Nursing Elites

1. When picked up by a parent or the nurse, an 8-month-old infant screams and seems to be in pain. After observing this behavior, what should the nurse discuss with the parent?

• A. Accidents and the importance of preventing them
• B. Limiting the infant's playtime with other children in the family
• C. Any other behaviors that the parent may have noticed
• D. Nutrition and specific vitamins recommended for infants

Correct answer: C

Rationale: Discussing any other observed behaviors with the parent is important to identify patterns or potential issues that could be affecting the infant's well-being. By exploring additional behaviors, the nurse can gather more information to assess the infant comprehensively. This approach allows for a more holistic understanding of the infant's health status, rather than focusing solely on the observed behavior of screaming and apparent pain. Options A, B, and D are incorrect as they do not directly address the need to explore other behaviors that may provide insights into the infant's condition and well-being.

2. A parent tearfully tells a nurse, 'They think our child is developmentally delayed. We are thinking about investigating a preschool program for cognitively impaired children.' What is the nurse’s most appropriate response?

• A. Praise the parent for the decision and encourage the plan.
• B. Ask for more specific information related to the developmental delays.
• C. Advise the parent to have the healthcare provider help choose an appropriate program.
• D. Explain that this may be a premature action and the developmental delays could disappear.

Correct answer: B

Rationale: The most appropriate response in this situation is to ask for more specific information related to the developmental delays. By seeking additional details, the nurse can better understand the child's needs and provide tailored guidance and support to the parent. Praising the parent (Choice A) before fully grasping the situation may not be beneficial. Advising the parent to involve the healthcare provider in selecting a program (Choice C) is premature without a comprehensive understanding of the child's developmental delays. Explaining that the delays might resolve on their own (Choice D) is inappropriate as it dismisses the parent's concerns and the necessity for timely and appropriate interventions.

3. A nurse is planning an evening snack for a child receiving Novolin N insulin. What is the reason for this nursing action?

• A. To encourage the child to stay on the diet.
• B. Energy is needed for immediate utilization.
• C. Extra calories will help the child gain weight.
• D. Nourishment helps to counteract late insulin activity.

Correct answer: D

Rationale: The correct answer is D. Novolin N insulin peaks in the evening, leading to a higher risk of hypoglycemia during this time. Providing a snack before bedtime helps counteract the late insulin activity and prevent hypoglycemia. Choice A is incorrect as the primary reason for the snack is related to insulin activity rather than diet compliance. Choice B is not directly related to the timing of Novolin N insulin administration. Choice C is unrelated to the specific need for a snack in the evening to address insulin activity.

4. A child with a diagnosis of celiac disease is being discharged. What dietary instructions should the nurse provide?

• A. Avoid dairy products
• B. Avoid gluten
• C. Avoid high-fat foods
• D. Avoid foods high in sugar

Correct answer: B

Rationale: The correct answer is B: 'Avoid gluten.' Celiac disease is a condition in which the immune system reacts to gluten, a protein found in wheat, barley, and rye. Avoiding gluten is essential in managing celiac disease as it helps prevent damage to the small intestine and alleviate symptoms. Choices A, C, and D are incorrect because dairy products, high-fat foods, and foods high in sugar do not directly relate to the management of celiac disease. It is crucial to focus on eliminating gluten-containing foods to effectively control the condition.

5. The school nurse is caring for a boy with hemophilia who fell on his arm during recess. What supportive measures should the nurse use until factor replacement therapy can be instituted?

• A. Apply warm, moist compresses
• B. Apply pressure for at least 1 minute
• C. Elevate the area above the level of the heart
• D. Begin passive range-of-motion unless the pain is severe

Correct answer: C

Rationale: Elevating the affected area above the level of the heart is the correct supportive measure for a child with hemophilia who has experienced trauma. This action helps reduce bleeding and swelling by promoting venous return and preventing further pooling of blood in the affected area. Applying warm, moist compresses (Choice A) may not be recommended as it can potentially increase bleeding by dilating blood vessels. Applying pressure for at least 1 minute (Choice B) can be helpful for minor cuts or wounds but may not be as effective in managing bleeding in a child with hemophilia. Beginning passive range-of-motion (Choice D) should be avoided as it can exacerbate bleeding and cause further damage in a child with hemophilia.

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