The healthcare provider is assessing an infant with diarrhea and lethargy. Which finding should the provider identify that is consistent with early dehydration?
- A. Tachycardia
- B. Bradycardia
- C. Dry mucous membranes
- D. Decreased skin turgor
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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Which nursing intervention is most important to assist in detecting hypopituitarism and hyperpituitarism in children?
- A. Carefully recording the height and weight of children to detect inappropriate growth.
- B. Performing head circumference measurements on infants under one year of age.
- C. Assessing for behavioral problems at home and school by interviewing the parents.
- D. Noting tracked weight gain without a gain in height on a growth chart.
Correct Answer: A
Rationale: Recording the height and weight of children is crucial in detecting growth abnormalities like hypopituitarism and hyperpituitarism. Inappropriate growth patterns, such as disproportionate weight gain or stunted height, can be indicative of these conditions. Regular monitoring of height and weight is a fundamental nursing intervention that can aid in the early identification and management of pituitary-related disorders in children.
Why is honest information important in building a trusting relationship with adolescent patients?
- A. Encourage the adolescent to seek help outside of the school clinic.
- B. Keep disclosures from the adolescent confidential.
- C. Honest information ensures establishing a trusting relationship.
- D. Discourage minor adolescents from disclosing private concerns.
Correct Answer: C
Rationale: Honesty is fundamental in building trust with adolescent patients as it helps create an environment where they feel safe to share their concerns openly. By being honest and maintaining confidentiality, healthcare providers can establish a strong and trusting relationship with adolescents, ultimately leading to better healthcare outcomes.
A 7-year-old child with sickle cell anemia presents to the emergency department with severe pain in the arms and legs. What is the nurse's priority action?
- A. Administer prescribed pain medication
- B. Apply warm compresses to the affected areas
- C. Encourage the child to drink fluids
- D. Monitor the child's oxygen saturation
Correct Answer: A
Rationale: In a sickle cell crisis, pain management is a priority due to the severe pain experienced by the child. Administering prescribed pain medication is crucial to alleviate the pain and provide comfort to the child. Once pain is controlled, other comfort measures like applying warm compresses and encouraging fluid intake can be implemented. Monitoring oxygen saturation is important but not the priority action when dealing with severe pain in a sickle cell crisis.
What age-appropriate play activity should the practical nurse suggest to the parents of a 7-month-old infant to encourage visual stimulation?
- A. Play peek-a-boo.
- B. Play pat-a-cake.
- C. Imitate animal sounds.
- D. Show how to clap hands.
Correct Answer: A
Rationale: The practical nurse should suggest playing peek-a-boo to the parents of a 7-month-old infant to encourage visual stimulation. Peek-a-boo is a suitable game for this age group as it helps develop visual tracking skills and the concept of object permanence. By covering and uncovering their face or a toy, the infant learns that things still exist even when they cannot be seen, promoting cognitive development and visual engagement.
A mother brings her 3-week-old infant to the clinic because the baby vomits after eating and always seems hungry. Further assessment indicates that the infant's vomiting is projectile, and the child seems listless. Which additional assessment finding indicates the possibility of a life-threatening complication?
- A. Irregular palpable pulse
- B. Hyperactive bowel sounds
- C. Underweight for age
- D. Crying without tears
Correct Answer: D
Rationale: Crying without tears is a sign of severe dehydration, which is a potentially life-threatening complication in infants with projectile vomiting. Dehydration can rapidly progress in infants, leading to serious consequences if not promptly addressed. The combination of projectile vomiting, listlessness, and absence of tears when crying should raise concerns about severe dehydration and the need for urgent intervention to prevent further complications.