Fluid & Elect
A 1-month-old client is admitted to the emergency room with severe diarrhea. Which assessment suggests the client is severely dehydrated?
1. Skin moist and flushed; mucous membranes dry
2. Low specific gravity of urine; skin color pale
3. Fontanels depressed; capillary refill greater than three seconds
4. High specific gravity of urine; moist mucous membranes
Answer: 3
Explanation: 1. Two signs of severe dehydration are depressed fontanels and capillary refill time greater than three seconds. Moist, flushed skin; moist mucous membranes; and low specific gravity of urine are not signs of dehydration. Dry mucous membranes and pale skin color are signs of mild dehydration, not severe.
2. Two signs of severe dehydration are depressed fontanels and capillary refill time greater than three seconds. Moist, flushed skin; moist mucous membranes; and low specific gravity of urine are not signs of dehydration. Dry mucous membranes and pale skin color are signs of mild dehydration, not severe.
3. Two signs of severe dehydration are depressed fontanels and capillary refill time greater than three seconds. Moist, flushed skin; moist mucous membranes; and low specific gravity of urine are not signs of dehydration. Dry mucous membranes and pale skin color are signs of mild dehydration, not severe.
4. Two signs of severe dehydration are depressed fontanels and capillary refill time greater than three seconds. Moist, flushed skin; moist mucous membranes; and low specific gravity of urine are not signs of dehydration. Dry mucous membranes and pale skin color are signs of mild dehydration, not severe.
The nurse is planning care for a 3-month-old infant diagnosed with eczema. Which should be the focus of the nurse's care for this infant?
1. Maintaining adequate nutrition
2. Keeping the baby content
3. Preventing infection of lesions
4. Applying antibiotics to lesions
Answer: 3
Explanation: 1. Nursing care should focus on preventing infection of lesions. Due to impaired skin-barrier function and cutaneous immunity, an infant with eczema is at greater risk for the development of skin infections by organisms. Maintaining adequate nutrition and keeping the infant content are not as high a priority. Antibiotics are not routinely applied to the lesions.
2. Nursing care should focus on preventing infection of lesions. Due to impaired skin-barrier function and cutaneous immunity, an infant with eczema is at greater risk for the development of skin infections by organisms. Maintaining adequate nutrition and keeping the infant content are not as high a priority. Antibiotics are not routinely applied to the lesions.
3. Nursing care should focus on preventing infection of lesions. Due to impaired skin-barrier function and cutaneous immunity, an infant with eczema is at greater risk for the development of skin infections by organisms. Maintaining adequate nutrition and keeping the infant content are not as high a priority. Antibiotics are not routinely applied to the lesions.
4. Nursing care should focus on preventing infection of lesions. Due to impaired skin-barrier function and cutaneous immunity, an infant with eczema is at greater risk for the development of skin infections by organisms. Maintaining adequate nutrition and keeping the infant content are not as high a priority. Antibiotics are not routinely applied to the lesions.
The nurse completes parent education related to treatment for a pediatric client with congenital clubfoot. Which statement by the parents indicates the need for further education?
1. "We're happy this is the only cast our baby will need."
2. "We'll watch for any swelling of the feet while the casts are on."
3. "We'll keep the casts dry."
4. "We're getting a special car seat to accommodate the casts."
Answer: 1
Explanation: 1. Serial casting is the treatment of choice for congenital clubfoot. The cast is changed everyone to 2 weeks. Parents should be watching for swelling while the casts are on, keeping the casts dry, and using a car seat to accommodate the casts.
2. Serial casting is the treatment of choice for congenital clubfoot. The cast is changed every one to 2 weeks. Parents should be watching for swelling while the casts are on, keeping the casts dry, and using a car seat to accommodate the casts.
3. Serial casting is the treatment of choice for congenital clubfoot. The cast is changed every one to 2 weeks. Parents should be watching for swelling while the casts are on, keeping the casts dry, and using a car seat to accommodate the casts.
4. Serial casting is the treatment of choice for congenital clubfoot. The cast is changed every one to 2 weeks. Parents should be watching for swelling while the casts are on, keeping the casts dry, and using a car seat to accommodate the casts.
A school-age client diagnosed with diabetes insipidus (DI) is admitted to the pediatric unit. Which laboratory value does the nurse anticipate for this client based on the diagnosis?
1. Hyperglycemia
2. Hypernatremia
3. Hypercalcemia
4. Hypoglycemia
Answer: 2
Explanation: 1. In all forms of diabetes insipidus, serum sodium can increase to pathologic levels, so hypernatremia can occur and should be treated. The glucose level is not affected, so hypoglycemia or hyperglycemia is not caused by the diabetes insipidus. Hypercalcemia (high calcium) does not occur with this endocrine disorder.
