Nursing Elites

1. You have arrived for your shift on the children's ward and need to assess a 2-year-old who is accompanied by his father. Identify the appropriate strategy to successfully complete a focused assessment:

• A. Allow the child to inspect the equipment for faults before and during assessment
• B. Ask parent to leave room until assessment has been completed
• C. Perform traumatic or invasive procedures first
• D. Have the child sit in parents lap and request assistance if necessary

Correct answer: D

Rationale: Having the child sit in parent's lap can help reduce anxiety and allow for a more accurate assessment.

2. One of the signs of CHF is shortness of breath. What is the term for shortness of breath when lying down?

• A. Platypnea
• B. Orthopnea
• C. Apnea
• D. Epistaxis

Correct answer: B

Rationale: Orthopnea is the specific term used to describe shortness of breath when lying down. This condition is commonly seen in patients with congestive heart failure (CHF) due to the redistribution of fluid in the body when changing positions. Platypnea refers to shortness of breath that worsens when sitting or standing, apnea is the cessation of breathing, and epistaxis is the medical term for a nosebleed. Therefore, the correct answer is B (Orthopnea).

3. Which of the following is a sign of altered mental status in a small child?

• A. Fear of the EMT's presence.
• B. Recognition of the parents.
• C. Inattention to the EMT's presence.
• D. Consistent eye contact with the EMT.

Correct answer: C

Rationale: Inattention to the EMT's presence is a sign of altered mental status in a small child. When a child is not responsive or does not acknowledge the presence of the EMT, it could indicate a change in their mental status. This lack of attention or awareness may signify a neurological issue or other medical condition affecting the child's cognitive function.

4. When evaluating a client's fluid intake and output record, how should fluid intake and urine output relate?

• A. Fluid intake should double the urine output
• B. Fluid intake should be approximately equal to the urine output
• C. Fluid intake should be half the urine output
• D. Fluid intake should be inversely proportional to the urine output

Correct answer: B

Rationale: In assessing a client's fluid intake and output record, it is essential for fluid intake to be approximately equal to the urine output. This balance indicates proper hydration and renal function. Deviations from this balance could signify potential issues that need further investigation and management.

5. A 3-year-old is seen in the clinic and is diagnosed with an ear infection. The father reports that the child was awake several times during the night, crying. The PRIORITY nursing diagnosis for this child is:

• A. Sleep Pattern Disturbance related to pain.
• B. Pain related to ear infection.
• C. Altered Family Processes related to ill child.
• D. Ineffective Thermoregulation Related to Infection

Correct answer: B

Rationale: The priority nursing diagnosis for a child diagnosed with an ear infection and experiencing nighttime awakenings and crying would be 'Pain related to ear infection.' Pain management is crucial to ensure the child's comfort and well-being, which can also impact their sleep patterns. Addressing the pain as a priority can lead to improved sleep and overall recovery for the child.

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