Nokea
An infant is admitted to the pediatric unit with a diagnosis of hypertrophic pyloric stenosis after vomiting for several days. Which of the following nursing diagnoses should be the priority?
- A. Deficient fluid volume related to prolonged vomiting.
- B. Ineffective airway clearance related to impaired swallowing.
- C. Imbalanced nutrition: Less than body requirements.
- D. Bowel incontinence related to abdominal pain.
Correct Answer: A
Rationale: Prolonged vomiting in pyloric stenosis leads to significant fluid loss, making fluid volume deficit the priority.
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A child who limps and has pain has been found to have Legg-Calvé-Perthes disease. What should the nurse expect to include in the child's plan of care?
- A. Initiation of pain control measures, especially at night when acute.
- B. Promotion of ambulation despite child's discomfort in the affected hip.
- C. Prevention of flexion in the affected hip and knee.
- D. Advance of weight bearing on the head of the affected femur.
Correct Answer: A
Rationale: Pain control is essential in Legg-Calvé-Perthes disease, as pain is a common symptom, especially at night, due to inflammation and muscle spasms.
A father of a child with a urinary tract infection calls the clinic and explains, "My wife and I are concerned because our child refuses to obey us concerning the preventions you told us about. Our child refuses to take the medication unless we buy a present. We don't want to use discipline because of the illness, but we're worried about the behavior." Which response by the nurse is best?
- A. I sympathize with your difficulties
- B. but just ignore the behavior for now.
- C. I understand it's hard to discipline a child who is ill
- D. but things need to be kept as normal as possible.
- E. I understand that things are difficult for you right now
- F. but your child is ill and deserves special treatment.
- G. I understand your concern
Correct Answer: B
Rationale: Maintaining routines is essential.
The mother of a child with chronic renal failure who is receiving peritoneal dialysis at home asks the nurse what she can do if both inflow and drain times are increased. Which of the following instructions would be most appropriate for the nurse to include when responding to the mother?
- A. Assess the child for constipation.
- B. Decrease the amount of dialysate infused for each dwell.
- C. Incorporate the increased inflow and drain times into the dialysis schedule.
- D. Monitor the child for shoulder pain during inflow and drain times.
Correct Answer: A
Rationale: Constipation can affect dialysis flow.
Which of the following should the nurse assess in a newborn diagnosed with an anorectal malformation? Select all that apply.
- A. Abdominal distension.
- B. Loose stools.
- C. Vomiting.
- D. Meconium in the urine.
- E. Meconium stools.
Correct Answer: A,C,D
Rationale: Anorectal malformations can cause abdominal distension, vomiting, and meconium in the urine due to obstruction or fistulas.
A 14-year-old is using glargine (Lantus) and lispro (Humolog) to manage type I diabetes. The order for sliding scale lispro reads: Lispro subcutaneous give units according to sliding scale: Blood glucose: 70-150 mg/dL = 0 units, 151-200 mg/dL = 1 unit, 201-250 mg/dL = 2 units, 251-300 mg/dL = 3 units, 301-350 mg/dL = 4 units, Call for Blood glucose >350. In addition give 1 unit for every 15 grams of carbohydrate. The morning blood glucose is $202 \mathrm{mg} / \mathrm{dL}$ and the client is going to eat 2 carbohydrate exchanges. The nurse has the client administer how many units of lispro?
Correct Answer: 4
Rationale: Blood glucose of 202 mg/dL requires 2 units (sliding scale). Two carbohydrate exchanges (30 g) require 2 units (1 unit/15 g). Total: 2 + 2 = 4 units of lispro.