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. Which best describes a full-thickness (third-degree) burn?

• A. Erythema and pain
• B. Skin showing erythema followed by blister formation
• C. Destruction of all layers of skin evident with extension into subcutaneous tissue
• D. Destruction injury involving underlying structures such as muscle, fascia, and bone

Correct answer: C

Rationale: The correct answer is C: Full-thickness burns involve the destruction of all layers of skin, extending into the subcutaneous tissue. This type of burn causes severe damage and loss of sensation due to nerve destruction. Choice A, erythema and pain, describes superficial burns (first-degree). Choice B, skin showing erythema followed by blister formation, describes partial-thickness burns (second-degree). Choice D, destruction injury involving underlying structures such as muscle, fascia, and bone, goes beyond the description of full-thickness burns.

3. The nurse has developed a plan of care for a 6-year-old with muscular dystrophy. He was recently injured when he fell out of bed at home. Which intervention would the nurse suggest to prevent further injury?

• A. Recommend raising the bed's side rails throughout the day and night.
• B. Suggest having a caregiver present continuously to prevent falls from bed.
• C. Encourage the use of a loose restraint when he is in bed.
• D. Recommend raising the bed's side rails when a caregiver is not present.

Correct answer: D

Rationale: For a child with muscular dystrophy who fell out of bed, it is important to prevent further injuries. Using bed side rails when a caregiver is not present can help provide a safety measure and prevent falls. While continuous caregiver presence (choice B) may be ideal, it may not always be feasible. Recommending raising the bed's side rails throughout the day and night (choice A) may limit the child's mobility unnecessarily. Encouraging the use of a loose restraint (choice C) can be dangerous and may increase the risk of injury in case of a fall.

4. An infant is diagnosed with Hirschsprung disease. What nursing intervention is essential before surgery?

• A. Administering antibiotics
• B. Ensuring bowel rest
• C. Performing regular enemas
• D. Maintaining NPO status

Correct answer: D

Rationale: The correct nursing intervention essential before surgery for an infant with Hirschsprung disease is maintaining NPO (nothing by mouth) status. This is important to prevent aspiration during and after the surgical procedure. Administering antibiotics (Choice A) may be necessary in some cases but is not the priority intervention before surgery. Ensuring bowel rest (Choice B) is not directly related to preparing for surgery and may not be the most critical intervention. Performing regular enemas (Choice C) is not recommended before surgery for Hirschsprung disease as it can aggravate the condition.

5. What should the nurse include in the care plan for a 6-month-old infant admitted with a diagnosis of respiratory syncytial virus (RSV)?

• A. Provide small, frequent feedings
• B. Administer antibiotics
• C. Maintain strict isolation
• D. Elevate the head of the bed

Correct answer: D

Rationale: Elevating the head of the bed is crucial in the care plan for an infant with RSV as it helps improve breathing by facilitating better airflow and drainage of secretions. This position can also enhance comfort and reduce respiratory distress. Providing small, frequent feedings (Choice A) is generally beneficial for infants but is not specific to managing RSV. Administering antibiotics (Choice B) is not indicated for RSV as it is caused by a virus, and antibiotics are ineffective against viral infections. Maintaining strict isolation (Choice C) is important to prevent the spread of contagious infections but is not a direct intervention for improving the infant's respiratory status in RSV.

Similar Questions