2. In all forms of diabetes insipidus, serum sodium can increase to pathologic levels, so hypernatremia can occur and should be treated. The glucose level is not affected, so hypoglycemia or hyperglycemia is not caused by the diabetes insipidus. Hypercalcemia (high calcium) does not occur with this endocrine disorder.
3. In all forms of diabetes insipidus, serum sodium can increase to pathologic levels, so hypernatremia can occur and should be treated. The glucose level is not affected, so hypoglycemia or hyperglycemia is not caused by the diabetes insipidus. Hypercalcemia (high calcium) does not occur with this endocrine disorder.
4. In all forms of diabetes insipidus, serum sodium can increase to pathologic levels, so hypernatremia can occur and should be treated. The glucose level is not affected, so hypoglycemia or hyperglycemia is not caused by the diabetes insipidus. Hypercalcemia (high calcium) does not occur with this endocrine disorder.
The nurse is evaluating an infant's tolerance of feedings after a pyloromyotomy. Which finding indicates that the infant is not tolerating the feeding?
1. Need for frequent burping
2. Irritability during feeding
3. The passing of gas
4. Emesis after two feedings
Answer: 4
1. An infant is not tolerating feedings after a pyloromyotomy if emesis is present. Frequent burping, irritability, and the passing of gas would be expected findings following a pyloromyotomy and would indicate tolerance of the feeding.
2. An infant is not tolerating feedings after a pyloromyotomy if emesis is present. Frequent burping, irritability, and the passing of gas would be expected findings following a pyloromyotomy and would indicate tolerance of the feeding.
3. An infant is not tolerating feedings after a pyloromyotomy if emesis is present. Frequent burping, irritability, and the passing of gas would be expected findings following a pyloromyotomy and would indicate tolerance of the feeding.
4. An infant is not tolerating feedings after a pyloromyotomy if emesis is present. Frequent burping, irritability, and the passing of gas would be expected findings following a pyloromyotomy and would indicate tolerance of the feeding.
Parents of an infant with slow weight gain ask the nurse if they can feed their baby a highly concentrated formula. Which response by the nurse is the most appropriate?
1. "A higher-concentrated formula could lead to dehydration because of high sodium content; let's discuss other strategies."
2. "An undiluted formula concentrate could be given to help the child gain weight; let's look at brands."
3. "Evaporated milk could be given to the infant instead of the current formula you're using."
4. "A higher-concentrated formula could be given for daytime feedings; let's work on a schedule."
Answer: 1
Explanation: 1. Parents and caregivers of bottle-fed babies should be taught never to give undiluted formula concentrate or evaporated milk due to the high sodium content.
2. Parents and caregivers of bottle-fed babies should be taught never to give undiluted formula concentrate or evaporated milk due to the high sodium content.
3. Parents and caregivers of bottle-fed babies should be taught never to give undiluted formula concentrate or evaporated milk due to the high sodium content.
4. Parents and caregivers of bottle-fed babies should be taught never to give undiluted formula concentrate or evaporated milk due to the high sodium content.
An infant has a severe case of oral thrush (Candida albicans). Which nursing diagnosis is the priority for this infant?
1. Activity Intolerance Related to Oral Thrush
2. Ineffective Airway Clearance Related to Mucus
3. Ineffective Infant Feeding Pattern Related to Discomfort
4. Ineffective Breathing Pattern Related to Oral Thrush
Answer: 3
Explanation: 1. An infant with oral thrush may refuse to nurse or feed because of discomfort and pain. Prompt treatment is necessary so the infant can resume a normal feeding pattern. Activity intolerance, ineffective airway clearance, and ineffective breathing patterns are not usual associated problems.
2. An infant with oral thrush may refuse to nurse or feed because of discomfort and pain. Prompt treatment is necessary so the infant can resume a normal feeding pattern. Activity intolerance, ineffective airway clearance, and ineffective breathing patterns are not usual associated problems.
3. An infant with oral thrush may refuse to nurse or feed because of discomfort and pain. Prompt treatment is necessary so the infant can resume a normal feeding pattern. Activity intolerance, ineffective airway clearance, and ineffective breathing patterns are not usual associated problems.
4. An infant with oral thrush may refuse to nurse or feed because of discomfort and pain. Prompt treatment is necessary so the infant can resume a normal feeding pattern. Activity intolerance, ineffective airway clearance, and ineffective breathing patterns are not usual associated problems.
The nurse is teaching family members how to care for their infant in a Pavlik harness to treat congenital developmental dysplasia of the hip. Which statement will the nurse include in the teaching session?
