Nokea
The charge nurse in the pediatric unit is teaching nursing students about pyloric stenosis. A student asks what causes pyloric stenosis. How should the nurse respond?
- A. One portion of the intestines invaginates or telescopes into another
- B. Hypertrophy of the circular pylorus muscle
- C. Relaxed cardiac sphincter
- D. Absent ganglion cells in the colon
Correct Answer: B
Rationale: Pyloric stenosis is caused by the hypertrophy (thickening) of the circular muscle of the pylorus, leading to obstruction. Choice A is incorrect as it describes intussusception, not pyloric stenosis. Choice C is incorrect as a relaxed cardiac sphincter is related to gastroesophageal reflux. Choice D is incorrect as it describes Hirschsprung's disease, not pyloric stenosis.
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The nurse is planning care for a patient with a different ethnic background. Which should be an appropriate goal?
- A. Adapt, as necessary, ethnic practices to health needs
- B. Attempt, in a nonjudgmental way, to change ethnic beliefs
- C. Encourage continuation of ethnic practices in the hospital setting
- D. Strive to keep ethnic background from influencing health needs
Correct Answer: A
Rationale: Adapting ethnic practices to health needs respects the patient's cultural background while ensuring that care is effective and culturally sensitive.
Several types of seizures can occur in neonates. What is characteristic of clonic seizures?
- A. Apnea
- B. Tremors
- C. Extension of all four limbs
- D. Jerking that cannot be stopped by flexion of the affected limb
Correct Answer: D
Rationale: Clonic seizures are characterized by slow, rhythmic, jerking movements that cannot be stopped by flexion of the affected limb. Therefore, the correct characteristic of clonic seizures is option D. Option A, apnea, is not characteristic of clonic seizures. Option B, tremors, does not describe clonic seizures accurately. Option C, extension of all four limbs, is not a typical feature of clonic seizures but rather seen in tonic seizures.
The nurse is assessing a child with type 2 diabetes. The child is awake and alert with a serum glucose of 60 mg/dL. What action should the nurse take?
- A. Administer Insulin.
- B. Administer Epinephrine.
- C. Give 15 grams of carbohydrates.
- D. Give glucagon by injection.
Correct Answer: C
Rationale: For a conscious child with mild hypoglycemia, giving 15 grams of fast-acting carbohydrates is the appropriate intervention. This can quickly raise blood glucose levels to prevent further complications. Administering insulin (Choice A) would further lower the glucose level, which is not suitable in this scenario. Administering epinephrine (Choice B) is not indicated for hypoglycemia. Glucagon (Choice D) is used for severe hypoglycemia with altered consciousness, not for mild cases where the child is awake and alert.
Which physiological acid-base balance complication would be most important for the nurse to assess in a patient with diarrhea?
- A. High serum pH
- B. Normal serum pH
- C. Metabolic alkalosis
- D. Metabolic acidosis
Correct Answer: D
Rationale: The correct answer is metabolic acidosis. Diarrhea can lead to the loss of bicarbonate, causing an imbalance in the acid-base status of the body, specifically resulting in metabolic acidosis. High serum pH (choice A) is incorrect as diarrhea-induced bicarbonate loss would lower pH, not increase it. Normal serum pH (choice B) is not the best answer as diarrhea can disrupt the acid-base balance. Metabolic alkalosis (choice C) is an alkaline state, which is less likely to be caused by diarrhea.
A Hispanic toddler has pneumonia. The nurse notices that the parent consistently feeds the child only the broth that comes on the clear liquid tray. Food items, such as Jell-O, Popsicles, and juices, are left. Which statement best explains this?
- A. The parent is trying to feed the child only what the child likes most
- B. Hispanics believe the evil eye enters when a person gets cold
- C. The parent is trying to restore normal balance through appropriate hot remedies
- D. Hispanics believe an innate energy called chi is strengthened by eating soup
Correct Answer: C
Rationale: In Hispanic culture, the balance between hot and cold is important, and the parent may be giving the child broth to restore this balance while avoiding "cold" foods.