Nokea
Which clinical manifestation should the nurse expect to see as shock progresses in a child and becomes decompensated shock? (Select all that apply.)
- A. Thirst and diminished urinary output
- B. Irritability and apprehension
- C. Cool extremities and decreased skin turgor
- D. Confusion and somnolence
Correct Answer: C
Rationale: Cool extremities and decreased skin turgor (C) are indications of poor perfusion as shock progresses. The body is shunting blood away from the peripheries to maintain perfusion to vital organs.
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During a routine examination of a 10-mo-old male infant, you find a white pupillary reflex of the right eye; the eye movements are normal. You suspect retinoblastoma. Of the following, the BEST confirmatory diagnostic evaluation of this infant is
- A. indirect ophthalmoscopy with slit-lamp examination
- B. examination under general anesthesia by an experienced ophthalmologist
- C. orbital ultrasonography
- D. brain MRI
Correct Answer: B
Rationale: Examination under anesthesia by an experienced ophthalmologist is the gold standard for diagnosing retinoblastoma.
To return a patient with hyponatremia to normal sodium levels, it is safer to restrict fluid intake than to administer sodium:
- A. In patients who are unconscious
- B. In patients who show neurologic
- C. To prevent fluid overload symptoms
- D. To prevent dehydration
Correct Answer: C
Rationale: It is safer to restrict fluid intake rather than administer sodium to return a patient with hyponatremia to normal sodium levels to prevent fluid overload symptoms. Restoring normal sodium levels in patients with hyponatremia requires caution to prevent rapid correction which can lead to osmotic demyelination syndrome. By restricting fluid intake, the dilutional effect on sodium levels can be reduced, aiding in a safer and more controlled correction of hyponatremia without causing fluid overload. Administering sodium can lead to rapid changes in sodium levels, increasing the risk of complications.
Regarding the gross motor skills, a 2-year-old child can
- A. heel-toe walk
- B. balance on each foot 6 sec
- C. walk up and down stairs
- D. balance well on each foot
Correct Answer: C
Rationale: A 2-year-old typically can walk up and down stairs with support.
Which of the following conditions is suspected?
- A. Anemia
- B. Rheumatic arthritis
- C. Leukemia
- D. Systematic Lupus Erythematosus (SLE)
Correct Answer: C
Rationale: Leukemia is a type of cancer that affects the blood and bone marrow, leading to an overproduction of abnormal white blood cells. The symptoms of leukemia can include fatigue, weakness, weight loss, frequent infections, fever, bruising or bleeding easily, and bone pain. Given the vague presenting symptoms and the potential involvement of multiple bodily systems, leukemia is a condition that should be suspected and investigated further. Anemia, rheumatic arthritis, and systematic lupus erythematosus can also present with some similar symptoms, but for the given scenario, leukemia is the most probable condition to suspect.
Between 2-6 months of life, all are true about infant sleep EXCEPT
- A. total sleep hours are about 14-16 hr/24 hr
- B. sleeps about 9-10 hr concentrated at night
- C. sleeps 2 naps/day
- D. the sleep cycle time is similar to that of adults
Correct Answer: D
Rationale: Infant sleep cycles are shorter and differ from adult patterns.