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When evaluating the laboratory report of a 1-year-old infant's hematocrit, a healthcare professional compares it with the expected hematocrit range for this age group. What is the hematocrit of a healthy 12-month-old infant?
- A. 19% to 32%
- B. 29% to 41%
- C. 37% to 47%
- D. 42% to 69%
Correct Answer: C
Rationale: The correct answer is C: 37% to 47%. The normal hematocrit range for a 12-month-old infant is between 37% to 47%, which reflects the expected blood volume and red blood cell levels for this age. Choice A (19% to 32%) and Choice B (29% to 41%) are too low and do not encompass the typical hematocrit range for a healthy 1-year-old. Choice D (42% to 69%) is too high and falls outside the usual hematocrit values for this age group.
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A child with a fever is prescribed acetaminophen. What should the nurse teach the parents about administering this medication?
- A. Administer the medication with food
- B. Measure the dose with a household spoon
- C. Measure the dose with a proper measuring device
- D. Administer the medication only when the child has a high fever
Correct Answer: C
Rationale: The correct answer is to measure the dose with a proper measuring device. Using a proper measuring device ensures accurate dosing, which is crucial to avoid under or overdosing. Administering the medication with food (Choice A) is not necessary for acetaminophen. Using a household spoon (Choice B) can lead to inaccurate dosing due to variations in spoon sizes. Administering the medication only when the child has a high fever (Choice D) is not appropriate as acetaminophen can be used for fever management regardless of the fever intensity.
A 3-year-old child has a sudden onset of respiratory distress. The mother denies any recent illnesses or fever. You should suspect
- A. croup
- B. epiglottitis
- C. lower respiratory infection
- D. foreign body airway obstruction
Correct Answer: D
Rationale: In a 3-year-old child presenting with sudden respiratory distress without fever or recent illness, the most likely cause is a foreign body airway obstruction. Foreign body airway obstruction can lead to a sudden onset of respiratory distress as it blocks the air passage. Croup typically presents with a barking cough and stridor, often preceded by a viral illness. Epiglottitis is characterized by high fever, drooling, and a muffled voice. Lower respiratory infections usually present with symptoms such as cough, fever, and chest congestion. Therefore, in this case, the absence of recent illness or fever makes foreign body airway obstruction the most likely cause of the respiratory distress.
A nurse is providing care to a child with a diagnosis of bronchiolitis. What is the priority nursing intervention?
- A. Administering bronchodilators
- B. Providing respiratory therapy
- C. Monitoring oxygen saturation
- D. Encouraging fluid intake
Correct Answer: B
Rationale: The correct answer is providing respiratory therapy. In bronchiolitis, the priority is to maintain airway patency through interventions such as suctioning, positioning, and oxygen therapy. While bronchodilators may be used in some cases, they are not the initial priority. Monitoring oxygen saturation is important but comes after ensuring airway patency. Encouraging fluid intake is essential for hydration but is not the priority over maintaining a patent airway.
The nurse is assessing a 13-year-old boy with type 2 diabetes mellitus. What symptom would the nurse correlate with the disorder?
- A. The parents report that their child had a recent 'cold or flu.'
- B. Blood pressure is decreased during vital signs assessment.
- C. The parents report that their son 'can't drink enough water.'
- D. Auscultation reveals Kussmaul breathing.
Correct Answer: C
Rationale: The correct answer is C. In type 2 diabetes mellitus, excessive thirst (polydipsia) is a common symptom due to high blood glucose levels. This results in the patient feeling unable to drink enough water to satisfy their thirst. The other options are incorrect because a recent 'cold or flu' (choice A) is not directly related to diabetes mellitus, decreased blood pressure (choice B) is not a typical finding in uncontrolled diabetes, and Kussmaul breathing (choice D) is associated with diabetic ketoacidosis, which is more common in type 1 diabetes mellitus.
The nurse is teaching a father how to stimulate his 7-year-old son, who has a 'slow-to-warm-up' temperament. Which guidance will be most successful?
- A. Telling him to read stories to the child about famous athletes
- B. Suggesting he take the child to watch him play softball
- C. Urging him to sign the child up for little league football
- D. Proposing wrestling with the child and letting him win
Correct Answer: A
Rationale: The correct answer is A. Reading stories to the child about famous athletes would be the most successful guidance for a child with a 'slow-to-warm-up' temperament. This approach allows for a less active and more acceptable way of engaging with the child, aligning better with the child's temperament. Choices B, C, and D involve more active and potentially overwhelming activities for a child with such a temperament, which may not be as effective in stimulating and engaging the child.