Nokea
The nurse is assessing a 13-year-old boy with type 2 diabetes mellitus. What would the nurse correlate with the disorder?
- A. The parents report that their child had 'a cold or flu' recently.
- B. Blood pressure is decreased when checking vital signs.
- C. The parents report that their son 'can't drink enough water.'
- D. Auscultation reveals Kussmaul breathing.
Correct Answer: C
Rationale: The correct answer is C. Excessive thirst (polydipsia) is a common symptom of type 2 diabetes mellitus, indicating high blood glucose levels. This symptom occurs due to the body trying to get rid of excess glucose through urine, leading to dehydration and increased thirst. Choices A, B, and D are incorrect. Choice A is more indicative of a recent viral illness rather than a symptom of diabetes. Choice B, decreased blood pressure, is not typically associated with type 2 diabetes; in fact, diabetes can often lead to hypertension. Choice D, Kussmaul breathing, is more characteristic of diabetic ketoacidosis, which is more common in type 1 diabetes rather than type 2 diabetes.
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When picked up by a parent or the nurse, an 8-month-old infant screams and seems to be in pain. After observing this behavior, what should the nurse discuss with the parent?
- A. Accidents and the importance of accident prevention
- B. Limiting playtime with other children in the family
- C. Any other behaviors that the parent may have noticed
- D. Food and appropriate vitamins for infants
Correct Answer: C
Rationale: Discussing any other observed behaviors can help identify patterns or potential issues, which is crucial for assessing the infant's overall well-being. Option A about accidents and prevention is not pertinent to the situation described. Option B regarding playtime with other children does not address the infant's behavior and potential causes. Option D about food and vitamins is not relevant to the presented scenario and the observed behavior of the infant.
What type of play do nurses expect when observing a toddler in a playroom with other children?
- A. Parallel
- B. Solitary
- C. Cooperative
- D. Competitive
Correct Answer: A
Rationale: The correct answer is A: Parallel. Toddlers typically engage in parallel play, where they play alongside but not directly with other children. This type of play is common during early childhood as children are still developing social skills and may prefer to play independently while observing others. Choice B, Solitary play, refers to a child playing alone without interacting with others. Choice C, Cooperative play, involves children playing together towards a common goal or activity. Choice D, Competitive play, emphasizes winning and outperforming others, which is less common in toddlers as they are in the stage of exploring and learning through play rather than competing.
The nurse is caring for a 3-day-old girl with Down syndrome whose mother had no prenatal care. What is the priority nursing diagnosis?
- A. Imbalanced nutrition, less than body requirements related to the effects of hypotonia
- B. Deficient knowledge related to the presence of a genetic disorder
- C. Delayed growth and development related to a cognitive impairment
- D. Impaired physical mobility related to poor muscle tone
Correct Answer: A
Rationale: The priority nursing diagnosis for a 3-day-old girl with Down syndrome, whose mother had no prenatal care, is imbalanced nutrition, less than body requirements related to the effects of hypotonia. Newborns with Down syndrome often experience feeding difficulties due to hypotonia, which can lead to inadequate nutrition intake. Option B is incorrect because at this age, the infant is not capable of having knowledge deficits related to a genetic disorder. Option C is incorrect as delayed growth and development are not the immediate priority in this scenario. Option D is incorrect as impaired physical mobility is not typically a priority concern for a newborn with Down syndrome.
A child sitting on a chair in a playroom starts to have a tonic-clonic seizure with a clenched jaw. What is the nurse's best initial action?
- A. Attempt to open the jaw.
- B. Place the child on the floor.
- C. Call out for assistance from staff.
- D. Place a pillow under the child's head.
Correct Answer: B
Rationale: The correct initial action during a tonic-clonic seizure is to place the child on the floor to prevent injury. This action helps protect the child from falling off the chair and provides a safer environment for the seizure to occur. Attempting to open the jaw can cause harm or injury. Calling out for assistance is important but should follow the immediate action of moving the child to the floor. Placing a pillow under the child's head is not recommended as it may lead to airway obstruction or further injury during the seizure.
A major developmental milestone of a toddler is the achievement of autonomy. What should the parents do to enhance their toddler's need for autonomy?
- A. Teach the child to share with others.
- B. Help the child learn society's roles.
- C. Teach the child to accept external limits.
- D. Help the child develop internal controls.
Correct Answer: D
Rationale: Toddlers striving for autonomy need to develop internal controls to foster their independence. Teaching the child to share (Choice A) focuses more on social skills rather than autonomy. Helping the child learn society's roles (Choice B) is important but not directly related to enhancing autonomy. Teaching the child to accept external limits (Choice C) is contrary to promoting autonomy as it emphasizes conformity to external rules rather than internal self-regulation.