Nursing Elites

1. When assessing a 5-year-old boy with major trauma, his blood pressure is 70/40 mm Hg, and his pulse rate is 140 beats/min and weak. The child's blood pressure:

• A. indicates decompensated shock.
• B. reflects adequate compensation.
• C. suggests increased intracranial pressure.
• D. is appropriate based on his age.

Correct answer: A

Rationale: In a 5-year-old boy with major trauma, a blood pressure of 70/40 mm Hg and a pulse rate of 140 beats/min, and weak, indicate decompensated shock. This presentation signifies inadequate perfusion, leading to compensatory mechanisms being overwhelmed, resulting in decompensated shock. Choice B is incorrect as the vital signs suggest the body is unable to adequately compensate for the trauma. Choice C is incorrect as the vital signs are more indicative of shock rather than increased intracranial pressure. Choice D is incorrect as such low blood pressure is not appropriate for a child of this age and indicates a critical condition.

2. A toddler is admitted to the hospital because of sudden hoarseness, holding or pointing to their neck, and continuous cough. The nurse will be particularly concerned about:

• A. Acute respiratory tract infection
• B. Respiratory tract obstruction caused by a foreign body
• C. Retropharyngeal abscess
• D. Undetected laryngeal abnormality

Correct answer: B

Rationale: In a toddler presenting with sudden hoarseness, holding or pointing to their neck, and continuous cough, the nurse should be particularly concerned about respiratory tract obstruction caused by a foreign body. These symptoms are indicative of a possible foreign body in the airway, which can lead to serious complications and requires immediate attention to ensure the toddler's airway remains patent and unobstructed.

3. What is the purpose of the pediatric assessment triangle?

• A. Detect immediate life threats through a quick hands-on assessment.
• B. Identify if the child has a medical condition or a traumatic injury.
• C. Determine if the child's problem is respiratory or circulatory in nature.
• D. Form a general impression of the child without touching them.

Correct answer: D

Rationale: The pediatric assessment triangle is used to form a rapid, hands-off general impression of the child's condition without directly touching them. This visual assessment helps in identifying children who require immediate attention and further evaluation.

4. When performing CPR on an infant with suspected sudden infant death syndrome (SIDS), an important aspect to consider is:

• A. Focusing all of your attention on the infant, with minimal parental interaction.
• B. Carefully inspecting the environment in which the infant was found.
• C. Understanding that most infants with SIDS can be successfully resuscitated.
• D. Encouraging the presence of the parents during your resuscitation attempt.

Correct answer: B

Rationale: When dealing with a suspected case of SIDS, it is crucial to carefully inspect the environment in which the infant was found. This inspection can provide valuable information that may help determine the cause and support further investigation into the incident. By examining the surroundings, potential hazards or clues related to the sudden event may be identified, aiding in understanding the circumstances and potentially preventing similar incidents in the future.

5. A mother of a 6-year-old actively playing child, diagnosed with type 1 diabetes mellitus a year ago, calls a clinic nurse and reports that the child has been sick. She checked the child's urine, which was positive for ketones. What should the nurse instruct the mother to do?

• A. Administer an additional dose of regular insulin
• B. Come to the clinic immediately
• C. Encourage the child to drink liquids
• D. Hold the next dose of insulin

Correct answer: C

Rationale: Encouraging the child to drink liquids is essential in managing ketones in urine. Increased fluid intake can help prevent dehydration and aid in flushing out ketones, which is crucial in managing diabetic ketoacidosis, a serious complication of uncontrolled diabetes.

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