Nokea
In what condition should the nurse be alert for altered fluid requirements in children? (Select all that apply.)
- A. Oliguric renal failure
- B. Increased intracranial pressure
- C. Mechanical ventilation
- D. All above
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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Ongoing fluid losses can overwhelm the child's ability to compensate, resulting in shock. What early clinical sign precedes shock?
- A. Tachycardia
- B. Slow respirations
- C. Warm, flushed skin
- D. Decreased blood pressure
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A father calls the clinic because he found his young daughter squirting Visine eyedrops into her mouth. What is the most appropriate nursing action?
- A. Reassure the father that Visine is harmless.
- B. Direct him to seek immediate medical treatment.
- C. Recommend inducing vomiting with ipecac.
- D. Advise him to dilute Visine by giving his daughter several glasses of water to drink.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What amount of fluid loss occurs with moderate dehydration?
- A. <50 ml/kg
- B. 50 to 90 ml/kg
- C. <5% total body weight
- D. >15% total body weight
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is assessing a 3-year-old African American child whose height and weight are at the 20th percentile on the growth chart. What should the nurse recognize?
- A. The data suggest the child requires nutritional intervention
- B. The NCHS charts are accurate for U.S. African American children
- C. A correction factor is used for nonwhite ethnic groups
- D. No assessment can be made until several measurements are plotted over time
Correct Answer: B
Rationale: The NCHS growth charts serve as reference guides for all racial or ethnic groups, including African American children. The 20th percentile for height and weight does not indicate nutritional failure but provides a reference point for ongoing assessment. Choice A is incorrect because being at the 20th percentile does not automatically imply the need for nutritional intervention. Choice C is incorrect as there is no correction factor specifically used for nonwhite ethnic groups in this context. Choice D is incorrect as a single measurement at the 20th percentile can provide valuable information for assessment.
Where would nonpathologic cyanosis normally be present in the newborn shortly after birth?
- A. Feet and hands
- B. Bridge of nose
- C. Circumoral area
- D. Mucous membranes
Correct Answer: A
Rationale: Nonpathologic cyanosis in newborns shortly after birth is typically present in the feet and hands, known as acrocyanosis. This is a normal finding due to the immature peripheral circulation in newborns. Cyanosis of the bridge of the nose, circumoral area, and mucous membranes indicates generalized cyanosis, which suggests a potential underlying distress or major abnormality. Therefore, choice A is correct as it describes the expected location for nonpathologic cyanosis in newborns, while choices B, C, and D represent areas associated with abnormal cyanosis.