevent further transmission of infectious diseases within the foster home. Removing the child from the foster home (Choice A) may not be necessary if the child is adequately protected through immunization. Reporting the exposure to the health department (Choice B) is important but not the first action. Placing the child in reverse isolation (Choice C) is not indicated for pertussis exposure.

Similar Questions