Nokea
A 12-month-old boy weighed 8 lb 2 oz at birth. What weight should the nurse expect him to be now?
- A. 16 lb 4 oz
- B. 20 lb 5 oz
- C. 24 lb 6 oz
- D. 32 lb 8 oz
Correct Answer: C
Rationale: Infants typically triple their birth weight by 12 months. For an 8-lb infant, that would be approximately 24 lb.
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The lowest fasting plasma glucose level suggestive of a diagnosis of diabetes is:
- A. 90mg/dl
- B. 126mg/dl
- C. 115mg/dl
- D. 180mg/dl
Correct Answer: B
Rationale: A fasting plasma glucose level of 126mg/dl or higher is considered to be indicative of diabetes mellitus. This value represents the threshold for diagnosing diabetes based on fasting glucose levels according to the American Diabetes Association (ADA) criteria. Fasting glucose levels between 100-125mg/dl indicate impaired fasting glucose, which is a precursor to diabetes. Therefore, a fasting plasma glucose level of 126mg/dl is the lowest level at which a diagnosis of diabetes can be suggested.
For the first 72 hours thyroidectomy surgery, the nurse would assess the client for Chvostek's sign and Trousseau's sign because they indicate which of the following?
- A. Hypocalcamia
- B. hypokalemia
- C. Hypercalcemia
- D. Hyperkalemia
Correct Answer: A
Rationale: Chvostek's sign and Trousseau's sign are both clinical manifestations of hypocalcemia, which is a common complication following thyroidectomy surgery.
Which of the ff is the most important factor in the nursing management of a client with CFS?
- A. Teaching the client how to avoid aggravating the disease
- B. Informing the client about the drug therapy that will provide significant improvement
- C. Advising the client to alter the diet and environment
- D. Educating the client about the disease process and its limitations
Correct Answer: D
Rationale: Educating the client about the disease process and its limitations is the most important factor in the nursing management of a client with Chronic Fatigue Syndrome (CFS). Providing information about the disease, its symptoms, potential triggers, and the importance of self-care is crucial in empowering the client to manage their condition effectively. Understanding the limitations imposed by CFS can help the client make necessary adjustments in their lifestyle, activities, and energy management. Education also plays a key role in setting realistic expectations and preventing exacerbation of symptoms by avoiding overexertion or pushing beyond their limits. By understanding the disease process and its impact, the client can actively participate in their care and strive for better quality of life.
A previously "potty-trained" 30-month-old child has reverted to wearing diapers while hospitalized. The nurse should reassure the parents that this is normal because of which reason?
- A. Regression is seen during hospitalization.
- B. Developmental delays occur because of the hospitalization.
- C. The child is experiencing urinary urgency because of hospitalization.
- D. The child was too young to be "potty-trained."
Correct Answer: A
Rationale: Regression in toilet training is a common behavior seen in young children, especially during times of stress or change, such as hospitalization. The child may revert to familiar behaviors, such as wearing diapers, as a way of seeking comfort and security during a stressful experience like being in the hospital. It is important for the nurse to reassure the parents that this regression is temporary and normal under the circumstances. By providing support and understanding, the child will likely return to their previous toilet training habits once they are back in their usual environment.
Choose the most likely serum sodium (Na ) value for this patient.
- A. 110mEq/L
- B. 155mEq/L
- C. 165mEq/L
Correct Answer: B
Rationale: The most likely serum sodium (Na) value for this patient would be within the normal range which is typically between 135-145 mEq/L. A value of 155mEq/L would be considered hypernatremia, which is an elevated level of sodium in the blood, and is not a likely serum sodium value in this case. A level of 110mEq/L would be extremely low and indicate hyponatremia, while a level of 165mEq/L would be dangerously high and could indicate severe hypernatremia. Therefore, option B, 155mEq/L, falls within the normal range and is the most likely serum sodium value for this patient.