Nokea
The child who helps to undress, puts 3 words together (subject, verb, object), and handles a spoon well has an age around
- A. 15 mo
- B. 18 mo
- C. 24 mo
- D. 30 mo
Correct Answer: C
Rationale: These milestones are typically achieved around 24 months.
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A 6 months old boy presents with respiratory distress and feeding difficulty. On examination heart rate is 130/min and there is a pansystolic murmur at left lower sternal border. What is the most likely diagnosis?
- A. Mitral regurgitation
- B. Mitral valve prolapse
- C. Ventricular septal defect
- D. Coarctation of aorta
Correct Answer: C
Rationale: Ventricular septal defect (VSD) commonly presents with a pansystolic murmur and symptoms of congestive heart failure in infancy.
The nurse is working on the pediatric floor, caring for an infant who is very fussy and has a diagnosis of DI. Which parameter should the nurse monitor while the infant is on fluid restrictions?
- A. Oral intake.
- B. Urine output.
- C. Appearance of the mucous membranes.
- D. Pulse and temperature. 116
Correct Answer: B
Rationale: In a patient with diabetes insipidus (DI) who is on fluid restrictions, monitoring urine output is crucial to assess the effectiveness of the treatment regimen. DI is a condition characterized by excessive urination and thirst due to a deficiency of antidiuretic hormone (ADH). By monitoring urine output, the nurse can determine if the restrictions are achieving the goal of decreasing urine volume and preventing dehydration. Changes in urine output can also indicate the need for adjustments in the treatment plan. Monitoring oral intake, appearance of mucous membranes, and pulse and temperature are important aspects of pediatric care but are not as directly related to managing fluid restrictions in a patient with DI.
The child begins to understand right and left by age of
- A. 3 yr
- B. 4 yr
- C. 5 yr
- D. 6 yr
Correct Answer: C
Rationale: Understanding right and left typically develops around age 5.
The Glasgow coma scale is used to .evaluate the level of consciousness in the neurological and neurological patients. The three assessment factors included in this scale are:
- A. pupil size, response to pain, motor responses
- B. Pupil size, verbal response, motor response
- C. Eye opening, verbal response, motor response
- D. Eye opening, response to pain, motor response J.E, is an 18-year old freshman admitted to the ICU following a motor vehicle accident in which he sustained multiple trauma including a ruptured spleen, myocardial contusion, fractured pelvis, and fractured right femur. He had a mild contusion, but is alert and oriented. His vital signs BP 120/80, pulse 84, respirations 12, and temperature 99 F orally.
Correct Answer: C
Rationale: The Glasgow Coma Scale (GCS) is a neurological scale that is used to assess the level of consciousness in patients. It is based on three factors: eye opening, verbal response, and motor response. Each factor is scored on a scale of 1 to 4 or 6, with a lower total score indicating a lower level of consciousness.
The nurse is planning care for a newborn receiving IV calcium gluconate for treatment of hypocalcemia. Which intervention is the most appropriate during the acute phase?
- A. Allow newborn to sleep with pacifier to decrease stimuli.
- B. Keep newborn awake to monitor central nervous system changes.
- C. Encourage parents to hold and feed newborn to facilitate attachment during illness.
- D. Awaken newborn periodically to assess level of consciousness.
Correct Answer: D
Rationale: During the acute phase of treatment with IV calcium gluconate for hypocalcemia in a newborn, it is essential to closely monitor the newborn's level of consciousness. Hypocalcemia can lead to central nervous system changes, such as irritability, jitteriness, and seizures. By awakening the newborn periodically to assess their level of consciousness, the nurse can promptly identify any signs of worsening central nervous system involvement and take appropriate action. This intervention ensures timely detection of any neurological complications and allows for timely intervention to prevent serious consequences. The other options do not address the importance of monitoring for central nervous system changes during the acute phase of treatment for hypocalcemia.