Nokea
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.
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Which of the following actions by the staff nurse indicates an understanding of infection control practices?
- A. Maintains droplet precautions while the child is coughing and sneezing.
- B. Applies a face mask after entering the child's room.
- C. Wears gloves when assisting the child to the bathroom.
- D. Follows airborne precautions by wearing an N95 respirator while caring for the child.
Correct Answer: A
Rationale: The correct answer is A because maintaining droplet precautions while the child is coughing and sneezing is essential for preventing the spread of infection through respiratory droplets. This action shows understanding of infection control practices by implementing specific measures to reduce transmission of pathogens. Choice B is incorrect as wearing a face mask after entering the room does not provide adequate protection during exposure to respiratory secretions. Choice C is incorrect as gloves are not sufficient for preventing transmission of respiratory infections. Choice D is incorrect as airborne precautions are not necessary for droplet precautions.
Complete the following sentence by using the list of options. The nurse should first----- followed by -------
- A. Teach the child's parents the importance of inspecting the child's play area.
- B. Obtain informed consent.
- C. Monitor the child closely for return of gag reflex.
- D. Encourage the parents to inspect toys for easily removable parts.
- E. keep the child NPO
- F. prepare the child for flexible endoscopy
Correct Answer: E,F
Rationale: The correct answer is E, F. Firstly, keeping the child NPO (nothing by mouth) is essential before a flexible endoscopy to prevent aspiration during the procedure. Secondly, preparing the child for the flexible endoscopy involves informing them about the procedure and ensuring they are physically and emotionally ready. Choice A is incorrect as it does not directly relate to the procedure; B is not the immediate priority before the endoscopy; C is important post-procedure, not first; D is relevant but not the initial step.
Which of the following findings should the nurse report to the provider?
- A. Unable to roll from back to abdomen
- B. Exhibits head lag when pulled to a sitting position
- C. Unable to hold a bottle
- D. Absent grasp reflex
Correct Answer: B
Rationale: The correct answer is B: Exhibits head lag when pulled to a sitting position. This finding indicates poor head control, a developmental milestone typically achieved around 4 months. Reporting this to the provider is crucial for further assessment and intervention. Choice A is incorrect as rolling from back to abdomen is typically achieved around 5-6 months. Choice C is incorrect as holding a bottle is a milestone around 6-10 months. Choice D is incorrect as the grasp reflex typically disappears around 3-4 months. The key is to identify the finding that deviates significantly from the expected developmental milestone, which is demonstrated by choice B.
The nurse should monitor the child for which of the following complications?
- A. Nuchal rigidity when standing
- B. Double vision
- C. Headache
- D. Pain in the posterior iliac crest
Correct Answer: C
Rationale: The correct answer is C: Headache. In pediatric patients, headaches can be indicative of serious underlying conditions such as meningitis or increased intracranial pressure. Monitoring for headaches is crucial for early detection and intervention. Nuchal rigidity when standing (A) is more indicative of meningitis in adults. Double vision (B) is more associated with neurological issues. Pain in the posterior iliac crest (D) is not typically a complication that requires monitoring in children.
What is a 1-year-old with history of UTIs and diagnosed with vesicoureteral reflux s tachycardia at risk for?
- A. Nephrotic syndrome
- B. Renal Scarring
- C. Polycystic kidney
- D. Acute glomerulonephritis
- E. Pyclonephritis
Correct Answer: B,E
Rationale: The correct answers for a 1-year-old with history of UTIs and diagnosed with vesicoureteral reflux at risk for are B: Renal Scarring and E: Pyelonephritis. Vesicoureteral reflux increases the risk of recurrent UTIs, leading to pyelonephritis. Renal scarring can result from repeated pyelonephritis episodes. Nephrotic syndrome (A) is not typically associated with UTIs or reflux. Polycystic kidney (C) is a congenital condition, not related to the scenario. Acute glomerulonephritis (D) is usually caused by post-streptococcal infection, not UTIs.