Nokea
A child is being cared for following a head injury. Which of the following findings should indicate to the healthcare provider that the child is developing diabetes insipidus?
- A. Urine specific gravity of 1.045
- B. Sodium level of 155
- C. Blood glucose level of 45
- D. Urine output of 35 ml per hour
Correct Answer: B
Rationale: In a child with a head injury, the development of diabetes insipidus can occur due to pituitary hypofunction, leading to a deficiency of antidiuretic hormone. An elevated sodium level (hypernatremia) is a key finding in diabetes insipidus due to the excessive loss of free water in the urine, resulting in increased sodium concentration in the blood.
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The nurse is unsuccessful in inserting a nasogastric tube for a newborn client. The nurse suspects the newborn has esophageal atresia/tracheoesophageal (EA/TE) fistula. Which nursing action is appropriate while waiting for the healthcare provider to further assess the neonate?
- A. Position the newborn in a semi-Fowler position.
- B. Allow the newborn to stay in the nursery for observation.
- C. Offer the newborn pacifier for comfort.
- D. Wrap the newborn in blankets and place in an incubator.
Correct Answer: A
Rationale: Positioning the newborn in a semi-Fowler position is appropriate as it helps prevent aspiration in suspected EA/TE fistula. This position helps reduce the risk of regurgitation and aspiration of gastric contents. Placing the newborn in a semi-Fowler position promotes the drainage of secretions and reduces the risk of complications while awaiting further assessment by the healthcare provider.
Which principle does not follow neuromaturational theory?
- A. The sequence and rate of motor development are consistent among infants
- B. Movement emerges from an interaction and cooperation of many systems
- C. Movement progresses from primitive reflexes to voluntary control
- D. Low-level skills are prerequisites for certain high-level skills
Correct Answer: B
Rationale: Neuromaturational theory emphasizes that motor development progresses in a predictable sequence and rate, starting from primitive reflexes to voluntary control. It also states that low-level skills are foundational for higher-level skills. However, the theory does not support the idea that movement solely emerges from an interaction and cooperation of many systems, as it focuses more on the hierarchical development of motor skills.
A newborn diagnosed with an omphalocele defect is admitted to the intensive care nursery. Which nursing action is appropriate based on the current data?
- A. Placing the newborn on a radiant warmer
- B. Placing the newborn in an open crib
- C. Preparing the newborn for phototherapy
- D. Preparing the newborn for bottle-feeding
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
For a 6-year-old child with hypokalemia, which menu choice should the nurse encourage?
- A. Pizza with a fruit plate
- B. Chicken strips with chips
- C. Fajita with rice
- D. Hamburger with French fries
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A parent of a school-age child is receiving discharge teaching following a cardiac catheterization. Which of the following instructions should be included by the nurse?
- A. Allow the child to bathe 6 hours after the procedure.
- B. Keep the child on bed rest for 12 hours.
- C. Maintain a pressure dressing on the site for 8 hours.
- D. Resume regular activities the day after the procedure.
Correct Answer: B
Rationale: The correct instruction that the nurse should include is to keep the child on bed rest for 12 hours following a cardiac catheterization. This is important to prevent bleeding at the insertion site and ensure proper healing. Allowing the child to bathe soon after the procedure, maintaining a pressure dressing for only 8 hours, or resuming regular activities the day after the procedure can increase the risk of complications such as bleeding or infection.