Nokea
When planning the education for the parents of a child with type 1 diabetes mellitus, which of the following should the nurse include?
- A. Restrict the activity of the child
- B. Rotate insulin injection sites
- C. Avoid letting the child perform the home testing of blood sugar
- D. Encourage a high-carbohydrate diet
Correct Answer: B
Rationale: When planning education for the parents of a child with type 1 diabetes mellitus, the nurse should include rotating insulin injection sites. This is important to prevent lipohypertrophy, which is the buildup of fat under the skin, and to ensure consistent absorption of insulin. Rotating injection sites helps to maintain healthy tissue and promotes better insulin effectiveness in managing blood sugar levels. It is a key component of proper diabetes care and helps to reduce the risk of complications associated with continuous injection in the same area.
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An adolescent has been diagnosed with lactose maldigestion intolerance. The nurse teaches the adolescent about lactose maldigestion intolerance and notes the teen needs further teaching if which statement is made?
- A. "I will limit my milk consumption to one to two glasses a day."
- B. "I should drink the milk alone and not with other foods."
- C. "Hard cheese, cottage cheese, or yogurt can be substituted for milk."
- D. "I will take a calcium supplement daily."
Correct Answer: B
Rationale: This statement is incorrect because drinking milk alone without other foods is not necessary for someone with lactose maldigestion intolerance. Mixing milk with other foods or consuming dairy products alongside other foods can sometimes help to reduce symptoms. Therefore, the adolescent does not need further teaching if they make this statement. The other statements are all appropriate for managing lactose maldigestion intolerance.
Which statement best describes the clinical manifestations of the preterm newborn?
- A. Head is proportionately small in relation to the body.
- B. Sucking reflex is absent, weak, or ineffectual.
- C. Thermostability is well established.
- D. Extremities remain in attitude of flexion.
Correct Answer: D
Rationale: The statement that best describes the clinical manifestations of the preterm newborn is that the extremities remain in an attitude of flexion. This characteristic is known as the "fetal position" and is commonly observed in preterm infants due to their premature musculoskeletal development. The flexed position of the extremities is a result of the baby's position in the uterus and is a normal finding for preterm newborns. Other clinical manifestations of preterm newborns may include a disproportionately large head in relation to the body, an immature or weak sucking reflex, and decreased thermostability due to their underdeveloped thermoregulatory systems.
While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following nursing actions should be performed initially?
- A. Activate the code blue or emergency system
- B. Do nothing because acrocyanosis is normal in the neonate
- C. Immediately take the newborn's temperature according to hospital policy
- D. Notify the physician of the need for a cardiac consult
Correct Answer: B
Rationale: Acrocyanosis is a normal finding in newborns, characterized by bluish discoloration of the hands and feet due to immature circulation. It usually resolves on its own within 24 hours after birth and does not require any intervention. It is essential for the nurse to recognize this normal physiological process to avoid unnecessary interventions. Activating the code blue system, taking the newborn's temperature immediately, or notifying the physician of the need for a cardiac consult is not indicated in this scenario because acrocyanosis is a benign condition in neonates.
Which finding would you expect in a 4-week-old with biliary atresia?
- A. Abdominal distention, enlarged liver and spleen, clay-colored stools, and tea-colored urine.
- B. Abdominal distention with bruises and hematuria.
- C. Yellow sclera/skin, oily skin, and prolonged bleeding times.
- D. No manifestations until advanced disease.
Correct Answer: A
Rationale: Biliary atresia typically presents with hepatosplenomegaly, pale stools, and dark urine due to impaired bile excretion.
The age at which the infant achieves early head control with bobbing motion when pulled to sit is
- A. 2 mo
- B. 3 mo
- C. 4 mo
- D. 6 mo
Correct Answer: B
Rationale: Early head control with bobbing motion typically occurs around 3 months.