Final Flashcards

Question

Match the appropriate toys and development with the correct age group. Soft rattles, teething toys, mobiles, mirrors, soft books, and textured toys that promote sensory development. a. Infants (0-12 months) b. Toddlers (1-3 years) c. Preschoolers (3-5 years) d. School-age children (6-12 years) e. Adolescents (12+ years)

Answer 1

a. Infants (0-12 months)

Answer 2

b. Toddlers (1-3 years)

Answer 3

c. Preschoolers (3-5 years)

Answer 4

d. School-age children (6-12 years)

Answer 5

e. Adolescents (12+ years)

Answer 6

Effective communication involves understanding the patient’s age, developmental level, language, and cultural background.

Answer 7

SIDS prevention focuses on safe sleep practices to reduce the risk of sudden infant death.

Answer 8

C. Soft teething rings Rationale: Infants explore their environment through their mouths, making teething rings an appropriate choice. Small building blocks pose a choking hazard, jump ropes are for older children, and jigsaw puzzles require fine motor skills beyond an infant’s developmental level.

Answer 9

A. “A toy kitchen set or dolls can help with imaginative play.” Rationale: Preschoolers (3-5 years) engage in imaginative play, making pretend kitchen sets and dolls ideal. Video games are more suitable for older children, marbles and magnets are choking hazards, and a bicycle with hand brakes is too advanced for a 3-year-old.

Answer 10

D. Provide a simple explanation and allow the child to play with medical equipment. Rationale: Young children understand concepts better through hands-on experiences. Allowing them to explore medical equipment reduces fear. Using medical terminology, expecting them to read, or providing long lectures would not be effective at this age.

Answer 11

C. Provide straightforward explanations and allow the child to express concerns. Rationale: School-age children can understand logical explanations and should be given the opportunity to ask questions. Speaking only to the parent excludes the child, abstract language is confusing, and baby talk is inappropriate.

Answer 12

B. “I can let my baby sleep in my bed as long as I remove blankets and pillows.” Rationale: Bed-sharing increases the risk of SIDS, even without extra bedding. Infants should sleep in their own crib on a firm mattress. The other statements correctly describe safe sleep practices.

Answer 13

C. “Offer a pacifier at bedtime, as it may help reduce the risk of SIDS.” Rationale: Studies suggest pacifier use at bedtime may reduce SIDS risk. Babies should always sleep on their back, excessive layering can cause overheating, and pillows increase the risk of suffocation.

Answer 14

B. Respiratory rate of 65 breaths/min Rationale: The normal respiratory rate for a newborn is 30-60 breaths per minute. A rate above 60 may indicate respiratory distress, requiring further evaluation. The heart rate, blood pressure, and temperature are within the expected range.

Answer 15

D. Assess for signs of respiratory distress Rationale: A preschooler’s normal respiratory rate is 20-30 breaths per minute. A rate of 35 may indicate respiratory compromise. Assessing for signs of distress takes priority over fever management, BP reassessment, or fluid intake.

Answer 16

C. RR: 28 breaths/min Rationale: The normal respiratory rate for a school-age child (6-12 years) is 15-25 breaths per minute. A rate of 28 is elevated and may indicate respiratory distress. The other values are within normal limits.

Answer 17

C. “A respiratory rate of 25 breaths per minute is normal for my child.” Rationale: Toddlers (1-3 years) normally have a respiratory rate of 20-40 breaths per minute. A heart rate of 50-90 bpm is too low, 140/90 mmHg is hypertensive, and a temperature of 96.8°F (36°C) is slightly below the normal range of 97.7-99.5°F (36.5-37.5°C).

Answer 18

A. RR: 22 breaths/min Rationale: The normal respiratory rate for an infant (1-12 months) is 25-50 breaths per minute. A rate of 22 is too low and may indicate hypoventilation. The other values are within normal limits.

Answer 19

A. HR: 120 bpm B. RR: 45 breaths/min D. Temperature: 97.9°F (36.6°C) Rationale: A normal newborn’s vital signs include HR: 110-160 bpm, RR: 30-60 breaths/min, and temperature: 97.7-99.5°F (36.5-37.5°C). A BP of 90/60 mmHg is too high for a newborn (normal is 60-80/40-50 mmHg).

Answer 20

B. RR: 65 breaths/min D. Temperature: 100.4°F (38°C) E. HR: 180 bpm Rationale: A respiratory rate over 60 breaths/min in an infant is abnormal, a temperature of 100.4°F (38°C) or higher is considered a fever, and a heart rate over 160 bpm is concerning. A HR of 100 bpm and BP of 80/55 mmHg are within the expected range.

Answer 21

A. HR: 55 bpm E. HR: 120 bpm Rationale: The normal heart rate for an adolescent (13-18 years) is 60-100 bpm. A HR of 55 bpm is too low, and HR of 120 bpm is too high. The other values are within the normal range.

Answer 22

C. BP of 75/40 mmHg Rationale: Hypotension is a late sign of dehydration and shock. A BP of 75/40 mmHg is too low for a preschooler (normal: 80-115/55-80 mmHg). The other findings, though elevated, are within an acceptable range.

Answer 23

C. “A school-age child’s normal respiratory rate is 20-40 breaths per minute.” Rationale: The normal respiratory rate for school-age children is 15-25 breaths per minute. A rate of 20-40 is too high. The other statements are correct.

Answer 24

C. BP: 90/60 mmHg Rationale: For a 6-month-old, normal blood pressure is typically between 70-90/50-65 mmHg, and a BP of 90/60 mmHg is on the high end and should be monitored. The other vital signs are within the expected range for a 6-month-old infant.

Answer 25

D. Count the respiratory rate while the child is at rest Rationale: For toddlers, respiratory rates should be counted while the child is calm or at rest to avoid false elevations from crying. BP should be measured appropriately for age, and temperature should be taken axillary or rectally for accuracy.

Answer 26

C. Temperature of 102°F (38.9°C) Rationale: A temperature of 102°F (38.9°C) is elevated and could indicate an infection or fever. The other vital signs are within normal limits for a 10-year-old child.

Answer 27

B. Assess for signs of respiratory distress Rationale: A respiratory rate of 40 breaths/min is on the higher end of the normal range for a preschooler (20-30 breaths/min). The nurse should assess for signs of respiratory distress. The other actions are important but not the priority at this time.

Answer 28

A. HR: 140 bpm Rationale: The normal heart rate for a 3-month-old infant is between 100-160 bpm, so a heart rate of 140 bpm is on the higher end and may require monitoring if there is concern about fever-induced tachycardia. The other values are within normal limits.

Answer 29

B. Ensure the infant is warm and calm Rationale: It is essential to ensure that the newborn is warm and calm before assessing vital signs, as cold stress or crying can skew results, especially heart rate and respiratory rate.

Answer 30

D. BP: 130/85 mmHg Rationale: The normal blood pressure for a school-age child is typically 90-120/60-80 mmHg. A BP of 130/85 mmHg is elevated and may suggest hypertension, requiring further investigation.

Answer 31

D. Temperature of 101°F (38.3°C) Rationale: While the vital signs are within normal limits, a fever of 101°F (38.3°C) could be indicative of an infection, and the nurse should address this finding first. Fever management is key in preventing further complications, such as dehydration or febrile seizures.

Answer 32

D. Temperature: 99.8°F (37.7°C) Rationale: The normal temperature for a toddler is between 97.7-99.5°F (36.5-37.5°C). The heart rate, respiratory rate, and blood pressure in this question are outside the expected range for a toddler. HR should be 90-150 bpm, RR should be 20-40 breaths/min, and BP should be 80-110/50-80 mmHg.

Answer 33

A. HR: 110 bpm Rationale: The normal heart rate for a school-age child (6-12 years) is 70-120 bpm. A HR of 110 bpm is at the upper limit of the normal range but should be monitored, especially if it is associated with any other abnormal findings. The other vital signs are within the normal range for this age.

Answer 34

early signs of respiratory distress

Answer 35

early signs of respiratory distress

Answer 36

late signs of respiratory distress

Answer 37

late signs of respiratory distress

Answer 38

late signs of respiratory distress

Answer 39

cystic fibrosis

Answer 40

There is no cure, but management focuses on improving lung function, nutrition, and preventing complications.

Answer 41

C. Head bobbing and lethargy Rationale: Head bobbing and lethargy indicate severe respiratory distress and impending respiratory failure. Immediate intervention, such as oxygen therapy and possible intubation, is required.

Answer 42

C. Nasal flaring and grunting Rationale: Nasal flaring and grunting are early compensatory signs of respiratory distress. Cyanosis, bradycardia, and hypotension are late signs indicating respiratory failure.

