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A nurse is collecting data from a client who has a urinary tract infection. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Hematuria
- B. Urinary frequency
- C. Polyuria
- D. Dependent edema
- E. Dysuria
Correct Answer: A,B,E
Rationale: A. Hematuria: Hematuria, or blood in the urine, is a common finding in urinary tract infections (UTIs). It occurs due to irritation and inflammation of the urinary tract lining, causing small blood vessels to leak blood into the urine. B. Urinary frequency: Urinary frequency, or the need to urinate more often than usual, is a classic symptom of a UTI. It occurs because the infection irritates the bladder lining, leading to a frequent urge to urinate even when the bladder is not full. C. Polyuria: Polyuria, or excessive urination, is not typically associated with uncomplicated urinary tract infections. Instead, UTIs usually cause urinary frequency without necessarily increasing the total volume of urine produced (polyuria). D. Dependent edema: Dependent edema, or swelling in the lower extremities due to fluid accumulation, is not a typical finding in urinary tract infections. UTIs primarily affect the urinary system and do not typically cause system
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12-month-old boy weighed 8 lb 2 oz at birth. Understanding developmental milestones, what should the nurse caring for the child expect the current weight to be?
- A. 24 lb 6 oz
- B. 20 lb 5oz
- C. 32 lb 8 0z
- D. 16 lb 4 oz
Correct Answer: A
Rationale: The nurse should expect the 12-month-old boy to weigh approximately 24 lb 6 oz (since 0.375 lb ≈ 6 oz).
So, around 24 lbs 6 oz is a normal expected weight at 12 months for a baby born at 8 lb 2 oz.
A nurse is caring for a child who has atopic dermatitis. Which of the following findings should the nurse expect?
- A. Maculopapular lesions between fingers and toes
- B. Inflamed area with white exudate
- C. Nonpruritic erythematous papule
- D. Rash with thick skin
Correct Answer: D
Rationale: Maculopapular lesions between fingers and toes: This finding is not typically associated with atopic dermatitis. Maculopapular lesions between the fingers and toes are more commonly seen in conditions like scabies or fungal infections. Inflamed area with white exudate: This finding is also not characteristic of atopic dermatitis. An inflamed area with white exudate may indicate a bacterial infection rather than atopic dermatitis. Nonpruritic erythematous papule: Atopic dermatitis often presents with erythematous (red) papules (small raised bumps) that are pruritic (itchy). However, the presence of nonpruritic lesions is less typical of atopic dermatitis. Rash with thick skin: This finding is consistent with atopic dermatitis. Chronic scratching and rubbing of the affected areas can lead to thickening of the skin (lichenification) in individuals with atopic dermatitis.
When assessing a child with Wilm's tumor, the nurse should keep in mind that it is most important to avoid which of the following?
- A. Measuring the child's chest circumference
- B. Palpating the child's abdomen
- C. Measuring the child's occipitofrontal circumference
- D. Placing the child in an upright position
Correct Answer: B
Rationale: Measuring the child's chest circumference: Measuring the chest circumference may not directly aid in the assessment of Wilm's tumor. While it's important for assessing respiratory conditions or monitoring growth, it's not a primary assessment for Wilm's tumor, which primarily affects the abdomen. Palpating the child's abdomen: This is an essential action in assessing for Wilm's tumor. The nurse should carefully palpate the abdomen to check for any masses, swelling, or tenderness, as these could be indicative of the tumor. Measuring the child's occipitofrontal circumference: This measurement pertains to the head circumference and is not directly related to the assessment of Wilm's tumor. While it's important for monitoring head growth and development, it's not a priority when assessing for Wilm's tumor. Placing the child in an upright position: Placing the child in an upright position may be necessary for certain assessments or procedures, but it's not directly related to assessing for Wilm's tumor. The focus should primarily be on abdominal assessment and palpation to detect any signs of the tumor.
A nurse is providing teaching to a parent of a child who has celiac disease. The nurse should include which of the following as an acceptable food choice for this child?
- A. Barley
- B. Rye
- C. Rice
- D. Wheat
Correct Answer: C
Rationale: Barley: Barley is a grain that contains gluten. Foods made from barley, such as barley flour or barley-based products like bread, cereal, or beer, should be avoided by individuals with celiac disease because gluten can trigger an immune response that damages the small intestine. Rye: Similar to barley, rye is another grain that contains gluten. Foods made from rye, such as rye bread or rye-based cereals, should also be avoided by individuals with celiac disease because they can trigger adverse reactions due to gluten. Rice: Rice is a gluten-free grain and is safe for individuals with celiac disease to consume. It does not contain gluten proteins that can cause intestinal damage or trigger immune responses in those with gluten sensitivity or celiac disease. Wheat: Wheat is a major source of gluten and should be strictly avoided by individuals with celiac disease. Foods made from wheat, such as wheat bread, pasta, or baked goods, can lead to symptoms and intestinal damage in individuals with gluten intolerance or celiac disease.
A nurse is caring for a toddler who has intussusception. Which of the following manifestations should the nurse expect?
- A. Drooling
- B. Increased appetite
- C. Mucus in stools
- D. Jaundice
Correct Answer: C
Rationale: Drooling - Drooling is not typically associated with intussusception. Intussusception is a condition where one portion of the intestine telescopes into another, leading to bowel obstruction and subsequent symptoms such as abdominal pain, vomiting, and 'currant jelly' stools. Increased appetite - Increased appetite is unlikely in a toddler with intussusception. Instead, affected toddlers may experience symptoms such as abdominal pain, vomiting, and lethargy, which can lead to decreased appetite. Mucus in stools - Mucus in stools is a characteristic finding in intussusception. As the telescoping of the intestine causes irritation and inflammation, mucus may be passed in the stool along with blood and, in some cases, a characteristic 'currant jelly' appearance. Jaundice - Jaundice is not a typical manifestation of intussusception. It may be present in conditions affecting the liver or bile ducts, such as biliary atresia or obstructive jaundice, but it is not a direct symptom of intussusception.