Nursing Elites

1. While assessing an 18-month-old child, a nurse observes that the toddler can crawl upstairs but needs assistance when climbing the stairs upright. What does this action indicate to the nurse?

• A. Presence of talipes equinovarus
• B. Reflective of neurologic damage
• C. Expected behavior in a toddler of this age
• D. Existence of developmental dysplasia of the hip

Correct answer: C

Rationale: At 18 months of age, needing assistance to climb stairs upright is considered normal behavior for a toddler. Crawling upstairs is a different motor skill and does not necessarily correlate with the ability to climb stairs. The child is still developing gross motor skills, and climbing stairs upright typically requires more coordination and strength, which may not be fully developed at this age. Choices A, B, and D are not relevant in this scenario as the observed behavior is within the expected range of development for an 18-month-old child.

2. 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 accident prevention
• B. Limiting playtime with other children in the family
• C. Any other behaviors that the parent may have noticed
• D. Food and appropriate vitamins for infants

Correct answer: C

Rationale: Discussing any other observed behaviors can help identify patterns or potential issues, which is crucial for assessing the infant's overall well-being. Option A about accidents and prevention is not pertinent to the situation described. Option B regarding playtime with other children does not address the infant's behavior and potential causes. Option D about food and vitamins is not relevant to the presented scenario and the observed behavior of the infant.

3. A child with a diagnosis of cystic fibrosis is admitted to the hospital. What is the priority nursing intervention?

• A. Administering pancreatic enzymes
• B. Providing respiratory therapy
• C. Providing nutritional support
• D. Encouraging physical activity

Correct answer: A

Rationale: The correct answer is administering pancreatic enzymes. In cystic fibrosis, the pancreas is often affected, leading to insufficient production of digestive enzymes. Administering pancreatic enzymes is crucial to ensure proper digestion and absorption of nutrients. While respiratory therapy, nutritional support, and physical activity are essential components of care for individuals with cystic fibrosis, addressing the digestive aspect by administering pancreatic enzymes takes priority to prevent malnutrition and promote overall health.

4. A child with a diagnosis of nephrotic syndrome is being treated with corticosteroids. What is an important nursing consideration?

• A. Monitor for signs of infection
• B. Monitor blood pressure
• C. Monitor for hyperglycemia
• D. Monitor for hypertension

Correct answer: A

Rationale: When a child with nephrotic syndrome is undergoing treatment with corticosteroids, it is crucial to monitor for signs of infection. Corticosteroids can suppress the immune system, increasing the child's susceptibility to infections. Monitoring for signs of infection allows for early detection and prompt intervention, reducing the risk of complications. While monitoring blood pressure (choice B) is important in nephrotic syndrome, it is not the most immediate concern when the child is on corticosteroids. Monitoring for hyperglycemia (choice C) is relevant in corticosteroid therapy, but the priority in this scenario is to watch for signs of infection. Monitoring for hypertension (choice D) is important in nephrotic syndrome but is not the most critical consideration when the child is on corticosteroids.

5. The nurse is caring for a 3-day-old girl with Down syndrome whose mother had no prenatal care. What is the priority nursing diagnosis?

• A. Imbalanced nutrition, less than body requirements related to the effects of hypotonia
• B. Deficient knowledge related to the presence of a genetic disorder
• C. Delayed growth and development related to cognitive impairment
• D. Impaired physical mobility related to poor muscle tone

Correct answer: A

Rationale: The priority nursing diagnosis for a newborn with Down syndrome is often related to feeding difficulties due to hypotonia, making imbalanced nutrition the primary concern. Hypotonia, or poor muscle tone, can lead to challenges with feeding and, subsequently, affect the baby's nutritional intake. While choices B, C, and D may also be concerns for a child with Down syndrome, addressing the immediate need for adequate nutrition takes precedence to ensure the infant's well-being and growth.

Similar Questions