Nokea
The nurse is caring for a 10-year-old upon admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is
- A. Urinary output of 30 ml per hour
- B. No complaints of thirst
- C. Increased hematocrit
- D. Good skin turgor around burn
Correct Answer: A
Rationale: The correct answer is urinary output of 30 ml per hour. In a 10-year-old child, this level of urinary output is indicative of adequate fluid replacement without suggesting overload. Monitoring urinary output is crucial in assessing fluid balance. Choices B, C, and D are incorrect. No complaints of thirst do not provide a direct assessment of fluid status. Increased hematocrit is a sign of dehydration, not adequate fluid replacement. Good skin turgor around the burn is a general assessment but may not directly reflect the child's overall fluid status.
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Which fact about diabetes is true?
- A. Only children get type 1 diabetes.
- B. Only adults get type 2 diabetes.
- C. Children and adults can have type 1 diabetes.
- D. Both A and B
Correct Answer: C
Rationale: The correct answer is that children and adults can have type 1 diabetes. Although type 1 diabetes is sometimes known as 'childhood diabetes,' it can affect individuals of any age. Type 1 diabetes is not limited to children. While type 2 diabetes is often associated with adults, children can also develop it, especially due to factors like obesity. Choices A and B are incorrect because diabetes is not exclusive to either children or adults; both types of diabetes can affect individuals across different age groups.
The parents of a child with a hernia are instructed by the nurse on measures to reduce the hernia. Which statement indicates the parents understand the care for their child?
- A. We will encourage our child to cough every few hours on a daily basis.
- B. We will make sure that our child participates in physical activity every day.
- C. We will provide comfort measures to reduce any crying periods by our child.
- D. We will be sure to give our child a Fleet enema every day to prevent constipation.
Correct Answer: C
Rationale: The correct answer is providing comfort measures to reduce any crying periods by the child. This can include offering a warm bath, avoiding upright positioning, and using other comfort measures to reduce crying, which can help reduce a hernia. Encouraging coughing or physical activity can increase strain on the hernia. Giving a Fleet enema daily for constipation is not recommended as it can also increase strain on the hernia.
Which of these individuals would the nurse suspect as having the greatest risk of contracting Hepatitis B?
- A. A sexually active 45-year-old man who has Type 1 Diabetes
- B. A 75-year-old woman who lives in a crowded nursing home
- C. A child who lives in a country with poor sanitation and hygiene standards
- D. A sexually active 23-year-old man who works in a hospital
Correct Answer: D
Rationale: The correct answer is a sexually active 23-year-old man who works in a hospital. This individual is at the highest risk of contracting Hepatitis B due to exposure in a healthcare setting where potential bloodborne pathogens are present. Being sexually active also increases the risk of transmission through sexual contact. Choice A, a 45-year-old man with Type 1 Diabetes, is not directly associated with an increased risk of Hepatitis B. Choice B, a 75-year-old woman living in a crowded nursing home, is at risk for other infections due to the living environment but not specifically for Hepatitis B. Choice C, a child in a country with poor sanitation, is more at risk for water or foodborne illnesses rather than Hepatitis B transmission.
Septic, anaphylactic, and neurogenic shock are all categorized as:
- A. Hypovolemic shock
- B. Cardiogenic shock
- C. Distributive shock
- D. Obstructive shock
Correct Answer: C
Rationale: Septic, anaphylactic, and neurogenic shock are all types of distributive shock. Distributive shock is characterized by a decrease in systemic vascular resistance, leading to poor tissue perfusion. Septic shock is caused by severe infection, anaphylactic shock is an extreme allergic reaction, and neurogenic shock results from damage to the nervous system. Hypovolemic shock (Choice A) is characterized by a decrease in intravascular volume, cardiogenic shock (Choice B) is due to heart failure, and obstructive shock (Choice D) results from obstruction of blood flow. Therefore, the correct categorization for septic, anaphylactic, and neurogenic shock is distributive shock.
An emergency department nurse is performing an assessment on a child with a suspected diagnosis of intussusception. Which assessment question for the parents will elicit the most specific data related to this disorder?
- A. Does the child have any food allergies?
- B. What do the bowel movements look like?
- C. Has the child eaten any food in the last 24 hours?
- D. Can you describe the type of pain that the child is experiencing?
Correct Answer: D
Rationale: The correct answer is asking the parents to describe the type of pain the child is experiencing because a report of severe colicky abdominal pain in a healthy, thriving child between 3 and 17 months of age is the classic presentation of intussusception. Typical behavior includes screaming and drawing the knees up to the chest. This specific question helps in identifying the key symptom of intussusception. Choices A, B, and C are important aspects of a health history but are not specific to the diagnosis of intussusception. Food allergies, bowel movements, and recent food intake are relevant for a comprehensive assessment but do not directly relate to the specific symptoms of intussusception.