Nokea
A nursing action that promotes ideal nutrition in an infant with congestive heart failure (CHF) is:
- A. Feeding formula that is supplemented with additional calories.
- B. Allowing the infant to nurse at each breast for 20 minutes.
- C. Providing large feedings every 5 hours.
- D. Using firm nipples with small openings to slow feedings.
Correct Answer: A
Rationale: Supplementing formula with extra calories increases the caloric density to support growth in infants with CHF.
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A client with type 2 diabetes mellitus (DM) is admitted to the hospital for uncontrolled DM. Insulin therapy is initiated with an initial dose of Humulin N insulin at 0800. At 1600, the client complains of diaphoresis, rapid heartbeat, and feeling shaky. What should the nurse do first?
- A. Determine the client's current glucose level
- B. Administer 10 units of fast-acting insulin.
- C. Offer the client a snack with high protein.
- D. Increase the IV infusion rate of normal saline.
Correct Answer: A
Rationale: The symptoms suggest hypoglycemia. Checking the glucose level confirms the diagnosis and guides appropriate treatment.
Bed-wetting can be considered normal up to
- A. 4 years in boys and 5 years in girls
- B. 5 years in boys and 4 years in girls
- C. 4 years in both boys and girls
- D. 5 years in both boys and girls
Correct Answer: D
Rationale: Bed-wetting is considered normal up to 5 years of age in both boys and girls, as bladder control develops gradually.
Neurodegenerative diseases include the following:
- A. Niemann-Pick disease
- B. Metachromatic leukodystrophy
- C. Leigh's encephalopathy
- D. Canavan disease
Correct Answer: A
Rationale: The correct answer is A because Niemann-Pick disease is a neurodegenerative disorder. The other options (b-e) are also neurodegenerative diseases.
While preparing to discharge an 8-month-old infant who is recovering from gastroenteritis and dehydration, the nurse teaches the parents about their infant’s dietary and fluid requirements. The nurse should include which other topic in the teaching session?
- A. Nursery schools
- B. Toilet Training
- C. Safety guidelines
- D. Preparation for surgery
Correct Answer: C
Rationale: Safety guidelines are crucial for an 8-month-old infant who is becoming more mobile and curious, reducing the risk of accidents.
A tuberculosis intradermal skin test to detect tuberculosis infection is given to a high-risk adolescent. How long after the test is administered should the result be evaluated?
- A. Immediately
- B. Within 24 hours
- C. In 48 to 72 hours
- D. After 5 days
Correct Answer: C
Rationale: The tuberculin skin test reaction peaks in 48 to 72 hours, making this the optimal time for evaluation.