Nokea
Which findings by the nurse best indicate that the child is experiencing diabetic ketoacidosis? Select all that apply.
- A. Blood glucose level of 120 mg/dL
- B. Fruity-smelling breath
- C. Pale-colored face
- D. Excessive perspiration
- E. Deep, rapid breathing
- F. Dry, flushed skin
Correct Answer: B,E,F
Rationale: Diabetic ketoacidosis (DKA) is characterized by hyperglycemia (blood glucose typically >250 mg/dL, so 120 mg/dL is incorrect), fruity-smelling breath due to acetone, deep and rapid breathing (Kussmaul respirations) to compensate for acidosis, and dry, flushed skin due to dehydration.
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The nurse completed discharge education to the Native American parents of a 48-hour-old,full-term infant. The nurse concludes that the mother needs additional teaching about jaundice when she makes which statement?
- A. “I know keeping my baby warm will help to decrease jaundice.”
- B. “I know the jaundice should start to decrease after about 3 days.”
- C. “The bilirubin causing the jaundice is eliminated in my baby’s stools.”
- D. “Feeding my baby frequently will help to decrease the jaundice.”
Correct Answer: B
Rationale: In Native American infants jaundice persists longer than in Caucasians with peak bilirubin at 3–5 days. Keeping warm frequent feeding and stool elimination of bilirubin are correct.
Which statement by the client indicates a need for additional teaching about genital herpes?
- A. Males who have genital herpes need a yearly prostate-specific antigen (PSA) test.
- B. Females who have genital herpes need a Papanicolaou (Pap) test every 6 months.
- C. Genital herpes is closely associated with the occurrence of sterility.
- D. Genital herpes is closely associated with Hodgkin's disease.
Correct Answer: A
Rationale: Genital herpes is not associated with a need for yearly PSA tests in males, indicating a misconception. Regular Pap tests may be recommended for females due to increased cervical cancer risk with certain STIs, but the PSA statement is incorrect.
Which nursing action would best promote the adolescent's compliance with wearing the brace?
- A. Advising the parents to keep a constant watch on their daughter to make sure she wears her brace
- B. Suggesting that the parents help their daughter find stylish clothing that will hide the brace
- C. Telling the parents that it might be best to arrange for a homebound teacher
- D. Advising the parents to limit their daughter's participation in school activities
Correct Answer: B
Rationale: Helping the adolescent find stylish clothing to conceal the brace addresses body image concerns, promoting compliance by making the brace less noticeable.
Which finding best indicates that a school-age child has acute glomerular nephritis?
- A. Periorbital edema
- B. Excessive urination
- C. Increased appetite
- D. Low blood pressure
Correct Answer: A
Rationale: Periorbital edema is a classic sign of acute glomerular nephritis due to fluid retention from impaired glomerular filtration, reflecting reduced sodium and water excretion.
The nurse advises the parents that, in most cases, children who have had an appendectomy usually return to school within what time frame?
- A. 5 days
- B. 2 weeks
- C. 4 weeks
- D. 6 weeks
Correct Answer: B
Rationale: Most children recover from an uncomplicated appendectomy within 1-2 weeks, allowing a return to school in about 2 weeks, depending on individual healing.