Nokea
To help the adolescent deal with diabetes, the nurse must consider which developmental characteristic of adolescence?
- A. Desire to be unique
- B. Preoccupation with the future
- C. Need to be perfect and similar to peers
- D. Need to make peers aware of the seriousness of hypoglycemic reactions
Correct Answer: C
Rationale: The correct answer is C: Need to be perfect and similar to peers. During adolescence, individuals often have a strong desire to fit in and be accepted by their peers, leading to a need to conform and be similar to their peers. This characteristic is important to consider when helping an adolescent deal with diabetes as it may impact their adherence to treatment and management of their condition. Choices A, B, and D are incorrect because while adolescents may have a desire to be unique or preoccupied with the future, these characteristics are not specifically related to managing diabetes. Additionally, the need to make peers aware of hypoglycemic reactions may not be the most effective or appropriate way to manage the condition.
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Parents of a 4-year-old with congenital heart disease are afraid to let their child play with other children because of possible overexertion. The nurse's reply should be based on which statement?
- A. Parents can meet all the needs of their child
- B. Children need to understand the activities of their peers are too strenuous
- C. Constant parental supervision is required to avoid overexertion
- D. Children need opportunities to play with their peers to foster their growth and development
Correct Answer: D
Rationale: The correct answer is D: Children need opportunities to play with their peers to foster their growth and development. The rationale is as follows: Playing with peers is essential for a child's social, emotional, and cognitive development. It helps them learn important skills like cooperation, communication, and problem-solving. Restricting the child's play due to fear of overexertion can have negative consequences on their overall development. It is important for children to engage in age-appropriate play activities under supervision to ensure safety while promoting growth.
Now, let's analyze why the other choices are incorrect:
A: Parents can meet all the needs of their child - While parents play a crucial role in meeting a child's needs, social interaction with peers is also important for holistic development.
B: Children need to understand the activities of their peers are too strenuous - This places the burden on the child to limit their activities rather than promoting healthy play.
C: Constant parental supervision is required to avoid overexertion
A child admitted with extensive burns. The nurse notes that there are burns on the child's lips and singed nasal hairs. The nurse should suspect that the child has a(n):
- A. Chemical burn
- B. Inhalation injury
- C. Electrical burn
- D. Hot-water scald
Correct Answer: B
Rationale: The correct answer is B: Inhalation injury. The presence of burns on the lips and singed nasal hairs indicate that the child has likely inhaled hot gases or smoke, which can cause damage to the respiratory tract. This is a common finding in cases of inhalation injury resulting from exposure to fire or smoke. Inhalation injury can lead to airway compromise, respiratory distress, and other serious complications. The other choices (A: Chemical burn, C: Electrical burn, D: Hot-water scald) do not specifically indicate damage to the respiratory tract, making them less likely in this scenario.
A home health nurse is caring for a child who has lyme disease. Which of the following is an appropriate action for the nurse to take
- A. Ensure the state health department has been notified
- B. Administer antitoxin
- C. Educate the family to avoid sharing personal belongings
- D. Assess for skin necrosis
Correct Answer: B
Rationale: The correct answer is B: Administer antitoxin. Lyme disease is caused by a bacterium, not a toxin, so administering antitoxin is not appropriate. Option A is incorrect because notifying the state health department is not a direct action for the nurse to take in caring for the child. Option C is incorrect as educating the family to avoid sharing personal belongings is a preventive measure but not a direct action for the child's care. Option D is incorrect as skin necrosis is not a typical manifestation of Lyme disease. Administering appropriate antibiotics to treat the bacterial infection is the most appropriate action for the nurse to take in caring for the child with Lyme disease.
Signs of digoxin toxicity include of the following (Select all that apply):
- A. Vomiting
- B. Poor feeding
- C. Constipation
- D. Bradycardia
Correct Answer: A,B,D
Rationale: The correct signs of digoxin toxicity are vomiting, poor feeding, and bradycardia. Vomiting is a common early sign due to the drug's effect on the gastrointestinal system. Poor feeding can occur as a result of nausea and anorexia. Bradycardia is a classic sign of digoxin toxicity due to its effect on cardiac function. Constipation is not typically associated with digoxin toxicity. In summary, A, B, and D are correct as they align with the expected symptoms of digoxin toxicity, whereas C is incorrect as constipation is not a common sign.
When caring for a patient with Syndrome of inappropriate Antidiuretic Hormone Secretion (SIADH), the nurse would expect her patient to exhibit the following clinical signs and symptoms (Select all that apply):
- A. Fluid retention
- B. Hypotonicity
- C. Anorexia
- D. Frequent urination
Correct Answer: A,B,C
Rationale: Step-by-step rationale:
A: Fluid retention - In SIADH, there is excessive ADH secretion leading to water retention and dilutional hyponatremia.
B: Hypotonicity - Due to water retention, serum osmolality decreases leading to hypotonicity.
C: Anorexia - SIADH can cause nausea, vomiting, and anorexia due to hyponatremia and cerebral edema.
Incorrect choices:
D: Frequent urination - SIADH causes water retention, leading to decreased urine output, not frequent urination.