1. "Apply lotion or powder to minimize skin irritation."
2. "Put clothing over the harness for maximum effectiveness of the device."
3. "Check at least 2 or 3 times a day for red areas under the straps."
4. "Place a diaper over the harness, preferably using a thin, superabsorbent, disposable diaper."
Answer: 3
Explanation: 1. The brace should be checked 2 or 3 times for red areas under the straps. Lotion or powder can contribute to skin breakdown. A light layer of clothing should be under the brace, not over. The diaper should also be under the brace.
2. The brace should be checked 2 or 3 times for red areas under the straps. Lotion or powder can contribute to skin breakdown. A light layer of clothing should be under the brace, not over. The diaper should also be under the brace.
3. The brace should be checked 2 or 3 times for red areas under the straps. Lotion or powder can contribute to skin breakdown. A light layer of clothing should be under the brace, not over. The diaper should also be under the brace.
4. The brace should be checked 2 or 3 times for red areas under the straps. Lotion or powder can contribute to skin breakdown. A light layer of clothing should be under the brace, not over. The diaper should also be under the brace.
An adolescent client diagnosed with Graves' disease is admitted to the hospital. Which clinical manifestations would the nurse expect on assessment?
1. Weight gain, hirsutism, and muscle weakness
2. Dehydration, metabolic acidosis, and hypertension
3. Tachycardia, fatigue, and heat intolerance
4. Hyperglycemia, ketonuria, and glucosuria
Answer: 3
Explanation: 1. Graves' disease occurs when thyroid hormone levels are increased, resulting in excessive levels of circulating thyroid hormones. Clinical manifestations include tachycardia, fatigue, and heat intolerance. Weight gain, hirsutism, and muscle weakness are signs of Cushing syndrome. Dehydration, metabolic acidosis, and hypertension are signs of congenital adrenal hyperplasia. Hyperglycemia, ketonuria, and glucosuria are signs of diabetes.
2. Graves' disease occurs when thyroid hormone levels are increased, resulting in excessive levels of circulating thyroid hormones. Clinical manifestations include tachycardia, fatigue, and heat intolerance. Weight gain, hirsutism, and muscle weakness are signs of Cushing syndrome. Dehydration, metabolic acidosis, and hypertension are signs of congenital adrenal hyperplasia. Hyperglycemia, ketonuria, and glucosuria are signs of diabetes.
3. Graves' disease occurs when thyroid hormone levels are increased, resulting in excessive levels of circulating thyroid hormones. Clinical manifestations include tachycardia, fatigue, and heat intolerance. Weight gain, hirsutism, and muscle weakness are signs of Cushing syndrome. Dehydration, metabolic acidosis, and hypertension are signs of congenital adrenal hyperplasia. Hyperglycemia, ketonuria, and glucosuria are signs of diabetes.
4. Graves' disease occurs when thyroid hormone levels are increased, resulting in excessive levels of circulating thyroid hormones. Clinical manifestations include tachycardia, fatigue, and heat intolerance. Weight gain, hirsutism, and muscle weakness are signs of Cushing syndrome. Dehydration, metabolic acidosis, and hypertension are signs of congenital adrenal hyperplasia. Hyperglycemia, ketonuria, and glucosuria are signs of diabetes.
The nurse is providing instruction to the parents of an infant with a colostomy. Which statement by the parents indicates appropriate understanding of the teaching session?
1. "We will change the colostomy bag with each wet diaper."
2. "We will use adhesive enhancers when we change the bag."
3. "We will watch for skin irritation around the stoma."
4. "We will expect a moderate amount of bleeding after cleansing the area around the stoma."
Answer: 3
Explanation: 1. Skin irritation around the stoma should be assessed; it may indicate leakage. Physical or chemical skin irritation may occur if the appliance is changed too frequently or with each wet diaper. Adhesive enhancers should be avoided on the skin of newborns. Their skin layers are thin, and removal of the appliance can strip off the skin. Also, adhesive contains latex, and its constant use is not advised due to risk of latex allergy development. Bleeding is usually attributable to excessive cleaning.
2. Skin irritation around the stoma should be assessed; it may indicate leakage. Physical or chemical skin irritation may occur if the appliance is changed too frequently or with each wet diaper. Adhesive enhancers should be avoided on the skin of newborns. Their skin layers are thin, and removal of the appliance can strip off the skin. Also, adhesive contains latex, and its constant use is not advised due to risk of latex allergy development. Bleeding is usually attributable to excessive cleaning.
