Nokea
Which of the following is the priority nursing action if the child shows symptoms of hypoglycemic reaction?
- A. Give the child orange juice or milk to drink.
- B. Give the child 10% glucose I.V.
- C. Notify the physician immediately.
- D. Administer a second dose of insulin.
Correct Answer: A
Rationale: For hypoglycemia, the priority is to rapidly raise blood glucose. Giving orange juice or milk provides quick-acting carbohydrates, the first-line treatment for conscious patients with mild to moderate hypoglycemia.
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The nurse advises the parents that, to detect possible complications of juvenile rheumatoid arthritis, the child will require which periodic evaluation?
- A. Chest X-rays
- B. Dental examinations
- C. Hearing examinations
- D. Eye examinations
Correct Answer: D
Rationale: JRA can cause uveitis, an eye inflammation that may lead to vision loss if untreated. Periodic eye examinations are essential to detect this complication early.
Which statement by the client indicates a need for additional teaching about genital herpes?
- A. Males who have genital herpes need a yearly prostate-specific antigen (PSA) test.
- B. Females who have genital herpes need a Papanicolaou (Pap) test every 6 months.
- C. Genital herpes is closely associated with the occurrence of sterility.
- D. Genital herpes is closely associated with Hodgkin's disease.
Correct Answer: A
Rationale: Genital herpes is not associated with a need for yearly PSA tests in males, indicating a misconception. Regular Pap tests may be recommended for females due to increased cervical cancer risk with certain STIs, but the PSA statement is incorrect.
The nurse assesses that the 8-hour-old infant’s axillary temperature is 97°F (36.1°C). Which intervention should the nurse implement first?
- A. Document the findings as abnormal.
- B. Place the infant under a radiant warmer.
- C. Feed the infant formula that is warmed.
- D. Call the HCP to report the temperature.
Correct Answer: B
Rationale: An axillary temperature of 97°F is below the normal range (97.7°F–98.9°F). The infant should be gradually rewarmed under a radiant warmer. Documentation follows intervention feeding warm formula is unnecessary and HCP notification is needed only if warming fails.
The nurse is assessing the infant who may have FAS. Which findings,if observed,should the nurse associate with FAS? Select all that apply.
- A. Broad nasal bridge and flat midface
- B. Growth deficit in weight and length
- C. Excessive irritability and hypotonia
- D. Poor feeding and persistent vomiting
- E. Large jaw and overdeveloped maxilla
Correct Answer: A,B,C,D
Rationale: FAS features include broad nasal bridge flat midface growth deficits irritability hypotonia and poor feeding/vomiting due to alcohol’s effects. The jaw is small not large.
If the nurse documents all the following data, which finding should be reported immediately?
- A. Refusal to eat
- B. Complaint of nausea
- C. Absent bowel sounds
- D. Temperature of 101°F (38.3°C) orally
Correct Answer: C
Rationale: Absent bowel sounds may indicate peritonitis or bowel obstruction, serious complications of appendicitis requiring immediate reporting to prevent further deterioration.