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. The parents of a child born with ambiguous genitalia tell the nurse that family and friends are asking what caused the baby to be this way. Tests are being done to assist in gender assignment. What should the nurse's intervention include?

• A. Explain the disorder so they can explain it to others.
• B. Help parents understand that this is a minor problem.
• C. Suggest that parents avoid family and friends until the gender is assigned.
• D. Encourage parents not to worry while the tests are being done.

Correct answer: A

Rationale: It is important for the nurse to provide the parents with accurate information so they can confidently explain the situation to others, helping to reduce stress and misinformation. Avoiding family and friends or minimizing the problem is not helpful.

3. The school nurse suspects a testicular torsion in a young adolescent student. What action should the nurse take?

• A. Place a warm moist pack on the scrotal area.
• B. Instruct the adolescent to lie down and elevate the legs.
• C. Refer the adolescent for immediate medical evaluation.
• D. Suggest that the adolescent wear a scrotum-protecting guard.

Correct answer: C

Rationale: Testicular torsion is a surgical emergency requiring immediate medical evaluation. Applying heat or elevating the legs will not alleviate the torsion, and delaying care can lead to testicular necrosis.

4. Frequent urine tests for specific gravity are required on a 6-month-old infant. What method is the most appropriate way to collect small amounts of urine for these tests?

• A. Apply a urine collection bag to the perineal area.
• B. Tape a small medicine cup inside of the diaper.
• C. Aspirate urine from cotton balls inside the diaper with a syringe without a needle.
• D. Use a syringe without a needle to aspirate urine from a superabsorbent disposable diaper.

Correct answer: C

Rationale: Aspirating urine from cotton balls inside the diaper is a minimally invasive method and effective for collecting small amounts of urine. Using a collection bag can be more cumbersome, and other methods are not as effective for this age.

5. A 3-year-old child with Hirschsprung disease is hospitalized for surgery. A temporary colostomy will be necessary. How should the nurse prepare this child?

• A. It is unnecessary because of child’s age.
• B. It is essential because it will be an adjustment.
• C. Preparation is not needed because the colostomy is temporary.
• D. Preparation is important because the child needs to deal with negative body image.

Correct answer: B

Rationale: Preparation is essential even for a young child, as they need to adjust to the temporary colostomy and understand the changes to their body, which can be confusing and distressing without proper explanation.

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