3. Skin irritation around the stoma should be assessed; it may indicate leakage. Physical or chemical skin irritation may occur if the appliance is changed too frequently or with each wet diaper. Adhesive enhancers should be avoided on the skin of newborns. Their skin layers are thin, and removal of the appliance can strip off the skin. Also, adhesive contains latex, and its constant use is not advised due to risk of latex allergy development. Bleeding is usually attributable to excessive cleaning.
4. Skin irritation around the stoma should be assessed; it may indicate leakage. Physical or chemical skin irritation may occur if the appliance is changed too frequently or with each wet diaper. Adhesive enhancers should be avoided on the skin of newborns. Their skin layers are thin, and removal of the appliance can strip off the skin. Also, adhesive contains latex, and its constant use is not advised due to risk of latex allergy development. Bleeding is usually attributable to excessive cleaning.
In the morning, a nurse receives a report on four pediatric clients who have some form of fluid-volume excess. Which client should the nurse assess first?
1. A client with periorbital edema, normal respiratory rate
2. A client with tachypnea and pulmonary congestion
3. A client with dependent and sacral edema, regular pulse
4. A client with hepatomegaly, normal respiratory rate
Answer: 2
Explanation: 1. A child with respiratory distress should be the first client the nurse checks after receiving report. The child with periorbital edema and normal respiratory rate, the child with dependent and sacral edema and regular pulse, and the child with hepatomegaly and normal respiratory rate are all more stable than the child with tachypnea and pulmonary congestion.
2. A child with respiratory distress should be the first client the nurse checks after receiving report. The child with periorbital edema and normal respiratory rate, the child with dependent and sacral edema and regular pulse, and the child with hepatomegaly and normal respiratory rate are all more stable than the child with tachypnea and pulmonary congestion.
3. A child with respiratory distress should be the first client the nurse checks after receiving report. The child with periorbital edema and normal respiratory rate, the child with dependent and sacral edema and regular pulse, and the child with hepatomegaly and normal respiratory rate are all more stable than the child with tachypnea and pulmonary congestion.
4. A child with respiratory distress should be the first client the nurse checks after receiving report. The child with periorbital edema and normal respiratory rate, the child with dependent and sacral edema and regular pulse, and the child with hepatomegaly and normal respiratory rate are all more stable than the child with tachypnea and pulmonary congestion.
The nurse is providing education to the parents of a pediatric client who is diagnosed with tinea capitis (ringworm of the scalp). Which statement made the parents indicates an appropriate understanding of the teaching session?
1. "We will give the griseofulvin on an empty stomach."
2. "We're glad ringworm isn't transmitted from person to person."
3. "Once the lesion is gone, we can stop the griseofulvin."
4. "We will give the griseofulvin with milk or peanut butter."
Answer: 4
Explanation: 1. Parents are advised to give oral griseofulvin with fatty foods such as milk or peanut butter to enhance absorption. The medication must be used for the entire prescribed period even if the lesions are gone. All members of the family and household pets should be assessed for fungal lesions because person-to-person transmission is common.
2. Parents are advised to give oral griseofulvin with fatty foods such as milk or peanut butter to enhance absorption. The medication must be used for the entire prescribed period even if the lesions are gone. All members of the family and household pets should be assessed for fungal lesions because person-to-person transmission is common.
3. Parents are advised to give oral griseofulvin with fatty foods such as milk or peanut butter to enhance absorption. The medication must be used for the entire prescribed period even if the lesions are gone. All members of the family and household pets should be assessed for fungal lesions because person-to-person transmission is common.
4. Parents are advised to give oral griseofulvin with fatty foods such as milk or peanut butter to enhance absorption. The medication must be used for the entire prescribed period even if the lesions are gone. All members of the family and household pets should be assessed for fungal lesions because person-to-person transmission is common.
The nurse is caring for a pediatric client in Bryant skin traction. Which nursing intervention is most appropriate for this client?
1. Remove the adhesive traction straps daily to prevent skin breakdown.
2. Check the traction frequently to ensure that proper alignment is maintained.
3. Place the child in a prone position to maintain good alignment.
4. Move the child as infrequently as possible to maintain traction.
Answer: 2
Explanation: 1. The traction apparatus should be checked frequently to ensure that proper alignment is maintained. The adhesive straps should not be removed. The child should be placed in a supine position, and frequent repositioning is necessary to prevent complications of immobility.
2. The traction apparatus should be checked frequently to ensure that proper alignment is maintained. The adhesive straps should not be removed. The child should be placed in a supine position, and frequent repositioning is necessary to prevent complications of immobility.
3. The traction apparatus should be checked frequently to ensure that proper alignment is maintained. The adhesive straps should not be removed. The child should be placed in a supine position, and frequent repositioning is necessary to prevent complications of immobility.
