Nokea
Which of the following findings should the nurse identify as a manifestation of severe dehydration?
- A. Capillary refill time 3 seconds
- B. Sunken anterior fontanel
- C. Weight loss of 5%
- D. Produces tears when crying
Correct Answer: B
Rationale: The correct answer is B: Sunken anterior fontanel. This finding is indicative of severe dehydration in infants, as it suggests significant fluid loss and decreased tissue turgor. A sunken fontanel is a late sign of dehydration. Choice A is incorrect as a capillary refill time of 3 seconds is within normal limits. Choice C may be seen in mild to moderate dehydration, but severe dehydration would involve a greater weight loss. Choice D is not specific to dehydration, as tear production can still occur even in cases of dehydration.
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Which of the following findings is a clinical manifestation associated with this diagnosis?
- A. Tachypnea
- B. Tremors
- C. Increased appetite
- D. Bradycardia
Correct Answer: A
Rationale: The correct answer is A: Tachypnea. Tachypnea refers to rapid breathing, which is a common clinical manifestation associated with various medical conditions, including respiratory distress. In this particular diagnosis, tachypnea may indicate underlying respiratory issues or distress. Tremors (B) and increased appetite (C) are not typically associated with this diagnosis. Bradycardia (D), which is a slow heart rate, is also not a common clinical manifestation in this context.
Which of the following information should the nurse include in the teaching?
- A. Provide for periods of rest.
- B. Increase the child's oxygen flow rate until the child no longer has cyanosis.
- C. Withhold digoxin if the child's pulse is greater than 100/min.
- D. Weigh the child once each month.
Correct Answer: A
Rationale: Correct Answer: A - Provide for periods of rest.
Rationale: It is important for the nurse to include information about providing periods of rest in the teaching because rest is essential for recovery and healing. Rest allows the body to conserve energy, reduce stress, and promote overall well-being. By including this information, the nurse is promoting the child's health and supporting the healing process.
Summary of other choices:
B: Increasing oxygen flow rate until cyanosis resolves can lead to oxygen toxicity and is not a safe or appropriate intervention.
C: Withholding digoxin based solely on pulse rate without considering other factors or consulting the healthcare provider can be dangerous and potentially harmful.
D: Weighing the child once a month is important for monitoring growth and nutrition, but it is not directly related to the immediate care and teaching needed in this scenario.
Which of the following findings should the nurse recognize as being consistent with hyperglycemia?
- A. Sweating
- B. Tremors
- C. Pallor
- D. Thirst
Correct Answer: D
Rationale: The correct answer is D: Thirst. Hyperglycemia results in elevated blood sugar levels, leading to increased osmolality and dehydration, triggering thirst as the body attempts to dilute the blood. Sweating (A), tremors (B), and pallor (C) are not typically associated with hyperglycemia. Sweating is more commonly seen in hypoglycemia, tremors can be a sign of low blood sugar, and pallor is not a direct symptom of high blood sugar levels.
The nurse is planning care for the adolescent. Select the 5 interventions the nurse should include.
- A. Instruct the parent to ensure the pneumococcal vaccine is current.
- B. Administer folic acid as prescribed.
- C. Monitor oxygen saturation continuously.
- D. Place the client on strict bed rest.
- E. Apply cold compresses to the affected joints.
- F. Administer meperidine IV for pain.
Correct Answer: B,C,E,F,H
Rationale: The correct interventions for the adolescent are B, C, E, F, and H. Administering folic acid (B) is important for growth and development. Monitoring oxygen saturation (C) ensures respiratory function. Applying cold compresses (E) helps reduce inflammation in affected joints. Administering meperidine IV (F) addresses pain management. The rationale for excluding other choices: A is irrelevant for adolescent care, D may worsen joint symptoms, and G is incomplete.
Which of the following statements by the guardian indicates an understanding of the teaching?
- A. I will ensure that my child consumes a high-calorie diet.
- B. I will expect my child to need annual sweat chloride testing.
- C. I will have my child chew the pancrelipase medication before eating.
- D. I will administer dormase alfa every 4 hours for wheezing.
Correct Answer: A
Rationale: The correct answer is A because ensuring the child consumes a high-calorie diet demonstrates an understanding of the teaching regarding managing cystic fibrosis, a condition that requires a high-calorie intake to maintain weight and overall health. This statement aligns with the need for nutritional support in cystic fibrosis management.
Choice B is incorrect because annual sweat chloride testing is not related to dietary management. Choice C is incorrect as chewing pancrelipase medication before eating is not necessary for understanding the teaching about cystic fibrosis. Choice D is incorrect as administering dormase alfa every 4 hours for wheezing does not pertain to dietary requirements in cystic fibrosis.