Nokea
A 3-year-old with croup has the following vital signs: HR 90, RR 44, BP 100/52, T 98.8°F. The parents ask if these are normal. The nurse's best response is:
- A. Your son's blood pressure is elevated.
- B. Your son's temperature is elevated.
- C. Your son's respiratory rate is elevated; a normal rate for his age is 20-30 breaths per minute.
- D. Your son's heart rate is elevated.
Correct Answer: C
Rationale: The elevated respiratory rate is concerning since normal for a 3- to 6-year-old is about 20-30 breaths per minute.
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A client with newly diagnosed type 2 diabetes mellitus is admitted to the metabolic unit. The primary goal for this admission is education. Which of the following goals should the nurse incorporate into her teaching plan?
- A. Maintenance of blood glucose levels between 180 and 200mg/dl
- B. Smoking reduction but not complete cessation
- C. An eye examination every 2 years until age 50
- D. Exercise and a weight reduction diet
Correct Answer: D
Rationale: For a client with newly diagnosed type 2 diabetes mellitus, the primary focus should be on lifestyle modifications to help manage the condition. A key component of managing type 2 diabetes is maintaining a healthy weight through a balanced diet and regular exercise. Regular physical activity can help improve insulin sensitivity and can assist in weight management. A weight reduction diet can help control blood sugar levels and reduce the risk of complications associated with diabetes. Therefore, incorporating education on exercise and a weight reduction diet is essential in optimizing the client's health outcomes and quality of life.
The nurse is caring for an infant with a suspected urinary tract infection. Which clinical manifestations should be expected? (Select all that apply.)
- A. Vomiting
- B. Jaundice
- C. Failure to gain weight
- D. Swelling of the face
Correct Answer: A
Rationale: A urinary tract infection (UTI) in an infant may present with symptoms such as vomiting and failure to gain weight. Vomiting can be a common sign of UTI in infants due to irritation and inflammation in the urinary tract. Additionally, infants with UTIs may experience poor feeding and failure to gain weight due to the discomfort and systemic effects of the infection. While symptoms like jaundice, swelling of the face, back pain, and persistent diaper rash can be seen in other conditions, they are not typically associated with a urinary tract infection in infants.
By the age of 7 months, the infant is able to do all the following EXCEPT
- A. transfer object from hand to hand
- B. actively bounces
- C. uses radial palm grasp
- D. roll over
Correct Answer: D
Rationale: Rolling over is usually achieved earlier, by 4-6 months, while other skills are typical for 7 months.
A nurse is assessing a preterm newborn. Which assessment findings are consistent with prematurity? (Select all that apply.)
- A. Abundant lanugo over the body
- B. Ear cartilage soft and pliable
- C. Flexed body posture
- D. Deep creases on the sole of the foot
Correct Answer: A
Rationale: Abundant lanugo over the body: Premature newborns often have abundant lanugo, which is fine, soft hair covering their bodies. This is a common characteristic of prematurity as the baby has not had enough time to shed this hair before birth.
The basic principle of healthy sleep hygiene which is NOT included is
- A. set routine
- B. avoid stimulating activities as playing computer games
- C. makes sure child spends time outside every day
- D. gives a heavy meal within an hour of bedtime
Correct Answer: D
Rationale: Heavy meals close to bedtime disrupt sleep.