Nursing Elites

1. What is an essential nursing action when caring for a young child with severe diarrhea?

• A. Maintain the IV.
• B. Take daily weights.
• C. Replace the lost calories.
• D. Promote perianal skin integrity.

Correct answer: D

Rationale: Promoting perianal skin integrity is crucial when caring for a young child with severe diarrhea as it helps prevent skin breakdown from the irritation caused by frequent stooling. Maintaining the IV (Choice A) may be necessary but is not directly related to managing perianal skin integrity. Taking daily weights (Choice B) is important for monitoring fluid status but not the priority when addressing perianal skin integrity. While replacing lost calories (Choice C) is essential, promoting perianal skin integrity takes precedence in preventing complications associated with skin breakdown.

2. The nurse caring for families in crisis assesses the affective function of an immigrant family consisting of a father, mother, and two school-age children. Based on Friedman's structural functional theory, what defines this family component?

• A. Meeting the love and belonging needs of each member
• B. Teaching children how to function and assume adult roles in society
• C. Ensuring the family has necessary resources with appropriate allocation
• D. Involving the provision of physical care to keep the family healthy

Correct answer: A

Rationale: In Friedman's structural functional theory, the affective function of a family involves meeting the love and belonging needs of each member. This includes emotional support, care, and connections that contribute to the overall well-being of the family unit. Choice B is incorrect as it pertains more to the socialization function of the family, where children learn societal roles. Choice C relates to the economic function of the family, ensuring resources are available and allocated appropriately. Choice D focuses on the instrumental function of the family, which involves meeting the physical needs and health of its members.

3. A parent and 3-month-old infant are visiting the well-baby clinic for a routine examination. What should the nurse include in the accident prevention teaching plan?

• A. Remove small objects from the floor.
• B. Cover electric outlets with safety plugs.
• C. Remove toxic substances from low areas.
• D. Test the temperature of water before bathing.

Correct answer: D

Rationale: Testing the temperature of water before bathing is crucial to prevent burns, which is a significant risk for infants due to their sensitive skin. Infants have delicate skin that can easily be burned by water that is too hot. Testing the water temperature before bathing ensures that the water is at a safe and comfortable level for the infant. While choices A, B, and C are also important in accident prevention, such as reducing choking hazards, preventing electric shocks, and avoiding poisoning, testing the water temperature before bathing is the most immediate and direct action to prevent harm to the infant during bathing.

4. A 6-year-old child with asthma is admitted to the hospital with an acute exacerbation. What is the priority nursing intervention?

• A. Administering a bronchodilator
• B. Administering an antihistamine
• C. Administering a corticosteroid
• D. Administering oxygen

Correct answer: A

Rationale: Administering a bronchodilator is the priority intervention for a child experiencing an acute asthma exacerbation. Bronchodilators help to dilate the airways quickly, providing immediate relief by opening up the narrowed air passages in asthma. Antihistamines are not the first-line treatment for asthma exacerbations and may not address the underlying bronchoconstriction. Corticosteroids are important for long-term control of asthma but may take longer to have an effect compared to bronchodilators. Administering oxygen is essential for hypoxemia in asthma exacerbations, but the priority is to relieve bronchoconstriction promptly with a bronchodilator.

5. Which cardiac defects are associated with tetralogy of Fallot?

• A. Right ventricular hypertrophy, atrial and ventricular defects, and mitral valve stenosis
• B. Origin of the aorta from the right ventricle and of the pulmonary artery from the left ventricle
• C. Right ventricular hypertrophy, ventricular septal defect, pulmonic stenosis, and overriding aorta
• D. Altered connection between the pulmonary artery and the aorta, right ventricular hypertrophy, and an atrial septal defect

Correct answer: C

Rationale: Tetralogy of Fallot is characterized by a combination of four specific cardiac defects: right ventricular hypertrophy, ventricular septal defect, pulmonic stenosis, and overriding aorta. Choice A is incorrect as it includes mitral valve stenosis, which is not typically part of tetralogy of Fallot. Choice B describes transposition of the great arteries rather than tetralogy of Fallot. Choice D includes an atrial septal defect, which is not part of the classic presentation of tetralogy of Fallot.

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