Nursing Elites

1. You are called to a local park for a 7-year-old boy with respiratory distress. During your assessment, you find that the patient is wheezing and has widespread hives and facial edema. What should you suspect has occurred?

• A. Poison oak exposure
• B. Allergic reaction
• C. Heat illness
• D. Acute asthma attack

Correct answer: B

Rationale: The presentation of wheezing, widespread hives, and facial edema is consistent with an allergic reaction. These symptoms indicate a systemic response to an allergen, triggering respiratory distress and skin manifestations.

2. What is the most important intervention to decrease the stressors of hospitalization for a 9-month-old infant being treated for a bacterial infection?

• A. Encourage the infant's parents to remain at the bedside and actively participate in the infant's care.
• B. Provide a brightly lit environment for the infant.
• C. Play tapes of the mother's voice.
• D. Assign the same nurse to the infant as much as possible.

Correct answer: A

Rationale: Encouraging the infant's parents to remain at the bedside and actively participate in the infant's care is crucial in decreasing the stressors of hospitalization for the infant. Parental presence provides comfort and security, promotes bonding, and maintains a sense of familiarity for the infant during a potentially stressful situation. This involvement can help reduce anxiety and promote better outcomes for the infant's emotional well-being and overall hospital experience. Providing a brightly lit environment (choice B) can actually increase stress for the infant, as infants generally prefer dimly lit environments for better sleep. Playing tapes of the mother's voice (choice C) may offer some comfort but does not substitute for parental presence. While assigning the same nurse to the infant (choice D) can provide continuity of care, it is not as effective as having the parents present for emotional support and bonding.

3. A new mother asks the nurse when she should begin to breastfeed her newborn. The nurse's best response is:

• A. Within the first half-hour after birth
• B. After the newborn's first bath
• C. When the newborn begins to cry
• D. After administering vitamin K

Correct answer: A

Rationale: Initiating breastfeeding within the first half-hour after birth is crucial for successful breastfeeding and bonding, as recommended by the World Health Organization. This early initiation helps establish breastfeeding and supports the newborn's health by providing colostrum, the nutrient-rich first milk. Choice B, 'After the newborn's first bath,' is incorrect because initiating breastfeeding should not be delayed after birth. Choice C, 'When the newborn begins to cry,' is incorrect as it does not promote timely initiation of breastfeeding. Choice D, 'After administering vitamin K,' is incorrect because breastfeeding initiation should not be delayed for this procedure.

4. What characteristic indicates that a mass on a newborn's head is a cephalohematoma?

• A. The mass appears on the second day after birth.
• B. The mass grows larger when the newborn cries.
• C. The head appears asymmetrical.
• D. The mass is located on only one side of the head.

Correct answer: A

Rationale: A cephalohematoma typically appears between the first and second days after birth, making choice A the correct answer. It results from blood vessel rupture between a cranial bone and the periosteal membrane. Choices B, C, and D are incorrect because the growth of the mass when the newborn cries, asymmetrical head appearance, or the mass being located on only one side of the head are not specific indicators of a cephalohematoma.

5. When educating the mother of a child with respiratory disease who needs a lot of fluids, the mother tells the nurse that when she offers her 24-month-old son juice, he always shakes his head and says, 'No'. The nurse suggests that the mother:

• A. Be firm and hand him the glass
• B. Distract him with some food
• C. Let him see that he is making her angry
• D. Offer him a choice of two things to drink

Correct answer: D

Rationale: Offering a choice can help the child feel more in control and willing to drink. By providing the child with options, the mother empowers him to make a decision, which can increase his willingness to drink fluids. This approach promotes a sense of autonomy and may lead to a more positive response from the child, ultimately contributing to better fluid intake, especially important for a child with a respiratory disease.

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