Answer 43

B. Administer oxygen Rationale: Oxygen is the priority intervention to prevent hypoxia and respiratory failure. Chest X-ray and IV fluids may be needed later, but oxygen is the immediate action.

Answer 44

D. Meconium ileus at birth Rationale: Meconium ileus is often the first sign of CF in newborns due to thickened intestinal secretions blocking the bowel.

Answer 45

B. Before every meal and snack Rationale: Pancreatic enzymes should be taken before every meal and snack to help digest food properly.

Answer 46

C. Encourage physical activity to promote airway clearance Rationale: Physical activity helps loosen mucus, promoting airway clearance. Cough suppressants should be avoided, and hydration is encouraged to thin secretions. Antibiotics are often given prophylactically.

Answer 47

D. “My child only needs chest physiotherapy when sick.” Rationale: Chest physiotherapy should be done daily, not just when sick, to prevent mucus buildup and lung infections.

Answer 48

B. Notify the healthcare provider Rationale: A sodium level of 129 mEq/L is low and requires intervention. CF patients lose excessive salt in sweat, and sodium replacement may be needed.

Answer 49

D. All of the above Rationale: CF can cause hyperglycemia (CF-related diabetes), increased sweat chloride levels (diagnostic test), and electrolyte imbalances (such as hyponatremia due to excessive salt loss in sweat).

Answer 50

C. Use a high-frequency chest wall oscillation vest Rationale: A high-frequency chest wall oscillation vest helps loosen mucus. Bronchodilators should be used before physiotherapy, and it should be done before meals, not after to prevent vomiting.

Answer 51

A. Contact precautions Rationale: Contact precautions are necessary for CF patients with respiratory infections due to the risk of cross-infection with other CF patients (e.g., Pseudomonas aeruginosa, Burkholderia cepacia).

Answer 52

D. Decreased forced expiratory volume (FEV1) Rationale: FEV1 is decreased in CF due to mucus plugging and airway obstruction.

Answer 53

A. “My child should avoid other children with CF.” Rationale: CF patients should avoid other CF patients due to the risk of cross-infection with antibiotic-resistant bacteria.

Answer 54

A. Increased work of breathing and intercostal retractions Rationale: Increased work of breathing and intercostal retractions suggest severe respiratory distress, which can lead to respiratory failure.

Answer 55

A. “CF affects multiple organ systems, including the lungs and pancreas.” Rationale: CF is a multisystem disease affecting the lungs, pancreas, digestive system, and reproductive system.

Answer 56

c) Relaxes bronchial smooth muscle Rationale: Albuterol is a short-acting beta2-agonist (SABA) that provides rapid bronchodilation by relaxing the smooth muscle in the airway.

Answer 57

b) Rinse the mouth after each use Rationale: Inhaled corticosteroids (e.g., fluticasone) can cause oral thrush, so rinsing the mouth reduces the risk.

Answer 58

c) Tachycardia Rationale: Beta2-agonists like albuterol stimulate the sympathetic nervous system, leading to tachycardia as a common side effect.

Answer 59

d) “My child will take this medication daily to prevent asthma symptoms.” Rationale: Montelukast is a leukotriene receptor antagonist used daily to prevent asthma exacerbations.

Answer 60

a) Salmeterol Rationale: LABAs (e.g., salmeterol) should never be used without an inhaled corticosteroid due to the risk of severe asthma attacks.

Answer 61

c) Perform three attempts and record the highest reading Rationale: The best effort is used to monitor airway function.

Answer 62

b) Blurred vision and dry mouth Rationale: Ipratropium is an anticholinergic, causing dry mouth and blurred vision.

Answer 63

b) Albuterol Rationale: Albuterol (SABA) opens the airways first, allowing better absorption of the corticosteroid.

Answer 64

d) Preventing medication buildup in the mouth Rationale: Spacers improve medication delivery to the lungs, reducing the risk of oropharyngeal deposition and thrush.

Answer 65

b) Stridor at rest Rationale: Stridor at rest indicates severe airway obstruction requiring urgent intervention.

Answer 66

d) Examine the throat with a tongue depressor Rationale: Examining the throat can trigger complete airway obstruction.

Answer 67

a) Stridor that worsens despite treatment Rationale: Bacterial tracheitis can cause progressive airway obstruction, requiring intubation.

Answer 68

a) Decrease airway inflammation Rationale: Racemic epinephrine reduces swelling in the airway.

Answer 69

b) Hib Rationale: The Haemophilus influenzae type B (Hib) vaccine prevents epiglottitis.

Answer 70

c) Assess airway patency Rationale: Severe tonsillar swelling can obstruct the airway.

Answer 71

c) White exudate on tonsils Rationale: Group A Strep causes white exudate, requiring antibiotics.

Answer 72

a) Administer IV antibiotics Rationale: Bacterial tracheitis requires IV antibiotics to treat the infection.

Answer 73

b) Frequent swallowing Rationale: Frequent swallowing may indicate bleeding, requiring immediate intervention.

Answer 74

sickle cell anemia

Answer 75

B. Start oxygen therapy at 2 L/min via nasal cannula. Rationale: Oxygen is the priority to prevent further sickling. Pain management and hydration are also essential but should follow oxygenation.

Answer 76

D. Sudden onset of unilateral weakness Rationale: This indicates a stroke, a severe complication of sickle cell disease requiring immediate intervention.

Answer 77

C. Administer IV fluids and opioid analgesics as prescribed. Rationale: IV fluids reduce blood viscosity and opioid analgesics (e.g., morphine) manage severe pain. Cold therapy and fluid restriction can worsen sickling.

Answer 78

C. Swimming in a cold pool Rationale: Cold temperatures cause vasoconstriction, increasing the risk of sickling and vaso-occlusive crisis.

Answer 79

A. “Encourage your child to drink plenty of fluids.” B. “Administer penicillin daily until at least 5 years old.” D. “Ensure your child receives routine vaccines, including pneumococcal and meningococcal.” E. “Hydroxyurea may help reduce the frequency of crises.” Rationale: Hydration prevents sickling, prophylactic penicillin prevents infections, and vaccinations are crucial. Cold packs should not be used, as they cause vasoconstriction.

Answer 80

A. Dehydration B. Infection C. Exposure to high altitudes D. Fever Rationale: Dehydration, infection, high altitude, and fever increase sickling. Warm environments do not contribute to sickling.

Answer 81

A. Increased hemoglobin F (HbF) levels B. Decreased white blood cell count C. Signs of infection Rationale: Hydroxyurea increases fetal hemoglobin (HbF), reducing sickling, but can cause bone marrow suppression, leading to low WBCs and increased infection risk. It does not work immediately for pain relief.

Answer 82

C. Sudden severe abdominal pain with a rapidly enlarging spleen Rationale: Splenic sequestration crisis is life-threatening and causes hypovolemic shock.

Answer 83

B. To prevent bacterial infections such as pneumonia Rationale: Children with sickle cell disease have functional asplenia, increasing the risk of infections.

Answer 84

C. Begin IV antibiotics and oxygen therapy. Rationale: Acute chest syndrome is a life-threatening emergency requiring oxygen and antibiotics to prevent respiratory failure.

Answer 85

D. Increased bilirubin levels Rationale: Chronic hemolysis leads to increased bilirubin, causing jaundice.

Answer 86

A. “Cold packs are the best way to relieve pain during a crisis.” Rationale: Warm packs should be used for pain relief, as cold temperatures can worsen sickling.

Answer 87

Von Willebrand Disease (VWD)

Answer 88

Hemophilia

Answer 89

B. Prolonged bleeding after minor cuts Rationale: VWD causes prolonged bleeding due to defective platelet adhesion. Petechiae are rare, and joint/muscle bleeds are more common in hemophilia.

Answer 90

C. Decreased von Willebrand factor and prolonged bleeding time Rationale: VWD results in decreased vWF and prolonged bleeding time due to impaired platelet function. Factor IX deficiency is seen in Hemophilia B.

Answer 91

A. Administration of Desmopressin (DDAVP) Rationale: DDAVP increases the release of stored vWF and Factor VIII, making it the first-line treatment for mild to moderate VWD.

Answer 92

D. “Aspirin is a safe pain reliever for my child.” Rationale: Aspirin and NSAIDs should be avoided as they impair platelet function and worsen bleeding.

Answer 93

A. “Use a soft toothbrush and avoid rough play.” Rationale: Soft toothbrushes and avoiding rough play help prevent bleeding episodes. Desmopressin is used only as needed, and mild nosebleeds can often be managed at home.

