Nokea
A nurse is assessing a 7-year-old child who has diabetes. Which of the following findings should the nurse identify as a manifestation of hypoglycemia?
- A. Increased capillary refill
- B. Thirst
- C. Shakiness
- D. Decreased appetite
Correct Answer: C
Rationale: The correct answer is C: Shakiness. Hypoglycemia in a child with diabetes can lead to a decrease in blood sugar levels, causing symptoms like shakiness due to the body's response to low glucose levels. Increased capillary refill (A) is not typically associated with hypoglycemia. Thirst (B) is more commonly seen in hyperglycemia. Decreased appetite (D) can be a symptom of hypoglycemia, but shakiness is a more specific indicator.
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The nurse is continuing to care for the child. Complete the following sentence by using the list of options. The child is at highest risk of developing------ as evidenced bt the child's------
- A. Deep vein thrombosis
- B. Osteomyelitis
- C. Compartment syndrome
- D. Swelling
- E. Warmth and redness
- F. Paresthesia
- G. Weak pulses
Correct Answer: C,F
Rationale: The correct answer is C, Compartment syndrome, and F, Paresthesia. Compartment syndrome results from increased pressure within a closed anatomical space, leading to compromised blood flow and nerve function. Paresthesia, abnormal sensations like tingling or numbness, is an early sign of nerve compression in compartment syndrome. The combination of these symptoms indicates a critical condition requiring immediate intervention to prevent tissue damage. Choices A, B, D, and E do not align with the clinical presentation of compartment syndrome, whereas choice G, weak pulses, may be seen in severe cases but are not specific enough to be the highest risk factor in this scenario.
A nurse in the emergency department is caring for a 10-year-old child. The nurse is assessing the child. Which of the following findings require follow-up? Select the 5 findings that require follow-up.
- A. Temperature
- B. Heart rate
- C. Report of pain
- D. Respiratory rate
- E. Tonsillar findings
- F. Oxygen saturation
Correct Answer: A,B,C,D,E,F
Rationale: The correct answer includes all options (A, B, C, D, E, F) because they are essential vital signs and key indicators of the child's health status. Temperature (A), heart rate (B), respiratory rate (D), and oxygen saturation (F) are crucial physiological parameters that can indicate underlying health issues if abnormal. Report of pain (C) is important to assess the child's comfort and potential underlying conditions. Tonsillar findings (E) could indicate infections or other throat issues. Follow-up on all these findings is necessary for a comprehensive assessment of the child's health.
A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis. Which of the following actions should the nurse take?
- A. Prepare to assist with intubation.
- B. Obtain a throat culture.
- C. Suction the child's oropharynx.
- D. Prepare a cool mist tent.
Correct Answer: A
Rationale: The correct answer is A: Prepare to assist with intubation. Epiglottitis is a medical emergency where the epiglottis becomes inflamed and can lead to airway obstruction. Intubation may be necessary to secure the airway and ensure the child can breathe. It is a priority action to maintain the child's oxygenation and ventilation. Obtaining a throat culture (B) can be important for diagnosis but is not the immediate priority. Suctioning the child's oropharynx (C) can trigger a spasm and worsen the obstruction. Cool mist tent (D) is not indicated in the management of epiglottitis.
A nurse is preparing to administer an IM injection to a 3-year-old child. Which of the following statements should the nurse make?
- A. If you don't cry, you can pick out a prize.
- B. This medicine will fix you to make you feel better.
- C. You will only feel a little stick
- D. You can choose which leg you get your medicine in.
Correct Answer: D
Rationale: The correct answer is D because allowing the child to choose which leg they receive the injection in gives them a sense of control and autonomy, reducing anxiety and fear. This empowers the child and can help build trust between the nurse and the child. Choices A and B involve rewards or vague promises, which may not be effective in alleviating the child's fear. Choice C may minimize the pain but does not address the child's potential anxiety.
A nurse is assessing a 5-year-old child who has diabetes insipidus and is receiving desmopressin. Which of the following findings should the nurse identify as an indication that the medication is effective?
- A. Heart rate 140/min
- B. Capillary refill 3 seconds
- C. Absence of hypoglycemic episodes
- D. Cessation of nocturnal enuresis
Correct Answer: D
Rationale: The correct answer is D: Cessation of nocturnal enuresis. Desmopressin is a medication used to treat diabetes insipidus by decreasing urine output. Nocturnal enuresis is a common symptom of diabetes insipidus due to excessive urine production at night. Therefore, the cessation of nocturnal enuresis indicates that the medication is effectively reducing urine output in the child. Choices A, B, and C are unrelated to the effectiveness of desmopressin in treating diabetes insipidus. Choice A, heart rate of 140/min, is not a specific indicator of desmopressin effectiveness. Choice B, capillary refill of 3 seconds, is a measure of peripheral perfusion and not directly related to diabetes insipidus. Choice C, absence of hypoglycemic episodes, is more relevant to diabetes mellitus and not diabetes insipidus.