Nokea
A nurse is teaching the parents of a child who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following manifestations should the nurse include in the teaching?
- A. Fruity breath odor
- B. Diaphoresis
- C. Dry mucous membranes
- D. Polyuria
Correct Answer: B
Rationale: Diaphoresis is a common symptom of hypoglycemia due to the activation of the sympathetic nervous system.
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A nurse is preparing to administer a dexamethasone 1.5 mg/kg/day PO to divide equally every 6 hr to a preschool-age child who weighs 22 lb. Available is dexamethasone oral solution 1 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 3.8 mL
- B. 2.8 mL
- C. 4.8 mL
- D. 1.8 mL
Correct Answer: 3.8
Rationale: Calculation: 22 lb ÷ 2.2 = 10 kg; 1.5 mg/kg/day × 10 kg = 15 mg/day; 15 mg ÷ 4 doses = 3.75 mg/dose; 3.75 mg × 1 mL/1 mg = 3.8 mL.
A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?
- A. Restrain the child's arms.
- B. Insert a padded tongue blade into the child's mouth.
- C. Place the child in a side-lying position.
- D. Elevate the child's legs on a pillow.
Correct Answer: C
Rationale: This helps maintain an open airway and allows for drainage of saliva or vomit reducing the risk of aspiration.
A nurse is calculating the output of an infant admitted who has dehydration. When weighing the diaper, the nurse should equate 1 g of wet diaper weight to which of the following amounts of urine?
- A. 30 mL
- B. 1 mL
- C. 15 mL
- D. 5 mL
Correct Answer: B
Rationale: It is a standard practice to equate 1 gram of wet diaper weight to 1 mL of urine providing an accurate measure for fluid balance in infants.
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. Lie prone on the examination table.
- C. Touch your chin to your chest, and then look up at the ceiling.
- D. Turn to the side, and remain in a relaxed position.
Correct Answer: A
Rationale: This position known as the Adam's forward bend test is commonly used to screen for scoliosis.
A nurse in a family health clinic is collecting data as part of a routine physical examination of a client who is about to enter high school. The nurse observes an abnormal lateral curvature of the spine. The nurse should expect the provider to document which of the following disorders?
- A. Scoliosis
- B. Ankylosis
- C. Kyphosis
- D. Lordosis
Correct Answer: A
Rationale: Scoliosis is characterized by an abnormal lateral curvature of the spine.