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The nurse is caring for a child with hypoparathyroidism who demonstrates a carpal spasm when pressure is applied to the upper arm. Which laboratory value should the nurse review?
- A. Potassium.
- B. Chloride.
- C. Sodium.
- D. Calcium.
Correct Answer: D
Rationale: Hypoparathyroidism causes low calcium levels, leading to carpal spasms, so reviewing calcium levels is critical.
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A male adolescent arrives at the clinic and reports intense pain in the testicular area that occurred during football practice at high school. The nurse observes the scrotum and identifies significant erythema and swelling. Which action should the nurse take?
- A. Report the findings immediately to the healthcare provider.
- B. Obtain a swab of secretions from the penis and urethra.
- C. Collect a sterile urine sample for culture and sensitivity.
- D. Provide the adolescent with a urinal for urinary hesitancy.
Correct Answer: A
Rationale: Significant erythema and swelling suggest testicular torsion, a medical emergency requiring immediate reporting.
The nurse is providing nutrition education to the parents of an infant with failure to thrive (FTT). Which statement made by the parent should the nurse recognize as an appropriate understanding of interventions?
- A. Breast milk provides adequate calories for the child.
- B. Regular syringe feedings promote rapid weight gain.
- C. High-calorie formula encourages increased growth.
- D. Fruit juice increases the child's daily vitamin intake.
Correct Answer: C
Rationale: High-calorie formula provides the increased caloric intake needed to promote growth in infants with FTT.
The nurse observes a mother giving her 11-month-old ferrous sulfate (iron drops), followed by 2 ounces (60 mL) of orange juice. What should the nurse do next?
- A. Suggest placing the iron drops in the orange juice and then feeding the infant.
- B. Give the mother positive feedback about the way she administered the medication.
- C. Instruct the mother to feed the infant nothing for 30 minutes after giving the iron drops.
- D. Tell the mother to follow the iron drops with infant formula instead of orange juice.
Correct Answer: B
Rationale: Giving orange juice after iron drops enhances iron absorption due to vitamin C, so positive feedback is appropriate.
A 7-year-old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In obtaining a health history from the child's mother, the recent occurrence of which illness is most significant?
- A. Mumps.
- B. Chickenpox.
- C. Sore throat.
- D. Influenza.
Correct Answer: C
Rationale: Acute rheumatic fever is often preceded by a streptococcal infection, commonly presenting as a sore throat.
The nurse is preparing to administer medications for an eight-month-old infant with heart failure. The infant has a blood pressure of 114/66 mm Hg, apical pulse of 88 beats/minute, and respirations of 30 breaths/minute. Which medication should the nurse withhold until the healthcare provider is notified?
- A. Digoxin.
- B. Furosemide.
- C. Hydralazine.
- D. Enalapril.
Correct Answer: A
Rationale: Digoxin should be withheld if the apical pulse is below 90 beats/minute in infants, as it may indicate toxicity.