Nokea
A previously "potty-trained" 30-month-old child has reverted to wearing diapers while hospitalized. The nurse should reassure the parents that this is normal because of which reason?
- A. Regression is seen during hospitalization.
- B. Developmental delays occur because of the hospitalization.
- C. The child is experiencing urinary urgency because of hospitalization.
- D. The child was too young to be "potty-trained."
Correct Answer: A
Rationale: Regression in toilet training is a common behavior seen in young children, especially during times of stress or change, such as hospitalization. The child may revert to familiar behaviors, such as wearing diapers, as a way of seeking comfort and security during a stressful experience like being in the hospital. It is important for the nurse to reassure the parents that this regression is temporary and normal under the circumstances. By providing support and understanding, the child will likely return to their previous toilet training habits once they are back in their usual environment.
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The nurse observes yellow staining in the sclera of eyes, soles of feet, and palms of hands. How should the nurse document these findings?
- A. Normal
- B. Erythema
- C. Jaundice
- D. Ecchymosis
Correct Answer: C
Rationale: Jaundice is the yellow discoloration of the skin, sclera (white part of the eyes), soles of feet, and palms of hands that occurs due to elevated levels of bilirubin in the blood. Bilirubin is a yellow pigment produced during the breakdown of red blood cells and is normally processed by the liver and excreted in bile. When the liver is unable to process bilirubin effectively, it can accumulate in the blood and cause jaundice. Therefore, the nurse should document these findings as jaundice, which is a sign of liver dysfunction or other underlying health issues that need further assessment and management.
The child who draws a man with 2-4 parts, imitates construction of 2 lines longer, and helps with dressing has an age around
- A. 24 mo
- B. 30 mo
- C. 48 mo
- D. 54 mo
Correct Answer: B
Rationale: These milestones are typically achieved around 30 months.
The beta subunit of human chorionic gonadotropin (HCG) is a useful surface marker in some malignant germ cell tumors (GCTs); it is secreted by syncytiotrophoblasts. In which of the following GCTs this surface marker is characteristically elevated?
- A. teratoma
- B. germinoma
- C. endodermal sinus tumor
- D. embryonal carcinoma
Correct Answer: D
Rationale: Embryonal carcinoma is strongly associated with elevated beta-HCG levels.
How many liters per minute of oxygen should be administered to the patient with emphysema?
- A. 2 L/min
- B. 10 L/min
- C. 6 L/min
- D. 95 L/min
Correct Answer: C
Rationale: Oxygen therapy for patients with emphysema aims to maintain adequate oxygen levels in the blood while avoiding toxic levels of oxygen. The recommended flow rate for oxygen administration in patients with emphysema is typically 1-3 liters per minute. Increasing the flow rate above this range may lead to oxygen toxicity in these patients. Therefore, a safe and appropriate oxygen flow rate for a patient with emphysema would be around 6 L/min, making option C, 6 L/min, the correct choice from the provided options.
Which of the following outcomes would indicate successful treatment of diabetes insipidus?
- A. Fluid intake of less than 2,500mL
- B. Blood pressure of 90/50mmHg
- C. Pulse rate of 126 beats/min
- D. Urine output of more than 200mL/hour
Correct Answer: A
Rationale: Successful treatment of diabetes insipidus is indicated when the patient's excessive urination (polyuria) and thirst (polydipsia) are controlled. One of the primary goals of treatment is to achieve fluid balance by reducing urine output and, consequently, decreasing the excessive thirst. When the fluid intake is less than 2,500mL, it suggests that the patient's excessive thirst has decreased, indicating successful management of the condition. Monitoring and managing fluid intake are crucial in the treatment of diabetes insipidus to prevent dehydration and electrolyte imbalances. A lower fluid intake is a positive indicator that the treatment is effectively addressing the increased urine output characteristic of diabetes insipidus.