Nokea
An 8-year-old with newly diagnosed diabetes is in the hospital for regulation of diet and medications. The child is using an exchange method for the diet. The nurse should instruct the client that the American Diabetes Association's (ADA's) exchange method for dietary regulation includes:
- A. Choosing food from each exchange list.
- B. Using a scale to weigh all food.
- C. Selecting from lists that group food according to protein, fat, and carbohydrate content.
- D. Carbohydrate counting for each meal and snack.
Correct Answer: C
Rationale: The ADA exchange method groups foods by protein, fat, and carbohydrate content to balance macronutrients. It does not require weighing all food or exclusive carbohydrate counting, though lists are used.
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A 10-month-old looks for objects that have been removed from his view. The nurse should instruct the parents that:
- A. Neuromuscular development enables the child to reach out and grasp objects.
- B. The child's curiosity has increased.
- C. The child understands the permanence of objects even though the child cannot see them.
- D. The child is now able to transfer objects from hand to hand.
Correct Answer: C
Rationale: This behavior indicates object permanence, a cognitive milestone typically achieved around 9-12 months.
An adolescent is to receive radioactive iodine for Graves' diseases. Which statement by the client reflects the need for more teaching?
- A. I plan to talk on Facebook since I have to keep several feet from my friends for 3 days.
- B. Taking radioactive iodine will not affect my ability to have children in the future.
- C. The advantage of radioactive iodine is that I will not need future medication for my disease.
- D. I should try to use a separate bathroom from the rest of my family for several days.
Correct Answer: C
Rationale: Radioactive iodine often leads to hypothyroidism, requiring lifelong thyroid hormone replacement. Options A, B, and D reflect correct understanding of radiation precautions and fertility.
Which of the following would be the best activity for the nurse to include in the plan of care for an infant experiencing severe diarrhea?
- A. Monitoring the total 8-hour formula intake.
- B. Weighing the infant each day.
- C. Checking the anterior fontanel every shift.
- D. Monitoring abdominal skin turgor every shift.
Correct Answer: B
Rationale: Daily weights provide an accurate measure of fluid loss in diarrhea.
The nurse is assessing a neonate with suspected tracheoesophageal fistula. Which of the following findings would be most concerning?
- A. Excessive drooling.
- B. Mild cyanosis during feeding.
- C. Heart rate of 140 bpm.
- D. Temperature of 37°C.
Correct Answer: B
Rationale: Mild cyanosis during feeding indicates potential airway compromise, a critical concern in TEF.
After teaching the parents of an infant with clubfoot about the condition and its management, which of the following statements by a parent indicates a need for additional teaching?
- A. My child will need several casts over a period of weeks to months.'
- B. Surgery may be needed if casting does not fully correct the foot.'
- C. The cast should be kept clean and dry at all times.'
- D. I should adjust the cast if it seems too tight.'
Correct Answer: D
Rationale: Parents should not adjust the cast themselves, as this could disrupt treatment; they should contact a healthcare provider if the cast seems too tight.