Nokea
A 24-hour-old term infant had a confirmed episode of hypoglycemia when 1 hour old. Which observation by the nurse would indicate the need for follow-up?
- A. Weight loss of 4 ounces and dry, peeling skin
- B. Blood glucose level of 40 \mathrm{mg} / \mathrm{dL}(2.28 \mathrm{mmol} / \mathrm{L}) before the last feeding
- C. Breast-feeding for 20 minutes or more, with strong sucking
- D. High-pitched cry, drinking 10 to 15mL of formula per feeding
Correct Answer: D
Rationale: Hypoglycemia causes central nervous system symptoms (high-pitched cry), and it is also exhibited by a lack of strength for eating enough for growth. At 24 hours old, a term infant should be able to consume at least 1 ounce of formula per feeding. A high-pitched cry is indicative of neurological involvement. Weight loss over the first few days of life and dry, peeling skin are normal findings for term infants. Blood glucose levels are acceptable at 40 \mathrm{mg} / \mathrm{dL}(2.28 \mathrm{mmol} / \mathrm{L}) during the first few days of life.
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A home care nurse is assigned to visit a preschooler who has a diagnosis of scarlet fever and is on bed rest. What data obtained by the nurse would indicate that the child is coping with the illness and bed rest?
- A. The child insists that his mother stay in the room.
- B. The child is coloring and drawing pictures in a notebook.
- C. The mother keeps providing new activities for the child to do.
- D. The child sucks his thumb whenever he does not get what he asked for.
Correct Answer: B
Rationale: According to Jean Piaget, for the preschooler, play is the best way for children to understand and adjust to life's experiences. They are able to use pencils and crayons, and they can draw stick figures and other rudimentary things. A child with scarlet fever needs quiet play, and drawing will provide that. Based on this information, none of the remaining options address positive coping mechanisms.
The nurse has provided discharge instructions to the parent of a child who has undergone heart surgery. Which statement by the parent would indicate the need for further instruction?
- A. My child can return to school for full days 2 weeks after discharge.
- B. I should allow my child to play inside but omit outside play at this time.
- C. I should have my child avoid crowds and people for 2 weeks after discharge.
- D. I should call the primary health care provider if my child develops faster or harder breathing than normal.
Correct Answer: A
Rationale: The child may return to school the third week after hospital discharge, but he or she should go to school for half days for the first week. Outside play should be omitted for several weeks, with inside play allowed as tolerated. The child should avoid crowds of people for 2 weeks after discharge, including crowds at day care centers and churches. If any difficulty with breathing occurs, the parent should notify the primary health care provider.
The nurse has taught a client who is prescribed a xanthine bronchodilator about beverages to avoid. The nurse determines that the client understands the information if the client chooses which beverage from the dietary menu?
- A. Cola
- B. Coffee
- C. Chocolate milk
- D. Cranberry juice
Correct Answer: D
Rationale: Cola, coffee, and chocolate contain xanthine and should be avoided by the client who is taking a xanthine bronchodilator. This could lead to an increased incidence of cardiovascular and central nervous system side effects that can occur with the use of these types of bronchodilators.
The nurse caring for a client with Graves' disease is concerned about the client's calorie intake because of the resulting hypercatabolic state of the disorder. Which situation indicates a successful outcome for this concern?
- A. The client verbalizes the need to avoid snacking between meals.
- B. The client discusses the relationship between mealtime and the blood glucose level.
- C. The client maintains a normal weight or gradually gains weight if it is below normal.
- D. The client demonstrates knowledge regarding the need to consume a diet that is high in fat and low in protein.
Correct Answer: C
Rationale: Graves' disease causes a state of chronic nutritional and caloric deficiency caused by the metabolic effects of excessive T3 and T4. Clinical manifestations are weight loss and increased appetite. Therefore, it is a nutritional goal that the client will not lose additional weight and he or she will gradually return to the ideal body weight, if necessary. To accomplish this, the client must be encouraged to eat frequent high-calorie, high-protein, and high-carbohydrate meals and snacks.
An older client is a victim of elder abuse. He and his family have been attending counseling sessions for the past month. Which statement, made by the abusive family member, would indicate an understanding of more positive coping skills?
- A. I will be more careful to make sure that my father's needs are 100 \% met.
- B. I am so sorry and embarrassed that the abusive event occurred. It won't happen again.
- C. I feel better equipped to care for my father now that I know where to turn if I need assistance.
- D. Now that my father is going to move into my home with me, I will have to stop drinking alcohol.
Correct Answer: C
Rationale: Elder abuse is sometimes caused by family members who are being expected to care for their aging parents. This care can cause the family to become overextended, frustrated, or financially depleted. Knowing where to turn in the community for assistance with caring for an aging family member can bring much-needed relief. Using these alternatives is a positive coping skill for many families. The rest of the options are statements of good faith or promises, which may or may not be kept in the future.