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A nurse is counseling parents of a child beginning to show signs of being overweight. The nurse accurately relates which body mass index (BMI)-for-age percentile indicates a risk for being overweight?
- A. 10th percentile
- B. 9th percentile
- C. 85th percentile
- D. 95th percentile
Correct Answer: D
Rationale: The body mass index (BMI)-for-age percentile indicating a risk for being overweight is the 95th percentile. This means that if a child's BMI falls at or above the 95th percentile for their age group, they are classified as overweight. This percentile is used as a cutoff point to identify children at risk of being overweight and to guide intervention strategies such as lifestyle changes, increased physical activity, and dietary modifications. Parents should work with healthcare providers to address their child's weight status and implement appropriate measures to promote a healthy lifestyle.
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A client with end-stage acquired immunodeficiency syndrome (AIDS) has profound manifestations of Cryptosporidium infection caused by the protozoa. In planning the client's care, the nurse should focus on his need for:
- A. Pain management
- B. Antiretroviral therapy
- C. Fluid replacement
- D. High-calorie intake
Correct Answer: C
Rationale: In a client with end-stage acquired immunodeficiency syndrome (AIDS) manifesting with profound Cryptosporidium infection, fluid replacement is crucial for managing the symptoms and complications. Cryptosporidium infection can cause severe diarrhea and dehydration, leading to significant fluid loss. Therefore, the primary focus of care in this situation should be on maintaining adequate hydration through fluid replacement. This is essential for preventing further complications and supporting the client's overall health and well-being. Pain management, antiretroviral therapy, and high-calorie intake may be important aspects of care in other situations but are not the priority in managing a client with severe Cryptosporidium infection and dehydration.
The pediatric nurse advises a parent how to best convey the circumstances surrounding the sudden death of an 18-month-old patient to a four-year-old sibling. The nurse anticipates that the sibling:
- A. may feel guilty about the patient's death.
- B. may mistrust the parent.
- C. understands the permanence of death.
- D. will role-play the patient's death.
Correct Answer: A
Rationale: Young children often struggle with understanding death and may internalize feelings of guilt, believing they had a role in the event.
In an individual with Sjogren's syndrome, nursing care should focus on:
- A. Moisture replacement
- B. Nutritional supplementation
- C. Electrolyte balance
- D. Arrhythmia management
Correct Answer: A
Rationale: Sjogren's syndrome is an autoimmune disorder characterized by dryness of the eyes and mouth due to the destruction of moisture-producing glands. Nursing care for individuals with Sjogren's syndrome should focus on addressing the symptoms related to dryness. Moisture replacement is key in managing dry eyes and dry mouth, which can improve the patient's comfort and quality of life. Strategies for moisture replacement may include the use of artificial tears, saliva substitutes, and humidifiers to maintain adequate hydration and alleviate dryness. Nutritional supplementation, electrolyte balance, and arrhythmia management are not typically the primary focus of nursing care in individuals with Sjogren's syndrome.
When caring for a patient with AIDS, which of the following nursing actions would be the most appropriate for infection control?
- A. Wear gloves at all times
- B. Wear gown and mask at all times
- C. Wear gloves for blood/body fluid contact
- D. Wear a mask during patient contact times
Correct Answer: C
Rationale: The most appropriate nursing action for infection control when caring for a patient with AIDS is to wear gloves for blood/body fluid contact. HIV, the virus that causes AIDS, is primarily spread through exposure to infected blood or body fluids. Therefore, wearing gloves when there is a potential for blood or body fluid contact is crucial in preventing the transmission of the virus. Wearing gloves at all times may not be necessary if there is no direct contact with blood or body fluids, and wearing a gown and mask at all times may not be indicated unless there is a specific need based on the situation. Wearing a mask during patient contact times may also not be necessary unless there is a risk of exposure to respiratory secretions.
Prenatal screening is recommended for all pregnant women to detect neural tube defect. If a neural tube defect is present, one of the following is often elevated
- A. human chorionic gonadotropin
- B. a-fetoprotein
- C. estriol
- D. inhibin
Correct Answer: B
Rationale: Alpha-fetoprotein (AFP) levels are elevated in maternal serum when a neural tube defect is present due to fetal leakage of AFP into the amniotic fluid and maternal circulation.