Nokea
A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider?
- A. Pale and a 24-hr fluid deficit of 30 mL
- B. Sunken fontanels and dry mucous membranes
- C. Decreased appetite and irritability
- D. Temperature 38° C (100.4° F) and pulse rate 124/min
Correct Answer: B
Rationale: The correct answer is B: Sunken fontanels and dry mucous membranes. These findings indicate severe dehydration in the infant with gastroenteritis. Sunken fontanels suggest significant fluid loss, while dry mucous membranes also indicate dehydration. Dehydration in infants can lead to serious complications, so it is crucial for the nurse to report these findings to the provider promptly.
The other choices are not as concerning as choice B. Choice A indicates a fluid deficit but does not suggest severe dehydration. Choice C could be expected in a sick infant and does not require immediate provider notification. Choice D shows signs of fever and tachycardia, which are common in gastroenteritis and may not be as urgent as severe dehydration.
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A 7-year-old obese child was diagnosed at his 6-year primary care visit with idiopathic hypertension. The family was instructed to modify his diet and begin an exercise program to control the hypertension. At this visit, it was decided the child should begin a low dose of Lisinopril (Zestril) at 0.07 mg/kg/day. The child weighs 99 pounds. What is the correct dose for this child?
- A. 70 mg/day
- B. 30 mg/day
- C. 6 mg/day
- D. 3 mg/day
Correct Answer: D
Rationale: The correct dose for this child is 3 mg/day. To calculate the dose, we first need to convert the child's weight from pounds to kilograms by dividing by 2.2 (99 lbs / 2.2 = 45 kg). Next, we multiply the weight in kg by the prescribed dosage of 0.07 mg/kg/day (45 kg x 0.07 mg/kg/day = 3.15 mg/day). Since the dosing is typically rounded down for safety reasons, the correct dose is 3 mg/day.
Choice A (70 mg/day) is incorrect because it is too high for a child of this weight and could lead to adverse effects. Choice B (30 mg/day) is also too high. Choice C (6 mg/day) is incorrect as it does not reflect the calculated dosage based on the weight of the child. Therefore, the correct answer is D (3 mg/day) based on the calculated dosage per kg for this specific child.
When caring for a patient with Syndrome of inappropriate Antidiuretic Hormone Secretion (SIADH), the nurse would expect her patient to exhibit the following clinical signs and symptoms (Select all that apply):
- A. Fluid retention
- B. Hypotonicity
- C. Anorexia
- D. Frequent urination
Correct Answer: A,B,C
Rationale: Step-by-step rationale:
A: Fluid retention - In SIADH, there is excessive ADH secretion leading to water retention and dilutional hyponatremia.
B: Hypotonicity - Due to water retention, serum osmolality decreases leading to hypotonicity.
C: Anorexia - SIADH can cause nausea, vomiting, and anorexia due to hyponatremia and cerebral edema.
Incorrect choices:
D: Frequent urination - SIADH causes water retention, leading to decreased urine output, not frequent urination.
The nurse understands that the pathophysiology of a thermal injury includes (Select All that Apply):
- A. Hematuria
- B. Edema
- C. Hypovolemia
- D. Anemia
Correct Answer: B,C
Rationale: The correct answers are B: Edema and C: Hypovolemia. Edema occurs due to increased capillary permeability after a thermal injury, leading to fluid leakage into tissues. Hypovolemia results from fluid shift out of the blood vessels into the injured tissues, causing decreased blood volume. Hematuria (A) is not typically associated with thermal injuries. Anemia (D) is a decrease in the number of red blood cells or hemoglobin, not a direct result of thermal injury.
Parents of a 4-year-old with congenital heart disease are afraid to let their child play with other children because of possible overexertion. The nurse's reply should be based on which statement?
- A. Parents can meet all the needs of their child
- B. Children need to understand the activities of their peers are too strenuous
- C. Constant parental supervision is required to avoid overexertion
- D. Children need opportunities to play with their peers to foster their growth and development
Correct Answer: D
Rationale: The correct answer is D: Children need opportunities to play with their peers to foster their growth and development. The rationale is as follows: Playing with peers is essential for a child's social, emotional, and cognitive development. It helps them learn important skills like cooperation, communication, and problem-solving. Restricting the child's play due to fear of overexertion can have negative consequences on their overall development. It is important for children to engage in age-appropriate play activities under supervision to ensure safety while promoting growth.
Now, let's analyze why the other choices are incorrect:
A: Parents can meet all the needs of their child - While parents play a crucial role in meeting a child's needs, social interaction with peers is also important for holistic development.
B: Children need to understand the activities of their peers are too strenuous - This places the burden on the child to limit their activities rather than promoting healthy play.
C: Constant parental supervision is required to avoid overexertion
Anorexia nervosa may best be described as:
- A. Occurring most frequently in adolescent males
- B. Occurring most frequently in adolescents from lower socioeconomic groups
- C. Resulting from a posterior pituitary disorder
- D. Resulting in severe weight loss in the absence of obvious physical causes
Correct Answer: D
Rationale: Anorexia nervosa is characterized by severe weight loss due to restrictive eating behaviors and distorted body image. Choice D is correct as it accurately describes the hallmark symptom of anorexia. Choices A and B are incorrect because anorexia nervosa is more common in adolescent females and does not discriminate based on socioeconomic status. Choice C is incorrect as anorexia nervosa is primarily a psychological disorder, not a pituitary disorder.