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The healthcare provider is evaluating the effects of thyroid therapy used to treat a 5-month-old with hypothyroidism. Which behavior indicates that the treatment has been effective?
- A. Laughs readily, turns from back to side.
- B. Has strong Moro and tonic neck reflexes.
- C. Keeps fists clenched, opens hands when grasping an object.
- D. Can lift head, but not chest when lying on abdomen.
Correct Answer: A
Rationale: The ability to laugh readily and turn from back to side indicates the effectiveness of thyroid therapy and normal development in a 5-month-old. These behaviors suggest improved muscle tone and motor skills, which are positive outcomes of thyroid hormone replacement therapy for hypothyroidism. Choices B, C, and D describe developmental milestones that are not specific indicators of the effectiveness of thyroid therapy in treating hypothyroidism in a 5-month-old.
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The nurse determines that an infant admitted for surgical repair of an inguinal hernia voids a urinary stream from the ventral surface of the penis. What action should the nurse take?
- A. Document the finding
- B. Palpate scrotum for testicular descent
- C. Assess for bladder distension
- D. Auscultate bowel sounds
Correct Answer: A
Rationale: The correct action for the nurse to take in this situation is to document the finding. The infant voiding a urinary stream from the ventral surface of the penis suggests hypospadias, a condition where the urethral opening is on the underside of the penis. This finding is crucial information that needs to be documented for further evaluation. Palpating the scrotum for testicular descent, assessing for bladder distension, and auscultating bowel sounds are not appropriate actions based on the presented scenario and do not address the specific concern of the urinary stream location.
A 15-year-old adolescent with anorexia nervosa is admitted to the hospital for severe weight loss. The nurse notes that the client has dry skin, brittle hair, and is severely underweight. What is the nurse's priority intervention?
- A. Establish a therapeutic relationship with the client
- B. Monitor the client's vital signs frequently
- C. Initiate a structured eating plan
- D. Provide education about healthy eating habits
Correct Answer: C
Rationale: In this scenario, the priority intervention for the nurse is to initiate a structured eating plan. Anorexia nervosa is a serious eating disorder characterized by severe food restriction, which can lead to malnutrition and severe weight loss. By starting a structured eating plan, the nurse can ensure the client receives the necessary nutrition to begin the process of weight restoration and recovery. Monitoring vital signs is essential, but without addressing the nutrition deficiency, vital signs may not improve significantly. Establishing a therapeutic relationship is crucial for long-term care but may not address the immediate risk of malnutrition. Providing education about healthy eating habits is important but may not be effective initially due to the severity of the client's condition.
The practical nurse is providing care for a toddler who has just returned from surgery for a tonsillectomy. Which intervention is a priority in the immediate postoperative period?
- A. Offer clear fluids frequently.
- B. Encourage the child to cough and deep breathe.
- C. Monitor for frequent swallowing.
- D. Apply a warm compress to the throat area.
Correct Answer: C
Rationale: Monitoring for frequent swallowing is a priority intervention in the immediate postoperative period after a tonsillectomy. Frequent swallowing may indicate bleeding from the surgical site, which requires immediate attention to prevent complications such as hemorrhage. Offering clear fluids frequently may not be appropriate immediately after surgery. Encouraging coughing and deep breathing may increase the risk of bleeding. Applying a warm compress to the throat area is not recommended as it can increase blood flow to the surgical site, potentially causing bleeding.
A child with Graves' disease who is taking propranolol (Inderal) is seen in the clinic. The nurse should monitor the child for which therapeutic response?
- A. Increased weight gain
- B. Decreased heart rate
- C. Reduced headaches
- D. Diminished fatigue
Correct Answer: B
Rationale: The correct answer is B: 'Decreased heart rate.' Propranolol is a beta-blocker commonly used to manage symptoms of hyperthyroidism, including tachycardia. Monitoring for a decreased heart rate is important as it indicates the drug's therapeutic response in controlling the elevated heart rate associated with Graves' disease. Choices A, C, and D are incorrect because weight gain, reduced headaches, and diminished fatigue are not typical therapeutic responses to propranolol in the context of managing Graves' disease.
The healthcare provider is assessing an infant with pyloric stenosis. Which pathophysiological mechanism is the most likely consequence of this infant's clinical picture?
- A. Metabolic alkalosis.
- B. Respiratory acidosis.
- C. Metabolic acidosis.
- D. Respiratory alkalosis.
Correct Answer: A
Rationale: Pyloric stenosis leads to obstruction at the outlet of the stomach, causing frequent vomiting and loss of stomach acids. This results in a loss of hydrochloric acid and hydrogen ions, leading to metabolic alkalosis due to an increase in serum bicarbonate levels. Therefore, the correct answer is metabolic alkalosis. Choice B, respiratory acidosis, is incorrect as it is not typically associated with pyloric stenosis. Choice C, metabolic acidosis, is incorrect because the loss of stomach acids in pyloric stenosis leads to metabolic alkalosis, not acidosis. Choice D, respiratory alkalosis, is also incorrect as it is not the usual consequence of pyloric stenosis.