Nokea
The nurse is providing care for a pediatric client in the emergency department (ED) with a diagnosis of decreased level of consciousness (LOC) secondary to increased intracranial pressure (ICP). Which healthcare provider order should the nurse question?
- A. Passive range-of-motion exercises to promote hip flexion
- B. Oxygen at 2 L nasal cannula to maintain saturation above 95%
- C. Hourly vital signs and neurologic checks
- D. Elevate head of bed 30 degrees
Correct Answer: A
Rationale: In a pediatric client with increased intracranial pressure (ICP) and decreased level of consciousness (LOC), passive range-of-motion exercises to promote hip flexion should be questioned as they can potentially increase intracranial pressure. This action may not be safe for the client's condition. The other options are appropriate interventions for managing a pediatric client with increased ICP and decreased LOC.
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A 4-year-old child is admitted to the hospital secondary to dehydration. Laboratory tests indicate a high hemoglobin and hematocrit, and the serum sodium is below normal levels. Which condition does the nurse suspect based on the current data?
- A. Hypernatremia
- B. Metabolic acidosis
- C. Hypotonic dehydration
- D. Isotonic dehydration
Correct Answer: C
Rationale: The correct answer is hypotonic dehydration. The combination of high hemoglobin and hematocrit with low serum sodium indicates hypotonic dehydration. In this condition, there is an excess of solutes relative to water, leading to higher red blood cell concentration (elevated hemoglobin and hematocrit) and low serum sodium levels.
Diagnosis of attention deficit/hyperactivity disorder (ADHD) in children up to the age of 16 years requires the presence of at least
- A. 4 symptoms of inattention or4 symptoms of hyperactivity-impulsivity for at least 4 months in two or more environments
- B. 5 symptoms of inattention or 5 symptoms of hyperactivity-impulsivity for at least 5 months in two or more environments
- C. 6 symptoms of inattention or 6 symptoms of hyperactivity-impulsivity for at least 6 months in two or more environments
- D. 6 symptoms of inattention or 6 symptoms of hyperactivity-impulsivity for at least 3 months
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The child who imitates a bridge of 3 cubes, copies a circle, makes a tower of 10 cubes, and imitates a cross is
- A. 24 mo old
- B. 30 mo old
- C. 36 mo old
- D. 42 mo old
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A nurse administers naloxone (Narcan) to a post-op patient experiencing respiratory sedation. What undesirable effect would the nurse anticipate after giving this medication?
- A. Drowsiness
- B. Tics and tremors
- C. Increased Pain
- D. Nausea and vomiting
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
How should professionals communicate with parents and family members?
- A. Share information with both parents to distribute the stress equally
- B. Share information with one parent to ensure accuracy
- C. Share information with all individuals who interact with the child, whether family or not
- D. Provide information in writing exclusively to ensure clear communication
Correct Answer: C
Rationale: When professionals communicate with parents and family members, it is essential to share information with all individuals who interact with the child, whether they are family members or not. This inclusive approach ensures that everyone involved in the child's care and well-being is well-informed and can provide support as needed. It is important to consider the broader network of individuals who play a role in the child's life to promote comprehensive and effective communication.