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The healthcare provider is assessing an infant with diarrhea and lethargy. Which finding should the provider identify that is consistent with early dehydration?
- A. Tachycardia
- B. Bradycardia
- C. Dry mucous membranes
- D. Decreased skin turgor
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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Before administering a tube feeding to a child, what should the practical nurse (PN) assess?
- A. Tube placement.
- B. Bowel sounds.
- C. Abdominal circumference.
- D. Tube patency.
Correct Answer: A
Rationale: Assessing tube placement is critical before initiating a tube feeding to verify its correct positioning in the stomach. This assessment helps prevent potential complications such as aspiration if the tube is incorrectly placed in the respiratory tract. Checking bowel sounds, abdominal circumference, and tube patency are important assessments in the care of a child receiving tube feedings, but ensuring proper tube placement takes precedence to ensure safe and effective delivery of nutrition.
Which nursing intervention is most important to assist in detecting hypopituitarism and hyperpituitarism in children?
- A. Carefully recording the height and weight of children to detect inappropriate growth.
- B. Performing head circumference measurements on infants under one year of age.
- C. Assessing for behavioral problems at home and school by interviewing the parents.
- D. Noting tracked weight gain without a gain in height on a growth chart.
Correct Answer: A
Rationale: Recording the height and weight of children is crucial in detecting growth abnormalities like hypopituitarism and hyperpituitarism. Inappropriate growth patterns, such as disproportionate weight gain or stunted height, can be indicative of these conditions. Regular monitoring of height and weight is a fundamental nursing intervention that can aid in the early identification and management of pituitary-related disorders in children.
What suggestion should the nurse provide to prevent diaper rash in a 4-month-old infant as requested by the mother?
- A. Generously powder the baby's diaper area with talcum powder at each diaper change to promote dryness.
- B. Wash the diaper area every 2 hours with soap and water to help prevent skin breakdown.
- C. Use a barrier cream, such as zinc oxide, which does not have to be completely removed with each diaper change.
- D. Place a cloth diaper inside the disposable diaper for overnight periods when increased wearing time is likely.
Correct Answer: C
Rationale: Using a barrier cream like zinc oxide forms a protective layer on the skin, creating a barrier against irritants and moisture, thus helping to prevent diaper rash. Unlike other options, barrier creams do not need to be completely removed at each diaper change, allowing the skin to remain protected between changes.
The practical nurse (PN) is caring for an adolescent who has been diagnosed with mononucleosis. Which activity should the PN advise the adolescent to avoid?
- A. Playing video games.
- B. Drinking caffeinated beverages.
- C. Participating in contact sports.
- D. Eating spicy foods.
Correct Answer: C
Rationale: Contact sports should be avoided in mononucleosis due to the risk of spleen rupture, which is a serious complication of the disease. The spleen can enlarge in mononucleosis, making it more susceptible to injury from contact sports, potentially leading to a life-threatening situation if rupture occurs.
The nurse is caring for a 14-year-old adolescent who was admitted to the hospital after a suicide attempt. The adolescent's mood appears stable, and the healthcare provider has recommended discharge. What is the nurse's priority action?
- A. Ensure that a safety plan is in place before discharge
- B. Provide education about medication adherence
- C. Encourage the adolescent to participate in group therapy
- D. Schedule a follow-up appointment with a mental health professional
Correct Answer: A
Rationale: The priority action for the nurse is to ensure that a safety plan is in place before discharge. A safety plan is essential to assist the adolescent in managing future crises and decreasing the likelihood of another suicide attempt. It provides guidance on coping strategies and resources to help the adolescent stay safe in times of distress.