Nokea
Which of the following blood values would require further nursing action in a newborn who is 4 hours old?
- A. Hemoglobin 17.2 g/dL
- B. Platelets 250,000/mm3
- C. Serum glucose 30 mg/dL
- D. White blood cells 18,000/mm3
Correct Answer: C
Rationale: A serum glucose of 30 mg/dL in the first 72 hours of life is indicative of hypoglycemia and warrants further intervention.
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A family by court order undergoes treatment by a family therapist for child abuse. The nurse, who is the child's case manager knows that treatment has been effective when:
- A. The child is removed from the home and placed in foster care
- B. The child's parents identify the ways in which he is different from the rest of the family
- C. The child's father is arrested for child abuse
- D. The child's parents can identify appropriate behaviors for children in his age group
Correct Answer: D
Rationale: Removing an abused child from the home and placement in a foster home are not the desired outcome of treatment. Children who are perceived as 'different' from the rest of the family are more likely to be abused. Although legal action may be taken against abusive parents, it is not an indicator of an effective treatment program. Identification of age-appropriate behaviors is essential to the role of parents, because misunderstanding children's normal developmental needs often contributes to abuse or neglect.
A client with a history of a brain tumor is receiving Decadron (dexamethasone). The nurse should monitor the client for:
- A. Weight gain
- B. Hypotension
- C. Hypoglycemia
- D. Hair loss
Correct Answer: A
Rationale: Dexamethasone, a corticosteroid, causes weight gain due to fluid retention and increased appetite. Hypotension, hypoglycemia, and hair loss are not typical side effects.
A mother frantically calls the emergency room (ER) asking what to do about her 3-year-old girl who was found eating pills out of a bottle in the medicine cabinet. The ER nurse tells the mother to:
- A. Give the child 15 mL of syrup of ipecac.
- B. Give the child 10 mL of syrup of ipecac with a sip of water.
- C. Give the child 1 cup of water to induce vomiting.
- D. Bring the child to the ER immediately.
Correct Answer: D
Rationale: Before giving any emetic, the substance ingested must be known. At least 8 oz of water should be administered along with ipecac syrup to increase volume in the stomach and facilitate vomiting. Water alone will not induce vomiting. An emetic is necessary to facilitate vomiting. Vomiting should never be induced in an unconscious client because of the risk of aspiration.
Place in sequence from 1-5 the proper order for introducing items to the infant's diet.
- A. Strained meats
- B. Whole milk
- C. Rice cereal
- D. Fruits
- E. Vegetables
Correct Answer: C, D, E, A, B
Rationale: Infant diet sequence: rice cereal (C) at 6 months, then fruits (D) and vegetables (E), strained meats (A) around 7-8 months, and whole milk (B) after 12 months.
A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should give priority to:
- A. Withholding all morning medications
- B. Ordering a CBC and CPK
- C. Administering prescribed anti-Parkinsonian medication
- D. Transferring the client to a medical unit
Correct Answer: D
Rationale: Muscle rigidity and fever suggest neuroleptic malignant syndrome (NMS), a life-threatening reaction to olanzapine. Immediate transfer to a medical unit for urgent treatment is critical.