Nokea
Which statement by the mother of an 18-month-old would lead the nurse to believe that the child should be referred for further evaluation for developmental delay?
- A. My child is able to stand but is not yet taking steps independently.
- B. My child has a vocabulary of approximately 15 words.
- C. My child is still sucking his thumb.
- D. My child seems to be quite wary of strangers.
Correct Answer: A
Rationale: By 15 to 18 months, most toddlers should be walking independently. An 18-month-old who is not yet walking warrants further evaluation.
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A 1-year-old with acute renal failure (ARF) is edematous with minimal urine output. Vital signs: HR 146, BP 176/92, RR 42; the child has nasal flaring and retractions. Despite oral Kayexalate, serum potassium continues to rise. Which treatment will most benefit the child?
- A. Additional rectal Kayexalate.
- B. Intravenous furosemide.
- C. Endotracheal intubation and ventilatory assistance.
- D. Placement of a Tenckhoff catheter for peritoneal dialysis.
Correct Answer: D
Rationale: When ARF deteriorates and electrolyte imbalances worsen, peritoneal dialysis (via a Tenckhoff catheter) is indicated.
The nurse is conducting a staff in-service on appearance of childhood skin conditions. Lymphangitis ("streaking") is frequently seen in which condition?
- A. Cellulitis
- B. Folliculitis
- C. Impetigo contagiosa
- D. Staphylococcal scalded skin
Correct Answer: A
Rationale: Lymphangitis, characterized by "streaking" of red lines extending from the site of infection, is frequently seen in cellulitis. Cellulitis is a bacterial skin infection that affects the deeper layers of the skin and subcutaneous tissues. The red streaking in lymphangitis indicates an infection and inflammation of the lymphatic vessels, which are responsible for removing waste and fluids from the tissues. In cellulitis, bacteria enter the skin through a crack or break, leading to infection, inflammation, and the characteristic presentation of lymphangitis. This condition requires prompt medical attention and treatment with antibiotics to prevent further complications.
The screening test for PKU is most reliable if the blood sample is:
- A. from cord blood.
- B. taken 14 days after birth.
- C. taken before oral feedings are initiated.
- D. fresh blood from the heel.
Correct Answer: D
Rationale: The screening test for PKU (Phenylketonuria) is most reliable when the blood sample is fresh and taken from the heel. This is because the test requires a small amount of blood, and obtaining a fresh sample from the heel minimizes the risk of contamination and ensures accurate results. Additionally, collecting the blood sample from the heel is less invasive for the newborn and is a common practice for newborn screening tests. Blood samples taken from cord blood, 14 days after birth, or before oral feedings are initiated may not provide accurate results for the PKU screening test.
A nursing intervention for anemia is:
- A. Medical therapy
- B. High protein, vitamin and iron diet
- C. Fluid therapy
- D. Chemotherapy
Correct Answer: B
Rationale: Anemia is a condition characterized by a low red blood cell count or insufficient hemoglobin levels, resulting in decreased oxygen-carrying capacity in the blood. One of the nursing interventions for anemia is to promote a high protein, vitamin, and iron diet. Iron is essential for the production of hemoglobin, which carries oxygen in the blood. Including foods rich in iron, such as lean meats, dark leafy greens, beans, and fortified cereals, can help boost iron levels in the body. Additionally, consuming foods high in vitamin C can also aid in iron absorption. Protein is crucial for overall health and plays a role in red blood cell production. By encouraging a nutrient-rich diet, nurses can help support the body's ability to replenish its red blood cell supply and improve the symptoms associated with anemia.
Which of the following should be included when developing a teaching plan to prevent urinary tract infection? Select all that apply.
- A. Maintaining adequate fluid intake
- B. Avoiding urination before and after intercourse
- C. Emptying bladder with urination
- D. Wearing underwear made of synthetic material such as nylon
Correct Answer: A
Rationale: Maintaining adequate fluid intake: Adequate fluid intake helps to flush out bacteria from the urinary tract, reducing the risk of infection.