Nokea
The nurse is expecting the admission of a child with severe isotonic dehydration. Which intravenous fluid prescription does the nurse anticipate for this child?
- A. 0.9% normal saline (NS)
- B. D5 0.2% (¼) normal saline
- C. D5W
- D. Albumin
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A 9-month-old infant who is not sitting independently has been diagnosed with ataxic cerebral palsy (CP). Which clinical manifestations would the nurse expect to see in the baby?
- A. Hypotonia and muscle instability
- B. Hypertonia and persistence of primitive reflexes
- C. Tremors and exaggerated posturing
- D. Hemiplegia and hypertonia
Correct Answer: A
Rationale: In ataxic cerebral palsy, the characteristic features include hypotonia (low muscle tone) and muscle instability. These manifestations contribute to the infant's difficulty in achieving independent sitting. Hypertonia (increased muscle tone) and persistence of primitive reflexes, as mentioned in option B, are more commonly associated with other types of cerebral palsy. Tremors and exaggerated posturing (option C) are not typical features of ataxic CP. Hemiplegia (paralysis of one side of the body) and hypertonia (increased muscle tone) mentioned in option D are more commonly seen in other types of cerebral palsy, such as spastic CP.
Which is NOT one of the functions of challenging behaviors?
- A. Avoiding a situation
- B. Escaping from an undesired object or event
- C. to make others happy
- D. Sensory functions
Correct Answer: C
Rationale: Challenging behaviors often serve functions related to avoiding, escaping, obtaining, or sensory needs. The question is asking for the function that does not typically apply to challenging behaviors. Choices A, B, C, and D align with the common functions associated with challenging behaviors. Therefore, 'E' is the correct answer as it does not represent a typical function of challenging behaviors.
The age at which the infant can achieve early head control with bobbing motion when pulled to sit is
- A. 2 months
- B. 3 months
- C. 4 months
- D. 6 months
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A patient develops hypotension, laryngeal edema, and bronchospasm after eating peanuts. Which medication should the nurse prepare to administer?
- A. Promethazine
- B. Epinephrine
- C. Diphenhydramine
- D. Hydroxyzine
Correct Answer: B
Rationale: The patient is exhibiting symptoms of anaphylaxis triggered by a peanut allergy, which is a severe and potentially life-threatening allergic reaction. The appropriate medication for anaphylaxis is epinephrine. Epinephrine acts quickly to reverse the symptoms by constricting blood vessels, relaxing bronchial muscles, and reducing laryngeal edema, making it the drug of choice for this situation. Promethazine, diphenhydramine, and hydroxyzine are not the first-line treatments for anaphylaxis and may not address the severe manifestations seen in this case.
A 7-year-old child with acute glomerulonephritis has gross hematuria and has been confined to bed. What is the most appropriate nursing intervention for this child?
- A. Providing activities for the child on restricted activity
- B. Feeding the child a protein-restricted diet
- C. Carefully handling edematous extremities
- D. Observing the child for evidence of hypotension
Correct Answer: A
Rationale: The most appropriate nursing intervention for a 7-year-old child with acute glomerulonephritis experiencing gross hematuria and bed rest is to provide activities for the child on restricted activity. Although the child may feel well, it is essential to limit activity until hematuria resolves to prevent complications and promote recovery.