Nokea
Which of the following clinical assessment would most likely be demonstrated in severe dehydration?
- A. Pale skin turgor
- B. Normal skin turgor
- C. Marked oliguria
- D. Normal blood pressure
Correct Answer: C
Rationale: Severe dehydration is marked by reduced urine output (oliguria) due to significant fluid loss, a key clinical sign, unlike normal skin turgor or blood pressure which deteriorate later.
You may also like to solve these questions
Mother Riza brings her normally developed 3-year old to the clinic for a check-up. The nurse would expect that the child would be at least skilled in...
- A. Riding a bicycle
- B. Tying shoelaces
- C. Stringing large beads
- D. Using blunt scissors
Correct Answer: C
Rationale: Stringing large beads is a fine motor skill expected of a 3-year-old.
Student practical nurses are discussing the North American Nursing Diagnosis Association International (NANDA-I) taxonomy in post conference on the acute care clinical setting. The students are aware that the role of the LPN with nursing diagnosis formulation is what?
- A. To initiate and identify nursing diagnosis specific to patient
- B. To update changes in nursing diagnosis as needed
- C. To have an understanding of nursing diagnosis terminology
- D. To accurately document nursing diagnosis on patient plan of care
Correct Answer: C
Rationale: The registered nurse is responsible to initiate, identify, update, and document nursing diagnoses. The licensed practical nurse is responsible to have an understanding of nursing diagnosis terminology.
The nurse is developing a plan of care for a child who is 7-years-old. Which developmental period does the child fall under?
- A. Trust vs. mistrust
- B. Autonomy vs. shame/doubt
- C. Initiative vs. guilt
- D. Industry vs. inferiority
Correct Answer: D
Rationale: Per Erikson, 7-year-olds are in the industry vs. inferiority stage (school age, 6-12 years), focusing on competence and achievement.
Nurse Bryan knows that one of the most effective strategies to teach a Four year old about safety is to...
- A. Show him potential dangers to avoid
- B. Tell him he is bad when they do something dangerous
- C. Provide good examples of safety behavior
- D. Show him pictures of children who have involve with accidents
Correct Answer: C
Rationale: Modeling safety behavior is an effective way to teach preschoolers.
When assessing a child with a cleft palate, the nurse is aware that the child is at risk for more frequent episodes of otitis media due to which of the following?
- A. Lowered resistance from malnutrition
- B. Ineffective functioning of the Eustachian tubes
- C. Plugging of the Eustachian tubes with food particles
- D. Associated congenital defects of the middle ear.
Correct Answer: B
Rationale: Because of the structural defect, children with cleft palate may have ineffective functioning of their Eustachian tubes creating frequent bouts of otitis media.