Nokea
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.
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A nurse is reinforcing discharge teaching with the parent of a child who has a new diagnosis of diabetes mellitus. Which of the following statements by the parent requires a clarification of the teaching?
- A. Sweating can occur with hypoglycemia.
- B. My son might have nausea and vomiting with hypoglycemia.
- C. My son might complain of feeling shaky when he has a low blood glucose level.
- D. The onset of low blood glucose usually occurs rapidly.
Correct Answer: B
Rationale: Nausea and vomiting are typically associated with hyperglycemia and diabetic ketoacidosis (DKA) not hypoglycaemia. Hypoglycaemia usually presents with symptoms like sweating shakiness confusion and hunger.
A nurse is caring for a 7-year-old client who has an upper respiratory infection and a history of type 1 diabetes mellitus. Which of the following statements by the mother indicates a need for further instruction?
- A. I will notify the doctor if his temperature is not controlled with acetaminophen.
- B. I will continue to check his blood sugar two times every day.
- C. I will report a change in breathing or signs of confusion.
- D. I will encourage him to drink a half a cup of water or sugar-free fluid every 30 minutes.
Correct Answer: B
Rationale: Checking blood sugar only twice a day is insufficient during illness especially for a child with type 1 diabetes. Blood glucose levels can fluctuate significantly due to infection and more frequent monitoring (at least 4 times a day or as recommended) is necessary.
A nurse is caring for an adolescent. The nurse should expect that the adolescent is working on which of the following developmental tasks?
- A. Defining a sense of self
- B. Learning to perform tasks independently
- C. Learning to use creative energies
- D. Building a sense of trust
Correct Answer: A
Rationale: Adolescence is characterized by the search for identity and defining a sense of self. Erikson identifies this stage as "Identity vs. Role Confusion where individuals explore and form their own identity separate from their family and childhood roles.
A nurse is caring for a 4-year-old child who has dehydration. Which of the following findings should the nurse identify as the priority?
- A. Sodium 142 mEq/L
- B. Urine specific gravity 1.025
- C. Potassium 2.5 mEq/L
- D. Blood glucose 110 mg/Dl
Correct Answer: C
Rationale: Potassium 2.5 mEq/L is below the normal range for potassium (3.5-5.0 mEq/L) and indicates hypokalemia which can cause serious cardiac issues and muscle weakness.
A nurse is providing teaching about Iron deficiency anemia to the parents of a 14-month-old. Which of the following should the nurse recommend as a method of preventing iron deficiency anemia?
- A. Avoid a diet consisting of primarily milk.
- B. Include whole grains and legumes in the diet.
- C. Administer fat-soluble vitamins daily.
- D. Limit intake of high-protein foods.
Correct Answer: A
Rationale: Milk especially cow's milk is low in iron and can inhibit iron absorption. Excessive milk consumption can also lead to iron deficiency anemia by displacing iron-rich foods from the diet and potentially causing gastrointestinal bleeding in infants.