Nokea
Which of the following findings should the nurse expect?
- A. Pinpoint pupils
- B. Ataxia
- C. Hyperactive reflexes
- D. Hypothermia
Correct Answer: B
Rationale: The correct answer is B: Ataxia. Ataxia is a neurological finding characterized by lack of coordination and unsteady gait, commonly seen in conditions like cerebellar dysfunction. Pinpoint pupils (A) suggest opioid toxicity, hyperactive reflexes (C) indicate possible hyperthyroidism or CNS injury, and hypothermia (D) is associated with hypothyroidism or hypothermia. Ataxia is the most relevant finding in this context, indicating a potential neurological issue.
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What is a 1-year-old with history of UTIs and diagnosed with vesicoureteral reflux s tachycardia at risk for?
- A. Nephrotic syndrome
- B. Renal Scarring
- C. Polycystic kidney
- D. Acute glomerulonephritis
- E. Pyclonephritis
Correct Answer: B,E
Rationale: The correct answers for a 1-year-old with history of UTIs and diagnosed with vesicoureteral reflux at risk for are B: Renal Scarring and E: Pyelonephritis. Vesicoureteral reflux increases the risk of recurrent UTIs, leading to pyelonephritis. Renal scarring can result from repeated pyelonephritis episodes. Nephrotic syndrome (A) is not typically associated with UTIs or reflux. Polycystic kidney (C) is a congenital condition, not related to the scenario. Acute glomerulonephritis (D) is usually caused by post-streptococcal infection, not UTIs.
Which of the following reactions is an age-appropriate response to death?
- A. The child views the sibling's death as permanent.
- B. The child is curious about what happened to the sibling's body.
- C. The child can give a logical explanation for the sibling's death.
- D. The child feels responsible for the sibling's death.
Correct Answer: B
Rationale: The correct answer is B because it reflects a common and age-appropriate response to death in children. Curiosity about what happened to the body is natural as children try to make sense of the concept of death. It shows a child's attempt to understand the physical aspect of death without fully grasping its emotional implications. Choices A, C, and D are incorrect. A is incorrect because children often struggle with understanding death as permanent. C is incorrect because logical explanations for death usually come later in development. D is incorrect because children typically do not feel responsible for a sibling's death at a young age.
Which of the following information should the nurse include in the teaching?
- A. Place an infant who is 5 months old in a high chair to feed.
- B. Position a 1-month-old infant supine on a soft mattress.
- C. Provide an infant with a one-piece pacifier for non-nutritive sucking.
- D. Secure the infant's car seat behind an airbag.
Correct Answer: C
Rationale: The correct answer is C because providing an infant with a one-piece pacifier for non-nutritive sucking reduces the risk of choking and aspiration compared to multi-piece pacifiers. This information is crucial for infant safety during feeding. Choice A is incorrect as a 5-month-old infant should be seated in a high chair only if they can sit upright without support to prevent falls. Choice B is incorrect as placing a 1-month-old infant supine on a soft mattress increases the risk of sudden infant death syndrome (SIDS). Choice D is incorrect as securing an infant's car seat behind an airbag can be dangerous due to the risk of injury from the airbag deployment.
Specify what condition the client is most likely experiencing.
- A. Pyloric stenosis
- C. Congestive heart failure
- D. Respiratory syncytial virus bronchiolitis
Correct Answer: C
Rationale: The correct answer is C: Congestive heart failure. The client is most likely experiencing Congestive heart failure due to presenting symptoms such as dyspnea, fatigue, edema, and possibly crackles on lung auscultation. These symptoms are indicative of fluid accumulation in the lungs and peripheral tissues, common in congestive heart failure. Pyloric stenosis (A) is a gastrointestinal condition, not related to the symptoms described. Respiratory syncytial virus bronchiolitis (D) typically presents with respiratory distress in infants. The other choices are omitted as they are not relevant to the symptoms described.
Which of the following actions should the nurse take first?
- A. Obtain an x-ray of the child's neck.
- B. Administer intravenous antibiotics.
- C. Initiate droplet precautions.
- D. Place intubation equipment at the bedside.
Correct Answer: D
Rationale: The correct action for the nurse to take first is to place intubation equipment at the bedside (Choice D). This is crucial in case the child's condition deteriorates rapidly and respiratory support is needed. Placing the intubation equipment ensures immediate access to airway management, which takes precedence over other actions. Obtaining an x-ray may provide diagnostic information but is not as urgent as ensuring airway patency. Administering antibiotics and initiating droplet precautions (Choice C) are important but not the immediate priority in this scenario. Therefore, Choice D is the correct first action to ensure the child's safety and optimal care.