Nokea
Which finding by the nurse strongly indicates that a child is experiencing hypokalemia?
- A. Full, bounding pulses
- B. Muscle weakness
- C. Elevated blood pressure
- D. Hyperactive bowel sounds
Correct Answer: B
Rationale: Hypokalemia causes muscle weakness due to impaired muscle contraction, a key manifestation resulting from low potassium levels affecting neuromuscular function.
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The nurse is concerned that a newborn may have congenital hydrocephalus. Which finding did the nurse likely observe on assessment?
- A. Bulging anterior fontanel
- B. Head and chest circumference equal
- C. A narrowed posterior fontanel
- D. Low-set ears
Correct Answer: A
Rationale: A bulging anterior fontanel suggests hydrocephalus due to increased intracranial pressure. Equal head/chest circumferences narrow posterior fontanel and low-set ears are normal or unrelated.
A breastfeeding mother is being discharged with her 2-day-old,full-term newborn. The nurse recognizes that the mother understands how to determine if her newborn is getting enough breast milk when making which statement?
- A. “He should have at least three wet diapers tomorrow.”
- B. “He should have one stool per day during the next week.”
- C. “At his 1-week checkup,he should weigh an additional 8 ounces.”
- D. “He should nurse for 5 minutes on each breast to get enough milk.”
Correct Answer: A
Rationale: A 3-day-old should have at least three wet diapers indicating adequate intake. Breastfed infants stool 3–10 times daily lose 5–10% birth weight initially and nurse 10–20 minutes per breast.
While caring for the small-for-gestational-age newborn (SGA),the nurse notes slight tremors of the extremities a high-pitched cry and an exaggerated Moro reflex. In response to these assessment findings what should be the nurse’s first action?
- A. Assess the infant’s blood sugar level.
- B. Document the findings in the infant’s medical record.
- C. Immediately inform the pediatrician of the symptoms.
- D. Assess the infant’s axillary temperature.
Correct Answer: A
Rationale: SGA infants risk hypoglycemia due to low glycogen stores causing tremors high-pitched cry and exaggerated reflexes. Checking blood sugar is the priority action.
Which statement by the parents indicates they understand the home care needs for a child with sickle cell anemia?
- A. We'll limit our child's fluid intake to prevent swelling.
- B. We'll encourage our child to rest during sickle cell crises.
- C. We'll give our child aspirin for fever.
- D. We'll avoid taking our child to the doctor for regular checkups.
Correct Answer: B
Rationale: Encouraging rest during sickle cell crises reduces oxygen demand and prevents exacerbation of vaso-occlusive episodes, indicating understanding of home care needs.
Which clinical manifestation of the client's full-thickness burns would the nurse detect during an assessment?
- A. Moderate level of pain due to exposed nerve endings
- B. Eschar formation throughout the area of the burn
- C. The appearance of blister formation throughout the area of the burn
- D. Noted tissue destruction extending to the subcutaneous layer
Correct Answer: D
Rationale: Full-thickness burns involve destruction of all skin layers, including the subcutaneous layer, resulting in a leathery or charred appearance. Pain is minimal due to nerve destruction, and blisters are characteristic of partial-thickness burns.