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A child with acute glomerulonephritis is in the playroom and experiences blurred vision and a headache. What action should the nurse take?
- A. Check the urine to see if hematuria has increased.
- B. Obtain the child's blood pressure and notify the healthcare provider.
- C. Obtain serum electrolytes and send urinalysis to the laboratory.
- D. Reassure the child and encourage bed rest until the headache improves.
Correct Answer: B
Rationale: Blurred vision and headache in a child with acute glomerulonephritis may indicate severe hypertension, which requires immediate assessment and intervention. Blood pressure should be checked, and the healthcare provider notified.
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According to Erikson's developmental theory, toddlers need to be encouraged to become independent to successfully complete which developmental challenge?
- A. Trust vs. mistrust
- B. Industry vs. inferiority
- C. Autonomy vs. shame and doubt
- D. Initiative vs. guilt
Correct Answer: C
Rationale: The correct answer is C: Autonomy vs. shame and doubt. Erikson's developmental stage for toddlers focuses on the conflict between developing a sense of independence (autonomy) and feelings of inadequacy (shame and doubt). Encouraging toddlers to explore their environment and make choices helps them build self-confidence and independence. Choices A, B, and D are incorrect because trust vs. mistrust relates to infancy, industry vs. inferiority is associated with school-age children, and initiative vs. guilt is linked to preschoolers.
A parent asks the nurse what would be the first indication that acute glomerulonephritis was improving. What would be the nurse's best response?
- A. Blood pressure will stabilize.
- B. Your child will have more energy.
- C. Urine will be free of protein.
- D. Urine output will increase.
Correct Answer: D
Rationale: Increased urine output is often the first sign that acute glomerulonephritis is improving, as it indicates a reduction in fluid retention and better kidney function. Stabilization of blood pressure and other symptoms typically follow.
When taking a child's blood pressure, what percentage of the upper arm should the nurse ensure the cuff bladder width covers?
- A. 20%
- B. 40%
- C. 60%
- D. 80%
Correct Answer: B
Rationale: When taking a child's blood pressure, the nurse should select a cuff with a bladder width that covers 40% of the arm circumference at the midpoint of the upper arm. This ensures accurate readings. Choosing a cuff that covers less or more than 40% can lead to incorrect blood pressure measurements. Therefore, options A, C, and D are incorrect.
A parent calls the hospital nursing hotline and asks, 'My 8-week-old infant cries 8 hours a day, and is hard to console. Is that normal?' What should the nurse's response be to this parent?
- A. No, call your health care provider.
- B. Let me ask you some more questions to see if there are symptoms of colic.
- C. Yes, maybe your infant is just tired.
- D. Yes, infants cry all the time at that age.
Correct Answer: B
Rationale: The correct response for the nurse to provide in this situation is to ask more questions to determine if the infant is displaying symptoms of colic. Colic is a common condition in infants that can lead to prolonged crying and fussiness. It is essential to assess for other symptoms before giving advice to the parent. Choices A, C, and D are incorrect because they do not address the possibility of colic or the need for further assessment of the infant's condition.
Which clinical manifestations should the nurse anticipate when assessing a child for hypoglycemia?
- A. Lethargy
- B. Thirst
- C. Nausea and vomiting
- D. Shaky feeling and dizziness
Correct Answer: D
Rationale: The correct answer is D: 'Shaky feeling and dizziness.' Hypoglycemia in children often presents with symptoms like shakiness, dizziness, sweating, hunger, and irritability. These symptoms occur because the brain and body are deprived of the glucose they need to function properly. Choices A, B, and C are incorrect because lethargy, thirst, nausea, and vomiting are not typically primary manifestations of hypoglycemia in children.