Nursing Elites

1. What clinical manifestation(s) should the nurse expect to see as shock progresses in a child and becomes decompensated shock?

• A. Thirst
• B. Irritability
• C. Apprehension
• D. Confusion and somnolence

Correct answer: D

Rationale: As shock progresses and decompensation occurs, confusion and somnolence are indicative of reduced cerebral perfusion. Early signs include thirst and irritability, while confusion and altered consciousness appear as the condition worsens.

2. What information should be given to the parents of a 12-month-old child regarding appropriate play activities for this age?

• A. Give large push-pull toys for kinetic stimulation
• B. Place a cradle gym across the crib to help develop fine motor skills
• C. Provide the child with finger paints to enhance fine motor skills
• D. Provide a stick horse to develop gross motor coordination

Correct answer: A

Rationale: Large push-pull toys are suitable for a 12-month-old as they encourage gross motor skills and physical activity, which are crucial for their development at this age.

3. The parent asks when the soft area in the infant's head will go away. What is the best response by the nurse?

• A. The area is called the anterior fontanel (fontanelle) and typically closes anytime up to 18 months of age.
• B. The area is called a fontanel (fontanelle). They remain open to allow for rapid brain growth in the first months of life.
• C. The soft spots may stay open until your infant is 2 or 3 years old.
• D. Soft spots on the infant's head should have closed by now.

Correct answer: A

Rationale: The best response by the nurse is A, as the anterior fontanel typically closes between 12-18 months of age, allowing for brain growth during infancy. Choice B is incorrect because it does not provide a specific timeframe for the closure of the fontanel. Choice C is incorrect as it suggests a later closure timeframe than usual. Choice D is incorrect as it states that the soft spots should have closed already, which is inaccurate for a 6-month-old infant.

4. The nurse is caring for an adolescent who has just started dialysis. The child always seems angry, hostile, or depressed. The nurse should recognize that this is most likely related to what underlying cause?

• A. Physiologic manifestations of renal disease
• B. The fact that adolescents have few coping mechanisms
• C. Neurologic manifestations that occur with dialysis
• D. Resentment of the control and enforced dependence imposed by dialysis

Correct answer: D

Rationale: Adolescents may feel anger and depression due to the loss of independence and control over their lives, which is imposed by the need for regular dialysis treatments. This reaction is common as they struggle with the restrictions placed on their social and personal lives.

5. Because children younger than 5 years are egocentric, the nurse should do which when communicating with them?

• A. Focus communication on the child.
• B. Use easy analogies when possible.
• C. Explain experiences of others to the child
• D. Assure the child that communication is private

Correct answer: A

Rationale: Focusing communication directly on the child aligns with their egocentric nature and helps engage them in the conversation.

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