Nokea
When instructing the client diagnosed with hyperparathyroidism about diet, the nurse should stress the importance of which of the following?
- A. Restricting fluids
- B. Forcing fluids
- C. Restricting sodium
- D. Restricting potassium
Correct Answer: C
Rationale: For clients diagnosed with hyperparathyroidism, it is important to restrict sodium in the diet. High sodium intake can worsen calcium loss from the bones and increase the risk of kidney stones, both of which are concerns for individuals with hyperparathyroidism. Therefore, it is crucial to advise the client to limit their sodium intake to help manage their condition effectively.
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The nurse is using calipers to measure skinfold thickness over the triceps muscle in a school- age child. What is the purpose of doing this?
- A. To measure body fat
- B. To measure muscle mass
- C. To determine arm circumference
- D. To determine accuracy of weight measurement
Correct Answer: A
Rationale: Skinfold thickness measurements using calipers are commonly used in assessing body composition, specifically to estimate body fat percentage. By measuring skinfold thickness over the triceps muscle in combination with measurements from other sites on the body, healthcare professionals can estimate the amount of subcutaneous fat present. This information is valuable in evaluating an individual's overall body composition and health status. The triceps skinfold measurement is a commonly included site in body fat calculations, especially in school-age children, where it can provide insights into growth and development.
The nurse is assisting the family of a child with a history of encopresis. Which should be included in the nurse's discussion with this family?
- A. Instruct the parents to sit the child on the toilet at twice-daily routine intervals.
- B. Instruct the parents that the child will probably need to have daily enemas.
- C. Suggest the use of stimulant cathartics weekly.
- D. Reassure the family that most problems are resolved successfully, with some relapses during periods of stress.
Correct Answer: D
Rationale: The most appropriate response for the nurse to include in the discussion with the family of a child with a history of encopresis is to reassure them that most problems are resolved successfully, with some relapses during periods of stress. Encopresis is a common disorder in childhood, characterized by the repeated passage of feces in inappropriate places. It is often related to chronic constipation and fecal impaction. Treatment for encopresis includes addressing the underlying constipation through interventions like dietary changes, behavioral therapies, and possibly medications. It is important for the nurse to educate the family that although it may take time and effort, most children improve with treatment. Reassuring the family that relapses during periods of stress are to be expected can help to alleviate some of their anxiety and encourage them to continue with the treatment plan.
The nurse is caring for a client who is receiving antibiotics to treat a gram-negative bacterial infection. Because antibiotics destroy the body's normal flora, the nurse must monitor the client for:
- A. Platelet dysfunction
- B. Stomatitis
- C. Oliguria and dysuria
- D. Diarrhea
Correct Answer: D
Rationale: When a client is receiving antibiotics to treat an infection, especially a gram-negative bacterial infection, the antibiotics may disrupt the balance of normal flora in the gastrointestinal tract. This disruption can lead to an overgrowth of pathogenic bacteria, resulting in diarrhea. Clostridium difficile-associated diarrhea is a common complication of antibiotic therapy due to the disruption of normal gut flora. Therefore, the nurse must monitor the client for signs and symptoms of diarrhea and intervene promptly to prevent complications such as dehydration and electrolyte imbalances. Platelet dysfunction, stomatitis, and oliguria/dysuria are not typically associated with the destruction of normal flora due to antibiotic therapy for a gram-negative bacterial infection.
Wilma is using a portable suction unit at home, What is the amount of suction required by James using this unit?
- A. 2-5 mmHg
- B. 10-15 mmHg
- C. 5-10 mmHg
- D. 20-25 mmHg
Correct Answer: A
Rationale: The amount of suction typically required for routine suctioning for adults using a portable suction unit at home is 80-120 mmHg for an adult patient. However, for children or individuals with sensitive airways, the recommended amount of suction is lower, ranging from 2-5 mmHg. Since the question mentions that James is using the unit at home, it is safer to assume that a lower amount of suction (2-5 mmHg) would be appropriate for his needs.
What is the best age for solid food to be introduced into the infant's diet?
- A. 2 to 3 months
- B. 4 to 6 months
- C. When birth weight has tripled
- D. When tooth eruption has started
Correct Answer: B
Rationale: The American Academy of Pediatrics recommends introducing solid foods into an infant's diet between 4 to 6 months of age. At this stage, most infants have developed the necessary motor skills to start eating solid foods, such as being able to sit up and hold their head steady. Additionally, their digestive system has matured enough to handle solid foods. Introducing solid foods too early, such as at 2 to 3 months (Option A), can increase the risk of digestive issues and allergies. Waiting for tooth eruption (Option D) is not a reliable indicator as some infants may begin teething earlier or later than others. Waiting for the birth weight to triple (Option C) is not necessary as infants can start on solid foods once they reach the appropriate developmental stage around 4 to 6 months.