Nursing Elites

1. When assessing a child with suspected meningitis, which finding is a characteristic sign of meningitis?

• A. High-pitched cry
• B. Tachycardia
• C. Photophobia
• D. Hypotension

Correct answer: C

Rationale: Photophobia, which is sensitivity to light, is a characteristic sign of meningitis in children. It commonly presents along with symptoms such as headache and neck stiffness. This symptom is important to recognize early for prompt diagnosis and treatment of meningitis.

2. When screening a 5-year-old for strabismus, what action should the nurse take?

• A. Have the child identify colored patterns on polychromatic cards.
• B. Direct the child through the six cardinal positions of gaze.
• C. Inspect the child for the setting sun sign.
• D. Observe the child for blank, sunken eyes.

Correct answer: B

Rationale: When screening a 5-year-old for strabismus, directing the child through the six cardinal positions of gaze is the most appropriate action. This method helps the nurse to assess eye alignment, which is crucial in identifying any misalignment that may indicate strabismus. Choices A, C, and D are incorrect. Having the child identify colored patterns on polychromatic cards is more related to visual acuity testing rather than strabismus screening. Inspecting the child for the setting sun sign is not a standard method for strabismus screening. Observing the child for blank, sunken eyes is not specific to strabismus assessment.

3. When assessing the breath sounds of an 18-month-old child who is crying, what action should the healthcare professional take?

• A. Document that the assessment is not available because the child is crying.
• B. Ask the caregiver to quiet the child so breath sounds can be auscultated.
• C. Allow the child to play with a stethoscope to distract them during auscultation.
• D. Auscultate and document breath sounds, noting that the child was crying at the time.

Correct answer: C

Rationale: Allowing the child to play with a stethoscope can help distract them, making it easier to auscultate breath sounds. This approach can create a more cooperative and engaging environment for the child, facilitating a more accurate assessment of their breath sounds. Choice A is incorrect because it does not address the need for an assessment. Choice B is not ideal as it puts pressure on the caregiver and may not be effective in calming the child. Choice D is not the best option as it does not actively involve the child in the assessment process and may not provide an accurate representation of their breath sounds.

4. A 6-year-old child with a history of asthma is brought to the clinic with complaints of wheezing and shortness of breath. The nurse notes that the child is using accessory muscles to breathe. What should the nurse do first?

• A. Administer a bronchodilator
• B. Obtain a peak flow reading
• C. Apply oxygen
• D. Perform a complete respiratory assessment

Correct answer: A

Rationale: Administering a bronchodilator is the initial priority as it helps open the child's airways, reducing the wheezing and shortness of breath. This intervention aims to provide immediate relief and improve the child's respiratory distress. Obtaining a peak flow reading or applying oxygen may be necessary after administering the bronchodilator, but the priority is to address the acute symptoms of wheezing and shortness of breath first. Performing a complete respiratory assessment can be done after the immediate intervention of administering the bronchodilator to further evaluate the child's respiratory status.

5. A child with pertussis is receiving azithromycin (Zithromax Injection) IV. Which intervention is most important for the nurse to include in the child's plan of care?

• A. Obtain vital signs to monitor for fluid overload
• B. Change IV site dressing every 3 days and as needed
• C. Monitor for signs of facial swelling or urticaria
• D. Assess for abdominal pain and vomiting

Correct answer: C

Rationale: When administering azithromycin IV, monitoring for signs of an allergic reaction, such as facial swelling or urticaria, is crucial. This helps in early detection of potential adverse reactions and ensures prompt intervention to prevent complications associated with the medication. The other options are not directly related to the administration of azithromycin IV in this scenario. Monitoring for fluid overload would be more relevant for fluid administration, changing IV site dressing is important but not the priority in this case, and assessing for abdominal pain and vomiting may be important but not as critical as monitoring for signs of an allergic reaction.

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