4. The traction apparatus should be checked frequently to ensure that proper alignment is maintained. The adhesive straps should not be removed. The child should be placed in a supine position, and frequent repositioning is necessary to prevent complications of immobility.
A nurse is planning care for a pediatric client diagnosed with adrenal insufficiency (Addison disease). Which nursing diagnosis is the priority for this client?
1. Risk for Deficient Fluid Volume
2. Risk for Injury Secondary to Hypertension
3. Acute Pain
4. Imbalanced Nutrition: More than Body Requirements
Answer: 1
Explanation: 1. Adrenal insufficiency can cause fluid deficit. The goal of care is to maintain fluid and electrolyte balance while normal levels of corticosteroids and mineral corticoids are established. Therefore, Acute Pain and Imbalanced Nutrition: More than Body Requirements are not priority nursing diagnoses. A symptom of adrenal insufficiency is hypotension, not hypertension.
2. Adrenal insufficiency can cause fluid deficit. The goal of care is to maintain fluid and electrolyte balance while normal levels of corticosteroids and mineral corticoids are established. Therefore, Acute Pain and Imbalanced Nutrition: More than Body Requirements are not priority nursing diagnoses. A symptom of adrenal insufficiency is hypotension, not hypertension.
3. Adrenal insufficiency can cause fluid deficit. The goal of care is to maintain fluid and electrolyte balance while normal levels of corticosteroids and mineral corticoids are established. Therefore, Acute Pain and Imbalanced Nutrition: More than Body Requirements are not priority nursing diagnoses. A symptom of adrenal insufficiency is hypotension, not hypertension.
4. Adrenal insufficiency can cause fluid deficit. The goal of care is to maintain fluid and electrolyte balance while normal levels of corticosteroids and mineral corticoids are established. Therefore, Acute Pain and Imbalanced Nutrition: More than Body Requirements are not priority nursing diagnoses. A symptom of adrenal insufficiency is hypotension, not hypertension.
The nurse is administering several medications to an infant with neurologic impairment and delay. Which medication is a proton pump inhibitor that is administered for gastroesophageal reflux?
1. Omeprazole
2. Ranitidine
3. Phenytoin
4. Glycopyrrolate
Answer: 1
Explanation: 1. Omeprazole is the proton pump inhibitor that blocks the action of acid-producing cells and is used to treat gastroesophageal reflux. Ranitidine causes the stomach to produce less acid and may be used to treat gastroesophageal reflux, but it is a histamine-2 receptor blocker. Phenytoin is an anticonvulsant used to treat seizures, and glycopyrrolate is an anticholinergic agent used to inhibit excessive salivation.
2. Omeprazole is the proton pump inhibitor that blocks the action of acid-producing cells and is used to treat gastroesophageal reflux. Ranitidine causes the stomach to produce less acid and may be used to treat gastroesophageal reflux, but it is a histamine-2 receptor blocker. Phenytoin is an anticonvulsant used to treat seizures, and glycopyrrolate is an anticholinergic agent used to inhibit excessive salivation.
3. Omeprazole is the proton pump inhibitor that blocks the action of acid-producing cells and is used to treat gastroesophageal reflux. Ranitidine causes the stomach to produce less acid and may be used to treat gastroesophageal reflux, but it is a histamine-2 receptor blocker. Phenytoin is an anticonvulsant used to treat seizures, and glycopyrrolate is an anticholinergic agent used to inhibit excessive salivation.
4. Omeprazole is the proton pump inhibitor that blocks the action of acid-producing cells and is used to treat gastroesophageal reflux. Ranitidine causes the stomach to produce less acid and may be used to treat gastroesophageal reflux, but it is a histamine-2 receptor blocker. Phenytoin is an anticonvulsant used to treat seizures, and glycopyrrolate is an anticholinergic agent used to inhibit excessive salivation.
A nurse is planning care for a child with hyponatremia. The nurse, delegating care of this child to a new RN on the pediatric unit, cautions the new nurse to be especially alert for which condition in the child?
1. Seizures
2. Bradycardia
3. Respiratory distress
4. Hyperthermia
Answer: 1
Explanation: 1. A child with hyponatremia is at risk for seizures. Bradycardia, respiratory distress, and hyperthermia are not risks of hyponatremia.
2. A child with hyponatremia is at risk for seizures. Bradycardia, respiratory distress, and hyperthermia are not risks of hyponatremia.
3. A child with hyponatremia is at risk for seizures. Bradycardia, respiratory distress, and hyperthermia are not risks of hyponatremia.
4. A child with hyponatremia is at risk for seizures. Bradycardia, respiratory distress, and hyperthermia are not risks of hyponatremia.
