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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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.
If the parents of a child with Duchenne's muscular dystrophy are having a difficult time accepting the diagnosis, which nursing action is most beneficial to the family?
- A. Recommend that the parents place the child in an institution.
- B. Recommend that the parents contact the local social welfare agency.
- C. Recommend that the parents talk with other parents who have children with muscular dystrophy.
- D. Recommend that the parents read as much literature as possible about treatment of muscular dystrophy.
Correct Answer: C
Rationale: Connecting with other parents who have children with Duchenne's muscular dystrophy provides emotional support and practical insights, helping the family cope with the diagnosis.
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.
Which nursing interventions are essential to restore the child's fluid and electrolyte balance during the emergent phase of burn care and treatment? Select all that apply.
- A. Initiate the administration of I.V. fluids.
- B. Track the child's vital signs.
- C. Give the child sips of water.
- D. Encourage the child to consume protein-rich feedings.
- E. Monitor the child's urine output.
- F. Assemble equipment for a small-gauge venous catheter.
Correct Answer: A,B,E,F
Rationale: During the emergent phase, I.V. fluids restore fluid and electrolyte balance due to massive losses. Monitoring vital signs and urine output assesses fluid status, and preparing venous access ensures timely administration. Oral fluids and protein-rich feedings are inappropriate due to gastrointestinal dysfunction.
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.