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The nurse is conducting an admission assessment on a school-age child with acute renal failure. Which are the primary clinical manifestations the nurse expects to find with this condition?
- A. Oliguria and hypertension
- B. Hematuria and pallor
- C. Proteinuria and muscle cramps
- D. Bacteriuria and facial edema
Correct Answer: A
Rationale: Acute renal failure is characterized by a sudden decrease in kidney function, resulting in the reduced ability to excrete waste products and maintain fluid balance. The primary clinical manifestations typically seen in acute renal failure include oliguria (low urine output) due to decreased kidney function, and hypertension (high blood pressure) as the body retains excess fluid and waste products. These symptoms indicate impaired kidney function and the need for immediate medical intervention to prevent further complications. Hematuria, proteinuria, muscle cramps, bacteriuria, and facial edema are not typically primary clinical manifestations of acute renal failure.
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A nurse is preparing to accompany a medical mission's team to a third world country. Marasmus is seen frequently in children 6 months to 2 years in this country. Which symptoms should the nurse expect for this condition?
- A. Loose, wrinkled skin
- B. Edematous skin
- C. Depigmentation of the skin
- D. Dermatoses
Correct Answer: A
Rationale: Marasmus is a form of severe malnutrition characterized by a significant deficiency in calories and protein intake. Symptoms of marasmus include severe wasting of muscle and fat stores, giving the appearance of loose, wrinkled skin due to the loss of subcutaneous fat. Other symptoms may include lethargy, irritability, delayed growth and development, and weakened immune function. Edematous skin is more commonly associated with kwashiorkor, another form of severe malnutrition characterized by protein deficiency with adequate caloric intake. Depigmentation of the skin and dermatoses are not typical symptoms of marasmus.
A patient has end-stage dilated cardiomyopathy. He comes to the emergency department with dyspnea. He says he went to bed and awoke with a feeling of suffocation. He says it was frightening. Which of the ff. responses by the nurse is most appropriate?
- A. "You must have been dreaming."
- B. "Reclining decreases the heart's ability to pump blood." c."Sleeping increases heart rate, which increases the body's need for oxygen."
- C. "Reclining increases fluid returning to the heart, which builds up fluid in the lungs."
Correct Answer: C
Rationale: The most appropriate response by the nurse is option C, "Reclining increases fluid returning to the heart, which builds up fluid in the lungs." In a patient with end-stage dilated cardiomyopathy, reclining position can lead to increased fluid return to the heart due to the failing pump function. This can result in fluid backing up in the lungs, causing symptoms such as dyspnea or feeling of suffocation. By explaining this mechanism to the patient, the nurse can provide valuable information about the condition and the reason for the distressing symptoms experienced by the patient. It also highlights the importance of proper positioning to alleviate symptoms and improve the patient's comfort.
The child who can transfers object from hand to hand and babbles has achieved the developmental age of
- A. 4 months
- B. 6 months
- C. 8 months
- D. 10 months
Correct Answer: B
Rationale: Transferring objects and babbling typically occur around 6 months.
Which of the following lab value profiles should the nurse know to be consistent with hemolytic anemia?
- A. Increased RBC, decreased bilirubin, decreased Hgb and Hct, increased reticulocytes
- B. Decreased RBC, increased bilirubin, decreased Hgb and Hct, increased reticulocytes
- C. Decreased RBC, decreased bilirubin, increased Hgb and Hct, decreased reticulocytes
- D. Increased RBC, increased bilirubin, increased Hgb and Hct, decreased reticulocytes
Correct Answer: B
Rationale: Hemolytic anemias are characterized by the premature destruction of red blood cells. As a result, the lab values typically seen in hemolytic anemia include decreased red blood cell counts (RBC), increased bilirubin (due to the breakdown of red blood cells), decreased hemoglobin (Hgb) and hematocrit (Hct) levels, and increased reticulocytes (immature red blood cells released from the bone marrow in response to the increased demand for red blood cell production). Therefore, profile B aligns with the expected lab values consistent with hemolytic anemia.
A nurse is counseling parents of a child beginning to show signs of being overweight. The nurse accurately relates which body mass index (BMI)-for-age percentile indicates a risk for being overweight?
- A. 10th percentile
- B. 9th percentile
- C. 85th percentile
- D. 95th percentile
Correct Answer: D
Rationale: The body mass index (BMI)-for-age percentile indicating a risk for being overweight is the 95th percentile. This means that if a child's BMI falls at or above the 95th percentile for their age group, they are classified as overweight. This percentile is used as a cutoff point to identify children at risk of being overweight and to guide intervention strategies such as lifestyle changes, increased physical activity, and dietary modifications. Parents should work with healthcare providers to address their child's weight status and implement appropriate measures to promote a healthy lifestyle.