The nurse is caring for a pediatric client who sustained a severe burn. Determine the order of what would be done for this child when the medical team arrives on the scene:
Response 1. Start intravenous fluids.
Response 2. Provide for relief of pain.
Response 3. Establish an airway.
Response 4. Place a Foley catheter.
Answer: 3, 1, 2, 4
Establish an airway.
Start intravenous fluids.
Provide for relief of pain.
Place a Foley catheter.
Explanation: The first step in burn care is to ensure that the child has an airway, is breathing, and has a pulse. Due to the severity of the burn, establishing IV access and starting resuscitation fluids would be next, followed by addressing the area of pain and inserting a Foley catheter.
A school health nurse is screening school-age students for scoliosis. Which assessment findings indicate the need for further evaluation for scoliosis? Select all that apply.
1. Uneven shoulders and hips
2. A one-sided rib hump
3. Prominent scapula
4. Lordosis
5. Pain
Answer: 1, 2, 3
Explanation: 1. The classic signs of scoliosis include uneven shoulders and hips, a one-sided rib hump, and prominent scapula. Lordosis and pain are not present with scoliosis.
A pediatric client is admitted to the hospital unconscious. The client has a history of type 1 diabetes, and according to the client's mother, has been to two birthday parties in the last few days and has resisted taking the prescribed insulin. At school the client had two more pieces of birthday cake and some ice cream at a class birthday party. What is the likely reason for this client's unconscious state?
1. Metabolic alkalosis
2. Metabolic ketoacidosis
3. Insulin shock
4. Insulin reaction
Answer: 2
Explanation: 1. Metabolic acidosis or ketoacidosis could have occurred because of the excessive intake of sugar with no additional insulin. The body burns fat and protein stores for energy when no insulin is available to metabolize glucose. Altered consciousness occurs as symptoms progress. Metabolic alkalosis, insulin shock, or insulin reaction would not be happening in this case.
2. Metabolic acidosis or ketoacidosis could have occurred because of the excessive intake of sugar with no additional insulin. The body burns fat and protein stores for energy when no insulin is available to metabolize glucose. Altered consciousness occurs as symptoms progress. Metabolic alkalosis, insulin shock, or insulin reaction would not be happening in this case.
3. Metabolic acidosis or ketoacidosis could have occurred because of the excessive intake of sugar with no additional insulin. The body burns fat and protein stores for energy when no insulin is available to metabolize glucose. Altered consciousness occurs as symptoms progress. Metabolic alkalosis, insulin shock, or insulin reaction would not be happening in this case.
4. Metabolic acidosis or ketoacidosis could have occurred because of the excessive intake of sugar with no additional insulin. The body burns fat and protein stores for energy when no insulin is available to metabolize glucose. Altered consciousness occurs as symptoms progress. Metabolic alkalosis, insulin shock, or insulin reaction would not be happening in this case.
A newborn is diagnosed with Hirschsprung disease. Which clinical manifestations found on assessment support this newborn's diagnosis?
1. Acute diarrhea; dehydration
2. Failure to pass meconium; abdominal distension
3. Currant jelly; gelatinous stools; pain
4. Projectile vomiting; altered electrolytes
Answer: 2
Explanation: 1. Hirschsprung disease is the absence of autonomic parasympathetic ganglion cells in the colon that prevent peristalsis at that portion of the intestine. In newborns, the symptoms include failure to pass meconium and abdominal distension. Acute diarrhea and dehydration are symptoms characteristic of gastroenteritis. Currant jelly, gelatinous stools, and pain are symptoms of intussusception, and projectile vomiting and altered electrolytes are symptoms of pyloric stenosis.
2. Hirschsprung disease is the absence of autonomic parasympathetic ganglion cells in the colon that prevent peristalsis at that portion of the intestine. In newborns, the symptoms include failure to pass meconium and abdominal distension. Acute diarrhea and dehydration are symptoms characteristic of gastroenteritis. Currant jelly, gelatinous stools, and pain are symptoms of intussusception, and projectile vomiting and altered electrolytes are symptoms of pyloric stenosis.
3. Hirschsprung disease is the absence of autonomic parasympathetic ganglion cells in the colon that prevent peristalsis at that portion of the intestine. In newborns, the symptoms include failure to pass meconium and abdominal distension. Acute diarrhea and dehydration are symptoms characteristic of gastroenteritis. Currant jelly, gelatinous stools, and pain are symptoms of intussusception, and projectile vomiting and altered electrolytes are symptoms of pyloric stenosis.
