Nursing Elites

1. In an adolescent suspected of having type 1 diabetes mellitus, which clinical manifestation may be present?

• A. moist skin
• B. weight gain
• C. fluid overload
• D. poor wound healing

Correct answer: D

Rationale: Poor wound healing is a common clinical manifestation of type 1 diabetes mellitus. Elevated blood glucose levels in diabetes can lead to impaired wound healing by affecting various cellular processes involved in the healing cascade. Moist skin (Choice A) is not typically associated with type 1 diabetes mellitus. Weight gain (Choice B) is more commonly seen in type 2 diabetes due to insulin resistance. Fluid overload (Choice C) is not a typical clinical manifestation of type 1 diabetes mellitus. Therefore, the correct answer is poor wound healing.

2. When planning the discharge of a child who had surgery for a congenital heart defect, what is an important aspect of the discharge teaching?

• A. Teaching the parents about signs of infection
• B. Providing instructions on wound care
• C. Scheduling follow-up appointments
• D. Explaining the use of prescribed medications

Correct answer: D

Rationale: Explaining the use of prescribed medications is crucial because it helps ensure proper management of the child’s condition after discharge. While teaching the parents about signs of infection and providing instructions on wound care are important aspects of postoperative care, they are not as critical as ensuring the correct understanding and administration of prescribed medications. Scheduling follow-up appointments is also important but does not directly impact the immediate post-discharge care and medication adherence.

3. A parent tells the nurse in the emergency department, 'My 3-year-old has had a fever for several days and has been vomiting.' After instituting ordered measures to reduce the fever, what nursing action is most important?

• A. Preventing shivering
• B. Restricting oral fluids
• C. Measuring output hourly
• D. Taking vital signs hourly

Correct answer: A

Rationale: Preventing shivering is crucial in this scenario as it can increase body temperature and counteract the effects of antipyretic measures aimed at reducing the fever. Shivering generates heat through muscle activity, which can elevate the body temperature. Restricting oral fluids (choice B) is inappropriate as maintaining hydration is vital, especially in cases of fever and vomiting. Measuring output hourly (choice C) and taking vital signs hourly (choice D) are important nursing actions but not the most critical in this case where preventing shivering takes precedence.

4. A child sitting on a chair in a playroom starts to have a tonic-clonic seizure with a clenched jaw. What is the nurse’s best initial action?

• A. Attempt to open the jaw.
• B. Place the child on the floor.
• C. Call out for assistance from staff.
• D. Place a pillow under the child’s head.

Correct answer: B

Rationale: The best initial action during a tonic-clonic seizure is to place the child on the floor. This action helps prevent injury by providing a safe environment and allows for better management of the seizure episode. Attempting to open the jaw is not recommended as it may cause harm to the child or the nurse. Calling out for assistance is important but should not delay ensuring the child's safety first. Placing a pillow under the child's head is not advisable during a seizure as it can pose a risk of suffocation or choking.

5. A nurse is evaluating a 3-year-old child’s developmental progress. The inability to perform which task indicates to the nurse that there is a developmental delay?

• A. Copying a square
• B. Hopping on one foot
• C. Catching a ball reliably
• D. Using a spoon effectively

Correct answer: A

Rationale: The inability to copy a square at 3 years old indicates a potential developmental delay in fine motor skills. At this age, children should be able to copy basic shapes like circles and crosses. Hopping on one foot is typically expected around the age of 4, catching a ball reliably around 5, and using a spoon effectively by 2-3 years old. Therefore, choices B, C, and D are not as indicative of a developmental delay at 3 years old as the inability to copy a square.

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