Nokea
When developing the plan of care for a newly admitted 2-year-old child with the diagnosis of Kawasaki disease, which of the following should be the priority?
- A. Taking vital signs every 6 hours.
- B. Monitoring intake and output every hour.
- C. Minimizing skin discomfort.
- D. Providing passive range-of-motion exercises.
Correct Answer: B
Rationale: Monitoring intake and output hourly is critical in Kawasaki disease to assess for fluid balance and potential cardiac complications like coronary artery involvement.
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A parent asks which nutrient deficiency is common in children with celiac disease. The nurse should respond:
- A. Vitamin C.
- B. Iron.
- C. Vitamin A.
- D. Magnesium.
Correct Answer: B
Rationale: Iron deficiency is common in celiac disease due to malabsorption in the small intestine. Other deficiencies (e.g., vitamin D, B vitamins) may occur, but iron is most frequent.
The breast-feeding mother of a 1-month-old diagnosed with cow's milk sensitivity asks the nurse what she should do about feeding her infant. Which of the following recommendations would be most appropriate?
- A. Continue to breast-feed but eliminate all milk products from your own diet.
- B. Discontinue breast-feeding and start using a predigested formula.
- C. Limit breast-feeding to once per day and begin feeding an iron-fortified formula.
- D. Change to a soy-based formula exclusively and begin solid foods.
Correct Answer: A
Rationale: Eliminating dairy from the mother's diet prevents milk proteins from passing to the infant via breast milk, allowing breastfeeding to continue. Formula or solids are less appropriate at this age.
Eight hours ago, an infant with Hirschsprung's disease had surgery to create a colostomy. Which of the following findings should alert the nurse to notify the physician immediately?
- A. A 3-cm increase in abdominal circumference.
- B. Periods of occasional fussiness.
- C. Absence of bowel sounds since surgery.
- D. Evidence of the infant's returning appetite.
Correct Answer: A
Rationale: A 3-cm increase in abdominal circumference may indicate complications like obstruction or bleeding.
After 6 months of treatment with diet and exercise, a 12-year-old with type 2 diabetes still has a fasting blood glucose level of 140 mg/dL. The primary care provider has decided to begin metformin (Glucophage). The adolescent asks how the medication works. The nurse should tell the client that the medicine decreases the glucose production and:
- A. Replaces natural insulin.
- B. Helps the body make more insulin.
- C. Increases insulin sensitivity.
- D. Decreases carbohydrate adsorption.
Correct Answer: C
Rationale: Metformin reduces hepatic glucose production and increases insulin sensitivity in peripheral tissues, improving glucose uptake. It does not replace insulin, stimulate insulin production, or affect carbohydrate absorption.
The nurse should refer the parents of an 8-month-old child to a health care provider if the child is unable to:
- A. Stand momentarily without holding onto furniture.
- B. Stand alone well for long periods of time.
- C. Stoop to recover an object.
- D. Sit without support for long periods of time.
Correct Answer: D
Rationale: An 8-month-old should be able to sit without support; inability to do so warrants further evaluation.