4. Hirschsprung disease is the absence of autonomic parasympathetic ganglion cells in the colon that prevent peristalsis at that portion of the intestine. In newborns, the symptoms include failure to pass meconium and abdominal distension. Acute diarrhea and dehydration are symptoms characteristic of gastroenteritis. Currant jelly, gelatinous stools, and pain are symptoms of intussusception, and projectile vomiting and altered electrolytes are symptoms of pyloric stenosis.
A preschool-aged client, diagnosed with croup, has an increased pCO2, a decreased pH, and a normal HCO3 blood-gas value. Which documentation in the medical record is the most appropriate?
1. Uncompensated respiratory acidosis
2. Uncompensated respiratory alkalosis
3. Uncompensated metabolic acidosis
4. Uncompensated metabolic alkalosis
Answer: 1
Explanation: 1. If the pH is decreased and the pCO2 is increased with a normal HCO3, it is uncompensated respiratory acidosis. Also, croup can be a disease process that causes respiratory acidosis. Uncompensated respiratory alkalosis has an increased pH, decreased pCO2 and normal HCO3; uncompensated metabolic acidosis has a decreased pH, normal pCO2 and normal HCO3; and uncompensated metabolic alkalosis has an increased pH, normal pCO2, and increased HCO3.
2. If the pH is decreased and the pCO2 is increased with a normal HCO3, it is uncompensated respiratory acidosis. Also, croup can be a disease process that causes respiratory acidosis. Uncompensated respiratory alkalosis has an increased pH, decreased pCO2 and normal HCO3; uncompensated metabolic acidosis has a decreased pH, normal pCO2 and normal HCO3; and uncompensated metabolic alkalosis has an increased pH, normal pCO2, and increased HCO3.
3. If the pH is decreased and the pCO2 is increased with a normal HCO3, it is uncompensated respiratory acidosis. Also, croup can be a disease process that causes respiratory acidosis. Uncompensated respiratory alkalosis has an increased pH, decreased pCO2 and normal HCO3; uncompensated metabolic acidosis has a decreased pH, normal pCO2 and normal HCO3; and uncompensated metabolic alkalosis has an increased pH, normal pCO2, and increased HCO3.
4. If the pH is decreased and the pCO2 is increased with a normal HCO3, it is uncompensated respiratory acidosis. Also, croup can be a disease process that causes respiratory acidosis. Uncompensated respiratory alkalosis has an increased pH, decreased pCO2 and normal HCO3; uncompensated metabolic acidosis has a decreased pH, normal pCO2 and normal HCO3; and uncompensated metabolic alkalosis has an increased pH, normal pCO2, and increased HCO3.
The nurse is teaching a group of students about wound healing. Which items will the nurse include as occurring during the hemostasis and inflammation stage of wound healing?
Select all that apply.
1. Clot formation to seal the wound
2. Production of collagen and granulation tissue
3. Scar formation and strengthening
4. Release of inflammatory mediators by platelets
5. Swelling as a result of increased capillary permeability
Answer: 1, 2, 5
Explanation: 1. During the hemostasis and inflammation stage of wound healing, the nurse would state that clot formation occurs to seal the wound; platelets release inflammatory mediators; and increased capillary permeability results in swelling. Scar formation and strengthening occur during maturation. Collagen and granulation tissue are produced during tissue formation.
2. During the hemostasis and inflammation stage of wound healing, the nurse would state that clot formation occurs to seal the wound; platelets release inflammatory mediators; and increased capillary permeability results in swelling. Scar formation and strengthening occur during maturation. Collagen and granulation tissue are produced during tissue formation.
3. During the hemostasis and inflammation stage of wound healing, the nurse would state that clot formation occurs to seal the wound; platelets release inflammatory mediators; and increased capillary permeability results in swelling. Scar formation and strengthening occur during maturation. Collagen and granulation tissue are produced during tissue formation.
4. During the hemostasis and inflammation stage of wound healing, the nurse would state that clot formation occurs to seal the wound; platelets release inflammatory mediators; and increased capillary permeability results in swelling. Scar formation and strengthening occur during maturation. Collagen and granulation tissue are produced during tissue formation.
5. During the hemostasis and inflammation stage of wound healing, the nurse would state that clot formation occurs to seal the wound; platelets release inflammatory mediators; and increased capillary permeability results in swelling. Scar formation and strengthening occur during maturation. Collagen and granulation tissue are produced during tissue formation.
A nurse is assessing a child after an open reduction of a fractured femur. Which assessment findings would indicate that the child is experiencing compartment syndrome? Select all that apply.
