Nursing Elites

1. What should be the priority action when caring for a child with acute laryngotracheobronchitis?

• A. Initiate measures to reduce fever.
• B. Ensure delivery of humidified oxygen.
• C. Provide support to reduce apprehension.
• D. Continually assess the respiratory status.

Correct answer: D

Rationale: When caring for a child with acute laryngotracheobronchitis, the priority action should be to continually assess the respiratory status. This is crucial to detect early signs of respiratory distress, such as worsening stridor or increased work of breathing. Prompt intervention can prevent further deterioration of the child's condition. Initiating measures to reduce fever (Choice A) may be necessary but is not the priority in this situation. Ensuring delivery of humidified oxygen (Choice B) is important for maintaining oxygenation but should follow the assessment of respiratory status. Providing support to reduce apprehension (Choice C) is also important for the child's comfort but is not the priority over assessing and managing respiratory distress.

2. During a clinical conference with a group of nursing students, the instructor is describing burn classifications. The instructor determines that the teaching has been successful when the group identifies what as characteristic of full-thickness burns?

• A. Skin that is reddened, dry, and slightly swollen
• B. Skin appearing wet with significant pain
• C. Skin with blistering and swelling
• D. Skin that is leathery and dry with some numbness

Correct answer: D

Rationale: Full-thickness burns, also known as third-degree burns, are characterized by a leathery, dry appearance with numbness due to nerve damage. This type of burn extends through all layers of the skin, affecting nerve endings. Choice A describes characteristics of superficial partial-thickness burns, which involve the epidermis and part of the dermis. Choice B describes characteristics of superficial burns, or first-degree burns, which only affect the epidermis. Choice C describes characteristics of superficial to mid-dermal burns, also known as second-degree burns, which involve the epidermis and part of the dermis but do not extend through all skin layers. Therefore, the correct answer is D.

3. A newborn with an anorectal anomaly had an anoplasty performed. At the 2-week follow-up visit, a series of anal dilations is begun. What should the nurse recommend to the parents to help prevent the infant from becoming constipated?

• A. Use a soy formula if necessary.
• B. Breastfeed if possible.
• C. Avoid administering a suppository nightly.
• D. Do not offer glucose water between feedings.

Correct answer: B

Rationale: Breastfeeding is recommended to help prevent constipation in infants due to the easily digestible nature of breast milk, which often leads to softer stools. Breastfeeding is preferred over formula feeding as it provides optimal nutrition for the infant's digestive system. Choice A, using a soy formula if necessary, may be considered only if there are specific dietary concerns or allergies; however, breast milk is still the preferred option. Choice C, avoiding administering a suppository nightly, is correct as it is not a routine method for preventing constipation in infants and may not be appropriate without medical advice. Choice D, not offering glucose water between feedings, is recommended as it may not address the root cause of constipation and may introduce unnecessary sugar to the infant's diet.

4. A parent of an 11-month-old infant who has a cleft palate asks the nurse why it was recommended that closure of the palate should be done before the age of 2. How should the nurse respond?

• A. “After age 2, surgery is frightening and should be avoided if possible.”
• B. “Eruption of the 2-year molars often complicates the surgical procedure.”
• C. “As your child gets older, the palate gets wider and more difficult to repair.”
• D. “Surgery should be performed before your child starts to use faulty speech patterns.”

Correct answer: D

Rationale: Closure of the cleft palate is recommended before the age of 2 to prevent the development of faulty speech patterns. Performing surgery at a younger age helps avoid speech difficulties that may arise if the repair is delayed. Choice A is incorrect as it focuses on fear, not the developmental aspect. Choice B is incorrect as the eruption of molars is not the primary reason for early surgery. Choice C is incorrect because the difficulty of repair is not solely related to the width of the palate but also to speech development.

5. A nurse is assessing the oral cavity of a 6-month-old infant. The parent asks which teeth will erupt first. How should the nurse respond?

• A. Incisors
• B. Canines
• C. Upper molars
• D. Lower molars

Correct answer: A

Rationale: The correct answer is A: Incisors. In infants, incisors are usually the first teeth to erupt, typically around 6 months of age. These are the front teeth used for cutting food. Canines (Choice B), upper molars (Choice C), and lower molars (Choice D) typically erupt after the incisors. Canines are sharp teeth used for tearing food, while molars are flat teeth used for grinding food.

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