Nokea
While caring for a hospitalized child, which of the following signs would lead the nurse to suspect the child has diabetes insipidus?
- A. Increased urination
- B. Fruity breath
- C. Weight gain
- D. Slurred speech
Correct Answer: A
Rationale: The correct answer is A: Increased urination. Diabetes insipidus is characterized by excessive urination (polyuria) due to the inability of the kidneys to concentrate urine. This leads to a large volume of dilute urine being produced. The other options are not indicative of diabetes insipidus. Fruity breath (B) is a sign of diabetic ketoacidosis, not diabetes insipidus. Weight gain (C) is not a typical symptom of diabetes insipidus, as patients may even experience weight loss due to dehydration. Slurred speech (D) is not directly related to diabetes insipidus.
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A home health nurse is caring for a child who has lyme disease. Which of the following is an appropriate action for the nurse to take
- A. Ensure the state health department has been notified
- B. Administer antitoxin
- C. Educate the family to avoid sharing personal belongings
- D. Assess for skin necrosis
Correct Answer: B
Rationale: The correct answer is B: Administer antitoxin. Lyme disease is caused by a bacterium, not a toxin, so administering antitoxin is not appropriate. Option A is incorrect because notifying the state health department is not a direct action for the nurse to take in caring for the child. Option C is incorrect as educating the family to avoid sharing personal belongings is a preventive measure but not a direct action for the child's care. Option D is incorrect as skin necrosis is not a typical manifestation of Lyme disease. Administering appropriate antibiotics to treat the bacterial infection is the most appropriate action for the nurse to take in caring for the child with Lyme disease.
Which should be the major consideration in selecting toys for a child who is cognitively impaired?
- A. Age appropriateness
- B. Ability to teach useful skills
- C. Safety
- D. Ability to provide exercise
Correct Answer: C
Rationale: The major consideration in selecting toys for a cognitively impaired child should be safety (Choice C). Safety is crucial as children with cognitive impairments may have difficulty understanding potential dangers or using toys appropriately. Age appropriateness (Choice A) is important, but safety should take precedence. Teaching useful skills (Choice B) can be beneficial but may not be the primary focus. Providing exercise (Choice D) is valuable, but ensuring safety should come first.
The nurse is caring for a child with frostbite would expect the patient to display:
- A. Redness and swelling of the hands
- B. Blisters that appear 24 to 48 hours after rewarming
- C. Itching and burning that persists after rewarming
- D. Fever
Correct Answer: B
Rationale: The correct answer is B because blisters appearing 24 to 48 hours after rewarming is a common symptom of frostbite. This occurs due to damage to the blood vessels and tissues. A: Redness and swelling are more indicative of mild frostbite. C: Itching and burning are not typical symptoms of frostbite. D: Fever is not a common symptom of frostbite.
The emergency room nurse is caring for a patient with severe burns knows that the priority immediate intervention is which of the following?
- A. Cover the burns to prevent infection
- B. Provide anti-inflammatory medication
- C. Stop the burning process
- D. Provide anti-cyanide medication
Correct Answer: C
Rationale: The correct answer is C: Stop the burning process. This is the priority immediate intervention for a patient with severe burns because stopping the burning process helps prevent further tissue damage. It involves removing the patient from the source of the burn, extinguishing any flames, and cooling the burn with water. This action is crucial in minimizing the extent of the injury and improving outcomes.
A: Covering the burns to prevent infection is important but not the immediate priority.
B: Providing anti-inflammatory medication can be considered later but is not the primary immediate intervention.
D: Providing anti-cyanide medication is not relevant for severe burns.
A mother brings her child into the pediatrician's office for a follow up appointment and voices concern that her child has started urinating more frequently and is constantly hungry and thirsty. The nurse suspects:
- A. Hypoglycemia
- B. Huntington disease
- C. Diabetes mellitus
- D. Phenylketonuria
Correct Answer: C
Rationale: The correct answer is C: Diabetes mellitus. The symptoms of increased urination, hunger, and thirst are classic signs of diabetes mellitus. In diabetes, the body cannot properly regulate blood sugar levels, leading to excessive urination (as the body tries to get rid of excess sugar), increased hunger (as cells are not getting enough glucose for energy), and increased thirst (due to dehydration from frequent urination). Hypoglycemia (choice A) would present with low blood sugar symptoms, not high blood sugar symptoms. Huntington disease (choice B) is a genetic disorder affecting the brain, not related to the symptoms described. Phenylketonuria (choice D) is a metabolic disorder related to the inability to break down phenylalanine, not associated with the symptoms described.