1. Pink, warm extremity
2. Pain not relieved by pain medication
3. Dorsalis pedis pulse present
4. Prolonged capillary-refill time with paresthesia
5. Skin appears tense.
Answer: 2, 4, 5
Explanation: 1. The major serious complication post-fracture reduction is compartment syndrome. A prolonged capillary-refill time with loss of paresthesia, pain not relieved by medication, and skin that appears tense are signs of compartment syndrome. Pink, warm extremity; pain relieved by medication; and a present dorsalis pedis pulse would all be normal findings post-fracture reduction.
2. The major serious complication post-fracture reduction is compartment syndrome. A prolonged capillary-refill time with loss of paresthesia, pain not relieved by medication, and skin that appears tense are signs of compartment syndrome. Pink, warm extremity; pain relieved by medication; and a present dorsalis pedis pulse would all be normal findings post-fracture reduction.
3. The major serious complication post-fracture reduction is compartment syndrome. A prolonged capillary-refill time with loss of paresthesia, pain not relieved by medication, and skin that appears tense are signs of compartment syndrome. Pink, warm extremity; pain relieved by medication; and a present dorsalis pedis pulse would all be normal findings post-fracture reduction.
4. The major serious complication post-fracture reduction is compartment syndrome. A prolonged capillary-refill time with loss of paresthesia, pain not relieved by medication, and skin that appears tense are signs of compartment syndrome. Pink, warm extremity; pain relieved by medication; and a present dorsalis pedis pulse would all be normal findings post-fracture reduction.
5. The major serious complication post-fracture reduction is compartment syndrome. A prolonged capillary-refill time with loss of paresthesia, pain not relieved by medication, and skin that appears tense are signs of compartment syndrome. Pink, warm extremity; pain relieved by medication; and a present dorsalis pedis pulse would all be normal findings post-fracture reduction.
Which teaching tips should be included when instructing parents on hydrocortisone administration?
Select all that apply.
1. Maintain prescribed administration times.
2. Never discontinue medication abruptly.
3. Injections might be necessary when unable to take by mouth.
4. Lower doses are needed during illness.
5. Keep an emergency kit with the child at all times.
Answer: 1, 2, 3, 5
Explanation: 1. Maintaining prescribed administration times is important, as they follow the normal body release of cortisol. Abruptly discontinuing a steroid is not recommended. Giving injections when unable to take by mouth and during emergencies is important to maintain cortisol levels. Higher, not lower, doses are needed during illness.
2. Maintaining prescribed administration times is important, as they follow the normal body release of cortisol. Abruptly discontinuing a steroid is not recommended. Giving injections when unable to take by mouth and during emergencies is important to maintain cortisol levels. Higher, not lower, doses are needed during illness.
3. Maintaining prescribed administration times is important, as they follow the normal body release of cortisol. Abruptly discontinuing a steroid is not recommended. Giving injections when unable to take by mouth and during emergencies is important to maintain cortisol levels. Higher, not lower, doses are needed during illness.
4. Maintaining prescribed administration times is important, as they follow the normal body release of cortisol. Abruptly discontinuing a steroid is not recommended. Giving injections when unable to take by mouth and during emergencies is important to maintain cortisol levels. Higher, not lower, doses are needed during illness.
5. Maintaining prescribed administration times is important, as they follow the normal body release of cortisol. Abruptly discontinuing a steroid is not recommended. Giving injections when unable to take by mouth and during emergencies is important to maintain cortisol levels. Higher, not lower, doses are needed during illness.
The nurse is caring for a school-age client who had an appendectomy after a ruptured appendix. Which orders does the nurse anticipate for this client? Select all that apply.
1. Antibiotics
2. A clear liquid diet
3. NG tube
4. Vital signs every 4 hours
5. Frequent monitoring of bowel sounds
Answer: 1, 3, 4, 5
Explanation: 1. Antibiotics, an NG tube, vital signs every 4 hours, and frequent monitoring of bowel sounds are appropriate interventions following a ruptured appendix. The client is NPO until bowel sounds return.
2. Antibiotics, an NG tube, vital signs every 4 hours, and frequent monitoring of bowel sounds are appropriate interventions following a ruptured appendix. The client is NPO until bowel sounds return.
3. Antibiotics, an NG tube, vital signs every 4 hours, and frequent monitoring of bowel sounds are appropriate interventions following a ruptured appendix. The client is NPO until bowel sounds return.
4. Antibiotics, an NG tube, vital signs every 4 hours, and frequent monitoring of bowel sounds are appropriate interventions following a ruptured appendix. The client is NPO until bowel sounds return.
5. Antibiotics, an NG tube, vital signs every 4 hours, and frequent monitoring of bowel sounds are appropriate interventions following a ruptured appendix. The client is NPO until bowel sounds return.