Answer 94

B. Naproxen Rationale: NSAIDs like naproxen impair platelet function and increase bleeding risk in VWD.

Answer 95

B. Apply pressure to the bridge of the nose and administer DDAVP. Rationale: Applying pressure and using DDAVP (if prescribed) can help control bleeding. The head should not be tilted back to prevent aspiration.

Answer 96

D. von Willebrand Factor Rationale: von Willebrand factor is deficient or dysfunctional, leading to impaired platelet adhesion and clot formation.

Answer 97

C. Administer Factor VIII replacement therapy. Rationale: Factor VIII replacement is the primary treatment for hemophilia A. Heat and massage increase bleeding, and ROM exercises should be delayed until bleeding resolves.

Answer 98

B. Prolonged PTT and normal PT Rationale: Hemophilia affects the intrinsic clotting pathway, leading to prolonged PTT while PT remains normal.

Answer 99

A. Apply direct pressure and administer Factor VIII or IX. Rationale: Direct pressure helps control bleeding, and factor replacement is needed to support clot formation.

Answer 100

A. “It helps release stored Factor VIII from endothelial cells.” Rationale: DDAVP stimulates the release of Factor VIII from endothelial cells, improving clotting in mild cases.

Answer 101

B. Tingling or warmth in the joint Rationale: Tingling and warmth are early signs of joint bleeding, which can progress to swelling and pain if untreated.

Answer 102

D. “We should apply ice and pressure if bleeding occurs.” Rationale: Ice and pressure help control bleeding. Vaccinations are safe but should be given subcutaneously with pressure applied.

Answer 103

C. Before physical activity or sports Rationale: Prophylactic Factor VIII is often given before activities that increase bleeding risk, such as sports.

Answer 104

D. Monitor the child closely for excessive bruising and joint pain. Rationale: Early recognition of bleeding signs is crucial for prompt treatment. Factor administration requires a healthcare provider.

Answer 105

aplastic anemia

Answer 106

B. Decreased red blood cell count, white blood cells, and platelets Rationale: Aplastic anemia causes pancytopenia, which means decreased red blood cells, white blood cells, and platelets. This is a key diagnostic feature.

Answer 107

B. Hypocellular bone marrow with a predominance of fat cells Rationale: In aplastic anemia, the bone marrow is typically hypocellular, meaning it contains fewer hematopoietic (blood-forming) cells and may have a higher proportion of fat cells.

Answer 108

D. “I can continue with my normal physical activity and exercise regimen without limitations.” Rationale: Patients with aplastic anemia often experience fatigue, weakness, and a higher risk of bleeding or infection, so activity should be restricted to prevent complications.

Answer 109

A. To decrease the destruction of bone marrow by the immune system Rationale: Immunosuppressive therapy is used in aplastic anemia to suppress the immune system’s attack on the bone marrow, which is often the cause of the condition in acquired cases.

Answer 110

C. Hypocellular bone marrow with reduced hematopoietic cells Rationale: A bone marrow biopsy showing hypocellular marrow with reduced hematopoietic cells is a key diagnostic test for aplastic anemia.

Answer 111

A. The bone marrow is producing insufficient red blood cells Rationale: A low reticulocyte count indicates that the bone marrow is not producing enough red blood cells, which is a hallmark of aplastic anemia.

Answer 112

A. Administer broad-spectrum antibiotics and initiate transfusions. Rationale: The patient’s signs of infection and bleeding are critical complications of aplastic anemia. Broad-spectrum antibiotics are needed to treat infection, and transfusions may be necessary to manage bleeding and anemia.

Answer 113

iron-deficiency anemia

Answer 114

D. Eat foods high in vitamin C with iron-rich plant foods. Rationale: Vitamin C enhances the absorption of non-heme iron from plant-based foods, so the nurse should recommend eating foods rich in vitamin C (e.g., citrus fruits, tomatoes) alongside iron-rich meals.

Answer 115

B. Spinach and lentils Rationale: Spinach and lentils are excellent sources of non-heme iron, which can help prevent iron-deficiency anemia in a vegetarian diet. While fruits and vegetables are important, they do not provide significant iron.

Answer 116

C. Limit the child’s intake of milk to 16-24 ounces per day. Rationale: Excessive milk intake (over 24 ounces per day) can reduce the absorption of iron in young children and lead to iron-deficiency anemia. The nurse should limit milk intake and ensure the child consumes iron-rich foods.

Answer 117

C. “I should drink coffee and tea with meals to help with iron absorption.” Rationale: Coffee and tea can inhibit the absorption of iron, so the patient should avoid drinking these beverages with iron-rich meals. The nurse should encourage the patient to focus on vitamin C-rich foods to enhance absorption.

Answer 118

D. “Include foods high in iron, such as lean meats, beans, and fortified cereals.” Rationale: The patient should be instructed to include iron-rich foods like lean meats, beans, and fortified cereals to prevent iron-deficiency anemia. Dairy and certain fruits/vegetables can interfere with iron absorption, so the nurse should not recommend limiting iron-rich foods.

Answer 119

Atrial Septal Defect (ASD)

Answer 120

Coarctation of the Aorta

Answer 121

Tetralogy of Fallot

Answer 122

1. Ventricular Septal Defect (VSD) - A hole between the two ventricles. 2. Pulmonary Stenosis - Narrowing of the pulmonary valve or artery, restricting blood flow to the lungs. 3. Overriding Aorta - The aorta is positioned directly over the ventricular septal defect, allowing oxygen-poor blood to flow into the aorta. 4. Right Ventricular Hypertrophy - Thickening of the right ventricle due to the increased workload.

Answer 123

B. Systolic murmur and fatigue during physical activities Rationale: A systolic murmur and fatigue during physical activities are common signs of ASD due to abnormal blood flow between the atria.

Answer 124

B. Shortness of breath during activities Rationale: Shortness of breath during activities is a common sign of ASD, as the heart is working harder to pump oxygenated blood to the body.

Answer 125

C. “My child will likely have a significant amount of cyanosis.” Rationale: Significant cyanosis is not a typical sign of ASD unless the defect is very large. Mild cyanosis might occur in severe cases but is not as prominent as in other defects like tetralogy of Fallot.

Answer 126

A. Document the finding and continue monitoring. Rationale: A murmur is common in ASD and typically does not require immediate intervention unless other severe symptoms are present. The nurse should monitor and document the finding.

Answer 127

B. Blood pressure higher in the arms than in the legs Rationale: In coarctation of the aorta, the blood pressure is higher in the upper body (arms) due to the narrowing of the aorta.

Answer 128

A. Weak or absent pulses in the lower extremities Rationale: Coarctation of the aorta causes decreased blood flow to the lower body, leading to weak or absent pulses in the lower extremities.

Answer 129

D. “The heart murmur may be heard due to blood flow across the narrowed aorta.” Rationale: A murmur is often heard due to the turbulence of blood flow across the narrowed aorta in coarctation.

Answer 130

D. Surgical repair or balloon angioplasty to widen the narrowed aorta Rationale: Coarctation of the aorta often requires surgical repair or balloon angioplasty to widen the narrowed aorta and restore normal blood flow.

Answer 131

B. Have the child squat to increase blood flow to the lungs. Rationale: Squatting helps increase blood flow to the lungs and improve oxygenation during a tet spell, as it increases systemic vascular resistance.

Answer 132

A. Severe cyanosis, particularly during crying or feeding Rationale: Cyanosis, especially during crying or feeding, is a hallmark sign of TOF due to decreased oxygenation in the blood.

Answer 133

D. “My child should avoid physical activity and exercise until treatment is completed.” Rationale: Physical activity may increase the risk of tet spells. However, after surgical repair, physical activity can typically be resumed.

Answer 134

A. Pulmonary stenosis Rationale: Pulmonary stenosis is the most significant cause of cyanosis and hypoxia in TOF because it obstructs blood flow to the lungs, leading to decreased oxygenation.

Answer 135

A. Jugular venous distention (JVD) Rationale: JVD is a key sign of poor cardiac output or heart failure, indicating that the right side of the heart is not pumping efficiently.

Answer 136

B. Decreased cerebral perfusion from heart failure Rationale: Confusion and lethargy are signs of poor cerebral perfusion due to inadequate cardiac output in heart failure, which may impair oxygen delivery to the brain.

Answer 137

C. Crushing or tight, radiating to the arm or jaw Rationale: A crushing or tight pain that radiates to the arm or jaw is characteristic of myocardial ischemia and should be evaluated as a possible acute MI.

Answer 138

A. Notify the healthcare provider for further assessment Rationale: A heart murmur requires further evaluation to determine its cause, which may be indicative of structural heart disease.

