Nokea
A nurse is reviewing the medical record of an adolescent and notes a calcium level of 11.4 mEq/L. Which of the following findings should the nurse expect?
- A. Tachycardia
- B. Diarrhea
- C. Positive Chvostek's sign
- D. Muscle hypotonicity
Correct Answer: D
Rationale: Hypercalcemia can lead to muscle weakness and hypotonicity due to its effects on nerve and muscle function.
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An adolescent was recently diagnosed with acne vulgaris and was prescribed tetracycline. Which of the following statements indicates that the client requires further education?
- A. I'll take this medication at least an hour before I eat a meal
- B. I'll take this medication with a full glass of milk
- C. I'll take this medication with a full glass of water on an empty stomach
- D. I'll stay out of direct sunlight while taking this medication
Correct Answer: B
Rationale: Tetracycline should not be taken with dairy products including milk because calcium in dairy can bind to the antibiotic and significantly reduce its absorption.
A nurse is collecting data from a 5-month-old infant who has increased intracranial pressure (ICP) resulting from hydrocephalus. Which of the following manifestations should the nurse expect?
- A. Low-pitched cry
- B. Positive Babinski reflex
- C. Insomnia
- D. Bulging fontanel
Correct Answer: D
Rationale: A bulging fontanel is a key sign of increased ICP in infants. It occurs due to pressure within the skull causing the soft spot on the head to protrude.
A nurse is planning care for a child who has epiglottitis. Which of the following actions should the nurse plan to take?
- A. Obtain a throat culture.
- B. Visualize the epiglottis using a tongue depressor.
- C. Initiate airborne precautions.
- D. Prepare the child for a neck X Ray and possible tracheostomy
Correct Answer: D
Rationale: A neck X-ray can help diagnose epiglottitis by showing the characteristic "thumb sign."
A nurse is assisting with the admission of a 2-year-old toddler who has acute gastroenteritis. Which of the following actions should the nurse take first?
- A. Determine if the toddler is voiding.
- B. Request evaluation of the toddler's serum electrolytes.
- C. Initiate isotonic fluids with 20 mEq/L potassium chloride.
- D. Collect a stool sample from the toddler.
Correct Answer: A
Rationale: Assessing urine output is crucial for determining the child's hydration status. Voiding is an important indicator of kidney function and fluid balance.
A nurse is reinforcing teaching with the parents of an 8-month-old infant who will be admitted for surgery. Which of the following instructions should the nurse include in the teaching?
- A. You should bring the infant's favorite blanket to the hospital.
- B. You should begin to manipulate the infant's bedtime based on the hospitals visiting hours.
- C. You should read the child a story about hospitalization.
- D. You will need to go home when it is not visiting hours.
Correct Answer: A
Rationale: Bringing the infant's favourite blanket can provide comfort and a sense of security in an unfamiliar hospital environment. It helps the child feel more at ease and can reduce anxiety and stress associated with hospitalization.