Nokea
A mother brings her 18-month-old to the clinic because the child 'eats ashes, crayons, and paper.' Which of the following information about the toddler should the nurse assess first?
- A. Evidence of eruption of large teeth.
- B. Amount of attention from the mother.
- C. Any changes in the home environment.
- D. Intake of a soft, low-roughage diet.
Correct Answer: C
Rationale: Changes in the home environment may contribute to pica, which requires immediate assessment.
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Which of the following nursing diagnoses would be appropriate for the nurse to identify as a priority diagnosis for an infant just admitted to the hospital with a diagnosis of gastroenteritis?
- A. Pain related to repeated episodes of vomiting.
- B. Deficient fluid volume related to excessive losses from severe diarrhea.
- C. Impaired parenting related to infant's loss of feeding pattern.
- D. Impaired urinary elimination related to increased fluid intake.
Correct Answer: B
Rationale: Fluid loss from diarrhea is the most urgent concern in gastroenteritis.
When developing the plan of care for a child with cystic fibrosis (CF) who is scheduled to receive postural drainage, the nurse should anticipate performing postural drainage at which of the following times?
- A. After meals.
- B. Before meals.
- C. After rest periods.
- D. Before inhalation treatments.
Correct Answer: B
Rationale: Postural drainage should be performed before meals to avoid discomfort and reduce the risk of vomiting, as it involves positioning to facilitate mucus clearance.
A student with type 1 diabetes tells the nurse she is feeling light-headed. The student's blood sugar is 60 mg/dL. Using the 15-15 rule, the nurse should:
- A. Give 15 mL of juice and give another 15mL in 15 minutes.
- B. Give 15 g of carbohydrate and retest the blood sugar in 15 minutes.
- C. Give 15 g of carbohydrate and 15 g of protein.
- D. Give 15 oz of juice and retest in 15 minutes.
Correct Answer: B
Rationale: The 15-15 rule involves giving 15 g of fast-acting carbohydrate (e.g., 4 oz juice) and retesting after 15 minutes to correct hypoglycemia. Protein is not immediate, and incorrect volumes (15 mL or 15 oz) are ineffective.
When developing the teaching plan about illness for the mother of a preschooler, which of the following should the nurse include about how a preschooler perceives illness?
- A. A necessary part of life.
- B. A test of self-worth.
- C. A punishment for wrongdoing.
- D. The will of God.
Correct Answer: C
Rationale: Preschoolers often view illness as punishment for bad behavior due to magical thinking.
While assessing the penis of a child who has had surgery for repair of a hypospadias, the nurse observes the appearance of the penis. The nurse should report which aspect to the surgeon?
- A. Swollen.
- B. Dusky blue at the tip.
- C. Somewhat misshapen.
- D. Pink.
Correct Answer: B
Rationale: Dusky coloration may indicate compromised circulation.