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The nurse is caring for a child with hypoparathyroidism who exhibits a carpal spasm when pressure is applied to the upper arm. Which laboratory value should the nurse review?
- A. Sodium
- B. Calcium
- C. Potassium
- D. Chloride
Correct Answer: B
Rationale: Carpal spasm (Trousseau's sign) indicates hypocalcemia, common in hypoparathyroidism.
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The nurse is caring for an adolescent with type 1 diabetes mellitus who presents with an HbA1c of 11% (97 mmol/mol), thirst, and blurred vision. What action should the nurse take first?
- A. Obtain point-of-care glucose.
- B. Assess urine for ketones.
- C. Check blood pressure.
- D. Review prior insulin prescriptions.
Correct Answer: A
Rationale: Symptoms suggest hyperglycemia; point-of-care glucose testing confirms this and guides treatment.
The nurse is assessing the growth and development of a 3-year-old child. Which speech and language skills should the nurse identify as normal developmental milestones for this child?
- A. Recognizes most letters and numbers.
- B. Uses 1-word sentences.
- C. Speaks in simple sentences with four or more words.
- D. Uses gestures with 1 to 2-word sentences.
Correct Answer: C
Rationale: Speaking in simple sentences with four or more words is a normal milestone for a 3-year-old.
The nurse is getting ready to give medications to an eight-month-old infant diagnosed with heart failure. The infant's vital signs are as follows: blood pressure 114/66 mm Hg, apical pulse 88 beats/minute, and respirations 30 breaths/minute. Which medication should the nurse hold and inform the health care provider?
- A. Enalapril
- B. Digoxin
- C. Furosemide
- D. Hydralazine
Correct Answer: B
Rationale: The infant's apical pulse of 88 beats/minute is below the normal range (100-160 beats/minute) for an eight-month-old, indicating a need to hold Digoxin and notify the provider.
The nurse is caring for an adolescent with scoliosis who is recovering after a surgical spinal instrumentation. Which technique should the nurse use when moving the client?
- A. Flex the knees.
- B. Raise the hips.
- C. Cross the arms and legs.
- D. Perform a log roll.
Correct Answer: D
Rationale: Log rolling maintains spinal alignment, protecting the surgical site during movement.
A nurse is educating parents about essential dietary modifications for their child, who has recently been diagnosed with celiac disease. Which foods should the nurse include in the list of permissible foods for this child?
- A. Rice
- B. Barley
- C. Rye
- D. Oats
Correct Answer: A
Rationale: Rice is gluten-free and safe for celiac disease, unlike barley, rye, or most oats.