Nokea
A 15-month-old toddler was able to do all the following EXCEPT
- A. walks alone
- B. makes tower of 3 cubes
- C. inserts raisin in a bottle
- D. responds to his/her name
Correct Answer: D
Rationale: Responding to name usually occurs earlier, around 6-9 months.
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Which describes marasmus?
- A. Deficiency of protein with an adequate supply of calories
- B. Not confined to geographic areas where food supplies are inadequate
- C. Syndrome that results solely from vitamin deficiencies
- D. Characterized by thin, wasted extremities and a prominent abdomen resulting from edema (ascites)
Correct Answer: D
Rationale: Marasmus is a form of severe malnutrition characterized by a deficiency of both calories and protein in the diet. It typically occurs in young children and is often associated with a lack of adequate food intake. The classic presentation of marasmus includes extreme wasting of muscle and fat tissues, resulting in a gaunt appearance with thin limbs and a distended abdomen due to diminished muscle and subcutaneous fat. This differentiates it from kwashiorkor, another form of severe acute malnutrition characterized by edema and a protruding belly but with retained muscle mass. Therefore, option D, characterized by thin, wasted extremities and a prominent abdomen resulting from edema (ascites), accurately describes marasmus.
Which is the most reliable method for monitoring fluid balance?
- A. Daily intake and output
- B. Vital signs
- C. Daily weight
- D. Skin turgor
Correct Answer: A
Rationale: Monitoring daily intake and output is the most reliable method for assessing fluid balance in a patient. By accurately measuring the amount of fluids taken in through foods, drinks, and IV fluids, as well as the amount of fluids eliminated through urine, stool, vomit, and other means, healthcare providers can closely track the body's fluid balance. Discrepancies between intake and output can indicate potential issues such as dehydration or fluid overload. This method provides quantitative data that can guide appropriate interventions and treatment adjustments to maintain the patient's fluid balance within normal limits. While vital signs, daily weight, and skin turgor are also important indicators of fluid status, they may not always provide as specific or accurate information as the direct measurement of intake and output.
The nurse is working in a support group for client with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress?
- A. Avoiding the use of recreational drugs and alcohol
- B. Refraining from telling anyone about the diagnosis
- C. Following safer-sex practices
- D. Telling potential sex partners about the diagnosis, as required by the law
Correct Answer: C
Rationale: Following safer sex practices is the most important point for the nurse to stress when working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Safer sex practices, such as using condoms consistently and correctly, can help reduce the risk of transmitting the virus to others or acquiring other sexually transmitted infections. While avoiding the use of recreational drugs and alcohol is beneficial for overall health, it is not as crucial as practicing safer sex. Refraining from telling anyone about the diagnosis is not recommended, as social support is important for individuals living with AIDS. Telling potential sex partners about the diagnosis is also essential, not only for ethical reasons but also to prevent the transmission of the virus.
Nurse Veronica is teaching a group of parents about otitis media. When discussing why children are predisposed to this disorder, the nurse should mention the significance of which anatomical feature?
- A. Nasopharynx
- B. Eustachian tubes
- C. External ear canal
- D. Tympanic membrane 51
Correct Answer: B
Rationale: The Eustachian tubes are small passages that connect the middle ear to the back of the throat. In young children, these tubes are shorter, more horizontal, and more narrow than in adults, making them more prone to blockages and infections. When these tubes become blocked, usually due to factors like swelling from allergies or a cold, fluid can build up in the middle ear leading to otitis media or middle ear infection. Therefore, the anatomy and size of the Eustachian tubes play a significant role in the predisposition of children to otitis media.
An insulin-dependent diabetic delivered a 10-pound male. When the baby is brought to the nursery, the priority of care is to
- A. clean the umbilical cord with Betadine to prevent infection
- B. give the baby a bath
- C. call the laboratory to collect a PKU screening test
- D. check the baby's serum glucose level and administer glucose if < 40 mg/dL
Correct Answer: D
Rationale: The priority of care when a baby born to an insulin-dependent diabetic mother is brought to the nursery is to check the baby's serum glucose level and administer glucose if it is less than 40 mg/dL. Babies born to diabetic mothers, especially those with poorly controlled blood sugar levels, are at risk for hypoglycemia (low blood sugar) due to the sudden drop in glucose supply after delivery. Hypoglycemia can be dangerous for newborns and can lead to serious complications if left untreated. Therefore, monitoring the baby's serum glucose levels and providing appropriate intervention, such as administering glucose if necessary, is critical to ensure the baby's well-being.