Nokea
A nurse is caring for a 7-year-old client who has an upper respiratory infection and a history of type 1 diabetes mellitus. Which of the following statements by the mother indicates a need for further instruction?
- A. I will notify the doctor if his temperature is not controlled with acetaminophen.
- B. I will continue to check his blood sugar two times every day.
- C. I will report a change in breathing or signs of confusion.
- D. I will encourage him to drink a half a cup of water or sugar-free fluid every 30 minutes.
Correct Answer: B
Rationale: Checking blood sugar only twice a day is insufficient during illness especially for a child with type 1 diabetes. Blood glucose levels can fluctuate significantly due to infection and more frequent monitoring (at least 4 times a day or as recommended) is necessary.
You may also like to solve these questions
A nurse is talking with a 13-year-old female client who is having her annual health-screening visit. Which of the following comments by the client should concern the nurse?
- A. My parents treat me like a baby sometimes.
- B. There's a pimple on my face, and I worry that everyone will notice it.
- C. I start taking ibuprofen a few days before my period starts.
- D. None of the kids at my school like me, and I don't like them either.
Correct Answer: D
Rationale: This statement indicates social isolation and potential issues with peer relationships which can be a red flag for emotional distress or depression.
A nurse is attempting to obtain information from a child who is hearing impaired. Which of the following actions should the nurse take?
- A. Stand above the child's eye level when speaking.
- B. Talk directly into the child's impaired ear.
- C. Speak loudly to the child.
- D. Speak slowly while facing the child.
Correct Answer: D
Rationale: Speaking slowly and facing the child ensures that they can read lips and facial expressions.
A nurse is caring for a child who has Hirschsprung disease. Which of the following findings should the nurse expect?
- A. Ribbon Like
- B. foul-smelling stools
- C. Chronic hunger
- D. Projectile vomiting
- E. Rigid abdomen
Correct Answer: A
Rationale: Hirschsprung disease is characterized by a lack of nerve cells in parts of the colon, leading to obstruction and resulting in narrow ribbon-like stool.
A nurse is collecting data from a 4-year-old child. Which of the following findings should the nurse expect?"
- A. Heart rate 110/min
- B. Capillary refill greater than 3 seconds
- C. Weight gain of 0.9 kg (2 lb) in a year
- D. Respiratory rate 32/min
Correct Answer: A
Rationale: A heart rate of 110 beats per minute is within the normal range for a 4-year-old child. The typical heart rate for this age is between 80 to 120 beats per minute.
A nurse is preparing to administer acetaminophen 15 mg/kg PO to a preschool child for fever. The child weighs 30 lb. Available is acetaminophen liquid 160 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 6.4 mL
- B. 5.4 mL
- C. 7.4 mL
- D. 4.4 mL
Correct Answer: 6.4
Rationale: Calculation: 30 lb × 0.454 kg/lb = 13.62 kg; 15 mg/kg × 13.62 kg = 204.3 mg; 204.3 mg ÷ 160 mg/5 mL = 6.4 mL.