Nokea
Which complication is the nurse most concerned about in an obese child?
- A. Asthma.
- B. Type 2 diabetes.
- C. Seasonal allergies.
- D. Iron deficiency.
Correct Answer: B
Rationale: Obesity increases the risk of type 2 diabetes due to insulin resistance. Asthma and allergies may occur, but diabetes is a more significant concern. Iron deficiency is unrelated.
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The nurse is caring for a 2-year-old with iron deficiency anemia. Which laboratory finding would the nurse expect to see?
- A. Elevated hemoglobin levels.
- B. Decreased mean corpuscular volume (MCV).
- C. Increased serum ferritin levels.
- D. Elevated white blood cell count.
Correct Answer: B
Rationale: Iron deficiency anemia typically shows decreased MCV, indicating microcytic red blood cells, due to reduced iron availability for hemoglobin synthesis.
The nurse is monitoring an infant receiving IV fluids for gastroenteritis. Which finding suggests the infant is responding well to treatment?
- A. Dry mucous membranes.
- B. Weight gain of 50 grams daily.
- C. Urine output of 1 mL/kg/hour.
- D. Heart rate of 180 bpm.
Correct Answer: C
Rationale: Adequate urine output indicates effective rehydration.
The school nurse develops a plan with an adolescent to provide relief of dysmenorrhea to aid in her development of which of the following?
- A. Positive peer relations.
- B. Positive self-identity.
- C. A sense of autonomy.
- D. A sense of independence.
Correct Answer: C
Rationale: Managing dysmenorrhea supports autonomy by empowering the adolescent to control her health.
The parents of a child with a tracheoesophageal fistula express feelings of guilt about their baby's anomaly. Which of the following approaches by the nurse would best support the parents?
- A. Helping the parents accept their feelings as a normal reaction.
- B. Explaining that the parents did nothing to cause the newborn's defect.
- C. Encouraging the parents to concentrate on planning their baby's care.
- D. Urging the parents to visit their newborn as often as possible.
Correct Answer: A
Rationale: Acknowledging and normalizing the parents' guilt helps them process emotions and supports coping.
The nurse is assessing the infant shown in the figure. On observing the client from this angle, the nurse should document that this infant has which of the following?
- A. Ortolani’s “click.”
- B. Limited abduction.
- C. Galeazzi’s sign.
- D. Asymmetric gluteal folds.
Correct Answer: D
Rationale: This infant with congenital hip dysplasia has asymmetric gluteal folds. The Ortolani “click” occurs when the nurse feels the femur sliding into the acetabulum with a “click.” Limited abduction may be observed during an attempt to abduct the infant’s thighs. Galeazzi’s sign reveals femoral foreshortening and is observed by fl exing the thighs.