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A nurse is caring for an infant born with exstrophy of the bladder. What does the nurse determine is the greatest risk for this infant?
- A. Infection
- B. Dehydration
- C. Urinary retention
- D. Intestinal obstruction
Correct Answer: A
Rationale: Infection is the greatest risk for an infant with exstrophy of the bladder due to the exposure of the bladder and surrounding tissues. The exposed bladder increases the risk of infection as it lacks the protective covering of the skin. Dehydration (Choice B) may occur but is not the greatest risk compared to infection. Urinary retention (Choice C) is less likely due to the nature of the condition. Intestinal obstruction (Choice D) is not directly associated with exstrophy of the bladder.
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Which best describes a full-thickness (third-degree) burn?
- A. Erythema and pain
- B. Skin showing erythema followed by blister formation
- C. Destruction of all layers of skin evident with extension into subcutaneous tissue
- D. Destruction injury involving underlying structures such as muscle, fascia, and bone
Correct Answer: C
Rationale: The correct answer is C: Full-thickness burns involve the destruction of all layers of skin, extending into the subcutaneous tissue. This type of burn causes severe damage and loss of sensation due to nerve destruction. Choice A, erythema and pain, describes superficial burns (first-degree). Choice B, skin showing erythema followed by blister formation, describes partial-thickness burns (second-degree). Choice D, destruction injury involving underlying structures such as muscle, fascia, and bone, goes beyond the description of full-thickness burns.
A nurse is teaching the parents of a child with a diagnosis of type 1 diabetes mellitus about blood glucose monitoring. What should the nurse emphasize?
- A. Checking blood glucose levels before meals and at bedtime
- B. Using a lancet device to obtain blood samples
- C. Using urine test strips for monitoring
- D. Recognizing signs of hypoglycemia
Correct Answer: A
Rationale: Checking blood glucose levels before meals and at bedtime is essential for managing type 1 diabetes mellitus. This timing helps in assessing the effectiveness of insulin therapy, making adjustments to insulin doses, and preventing hyperglycemia and hypoglycemia. Option B is incorrect because it focuses on the method of obtaining blood samples rather than the timing of monitoring. Option C is incorrect as urine test strips are not recommended for accurate blood glucose monitoring in type 1 diabetes. Option D, recognizing signs of hypoglycemia, is important but not the primary emphasis when teaching about blood glucose monitoring.
While assessing an 18-month-old child, a nurse observes that the toddler can crawl upstairs but needs assistance when climbing the stairs upright. What does this action indicate to the nurse?
- A. Presence of talipes equinovarus
- B. Reflective of neurologic damage
- C. Expected behavior in a toddler of this age
- D. Existence of developmental dysplasia of the hip
Correct Answer: C
Rationale: The correct answer is C. Needing assistance to climb stairs is considered expected behavior for an 18-month-old toddler. At this age, children are still developing their gross motor skills, coordination, and balance, which can vary in proficiency. It is common for toddlers to be able to crawl upstairs before mastering the skill of climbing stairs upright. Options A, B, and D are incorrect because at 18 months, it is normal for children to require help and practice with climbing stairs and does not necessarily point to any specific medical conditions or developmental issues.
When teaching parents about preventing childhood obesity, what should the nurse recommend?
- A. Encourage high-calorie snacks
- B. Limit screen time
- C. Encourage fast food as a treat
- D. Allow the child to eat freely
Correct Answer: B
Rationale: Limiting screen time is a crucial recommendation to prevent childhood obesity. Excessive screen time is associated with sedentary behavior and increased consumption of unhealthy snacks, leading to weight gain. Encouraging high-calorie snacks (Choice A) contradicts the goal of preventing obesity. While fast food as a treat (Choice C) can be consumed occasionally, it should not be encouraged as a regular practice. Allowing the child to eat freely (Choice D) without restrictions can lead to overeating and unhealthy dietary habits, contributing to obesity risk.
A 3-year-old child is being discharged after being treated for dehydration. What should be included in the discharge teaching?
- A. Monitor for signs of infection
- B. Monitor for signs of dehydration
- C. Monitor for signs of hypovolemia
- D. Monitor for signs of malnutrition
Correct Answer: B
Rationale: The correct answer is to monitor for signs of dehydration. After treatment for dehydration, it is crucial to educate caregivers about recognizing early signs of dehydration to prevent its recurrence. Monitoring for dehydration ensures that appropriate measures can be taken promptly if signs reappear. Choices A, C, and D are incorrect because infection, hypovolemia, and malnutrition, while important considerations in healthcare, are not the primary focus after treating dehydration in a 3-year-old child.