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A parent brings a 2-month-old infant with Down syndrome to the pediatric clinic for a physical and administration of immunizations. Which clinical finding should alert the nurse to perform a further assessment?
- A. Flat occiput
- B. Small, low-set ears
- C. Circumoral cyanosis
- D. Protruding furrowed tongue
Correct Answer: C
Rationale: Circumoral cyanosis should alert the nurse to perform further assessment in a 2-month-old infant with Down syndrome. This finding may indicate cardiac or respiratory issues, such as inadequate oxygenation. Small, low-set ears and a protruding furrowed tongue are common physical characteristics associated with Down syndrome and may not necessarily warrant immediate further assessment. A flat occiput is a normal variation in infant anatomy and is not typically a cause for immediate concern in this context.
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In an adolescent suspected of having type 1 diabetes mellitus, which clinical manifestation may be present?
- A. moist skin
- B. weight gain
- C. fluid overload
- D. poor wound healing
Correct Answer: D
Rationale: Poor wound healing is a common clinical manifestation of type 1 diabetes mellitus. Elevated blood glucose levels in diabetes can lead to impaired wound healing by affecting various cellular processes involved in the healing cascade. Moist skin (Choice A) is not typically associated with type 1 diabetes mellitus. Weight gain (Choice B) is more commonly seen in type 2 diabetes due to insulin resistance. Fluid overload (Choice C) is not a typical clinical manifestation of type 1 diabetes mellitus. Therefore, the correct answer is poor wound healing.
Which is the most appropriate nursing diagnosis for a child with acute glomerulonephritis?
- A. Risk for injury related to malignant process and treatment
- B. Fluid volume deficit related to excessive losses
- C. Fluid volume excess related to decreased plasma filtration
- D. Fluid volume excess related to fluid accumulation in tissues and third spaces
Correct Answer: C
Rationale: The most appropriate nursing diagnosis for a child with acute glomerulonephritis is 'Fluid volume excess related to decreased plasma filtration.' Acute glomerulonephritis is characterized by inflammation in the glomeruli, leading to decreased plasma filtration and retention of fluid. This results in fluid volume excess rather than deficit, making choice C the correct answer. Choice A is incorrect because acute glomerulonephritis is not primarily associated with a malignant process. Choice B is incorrect as the condition typically presents with fluid volume excess rather than deficit. Choice D is also incorrect as fluid accumulation in tissues and third spaces is not a typical manifestation of acute glomerulonephritis.
A child is diagnosed with atopic dermatitis. Which laboratory test would the nurse expect the child to undergo to provide additional evidence for this condition?
- A. Erythrocyte sedimentation rate
- B. Potassium hydroxide prep
- C. Wound culture
- D. Serum immunoglobulin E (IgE) level
Correct Answer: D
Rationale: The correct answer is D: Serum immunoglobulin E (IgE) level. An elevated serum IgE level is commonly associated with atopic dermatitis, reflecting an allergic response. Choice A, erythrocyte sedimentation rate, is not typically used to diagnose atopic dermatitis. Choice B, potassium hydroxide prep, is used to identify fungal infections like ringworm, not for diagnosing atopic dermatitis. Choice C, wound culture, is performed to identify microorganisms in a wound, not to diagnose atopic dermatitis.
A nurse is evaluating a 3-year-old child's developmental progress. The inability to perform which task indicates to the nurse that there is a developmental delay?
- A. Copying a square
- B. Hopping on one foot
- C. Catching a ball reliably
- D. Using a spoon effectively
Correct Answer: A
Rationale: The inability to copy a square at 3 years old indicates a potential developmental delay in fine motor skills. At this age, children should be able to copy basic shapes like circles and crosses. Hopping on one foot is typically expected around the age of 4, catching a ball reliably around 5, and using a spoon effectively by 2-3 years old. Therefore, choices B, C, and D are not as indicative of a developmental delay at 3 years old as the inability to copy a square.
A nurse is evaluating a 3-year-old child's developmental progress. The inability to perform which task indicates to the nurse that there is a developmental delay?
- A. Copying a square
- B. Hopping on one foot
- C. Catching a ball reliably
- D. Using a spoon effectively
Correct Answer: A
Rationale: The correct answer is A: Copying a square. At 3 years old, children should be able to copy a square as part of their fine motor skill development. The inability to perform this task may indicate a developmental delay in fine motor skills. Choice B, hopping on one foot, typically develops around 4-5 years of age, so it is not a reliable indicator of a delay at 3. Choice C, catching a ball reliably, involves coordination skills that develop later in childhood, making it less relevant for a 3-year-old assessment. Choice D, using a spoon effectively, is more related to self-care and feeding skills rather than fine motor development, so it is not the best indicator of a developmental delay in this context.