Nokea
The presence of which pair of factors is a good predictor of a fluid deficit of at least 5% in an infant?
- A. Weight loss and decreased heart rate
- B. Capillary refill of less than 2 seconds and no tears
- C. Increased skin elasticity and sunken anterior fontanel
- D. Dry mucous membranes and generally ill appearance
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The clinic nurse is teaching parents about when to call the office immediately for a child with a fever. What should the nurse include in the teaching session? (Select all that apply.)
- A. The child has a stiff neck.
- B. The fever is over 40.6 C (105 F).
- C. The child is younger than 2 months.
- D. All of the above
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The parents of a child with acute postinfectious glomerulonephritis (APIGN) ask how they will know that the condition is improving. How should the nurse respond?
- A. Your child's urine output will increase, and the urine will become less brown in color.
- B. Your child will rest more comfortably.
- C. Your child's appetite will decrease.
- D. Your child's laboratory test values will show increased BUN.
Correct Answer: A
Rationale: Improvement in APIGN is indicated by an increase in urine output and a change in urine color from brown (due to hematuria) to a more normal appearance. This reflects a reduction in glomerular inflammation and improved kidney function. Choice B is incorrect because resting more comfortably is not a direct indicator of kidney function improvement. Choice C is incorrect because a decrease in appetite is not typically associated with improvement in APIGN. Choice D is incorrect because an increased BUN value would suggest worsening kidney function rather than improvement.
The parent of a 3-month-old infant is concerned because the infant is not able to sit independently. How should the nurse respond to this parent's concern?
- A. Sitting ability and the age of first tooth eruption are not correlated.
- B. Most infants sit steadily at 4 months.
- C. Most infants sit steadily at 3 months.
- D. Most infants do not sit steadily until 6-8 months.
Correct Answer: D
Rationale: The correct answer is D because sitting steadily typically occurs closer to 6-8 months of age, not 3 or 4 months. Choice A is incorrect because sitting ability and the age of first tooth eruption are not related. Choice B and C are incorrect as most infants do not sit steadily at 3 or 4 months, and it is more common for infants to achieve this milestone around 6-8 months.
When describing play by the school-aged child to a group of nursing students, the instructor would emphasize the need for which of the following?
- A. Recreation
- B. Ritualism
- C. Physical activity
- D. Rules
Correct Answer: D
Rationale: The correct answer is D: Rules. When discussing play in school-aged children, rules are essential as they help in structuring games and social interactions. Rules provide a framework for play, ensuring fairness and cooperation among children. Choice A, recreation, is too broad and doesn't specifically address the importance of rules in play. Choice B, ritualism, is unrelated to the concept of play in school-aged children. Choice C, physical activity, is important for overall health but doesn't capture the specific aspect of rules that are crucial in the play of school-aged children.
What is the most consistent and commonly used indicator of pain in infants?
- A. Increased respirations
- B. Increased heart rate
- C. Thrashing of arms and legs
- D. Facial expression of discomfort
Correct Answer: D
Rationale: Facial expression has consistently been validated as an indicator of pain in infants. Behavioral pain measures are most reliable for sharp procedural pain in infants. Increased heart rate and respirations are indicative of a generalized and complex response to stress, not specific for pain in infants. Thrashing of arms and legs is a reliable indicator in young children, not specifically in infants.