Nokea
Which is the most appropriate nursing diagnosis for the child with acute glomerulonephritis?
- A. Risk for Injury related to malignant process and treatment
- B. Fluid Volume Deficit related to excessive losses
- C. Fluid Volume Excess related to decreased plasma filtration
- D. Fluid Volume Excess related to fluid accumulation in tissues and third spaces
Correct Answer:
Rationale: Acute glomerulonephritis is characterized by inflammation of the glomeruli in the kidneys, leading to decreased plasma filtration. As a result, fluid volume excess occurs due to impaired kidney function in regulating the fluid balance. Symptoms may include hypertension, edema, weight gain, and oliguria. Therefore, the most appropriate nursing diagnosis for a child with acute glomerulonephritis would be "Fluid Volume Excess related to decreased plasma filtration". This diagnosis focuses on the pathophysiological process of the condition and helps guide nursing interventions aimed at managing fluid volume overload.
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By the age of 7 months, the infant is able to do all the following EXCEPT
- A. transfer object from hand to hand
- B. actively bounces
- C. uses radial palm grasp
- D. cruises
Correct Answer: D
Rationale: Cruising typically occurs later, around 9-10 months.
Which of the following is an adverse reaction to glipizide (Glucotrol)?
- A. Headache
- B. Hypotension
- C. Constipation
- D. Photosensitivity
Correct Answer: B
Rationale: Hypotension, which is low blood pressure, can be an adverse reaction to glipizide (Glucotrol). Glipizide is a medication used to treat type 2 diabetes by helping to control blood sugar levels. Hypotension could occur as a side effect of glipizide, causing symptoms such as dizziness, lightheadedness, and fainting. If a patient experiences hypotension while taking glipizide, medical attention should be sought immediately to address this potentially serious adverse reaction.
The nurse is guiding parents in selecting a daycare facility for their infant. Which is especially important to consider when making the selection?
- A. Health practices of facility
- B. Structured learning environment
- C. Socioeconomic status of children
- D. Cultural similarities of children
Correct Answer: A
Rationale: When selecting a daycare facility for an infant, it is crucial to consider the health practices of the facility. The health and safety of the infant are of utmost importance, as they are more susceptible to illnesses and infections. Ensuring that the daycare facility follows proper hygiene practices, has clean and sanitized environments, implements illness policies, and promotes healthy habits is essential in protecting the infant's well-being. Additionally, the presence of trained staff who can handle medical emergencies and provide proper care in case of illness is also a key factor to consider. By prioritizing the health practices of the facility, parents can help create a safe and nurturing environment for their infant while they are in daycare.
The nurse teaches a diabetic client that diet plays a crucial role in managing diabetes mellitus. When evaluating dietary intake, the nurse knows the client is eating the right foods if total daily caloric intake consists of:
- A. 30% to 35% carbohydrate, 40% fat, and 25% to 30% protein
- B. 40% to 45% carbohydrate, 40% fat, and 15% to 20% protein
- C. 50% to 55% carbohydrate, 35% fat, and 10% to 15% protein
- D. 55% to 60% carbohydrate, 30% fat and 10% to 15% protein
Correct Answer: A
Rationale: In managing diabetes mellitus, one of the key principles is proper macronutrient distribution in the diet. The recommended dietary intake for a diabetic client typically includes a moderate amount of carbohydrates (30% to 35% of total calories) in order to help control blood sugar levels. Including higher amounts of fat (around 40%) can be beneficial in managing this condition as well. Adequate protein intake (25% to 30%) is also important for overall health and satiety. This balanced macronutrient distribution helps in maintaining stable blood sugar levels throughout the day, supporting optimal diabetes management.
A male client is prescribed medications that depress thrombocytes. The nurse should monitor for which of the ff signs and symptoms in the client?
- A. Sore throat and swollen glands
- B. Pernicious anemia with weakness
- C. Bleeding gums and dark tarry tools
- D. Thickening of blood and bruising
Correct Answer: C
Rationale: Thrombocytes, also known as platelets, play a crucial role in blood clotting. Medications that depress thrombocytes can lead to decreased clotting ability and an increased risk of bleeding. Therefore, monitoring for signs and symptoms of bleeding is essential. Bleeding gums and dark tarry stools are indicative of bleeding in the oral cavity and gastrointestinal tract, respectively, and are key indicators to watch for in a client taking medications that depress thrombocytes. Options A, B, and D are not directly related to the impact of thrombocyte depression on clotting function.