Essential of Pediatric Nursing Test Bank

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A client is admitted with a serum glucose of 618mg/dl. The client is awake and oriented, with hot, dry skin; a temperature of 100.6F (38.1 C); a heart rate of 116beats/min; and a blood pressure of 108/70mmHg. Based on these findings, which nursing diagnosis takes highest priority?

  • A. Deficient fluid volume related to osmotic diuresis
  • B. Decreased cardiac output related to increased heart rate
  • C. Imbalanced nutrition: Less than body requirements related to insulin deficiency
  • D. Ineffective thermoregulation related to dehydration
Correct Answer: A

Rationale: The highest priority nursing diagnosis in this scenario is Deficient fluid volume related to osmotic diuresis. The client's serum glucose level of 618mg/dl indicates severe hyperglycemia, which is likely causing osmotic diuresis leading to fluid volume deficit. The client's hot, dry skin, along with a heart rate of 116 beats/min, and blood pressure of 108/70mmHg are symptoms of dehydration due to fluid loss. If left untreated, deficient fluid volume can lead to serious complications such as hypovolemic shock. Therefore, addressing the fluid volume deficit is essential to stabilize the client's condition before other nursing diagnoses are addressed.

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An obese Hispanic client, age 65, is diagnosed with type 2 diabetes mellitus. Which statement about diabetes mellitus is true?

  • A. Nearly two-thirds of client with diabetes mellitus are over age
Correct Answer: A

Rationale: Diabetes mellitus is a chronic condition that affects people of all ages, but the prevalence increases with age. As people get older, their risk of developing type 2 diabetes mellitus also increases. Research has shown that nearly two-thirds of individuals with diabetes are over the age of 60. Age is a significant risk factor for developing diabetes, especially type 2 diabetes, which is more common in older individuals. Therefore, the statement "Nearly two-thirds of clients with diabetes mellitus are over the age of 60" is true.

Which of the following positions would be most appropriate for a patient with right-sided paralysis following a stroke?

  • A. On the side with support to the back, with pillows to keep the body in alignment, hips slightly flexed, and hands tightly holding a rolled washcloth.
  • B. On the side with support to the back, pillows to keep the body in alignment, hips slightly flexed, and a washcloth placed so that fingers are slightly curled.
  • C. On the back with two large pillows under the head, pillow under" the knees, and a footboard.
  • D. On the back with no pillows used, with trochanter rolls and a footboard.
Correct Answer: B

Rationale: The most appropriate position for a patient with right-sided paralysis following a stroke is Option B - On the side with support to the back, pillows to keep the body in alignment, hips slightly flexed, and a washcloth placed so that fingers are slightly curled.

The nurse is using the FLACC scale to rate the pain level in a 9-month-old. Which is the nurse's best response to the father's question of what the FLACC scale is?

  • A. It estimates a child's level of pain utilizing vital sign information.
  • B. It estimates a child's level of pain based on parents' perception.
  • C. It estimates a child's level of pain utilizing behavioral and physical responses.
  • D. It estimates a child's level of pain utilizing a numeric scale from 0 to 5.
Correct Answer: C

Rationale: The FLACC scale uses observable behavioral and physical responses (facial expression, leg movement, activity, cry, and consolability) to estimate pain.

When the nurse interviews an adolescent, which is especially important?

  • A. Focus the discussion on the peer group.
  • B. Allow an opportunity to express feelings.
  • C. Emphasize that confidentiality will always be maintained.
  • D. Use the same type of language as the adolescent.
Correct Answer: B

Rationale: When the nurse interviews an adolescent, allowing an opportunity for the adolescent to express their feelings is especially important. Adolescents are at a stage in life where they are developing their own identity and dealing with a range of emotions. Providing a safe space for them to open up about their thoughts and feelings can help the nurse better understand and address their needs. This can also build a trustful relationship between the nurse and the adolescent, leading to more effective communication and care.

What dietary advice should the nurse give to clients with HIV/AIDS?

  • A. Encourage the intake of fat soluble vitamins in amounts 2 to 5 times the recommended daily allowance (RDA)
  • B. Encourage intake of water soluble vitamins in amounts 2 to 5 times the RDA
  • C. Increase the intake of iron and zinc
  • D. Decrease the intake of trace elements and antioxidant supplements
Correct Answer: D

Rationale: It is important for clients with HIV/AIDS to maintain a balanced diet that includes a variety of healthy foods to help support their immune system and overall health. While it may be beneficial for them to increase their intake of certain vitamins and minerals, such as vitamin C and zinc, it is generally recommended to get these nutrients from food sources rather than supplements. In fact, there is no evidence to support the routine use of trace elements and antioxidant supplements in individuals with HIV/AIDS. It is always best to consult with a healthcare provider or a dietitian for tailored dietary advice based on individual needs and health status.

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