Answer 139

D. Notify the healthcare provider for further evaluation Rationale: Pitting edema in the lower extremities may indicate fluid retention, possibly related to heart failure, and should be reported to the healthcare provider immediately.

Answer 140

C. A possible indication of right-sided heart failure Rationale: JVD is commonly associated with right-sided heart failure, where the heart is unable to effectively pump blood, leading to blood backup into the jugular veins.

Answer 141

B. Less than 2 seconds Rationale: Capillary refill time of less than 2 seconds is considered normal and indicates good peripheral circulation.

Answer 142

B. A third heart sound (S3) or gallop rhythm Rationale: An S3 heart sound (gallop rhythm) is often indicative of heart failure, especially in cases where there is fluid overload.

Answer 143

C. Elevated B-type natriuretic peptide (BNP) Rationale: Elevated BNP levels are a key diagnostic marker for heart failure, indicating increased myocardial stress and fluid overload.

Answer 144

hypercyanotic

Answer 145

A. Administer 100% oxygen via non-rebreather mask Rationale: Administering 100% oxygen is the first priority to increase oxygen levels in the blood and help improve the cyanosis in a child with a Tet spell. Oxygen is crucial in managing this emergency situation.

Answer 146

B. Knee-chest position Rationale: The knee-chest position increases systemic vascular resistance, which helps decrease the right-to-left shunting of blood and improves oxygenation during a hypercyanotic episode in children with Tetralogy of Fallot.

Answer 147

B. Propranolol Rationale: Propranolol is a beta-blocker that may be used to reduce the frequency and severity of Tet spells in children with Tetralogy of Fallot by decreasing the heart’s workload and improving blood flow. It is not indicated for pain relief (acetaminophen, ibuprofen) or bradycardia (atropine).

Answer 148

Kawasaki disease

Answer 149

B. Initiate a high-dose intravenous immunoglobulin (IVIG) infusion Rationale: Early administration of intravenous immunoglobulin (IVIG) is a key treatment for Kawasaki disease and helps reduce the risk of coronary artery aneurysms. It is more effective when given within 10 days of the onset of fever.

Answer 150

A. Bilateral conjunctivitis, peeling skin on the palms of the hands, and strawberry tongue Rationale: Key clinical manifestations of Kawasaki disease include bilateral conjunctival injection (red eyes), strawberry tongue, and peeling skin (desquamation), particularly on the palms and soles. These symptoms are consistent with Kawasaki disease.

Answer 151

B. Monitor for signs of fluid overload, including edema and dyspnea Rationale: IVIG therapy can cause fluid overload, especially in patients with Kawasaki disease who may already have cardiovascular involvement. Monitoring for signs of fluid overload, such as edema and dyspnea, is critical during treatment.

Answer 152

A. Coronary artery aneurysms Rationale: The most serious complication of Kawasaki disease is coronary artery aneurysms, which can lead to long-term heart problems. Early diagnosis and treatment with IVIG are essential to prevent coronary artery damage.

Answer 153

A. The child will likely need regular cardiac monitoring to assess for coronary artery abnormalities

Answer 154

dehydration

Answer 155

B. Moderate dehydration; initiate IV fluid therapy with normal saline Rationale: The child is showing signs of moderate dehydration, such as lethargy, sunken eyes, and poor skin turgor. IV fluid therapy with normal saline is needed to correct fluid deficits.

Answer 156

A. Administer a dose of oral rehydration solution (ORS) Rationale: This child has mild dehydration, which can be managed with oral rehydration solution (ORS). ORS helps replace fluids and electrolytes lost and should be given before considering IV fluids.

Answer 157

B. Start an IV line and infuse 20 mL/kg of isotonic IV fluid Rationale: In moderate dehydration, especially with an infant, IV fluid administration is typically required for rapid rehydration, particularly when the child is unable to tolerate oral rehydration or fluids.

Answer 158

C. Edema, dyspnea, and jugular vein distension Rationale: Signs of fluid overload include edema, dyspnea (difficulty breathing), and jugular vein distension, which are indications that the child is receiving too much fluid too quickly.

Answer 159

D. Ringer’s lactate or normal saline Rationale: Isotonic fluids, such as Ringer’s lactate or normal saline, are used for initial rehydration in severe dehydration as they help restore both fluid and electrolyte balance without causing further imbalances.

Answer 160

A. “Offer the child small sips of oral rehydration solution (ORS) every 5-10 minutes.” Rationale: Oral rehydration solution (ORS) is the most effective treatment for mild dehydration. Offering small sips frequently is key to preventing further fluid loss, whereas large volumes of fluids may not be tolerated.

Answer 161

C) Fistulas and abscesses Rationale: Fistulas and abscesses are common complications of Crohn’s disease due to inflammation affecting all layers of the bowel wall. Continuous inflammation and pseudopolyps are more characteristic of ulcerative colitis.

Answer 162

A) “You should have a colonoscopy every 1-2 years after 8 years of diagnosis.” Rationale: Long-term ulcerative colitis increases the risk of colorectal cancer, especially after 8 years of disease. Regular screenings are necessary for early detection.

Answer 163

B) Fistulas and strictures Rationale: Crohn’s disease can lead to fistulas, strictures, and malabsorption. Toxic megacolon and colon cancer are more commonly associated with ulcerative colitis.

Answer 164

C) Firm, non-tender abdomen with a palpable mass in the right lower quadrant Rationale: A palpable mass in the right lower quadrant could indicate a complication such as a fistula or abscess in a patient with Crohn’s disease.

Answer 165

C) Administer corticosteroids as prescribed to reduce inflammation Rationale: During a flare-up of ulcerative colitis, corticosteroids are commonly used to reduce inflammation and control symptoms. High-fiber foods are not recommended during flare-ups.

Answer 166

C) Suggest a low-residue diet to reduce bowel irritation. Rationale: A low-residue diet is often recommended for Crohn’s disease to reduce irritation and minimize symptoms. High-fat and high-fiber foods may exacerbate symptoms.

Answer 167

B) Toxic megacolon Rationale: Toxic megacolon is a life-threatening complication associated with severe ulcerative colitis, presenting with fever, abdominal pain, and distension.

Answer 168

D) Collaborate with a dietitian to provide a high-protein, high-calorie diet Rationale: Patients with Crohn’s disease may experience malabsorption and malnutrition, and a high-protein, high-calorie diet is necessary to help with healing and nutrient absorption.

Answer 169

pyloric stenosis

Answer 170

B) Projectile vomiting after feedings Rationale: Projectile vomiting is a classic sign of pyloric stenosis. This occurs because the thickened pyloric muscle causes a blockage, leading to forceful vomiting shortly after feeding. The other options are not typical signs of pyloric stenosis.

Answer 171

A) Monitor for signs of infection at the surgical site Rationale: After pyloromyotomy surgery, it is important to monitor for infection at the surgical site. Postoperatively, oral feedings can typically be introduced shortly after the procedure.

Answer 172

C) “Pyloric stenosis is a condition that can be managed with medication.” Rationale: Pyloric stenosis is typically treated with surgery (pyloromyotomy), not medication. If parents suggest that medication is the primary treatment, this indicates a misunderstanding and requires further teaching. The other statements are accurate about the condition and its treatment.

Answer 173

C) The infant’s weight and overall health Rationale: Surgery for cleft lip repair is typically performed when the infant is around 10 weeks old and weighs about 10 pounds. The child’s overall health is important to ensure they are ready for surgery. The other factors listed are not primary considerations for the surgery.

Answer 174

C) 9-12 months old Rationale: Cleft palate repair surgery is typically performed when the child is between 9 and 12 months old. This timing allows for optimal healing and speech development. The other age ranges are not typical for this surgery.

Answer 175

A) Administering pain medication as ordered Rationale: Administering pain medication as ordered is essential to manage discomfort after surgery. The child should not feed immediately after surgery to allow for healing, and the child should be placed on their back to sleep to avoid pressure on the repaired lip. Follow-up care is important and should not be limited to just one visit.

Answer 176

D) “My child will be able to eat solid foods immediately after surgery.” Rationale: After cleft palate surgery, the child typically cannot eat solid foods immediately. A soft or liquid diet is usually recommended initially, and solid foods are reintroduced gradually as healing progresses. The other statements are accurate and reflect appropriate care and expectations.

Answer 177

A) Referral to a speech therapist for evaluation and intervention Rationale: Speech therapy is often needed after cleft lip and palate repairs to address any speech delays. Early intervention with a speech therapist helps improve language development. The other actions are not appropriate for managing speech delays in a child who has had cleft lip and palate surgery.

