Nursing Elites

1. Which finding suggests fluid volume deficit in an infant presenting with vomiting and diarrhea for 2 days?

• A. Increased blood pressure
• B. A sunken fontanel
• C. Decreased pulse rate
• D. Low urine specific gravity

Correct answer: B

Rationale: A sunken fontanel is a classic sign of dehydration in infants, indicating a fluid volume deficit. In dehydration, the fontanel sinks due to decreased fluid volume in the body. Increased blood pressure (Choice A) is not typically associated with dehydration in infants. Decreased pulse rate (Choice C) is not a common finding in fluid volume deficit, as the body tries to increase the heart rate to compensate for decreased volume. Low urine specific gravity (Choice D) may be seen in dehydration, but it is not as specific or as easily observable as a sunken fontanel.

2. What procedure is most appropriate for the assessment of an abdominal circumference related to a bowel obstruction?

• A. Measuring the abdomen after feedings
• B. Marking the point of measurement with a pen
• C. Measuring the circumference at the symphysis pubis
• D. Using a new tape measure with each assessment to ensure accuracy

Correct answer: B

Rationale: Marking the point of measurement ensures consistent and accurate assessments of abdominal circumference, especially important in conditions like bowel obstruction where changes need to be monitored closely.

3. A nurse is evaluating the effectiveness of teaching regarding care of a child with minimal change nephrotic syndrome (MCNS) that is in remission after administration of prednisone. The nurse realizes further teaching is required if the parents state what?

• A. We will keep our child away from anyone who is ill.
• B. We will be sure to administer the prednisone as ordered.
• C. We will encourage our child to eat a balanced diet, but we will watch his salt intake.
• D. We understand our child will not be able to attend school, so we will arrange for home schooling.

Correct answer: D

Rationale: Children with MCNS in remission can usually return to school. Home schooling may be necessary only if there are complications. The other options show an understanding of proper care during remission.

4. What is an essential nursing care intervention for a neonate with a suspected tracheoesophageal fistula?

• A. Feed glucose water only.
• B. Elevate the patient's head for feedings.
• C. Raise the patient's head and give nothing by mouth.
• D. Avoid suctioning unless the infant is cyanotic.

Correct answer: C

Rationale: Raising the patient’s head and giving nothing by mouth is crucial in managing tracheoesophageal fistula. This intervention helps prevent aspiration and further complications until surgical correction can be performed. Feeding the neonate or suctioning could exacerbate the condition by risking aspiration. Elevating the head for feedings does not address the primary concern of preventing oral intake, making it less appropriate than the correct answer.

5. What information should the nurse include when teaching an adolescent with Crohn disease (CD)?

• A. How to cope with stress and adjust to chronic illness
• B. Preparation for surgical treatment and cure of CD
• C. Nutritional guidance and prevention of constipation
• D. Prevention of spread of illness to others and principles of high-fiber diet

Correct answer: A

Rationale: Teaching about coping with stress and adjusting to chronic illness is crucial for adolescents with Crohn disease. CD is a chronic condition with no cure, so focusing on managing the disease, stress, and diet is essential for improving the adolescent's quality of life. Choice B is incorrect because Crohn disease cannot be cured surgically. Choice C is relevant but not as essential as coping with stress and chronic illness. Choice D is not a priority in teaching an adolescent with Crohn disease as it mainly focuses on preventing the spread of illness to others, which is not a significant concern with CD, and high-fiber diets may not always be suitable for individuals with this condition.

Similar Questions