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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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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 that can cause rapid airway obstruction. Intubation ensures a secure airway and oxygenation. Throat culture (B) is not a priority in this acute situation. Suctioning (C) can provoke spasm and worsen obstruction. Cool mist tent (D) does not address the immediate need for securing the airway.
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 in a clinic is planning care for a child who has ADHD and is taking atomoxetine. Which of the following laboratory values should the nurse monitor?
- A. Liver function tests
- B. Kidney function tests
- C. Hemoglobin and hematocrit
- D. Serum sodium and potassium
Correct Answer: A
Rationale: The correct answer is A: Liver function tests. Atomoxetine, used to treat ADHD, can potentially cause liver injury. Monitoring liver function tests can help detect any liver abnormalities early on. Kidney function tests (B) are not typically affected by atomoxetine. Hemoglobin and hematocrit (C) are not directly impacted by this medication. Serum sodium and potassium (D) are not specifically associated with atomoxetine use.
A nurse is caring for a 1-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The guardian asks, 'What are the indications that my baby needs an IV?' Which of the following responses should the nurse make?
- A. Your baby needs an IV because she is not producing tears.
- B. Your baby needs an IV because her heart rate is decreased.
- C. Your baby needs an IV because she is breathing slower than normal.
- D. Your baby needs an IV because her fontanels are bulging.
Correct Answer: A
Rationale: The correct response is A: Your baby needs an IV because she is not producing tears. In infants, the inability to produce tears is a sign of severe dehydration, indicating a deficit in body fluids. Tears are composed of water and electrolytes, and the absence of tears suggests a significant fluid imbalance. This makes it crucial to administer parenteral fluid therapy via an IV to restore hydration levels.
Choices B, C, and D are incorrect because they do not directly correlate with the need for IV fluid therapy in this scenario. A decreased heart rate, slower breathing, and bulging fontanels may be signs of distress or other issues but do not specifically indicate the need for immediate IV fluid administration due to dehydration. Therefore, option A is the most appropriate and relevant response given the infant's presentation of severe dehydration.
A nurse is assessing a child who has measles. Which of the following areas should the nurse inspect for Koplik spots?
Correct Answer: C
Rationale: The correct answer is C. Koplik spots are small, white, grain-like spots with a red halo that appear on the buccal mucosa opposite the molars. They are specific to measles and typically appear 2-4 days before the rash. Inspecting other areas like the skin (choice A), scalp (choice B), nails (choice D), ears (choice E), throat (choice F), or feet (choice G) would not reveal Koplik spots as they are only found in the mouth. Therefore, choice C is the correct option for assessing Koplik spots in a child with measles.