Answer 178

Hirschsprung disease

Answer 179

B) Failure to pass meconium within the first 48 hours of life Rationale: One of the classic signs of Hirschsprung disease in a newborn is the failure to pass meconium within the first 24-48 hours of life due to the lack of ganglion cells in the colon. This leads to a functional obstruction of the intestines. The other options do not specifically relate to Hirschsprung disease.

Answer 180

B) Assess the infant’s hydration status and provide IV fluids if needed Rationale: Since infants with Hirschsprung disease often present with symptoms like vomiting, abdominal distention, and constipation, they may be dehydrated. Ensuring adequate hydration before surgery is crucial for the infant’s stability. The other options are not appropriate as preoperative interventions for this condition.

Answer 181

C) Corticosteroids Rationale: Corticosteroids are commonly used to control inflammation during an acute flare-up of IBD. They help reduce symptoms such as pain and diarrhea. Antibiotics, antacids, and diuretics are not appropriate treatments for IBD flare-ups.

Answer 182

D) “These medications will help me fight infections.” Rationale: Immunosuppressive drugs are used to reduce inflammation in IBD, but they do not help fight infections. In fact, these medications suppress the immune system, making the patient more vulnerable to infections, and any signs of infection should be promptly reported to the healthcare provider.

Answer 183

C) Increased risk of infections Rationale: Biologic therapies used to treat IBD work by suppressing the immune system, which increases the risk of infections. Hyperglycemia, weight loss, and hypertension are not common side effects of biologic therapies.

Answer 184

C) Eat small, frequent meals that are low in fat and easy to digest Rationale: During remission, patients with IBD should focus on eating small, frequent meals that are easy to digest and low in fat to prevent triggering symptoms. A high-fiber diet may irritate the bowel, and high-sugar beverages are not recommended for optimal nutrition.

Answer 185

A) Promote fluid intake to prevent dehydration Rationale: Promoting fluid intake is essential to prevent dehydration, which is a common concern for patients with IBD, especially during flare-ups or before surgery. While a high-protein diet, wound care education, and monitoring for bleeding are also important, maintaining hydration is a priority for the patient’s overall health and surgical outcome.

Answer 186

D) Right lower quadrant pain with rebound tenderness and guarding Rationale: Appendicitis typically presents with right lower quadrant pain, often associated with rebound tenderness (pain upon release of pressure) and muscle guarding. The other options do not accurately describe the common clinical manifestations of appendicitis.

Answer 187

B) Rovsing’s sign Rationale: Rovsing’s sign refers to pain in the right lower quadrant when pressure is applied to the left lower quadrant, indicating appendicitis. Murphy’s sign is related to gallbladder disease, Cullen’s sign indicates internal bleeding, and McBurney’s point tenderness is specific to appendicitis but directly over the right lower quadrant.

Answer 188

C) Preparing the child for immediate surgery or imaging studies Rationale: The clinical manifestations of appendicitis (fever, nausea, right lower quadrant pain, rebound tenderness, and guarding) suggest an emergency situation that requires further imaging studies and potentially surgery to prevent rupture. The other interventions are not appropriate for suspected appendicitis.

Answer 189

B) The pain starts as generalized abdominal pain and localizes to the right lower quadrant. Rationale: In appendicitis, the pain typically starts as a dull, generalized ache near the belly button and then localizes to the right lower quadrant as the inflammation worsens. The other descriptions do not accurately reflect the typical progression of appendicitis pain.

Answer 190

D) Cystitis Rationale: Cystitis, or bladder infection, is characterized by dysuria (painful urination), frequency, urgency, and suprapubic tenderness. These are common clinical manifestations of a lower urinary tract infection (UTI), typically involving the bladder.

Answer 191

C) Pyelonephritis Rationale: Pyelonephritis is characterized by fever, chills, nausea, vomiting, and flank pain, which suggest an upper urinary tract infection affecting the kidneys. Cystitis, prostatitis, and urethritis primarily involve the lower urinary tract.

Answer 192

B) Hematuria and flank pain Rationale: Pyelonephritis typically presents with symptoms such as hematuria (blood in the urine), flank pain (due to kidney inflammation), fever, and chills. Suprapubic tenderness and dysuria are more typical of cystitis.

Answer 193

C) “Pyelonephritis affects only the bladder and urethra.” Rationale: This statement is incorrect because pyelonephritis affects the kidneys, not just the bladder and urethra. Cystitis affects the bladder, while pyelonephritis involves an upper urinary tract infection, including the kidneys.

Answer 194

A) Lower urinary tract (bladder) Rationale: Fatigue, cloudy, and foul-smelling urine are common symptoms of a UTI in the lower urinary tract (bladder). Pyelonephritis (an upper urinary tract infection) would typically present with more systemic symptoms such as fever and flank pain.

Answer 195

B) Decreased serum albumin levels Rationale: Nephrotic syndrome is characterized by proteinuria, hypoalbuminemia, hyperlipidemia, and edema. The most prominent lab finding in nephrotic syndrome is decreased serum albumin levels, which results from the loss of proteins in the urine.

Answer 196

A) Presence of proteinuria greater than 3.5 g/day Rationale: Proteinuria greater than 3.5 g/day is a hallmark of nephrotic syndrome, as the kidneys lose large amounts of protein due to glomerular damage. The other options do not align with the typical presentation of nephrotic syndrome.

Answer 197

A) Hyperlipidemia Rationale: Hyperlipidemia (elevated cholesterol and triglyceride levels) is commonly associated with nephrotic syndrome due to the liver’s increased production of lipoproteins in response to protein loss.

Answer 198

B) Decreased glomerular filtration rate (GFR) Rationale: Elevated BUN and creatinine levels typically indicate renal dysfunction or a decreased GFR, which can occur in nephrotic syndrome as the kidneys are damaged and unable to efficiently filter waste products.

Answer 199

D) Lipid profile for elevated cholesterol and triglycerides Rationale: Nephrotic syndrome often results in elevated lipid levels, including increased cholesterol and triglycerides, due to the liver’s increased production of lipoproteins in response to the loss of albumin and other proteins in the urine. Monitoring the lipid profile is crucial.

Answer 200

B) Hypertension, hematuria, and proteinuria Rationale: Glomerulonephritis typically presents with hypertension due to fluid retention, hematuria (blood in the urine), and proteinuria (protein in the urine), which are classic signs of glomerular damage.

Answer 201

C) Elevated serum creatinine and BUN Rationale: In glomerulonephritis, the glomeruli are damaged, leading to impaired kidney function and a decreased glomerular filtration rate (GFR). This results in elevated serum creatinine and blood urea nitrogen (BUN) levels, which are indicative of renal dysfunction.

Answer 202

A) Low-sodium diet to manage fluid retention and hypertension Rationale: A low-sodium diet is essential for patients with glomerulonephritis to help manage fluid retention and hypertension, which are common complications of the condition. Excess sodium can worsen edema and high blood pressure.

Answer 203

A) Recent group A streptococcal infection Rationale: Glomerulonephritis can develop after a group A streptococcal infection, such as strep throat or skin infections. The immune response to this infection can trigger inflammation in the glomeruli, leading to glomerulonephritis.

Answer 204

B) Assessing respiratory status and oxygen saturation Rationale: The priority for a patient with a submersion injury is assessing airway, breathing, and circulation. Even if the child appears stable, delayed respiratory complications such as pulmonary edema and respiratory distress syndrome can occur.

Answer 205

B) “Even though your child seems fine now, complications like lung injury can develop hours later.” Rationale: Secondary complications, such as delayed pulmonary edema and acute respiratory distress syndrome (ARDS), can develop within 24 hours, requiring extended monitoring.

Answer 206

A) Pulmonary edema Rationale: Pulmonary complications, including pulmonary edema and ARDS, can develop hours after the incident due to lung injury from water aspiration.

Answer 207

C) Hypothermia Rationale: Prolonged submersion in cold water can lead to hypothermia, which may contribute to bradycardia, decreased cardiac output, and altered mental status.

Answer 208

D) Intercostal retractions and grunting Rationale: Retractions and grunting are signs of increased work of breathing, which may indicate impending respiratory failure, a common delayed complication of submersion injuries.

Answer 209

C) Coughing or difficulty breathing Rationale: Signs of respiratory distress, such as coughing or difficulty breathing, may indicate delayed pulmonary complications, requiring immediate medical attention.

Answer 210

B) Surfactant washout leading to atelectasis Rationale: Freshwater aspiration can dilute and wash out surfactant, leading to alveolar collapse (atelectasis) and impaired gas exchange.

