Nursing Elites

1. What is an appropriate screening test for hearing that the nurse can administer to a 5-year-old child?

• A. Rinne test
• B. Weber test
• C. Pure tone audiometry
• D. Eliciting the startle reflex

Correct answer: C

Rationale: Pure tone audiometry is an appropriate and effective screening test for hearing in a 5-year-old child, helping to assess the ability to hear various frequencies and volumes.

2. In assessing sexual maturity levels, which tool would you expect to use?

• A. Denver II Developmental Screening
• B. Tanner staging
• C. Antibody testing
• D. Nursing process

Correct answer: B

Rationale: The correct answer is B: Tanner staging. Tanner staging is a tool specifically used to assess sexual maturity in adolescents based on the development of secondary sexual characteristics. The Tanner scale ranges from stage 1 (prepubertal) to stage 5 (adult maturity). This tool helps healthcare providers evaluate the physical development and sexual maturation of individuals. Choice A, the Denver II Developmental Screening, is used to assess developmental milestones in children. Choice C, antibody testing, is a diagnostic tool used to detect the presence of specific antibodies in the blood. Choice D, the nursing process, is a systematic method that nurses use to deliver patient-centered care, involving assessment, diagnosis, planning, implementation, and evaluation.

3. The nurse is administering the first hepatitis A vaccine to an 18-month-old child. When should the child return to the clinic for the second dose of hepatitis A vaccination?

• A. After 2 months
• B. After 3 months
• C. After 4 months
• D. After 6 months

Correct answer: D

Rationale: The second dose of the hepatitis A vaccine is recommended 6 months after the first dose to ensure full immunity.

4. What findings on physical assessment of a neonate would indicate the need for further evaluation?

• A. Nystagmus
• B. Epstein pearls
• C. Low-set ears
• D. Positive Babinski reflex

Correct answer: C

Rationale: Low-set ears in a neonate suggest major abnormalities and should prompt further evaluation. The correct alignment of the top of the pinnae of the ear with the outer canthus of the eye is crucial. Nystagmus, an involuntary eye movement, is common in newborns and often resolves on its own. Epstein pearls, small cysts on the hard palate, are insignificant and disappear over time. A positive Babinski reflex is normal in infants up to 1 year of age. Therefore, the presence of low-set ears is the most concerning finding that requires immediate attention.

5. What term is appropriate terminology to use for an infant whose intrauterine growth rate was slowed and whose birth weight falls below the 10th percentile on intrauterine growth charts?

• A. Postterm
• B. Postmature
• C. Low birth weight
• D. Small for gestational age

Correct answer: D

Rationale: The correct answer is D, 'Small for gestational age.' A small for gestational age, or small-for-date, infant is any child whose intrauterine growth rate was slowed and whose birth weight falls below the 10th percentile on intrauterine growth curves. Choices A and B, 'Postterm' and 'Postmature,' refer to infants born after 42 weeks of gestational age regardless of birth weight, and do not specifically address growth rate. Choice C, 'Low birth weight,' refers to infants with a birth weight less than 2500 g (5.5 pounds) regardless of gestational age, which is a different classification compared to being small for gestational age.

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