Nokea
The nurse is reviewing the laboratory test results of a child with Addison's disease. What would the nurse expect to find?
- A. Hypernatremia
- B. Hyperkalemia
- C. Hyperglycemia
- D. Hypercalcemia
Correct Answer: B
Rationale: In Addison's disease, adrenal insufficiency leads to decreased aldosterone production. This results in impaired sodium retention and potassium excretion, leading to hyperkalemia. Therefore, the correct answer is hyperkalemia (choice B). Hypernatremia (choice A) is less likely because of the loss of sodium in Addison's disease. Hyperglycemia (choice C) and hypercalcemia (choice D) are not typically associated with Addison's disease and are less likely to be present in this condition.
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While teaching a parent how to prevent accidents while caring for a 6-month-old infant, what motor development ability should be emphasized?
- A. Sits up
- B. Rolls over
- C. Crawls short distances
- D. Stands while holding on to furniture
Correct Answer: B
Rationale: The correct answer is B: Rolls over. At 6 months, most infants can roll over, increasing the risk of falls. It is important to emphasize to the parent the need for careful supervision to prevent accidents. While choices A, C, and D are also milestones in infant motor development, rolling over at this age poses a higher risk of accidents due to the increased mobility and potential for falls.
A 12-month-old infant has become immunosuppressed during a course of chemotherapy. When preparing the parents for the infant's discharge, what information should the nurse give concerning the measles, mumps, and rubella (MMR) immunization?
- A. It should not be given until the infant reaches 2 years of age.
- B. Infants who are receiving chemotherapy should not be given these vaccines.
- C. It should be given to protect the infant from contracting any of these diseases.
- D. The parents should discuss this with their health care provider at the next visit.
Correct Answer: B
Rationale: The correct answer is B. Live vaccines like MMR should not be given to immunosuppressed infants because their weakened immune systems may not handle the vaccine safely. Choice A is incorrect as delaying the MMR vaccine until the infant reaches 2 years of age does not address the issue of immunosuppression. Choice C is incorrect because administering live vaccines to an immunosuppressed individual could lead to serious complications. Choice D is incorrect as immediate action is required to prevent potential harm to the immunosuppressed infant.
When developing the plan of care for a child with burns requiring fluid replacement therapy, what information would the nurse expect to include?
- A. Administration of colloid initially followed by a crystalloid
- B. Determination of fluid replacement based on the type of burn
- C. Administration of most of the volume during the first 8 hours
- D. Monitoring of hourly urine output to achieve less than 1 mL/kg/hr
Correct Answer: C
Rationale: The correct answer is C. In fluid replacement therapy for burns, it is crucial to administer most of the volume during the first 8 hours to prevent shock and maintain perfusion. This rapid administration is essential to stabilize the child's condition. Choices A and B are incorrect because the initial fluid replacement in burns typically involves administering crystalloids, not colloids, and the fluid replacement is generally calculated based on the extent of the burn injury, not the type of burn. Choice D is incorrect as monitoring hourly urine output to achieve less than 1 mL/kg/hr is not recommended in burn patients; instead, urine output should be monitored to achieve 1-2 mL/kg/hr in children to ensure adequate renal perfusion.
A 6-year-old child comes to the school nurse reporting a sore throat, and the nurse verifies that the child has a fever and a red, inflamed throat. When a parent of the child arrives at school to take the child home, the nurse urges the parent to seek treatment. The nurse is aware that the causative agent may be beta-hemolytic streptococcus, and the illness may progress to inflamed joints and an infection in the heart. What illness is of most concern to the nurse?
- A. Tetanus
- B. Influenza
- C. Scarlet fever
- D. Rheumatic fever
Correct Answer: D
Rationale: Rheumatic fever is the most concerning illness in this case. It can develop as a complication of untreated strep throat caused by beta-hemolytic streptococcus. If not properly treated, rheumatic fever can lead to serious complications such as inflamed joints and heart infections. Tetanus is caused by a toxin produced by Clostridium tetani bacteria and is not related to the symptoms described in the scenario. Influenza is a viral respiratory illness and does not typically lead to rheumatic fever. While scarlet fever is also caused by streptococcus bacteria, in this case, the symptoms described are more indicative of rheumatic fever than scarlet fever.
A nurse is caring for an infant with phenylketonuria (PKU). What diet should the nurse anticipate will be ordered by the health care provider?
- A. Fat-free
- B. Protein-enriched
- C. Phenylalanine-free
- D. Low-phenylalanine
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.