Answer 211

C) A 3-year-old who has unsupervised access to a backyard pool Rationale: Toddlers and young children are at the highest risk for submersion injuries, especially when left unsupervised near water sources.

Answer 212

C) Implementing passive range-of-motion exercises Rationale: Passive range-of-motion exercises help prevent contractures and maintain joint flexibility in young children with CP who may have limited voluntary movement. Mobility aids like walkers are typically introduced later as the child grows.

Answer 213

D) Allowing the use of assistive technology, such as speech-to-text software Rationale: Children with CP often have fine motor impairments that make writing difficult. Assistive technology like speech-to-text software supports communication and academic participation.

Answer 214

C) Adaptive tricycles and modified puzzles Rationale: Adaptive tricycles help strengthen muscles and promote movement, while modified puzzles improve fine motor skills. Play should be developmentally appropriate and focus on enhancing motor function.

Answer 215

D) Provide small, frequent meals with soft or pureed textures Rationale: Children with CP often have difficulty swallowing and controlling oral muscles. Soft or pureed foods in small portions help prevent choking and ensure adequate nutrition.

Answer 216

B) Baclofen Rationale: Baclofen is a muscle relaxant commonly used to reduce spasticity in patients with CP, improving mobility and comfort.

Answer 217

A) Using an augmentative and alternative communication (AAC) device Rationale: AAC devices, such as communication boards or speech-generating devices, help children with CP express their needs and interact effectively.

Answer 218

A) Encouraging vocational training and independent living skills Rationale: As children with CP grow, they should be encouraged to develop skills for independent living, education, and employment, based on their abilities and needs.

Answer 219

C) Turn the child onto their side and maintain a patent airway Rationale: Turning the child onto their side helps prevent aspiration and keeps the airway open. Restraining the child or placing objects in the mouth can cause further injury.

Answer 220

A) IV lorazepam Rationale: Benzodiazepines, such as lorazepam or diazepam, are the first-line treatment for an acute seizure due to their rapid action in stopping seizure activity.

Answer 221

C) Attempting to insert an oral airway during the seizure Rationale: Inserting anything into the mouth during a seizure can cause injury, aspiration, or airway obstruction. The focus should be on safety and positioning.

Answer 222

B) Reorient the child and allow for rest Rationale: After a seizure, children often experience postictal confusion, fatigue, and drowsiness. They should be allowed to rest and reorient gradually.

Answer 223

D) “I should hold my child down to prevent injury during the seizure.” Rationale: Restraining a child during a seizure can cause injury. Instead, caregivers should focus on ensuring a safe environment and positioning the child on their side.

Answer 224

C) Difficulty rising from the floor and using hands to push on thighs Rationale: This describes Gower’s sign, a hallmark of DMD. Children with DMD experience progressive muscle weakness, starting in the lower extremities, leading to difficulty standing up.

Answer 225

B) Enlarged calf muscles with muscle weakness Rationale: Pseudohypertrophy of the calves (enlarged calf muscles due to fatty and fibrotic tissue replacement) is a classic finding in DMD, along with progressive muscle weakness.

Answer 226

A) “You will notice muscle weakness that starts in the legs and spreads upward.” Rationale: DMD follows a progressive pattern of muscle weakness beginning in the lower extremities and moving upward, leading to loss of ambulation and respiratory complications.

Answer 227

A) Decreased respiratory effort and frequent lung infections Rationale: As DMD progresses, respiratory muscles weaken, leading to ineffective breathing, decreased lung function, and a high risk of respiratory infections.

Answer 228

C) “We expect his symptoms to improve as he gets older.” Rationale: DMD is a progressive disease that worsens over time. The nurse should provide education about its degenerative nature and available supportive treatments.

Answer 229

D) Unequal pupil size and decreased responsiveness Rationale: Unequal pupils and decreased responsiveness indicate increased intracranial pressure (ICP) or possible brain herniation, requiring immediate medical intervention.

Answer 230

A) Bradycardia and widened pulse pressure Rationale: Cushing’s triad, which includes bradycardia, hypertension with widened pulse pressure, and irregular respirations, is a late sign of increased ICP and requires immediate intervention.

Answer 231

C) Using the Glasgow Coma Scale Rationale: The Glasgow Coma Scale (GCS) is the standard tool for assessing consciousness in head injury patients by evaluating eye opening, verbal response, and motor response.

Answer 232

B) Test the fluid for glucose and notify the provider Rationale: Clear drainage from the nose could indicate cerebrospinal fluid (CSF) leakage, which suggests a skull fracture. Testing the fluid for glucose helps confirm the presence of CSF.

Answer 233

B) Use structured routines and visual schedules Rationale: Children with ASD thrive on routine and predictability. Structured routines and visual schedules help reduce anxiety and improve understanding of daily activities.

Answer 234

A) Minimize environmental stimuli and maintain a consistent routine Rationale: Children with ASD often have sensory sensitivities and difficulty with change. A consistent routine and a calm environment help them feel secure and reduce distress.

Answer 235

A) Rocking back and forth and covering ears Rationale: Sensory overload in children with ASD may manifest as repetitive behaviors, self-soothing actions like rocking, or covering ears in response to overwhelming stimuli.

Answer 236

D) “Sign language or picture communication systems may be helpful.” Rationale: Many children with ASD benefit from alternative communication methods such as sign language or picture exchange communication systems (PECS) to enhance their ability to express needs and emotions.

Answer 237

A) Redirect the child to a quiet, low-stimulation area Rationale: Children with ASD can become overwhelmed by excessive noise or activity. A quiet, controlled environment can help them regain a sense of calm.

Answer 238

B) Maintain a calm, structured approach with minimal changes Rationale: Children with ASD function best in structured environments with consistent caregivers. Sudden changes can cause distress and increased anxiety.

Answer 239

A) Applied behavior analysis (ABA) therapy to reinforce positive behaviors Rationale: ABA therapy is an evidence-based approach used to help children with ASD develop communication, social, and behavioral skills through positive reinforcement.

Answer 240

C) Provide a structured schedule with clear expectations and minimal distractions Rationale: Children with ADHD benefit from a structured environment that minimizes distractions and includes clear expectations. Predictability helps them focus and complete tasks more effectively. Seating arrangements should be in the front of the classroom to reduce external distractions, and breaking tasks into manageable steps with frequent breaks can improve performance.

Answer 241

B) “I will allow my child to watch television and play video games as a reward for completing homework.” Rationale: While rewards can be an effective behavioral management strategy, excessive screen time can worsen ADHD symptoms by increasing hyperactivity and reducing attention span. Instead, parents should use non-screen-based rewards such as outdoor play, stickers, or extra reading time.

Answer 242

B) “My child’s appetite may decrease, so I will encourage meals before taking the medication.” Rationale: Stimulant medications, such as methylphenidate and amphetamines, commonly cause appetite suppression. Administering the medication after breakfast helps ensure adequate nutrition. Medications should be taken as prescribed without doubling missed doses, and drug holidays should only be done under a healthcare provider’s guidance.

Answer 243

D) Implement frequent breaks and allow short bursts of physical activity Rationale: Children with ADHD often struggle with sitting still for long periods. Incorporating short, scheduled breaks and allowing movement can help them release energy and improve focus when they return to tasks. Additionally, tasks should be broken into smaller steps with immediate feedback.

Answer 244

A) “Maintain a highly structured routine and clear expectations at home.” Rationale: Children with ADHD thrive in environments with structure, consistency, and clear expectations. Providing predictable routines reduces anxiety and improves self-regulation. Strict punishment is ineffective in managing ADHD behaviors, and outdoor activities are beneficial for releasing excess energy and improving concentration.

Answer 245

C) The child does not make eye contact or respond to their name Rationale: Lack of eye contact and failure to respond to their name can be early indicators of autism spectrum disorder (ASD) or an intellectual disability. While two-word phrases at 3 years may be slightly delayed, it is not as concerning as the absence of social engagement. Difficulty dressing independently and inability to hop on one foot are not expected milestones at this age.

Answer 246

C) Speaking in unclear sentences that are difficult to understand Rationale: By age 4, a child’s speech should be mostly intelligible to strangers. Persistent speech difficulties may indicate a language or developmental delay. Occasional temper tantrums and difficulty recognizing colors and shapes can be typical for the age group, while a preference for solitary play may require further assessment but is not a definitive sign of a learning disability.

Answer 247

A) Providing repetitive, structured activities to reinforce learning Rationale: Children with intellectual disabilities benefit from repetition, structure, and clear, simple instructions. Breaking tasks into smaller steps and using hands-on activities can enhance understanding and retention. Learning independently without guidance may lead to frustration, and introducing multiple new concepts at once can be overwhelming.

