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. A child diagnosed with a soft tissue tumor is being treated with chemotherapy. Prior to administering the chemotherapy, which laboratory test should the nurse monitor to determine if the child has any capability of fighting infections?

• A. Hemoglobin
• B. Red blood cell count
• C. Platelets
• D. Absolute neutrophil count (ANC)

Correct answer: D

Rationale: The Absolute Neutrophil Count (ANC) is crucial for determining the child's ability to fight infections. Neutrophils play a key role in combating bacterial infections. Monitoring the ANC is essential before administering chemotherapy, as a low ANC indicates an increased risk of infection. Hemoglobin, red blood cell count, and platelets are important for assessing oxygen-carrying capacity, anemia, and clotting function, respectively, but they do not directly reflect the child's capability to fight infections.

3. Which of the following is a characteristic finding in Kawasaki disease?

• A. Strawberry tongue
• B. Polyarthritis
• C. Hematuria
• D. Rashes

Correct answer: A

Rationale: A 'strawberry tongue' is a characteristic finding in Kawasaki disease. The presence of a 'strawberry tongue' is a classic sign of Kawasaki disease, along with other features such as conjunctivitis and rash. Choice B, polyarthritis, is not typically seen in Kawasaki disease. Choice C, hematuria, is not a common finding in Kawasaki disease but may be seen in other conditions. Choice D, rashes, are present in Kawasaki disease but are not as specific or characteristic as the 'strawberry tongue'. Therefore, the correct answer is A.

4. A 6-year-old child has patient-controlled analgesia (PCA) for pain management after orthopedic surgery. The parents are worried that their child will be in pain. What should your explanation to the parents include?

• A. The child will continue to sleep and be pain-free
• B. Parents cannot administer additional medication with the button
• C. The pump can deliver baseline and bolus dosages
• D. There is a high risk of overdose, so monitoring is done every 15 minutes

Correct answer: C

Rationale: PCA pumps are designed to deliver both a continuous baseline dose and patient-activated bolus doses, which can help manage pain effectively while minimizing the risk of overdose.

5. The nurse needs to take the blood pressure of a small child. Of the cuffs available, one is too large and one is too small. The best nursing action is which?

• A. Use the small cuff
• B. Use the large cuff
• C. Use either cuff using the palpation method
• D. Wait to take the blood pressure until a proper cuff can be located

Correct answer: D

Rationale: It is essential to use the correct cuff size for accurate blood pressure readings; if the proper size is not available, it's best to wait until it can be obtained.

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