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A nurse is providing guidance to a toddler's parent about the types of food that are part of a clear liquid diet. Which food, if suggested by the parent, would indicate that they have understood the instructions?
- A. Yogurt
- B. Gelatin
- C. Strained soup
- D. Pureed fruit
Correct Answer: B
Rationale: Yogurt is not part of a clear liquid diet. It is a dairy product and is not clear or liquid at room temperature. Gelatin is part of a clear liquid diet. This type of diet is often prescribed before medical procedures or tests, or for patients with certain digestive issues. It consists of liquids and foods that are clear and liquid at room temperature. Strained soup might be allowed on a full liquid diet, but it is not part of a clear liquid diet. Only the broth of the soup, which is clear and liquid at room temperature, would be allowed. Pureed fruit is not part of a clear liquid diet. While it is a liquid at room temperature, it is not clear.
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A school nurse is screening an 11-year-old child for idiopathic scoliosis. Which of the following instructions should the nurse give the child for this examination?
- A. Bend forward from the waist with your head and arms downward.
- B. Touch your chin to your chest, and then look up at the ceiling.
- C. Lie prone on the examination table.
- D. Turn to the side and remain in a relaxed position.
Correct Answer: A
Rationale: Bending forward from the waist with the head and arms downward, also known as the Adams forward bend test, is the standard screening test for scoliosis. Touching the chin to the chest and then looking up at the ceiling does not provide a view of the spine necessary for scoliosis screening. Lying prone on the examination table is not a standard position for scoliosis screening. Turning to the side and remaining in a relaxed position is not a standard position for scoliosis screening.
A nurse is collecting data from a child and notes the presence of bruises on her arms and legs. Which of the following actions should the nurse take first?
- A. Tell the child what will happen to her when the abuse is reported.
- B. Request a social services referral.
- C. Report the suspected abuse to the authorities.
- D. Obtain a detailed history.
Correct Answer: D
Rationale: Telling the child what will happen when the abuse is reported is not the first action a nurse should take. It is important to first gather all necessary information and report the suspected abuse to the appropriate authorities. Requesting a social services referral is an important step when abuse is suspected, but it should come after obtaining a detailed history and reporting the suspected abuse. Reporting the suspected abuse to the authorities is crucial when child abuse is suspected. However, it is important to first obtain a detailed history to provide as much information as possible to the authorities. When a nurse notes the presence of bruises on a child's arms and legs, the first action should be to obtain a detailed history. This can provide important context for the bruises and help determine whether they are likely the result of accidental injury or possible abuse.
A 10-year-old child was admitted with full-thickness burns affecting more than 15% of the child's body surface. What manifestations of hypovolemic shock would you observe for over the next 48 hrs? Select all choices that apply:
- A. Rapid pulse.
- B. Decreased B/P.
- C. Pallor.
- D. Flushed Face.
Correct Answer: A,B,C
Rationale: Choice A rationale: Rapid pulse is a common manifestation of hypovolemic shock. When the body experiences a significant loss of fluid, such as in severe burns, the heart rate increases in an attempt to maintain adequate blood flow and oxygen delivery to the body's tissues. Choice B rationale: Decreased blood pressure is another typical sign of hypovolemic shock. As the body loses fluid, the volume of blood circulating through the body decreases. This drop in blood volume leads to a decrease in blood pressure. Choice C rationale: Pallor, or paleness of the skin, can occur in hypovolemic shock. This happens because the body prioritizes sending blood to vital organs like the heart and brain, which can result in less blood flow to the skin, causing it to appear pale. Choice D rationale: A flushed face is not typically associated with hypovolemic shock. In fact, the skin may actually appear pale or cool due to reduced blood flow.
A nurse is providing care to a group of children at a pediatric clinic. Which of the following children meets the criteria to receive a varicella vaccine?
- A. A child who received a blood transfusion 1 month ago.
- B. A child currently receiving immunoglobulins.
- C. A child currently receiving chemotherapy.
- D. A child who has a cold and nasal discharge.
Correct Answer: D
Rationale: A child who received a blood transfusion 1 month ago is not recommended to receive the varicella vaccine. This is because blood transfusions can introduce new antibodies into the body that may interfere with the immune response to the vaccine. A child currently receiving immunoglobulins should not receive the varicella vaccine. Immunoglobulins are proteins in the blood that function as antibodies. They can interfere with the body's immune response to the vaccine. A child currently receiving chemotherapy should not receive the varicella vaccine. Chemotherapy can weaken the immune system, making it less effective at responding to vaccines. A child who has a cold and nasal discharge can receive the varicella vaccine. Mild illnesses, such as a cold, do not interfere with the immune response to the vaccine.
A nurse is reinforcing teaching with a school-age child who has type 1 diabetes mellitus and his parent about illness management. Which of the following instructions should the nurse include?
- A. Withhold insulin dose if feeling nauseous.
- B. Test the urine for ketones.
- C. Limit fluid intake during meal time.
- D. Notify the provider if blood glucose levels are over 350 mg/dL.
Correct Answer: B
Rationale: Withholding insulin when feeling nauseous is not recommended. Insulin is necessary for the body to use glucose for energy. Without insulin, glucose stays in the bloodstream, leading to high blood sugar levels. Testing the urine for ketones is important in managing type 1 diabetes. When the body does not have enough insulin, it breaks down fat as fuel. This process produces a buildup of acids in the bloodstream called ketones, eventually leading to diabetic ketoacidosis if untreated. Limiting fluid intake during mealtime is not specifically related to the management of type 1 diabetes. It's important to stay hydrated, but it doesn't directly affect blood glucose levels. Notifying the provider if blood glucose levels are over 350 mg/dL is not the only time medical advice should be sought. Any persistent, unusual, or extreme blood glucose reading should be discussed with a healthcare provider.