Answer 248

A) Encouraging interaction with peers in a structured environment Rationale: Social interaction in a structured environment helps toddlers develop communication, cognitive, and motor skills. Early intervention is crucial for children with developmental delays, and waiting until school age can result in missed opportunities for growth. Active learning with engagement is more effective than passive approaches.

Answer 249

A) Offering multisensory learning experiences such as music, visuals, and hands-on activities Rationale: Children with learning disabilities benefit from multisensory approaches that reinforce concepts through visual, auditory, and kinesthetic learning. Short, simple instructions are more effective than lengthy explanations, and positive reinforcement encourages engagement and motivation.

Answer 250

D) “It is normal for some children to develop speech later, but an evaluation can help determine if therapy is needed.” Rationale: While some children develop speech later, early intervention is key for those with significant delays. An evaluation by a speech-language pathologist can help determine if therapy is necessary. Delayed speech is not always indicative of an intellectual disability, but it should not be ignored.

Answer 251

C) Expresses feelings of worthlessness and has a plan to harm themselves Rationale: A patient expressing suicidal ideation with a plan requires immediate intervention to ensure their safety. While sadness, changes in sleep and appetite, and social withdrawal are symptoms of depression, they do not pose an immediate life-threatening risk like suicidal intent does.

Answer 252

B) Provide a structured, predictable environment with emotional support Rationale: Children with PTSD benefit from a structured and predictable environment that fosters a sense of safety. Forcing the child to discuss their trauma too soon may retraumatize them, and avoiding the topic entirely does not help them process their emotions effectively.

Answer 253

B) Monitor for signs of self-harm and suicidal ideation Rationale: Suicide risk is a major concern in depressed adolescents, making frequent assessment for self-harm and suicidal ideation a priority. Encouraging social interaction should be done gradually and not forced. Allowing excessive sleep can worsen symptoms, and minimizing interactions can increase feelings of isolation.

Answer 254

A) Remind the child they are safe and reorient them to the present moment Rationale: During a flashback, grounding techniques such as reassurance and reorientation to the present moment help reduce distress. Forcing discussion about the trauma can worsen anxiety, and leaving the child alone may make them feel unsafe. Restraints should only be used as a last resort if the child is at risk of harming themselves or others.

Answer 255

C) Addressing safety concerns related to potential developmental delays Rationale: Children with Down syndrome and intellectual disabilities are at higher risk for developmental delays, including motor and cognitive skills. This increases the potential for injury or accidents. Prioritizing safety concerns, such as falls and accidental ingestion, is essential in planning care. While immunizations, communication, and dietary habits are important, safety is the primary concern in this scenario.

Answer 256

D) Refer the child to physical therapy to address coordination and balance issues Rationale: Children with Down syndrome often have delays in motor development, including difficulties with coordination and balance. Referral to physical therapy is essential for developing skills to improve mobility and reduce the risk of falls or other injuries. Swimming can be a beneficial activity, but physical therapy should be prioritized to address these specific issues.

Answer 257

B) “Your child may meet milestones at a later age, but with support, they will improve.” Rationale: Children with Down syndrome often experience delays in meeting developmental milestones, but with appropriate interventions, such as speech therapy, occupational therapy, and physical therapy, they can improve. Encouraging support and realistic expectations helps parents manage their child’s development effectively. It is not recommended to avoid interventions or let the child develop independently without support.

Answer 258

hip dysplasia

Answer 259

B) Limited range of motion in the hip joint Rationale: Legg-Calvé-Perthes disease typically presents with hip pain, limping, and limited range of motion due to disruption of blood flow to the femoral head, leading to avascular necrosis. Joint stiffness and swelling are more commonly seen in conditions like Juvenile Idiopathic Arthritis (JIA).

Answer 260

A) Pain and swelling of large joints, especially the knees and wrists Rationale: JIA typically affects large joints such as the knees, wrists, and ankles, and it is often associated with morning stiffness. Legg-Calvé-Perthes disease, on the other hand, involves the hip joint, not the knees or wrists.

Answer 261

C) Decreased range of motion in the hip Rationale: Children with Legg-Calvé-Perthes disease commonly exhibit limited range of motion in the affected hip joint due to avascular necrosis of the femoral head. This condition typically does not cause swelling or warmth in other joints like wrists and ankles.

Answer 262

A) Nonsteroidal anti-inflammatory drugs (NSAIDs) Rationale: The first-line treatment for JIA is typically NSAIDs to reduce inflammation and pain. Corticosteroid injections are used for more severe cases, but they are not typically the first treatment. Joint replacement is not a standard treatment for JIA in children, and complete bed rest is not recommended for long-term management.

Answer 263

A) “Your child will need to avoid weight-bearing activities to reduce pressure on the hip.” Rationale: Treatment for Legg-Calvé-Perthes disease includes avoiding weight-bearing activities to reduce stress on the femoral head and promote healing. Surgery is not required for all cases; physical therapy is often part of the treatment plan, and complete resolution without treatment is not common.

Answer 264

D) Swollen, warm, and tender joints in the hands and wrists Rationale: Swelling, warmth, and tenderness in the joints of the hands and wrists are characteristic of JIA. Legg-Calvé-Perthes disease primarily affects the hip joint, causing pain and limited range of motion but not swelling or warmth in other joints.

Answer 265

A) X-ray of the affected hip Rationale: An X-ray of the hip is the most commonly used diagnostic tool for confirming Legg-Calvé-Perthes disease. It will show the characteristic changes in the femoral head. While MRI and ultrasound can also provide useful information, an X-ray is typically the first diagnostic step.

Answer 266

B) To reduce pain and prevent further damage to the femoral head Rationale: The main goal in managing Legg-Calvé-Perthes disease is to reduce pain, protect the femoral head from further damage, and promote healing. Weight-bearing activities are generally avoided, and joint replacement is not typically needed in children with this condition.

Answer 267

D) Preventing joint deformities and preserving joint function Rationale: The primary goal in managing JIA is to prevent joint deformities and preserve joint function. Limiting physical activity may not be necessary, and encouraging social interaction is important for emotional well-being. Encouraging independence in daily activities is key in promoting development.

Answer 268

B) Observation with regular follow-up Rationale: A curve of 15 degrees is considered mild and typically requires observation with regular follow-up to monitor for progression. Surgery or bracing is not indicated for mild curves.

Answer 269

D) Spinal bracing to prevent further curvature Rationale: Moderate scoliosis (usually 25-45 degrees) is often managed with spinal bracing to prevent further progression. Surgery is not typically performed unless the curve exceeds 45 degrees or causes significant complications.

Answer 270

D) Surgical intervention to correct the deformity Rationale: Severe scoliosis (greater than 45 degrees) is often treated with surgery to correct the deformity and prevent further complications such as respiratory or cardiovascular issues. Bracing is no longer effective at this stage.

Answer 271

B) Spinal bracing to prevent further progression Rationale: Moderate scoliosis (typically between 25-45 degrees) is generally managed with spinal bracing to prevent the curve from worsening. Surgery is not indicated unless the curve progresses beyond 45 degrees.

Answer 272

A) The patient’s age and remaining growth potential Rationale: The need for bracing or surgery is largely determined by the patient’s age, skeletal maturity, and remaining growth potential. If a child is still growing, bracing may be more effective. Surgery is typically considered in severe cases or if the curve progresses despite bracing.

Answer 273

B) Ensuring the child wears the spinal brace as prescribed Rationale: For moderate scoliosis (25-45 degrees), spinal bracing is often the primary intervention to prevent further progression of the curve. Encouraging adherence to wearing the brace as prescribed is crucial to the success of this treatment.

Answer 274

C) Checking for neurovascular compromise (e.g., pulse, capillary refill, sensation) Rationale: The priority assessment in pediatric fractures includes evaluating for neurovascular compromise to ensure adequate blood flow and nerve function distal to the injury. This helps identify potential complications such as compartment syndrome or nerve damage.

Answer 275

D) “Monitor for signs of infection, such as fever, redness, or drainage from the cast.” Rationale: Monitoring for signs of infection is crucial, especially when the child has a cast. Signs like fever, redness, or drainage from the cast may indicate infection, and timely intervention is needed to prevent complications such as osteomyelitis.

Answer 276

B) Regularly checking for signs of impaired circulation and skin integrity Rationale: The nurse must regularly assess for impaired circulation and monitor skin integrity in patients in traction to prevent complications such as skin breakdown, compartment syndrome, or nerve damage. These are crucial to prevent further damage and promote healing.

