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A nurse is collecting data from a child who has acute appendicitis. Which of the following findings should the nurse expect?
- A. Bradycardia
- B. Hyperactive bowel sounds
- C. WBC 17,000/mm
- D. Left lower quadrant abdominal pain
Correct Answer: C
Rationale: Bradycardia, or a slower than normal heart rate, is not typically associated with acute appendicitis. In fact, tachycardia, or a faster than normal heart rate, may occur due to the body's response to inflammation and infection. Hyperactive bowel sounds are not a typical finding in acute appendicitis. In fact, bowel sounds may be normal or decreased due to the inflammatory process. A white blood cell (WBC) count of 17,000/mm is higher than the normal range, indicating the presence of an infection or inflammation in the body. This is a common finding in acute appendicitis. Pain from appendicitis is typically located in the right lower quadrant of the abdomen, not the left.
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A nurse is preparing a 4-year-old child for discharge following a bilateral myringotomy with tympanostomy tube placement. The mother asks what to do if the tubes fall out. Which of the following instructions should the nurse give the parent?
- A. Gently reinsert the tubes.
- B. Call the health care clinic to report that the tubes have fallen out.
- C. Reassure the mother that the tubes will not fall out.
- D. Take the child to an emergency department.
Correct Answer: B
Rationale: It is not advisable for a parent to attempt to reinsert the tubes if they fall out. This could potentially cause harm to the child's ear. If the tubes fall out, the parent should call the healthcare clinic to report this. The healthcare provider can then decide on the appropriate next steps. It is not accurate to reassure the mother that the tubes will not fall out. Tympanostomy tubes are designed to fall out on their own after a certain period of time. Taking the child to an emergency department is not necessary unless there are signs of infection or other complications.
A nurse is providing teaching to a school-age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates a need for additional teaching?
- A. I will test my blood sugar before meals and at bedtime.'
- B. I should not take my regular insulin when I am sick.'
- C. I will rotate injection sites within my abdominal area.'
- D. I should eat a snack before I play soccer.'
Correct Answer: B
Rationale: Regular blood sugar testing is crucial for managing type 1 diabetes. It helps the child and their caregivers monitor the child's blood sugar levels and make necessary adjustments to their insulin doses or diet. This statement indicates a need for additional teaching. Even when sick, it's important for individuals with type 1 diabetes to continue taking their insulin. Illness often causes blood sugar levels to rise, so insulin is still needed. Rotating injection sites can help prevent skin problems, such as lipodystrophy (a lump under the skin caused by the accumulation of extra fat at the site of many subcutaneous injections of insulin). Therefore, this is a correct practice. Physical activity can lower blood sugar levels. Eating a snack before physical activities like playing soccer can help prevent hypoglycemia (low blood sugar). This is a correct understanding of managing physical activity with type 1 diabetes.
A nurse is caring for a 2-year-old child who has been diagnosed with nephrotic syndrome. The nurse collects data knowing that a common characteristic associated with nephrotic syndrome is:
- A. Hypotension
- B. Generalized edema
- C. Increased urinary output
- D. Bright red blood in urine
Correct Answer: B
Rationale: Hypotension, or low blood pressure, is not typically associated with nephrotic syndrome. In fact, some patients with nephrotic syndrome may experience high blood pressure. Generalized edema, or swelling, is a common characteristic of nephrotic syndrome. It occurs due to the loss of proteins in the urine, which leads to a decrease in the amount of protein in the blood. This decrease in blood protein levels causes fluid to move from the blood vessels into the tissues, leading to swelling. Increased urinary output is not typically associated with nephrotic syndrome. In fact, some patients may experience decreased urine output. Bright red blood in the urine is not a typical symptom of nephrotic syndrome. Hematuria, or blood in the urine, when present in nephrotic syndrome, is usually microscopic and not visible to the naked eye.
A nurse is providing instructions about methylphenidate (Ritalin) to the parents of a school-age child who has ADHD. Which of the following instructions should the nurse include?
- A. You will need to give your child the medication after meals.
- B. You will need to have your child's blood glucose level checked monthly.
- C. You should not give your child the medication on weekends.
- D. You should give your child's last daily dose of the medication before 6 o'clock in the evening.
Correct Answer: D
Rationale: Methylphenidate (Ritalin) is a medication used to treat attention-deficit hyperactivity disorder (ADHD). It is not necessary to give the medication after meals. The medication can be taken with or without food. However, some people find that taking it with food can help prevent stomach upset. Regular blood glucose level checks are not typically required when a child is taking methylphenidate. This medication does not have a significant impact on blood sugar levels. It is not generally recommended to skip doses of methylphenidate on weekends. Consistent medication administration is important for managing ADHD symptoms. However, the prescribing doctor may sometimes recommend a 'drug holiday' or break from the medication. This should only be done under the guidance of a healthcare professional. This is the correct answer. Methylphenidate is a stimulant, and taking it later in the day can cause insomnia or trouble sleeping. Therefore, it is often recommended that the last dose of the medication be given before 6 o'clock in the evening to minimize sleep disturbances.
A nurse is reinforcing teaching about manifestations of hypoglycemia with an adolescent who has type 1 diabetes mellitus. Which of the following manifestations should the nurse include in the teaching?
- A. Rapid respirations
- B. Diminished reflexes
- C. Acetone breath
- D. Diaphoresis
Correct Answer: D
Rationale: Rapid respirations are not typically a manifestation of hypoglycemia. They are more commonly associated with conditions that cause metabolic acidosis, such as diabetic ketoacidosis. Diminished reflexes are not a typical manifestation of hypoglycemia. They may be seen in conditions affecting the nervous system. Acetone breath is not a manifestation of hypoglycemia. It is a sign of ketoacidosis, which is a complication of hyperglycemia, not hypoglycemia. Diaphoresis, or sweating, is a common symptom of hypoglycemia. The body produces sweat as part of the sympathetic nervous system's response to hypoglycemia.