Answer 277

B) Assessing for neurovascular status, including pulse, capillary refill, and sensation Rationale: Neurovascular assessment is essential to monitor for possible complications like compartment syndrome, which can occur with a fracture and cast. Ensuring blood flow and sensation remain intact is key for proper healing and early detection of problems.

Answer 278

C) Fat embolism Rationale: A spiral fracture, often seen in long bones like the humerus, carries a risk of fat embolism, where fat from the bone marrow enters the bloodstream. This can lead to respiratory distress, confusion, and other serious complications.

Answer 279

B) Perform a neurovascular assessment Rationale: Increasing pain in the leg could be a sign of complications such as compartment syndrome or impaired circulation. A neurovascular assessment (checking for pulse, capillary refill, and sensation) is necessary to rule out these issues and prevent further injury.

Answer 280

B) Neurovascular compromise Rationale: Displaced fractures can lead to neurovascular compromise, where circulation or nerve function is impaired. This can result in further damage and complications, so it is crucial for the nurse to regularly assess for neurovascular changes, such as decreased pulse, capillary refill, or sensation.

Answer 281

D) Checking for signs of constipation or urinary retention Rationale: A hip spica cast can restrict the child’s movement and bowel/bladder function, making constipation and urinary retention common complications. Ensuring proper hydration and monitoring for these symptoms are important aspects of care to prevent further complications.

Answer 282

B) Compartment syndrome Rationale: Compartment syndrome is a serious complication of fractures, especially in limbs that are placed in traction. It occurs when pressure builds up in a muscle compartment, restricting blood flow. Early recognition is essential to prevent permanent damage to muscles and nerves.

Answer 283

C) “Check the cast for any cracks or breaks as this could indicate a complication.” Rationale: While it is important to monitor the cast for signs of damage or complications, it is not typically appropriate for the family to attempt to assess cracks or breaks themselves. The healthcare provider should inspect the cast regularly for signs of damage or complications, such as infection or skin irritation.

Answer 284

Occurs when swelling or bleeding within a muscle compartment increases pressure, compromising blood flow and leading to tissue damage. It often results from trauma, such as fractures, and requires prompt recognition and intervention, typically through surgery (fasciotomy) to relieve the pressure and prevent permanent damage to muscles and nerves.

Answer 285

A. Progressive muscle weakness Rationale: Muscular dystrophy is characterized by progressive muscle weakness, particularly affecting the proximal muscles, leading to difficulty walking and rising from a sitting position.

Answer 286

A. Gower’s sign Rationale: Gower’s sign is a classic clinical manifestation of muscular dystrophy, where the child uses their hands to push off their legs to help stand due to proximal muscle weakness.

Answer 287

A. Loss of motor skills, including difficulty with balance and coordination Rationale: Muscular dystrophy leads to the progressive loss of motor skills, affecting balance and coordination as muscles weaken over time.

Answer 288

B. Calf muscle hypertrophy Rationale: Calf muscle hypertrophy is a common finding in muscular dystrophy due to muscle degeneration and replacement by connective tissue, a phenomenon often seen early in the disease.

Answer 289

D. Limited abduction of the hip Rationale: Limited abduction of the hip is a classic sign of developmental dysplasia of the hip in infants, indicating a potential dislocation or instability of the hip joint.

Answer 290

C. To assess for hip joint stability and detect dislocation Rationale: The Barlow test is used to assess for hip joint instability and detect dislocation by gently pushing the thigh backward, which can dislocate a hip that is already at risk.

Answer 291

C. Developmental dysplasia of the hip (DDH) Rationale: Asymmetric gluteal and thigh folds are a sign of developmental dysplasia of the hip, indicating potential hip dislocation or subluxation.

Answer 292

A. To check for hip joint dislocation and reduction Rationale: The Ortolani test is used to check for hip joint dislocation and reduction by gently abducting the infant’s hips to check for a “clunk” that indicates a reducible hip dislocation.

Answer 293

D. Difference in leg length Rationale: A difference in leg length is a common sign of developmental dysplasia of the hip, often due to a hip dislocation or subluxation that affects the symmetry of the lower extremities.

Answer 294

A medical device used to treat developmental dysplasia of the hip (DDH) in infants. It is designed to hold the baby’s hips in a flexed and abducted position, which helps to keep the femoral head within the hip socket and encourages proper hip development. The harness is worn full-time for several months, depending on the severity of the condition, and it helps to gradually stabilize the hip joint to prevent or correct dislocation.

Answer 295

A. Limited range of motion in the neck and head tilted to one side Rationale: Torticollis, or “twisted neck,” is characterized by the head being tilted to one side due to tightness or spasm in the neck muscles, often the sternocleidomastoid. This results in limited range of motion and asymmetry of head position.

Answer 296

B. Favoring one side of the head when lying down or sleeping Rationale: Infants with torticollis often favor one side of the head when lying down or sleeping, leading to positional flat head syndrome (plagiocephaly). It is important for parents to monitor and alternate the baby’s sleeping position to help prevent this.

Answer 297

C. Assess for other signs of neurological deficits Rationale: While torticollis is often a muscular issue, it can sometimes be associated with underlying neurological conditions. Therefore, it’s important to assess for other neurological signs to rule out any serious causes of the symptoms.

Answer 298

B. “You should support your child’s bones by providing appropriate safety measures and encouraging gentle activities.” Rationale: Osteogenesis imperfecta is a genetic disorder characterized by fragile bones, leading to frequent fractures. While it’s important to avoid high-risk activities, gentle exercise and safety measures can promote bone strength and development without causing harm.

Answer 299

C. “I should avoid giving my child supplements, as they are not helpful for bone health.” Rationale: Vitamin D and calcium are important for bone health and can help reduce the frequency of fractures in children with osteogenesis imperfecta. The parent should be educated on the role of supplements in addition to a balanced diet.

Answer 300

A. Gently lifting the child under the arms Rationale: Lifting a child with osteogenesis imperfecta under the arms can place excessive stress on the bones, potentially causing fractures. Proper lifting techniques should include supporting the head, neck, and body, avoiding lifting by the arms.

Answer 301

D. “Encourage your child to play with others in a safe, controlled environment.” Rationale: While safety is important, promoting socialization and play is critical for a child’s emotional and social development. Parents should be encouraged to create a safe environment where their child can interact with peers without excessive risk of injury.

Answer 302

B. Bisphosphonates Rationale: Bisphosphonates, such as pamidronate, are used to help increase bone density and reduce the risk of fractures in children with osteogenesis imperfecta. These medications work by inhibiting the activity of osteoclasts, the cells responsible for bone resorption.

Answer 303

B. Polyphagia, rapid weight loss, and ketoacidosis Rationale: Type 1 diabetes is typically characterized by polyphagia (increased hunger), rapid weight loss due to inability to use glucose, and the potential for developing diabetic ketoacidosis (DKA), which is more common in Type 1 than Type 2 diabetes.

Answer 304

B. Blood glucose of 250 mg/dL with fruity-smelling breath Rationale: A blood glucose level of 250 mg/dL with fruity-smelling breath is indicative of diabetic ketoacidosis (DKA), a life-threatening condition that requires immediate medical intervention.

Answer 305

A. Hyperglycemia Rationale: Hyperglycemia (high blood glucose) can lead to symptoms such as increased thirst (polydipsia), frequent urination (polyuria), and blurred vision. These are common manifestations in both Type 1 and Type 2 diabetes.

Answer 306

D. Acetone breath and confusion Rationale: Diabetic ketoacidosis (DKA) is characterized by acetone (fruity-smelling) breath and confusion. Other signs include dehydration, nausea, and vomiting. It is caused by an acute insulin deficiency leading to ketone production.

Answer 307

A. Administer insulin as ordered and monitor blood glucose Rationale: A blood glucose level of 350 mg/dL is significantly elevated and requires insulin administration for correction. Hyperglycemia at this level can lead to dehydration, and insulin is necessary to reduce blood glucose.

Answer 308

C. Deep, rapid breathing (Kussmaul respirations) Rationale: Kussmaul respirations, characterized by deep and rapid breathing, are a common compensatory mechanism in DKA. They occur as the body tries to reduce acidosis by expelling carbon dioxide.

Answer 309

C. Hyperosmolar hyperglycemic state (HHS) Rationale: Hyperosmolar hyperglycemic state (HHS) is a serious complication of Type 2 diabetes, characterized by extremely high blood glucose levels, dehydration, and altered mental status. Unlike DKA, HHS is not typically associated with ketone production.

Answer 310

C. Blood pH returns to normal range Rationale: In DKA, blood pH is typically acidic due to the accumulation of ketones. Improvement is indicated by a return to a normal pH level (7.35-7.45), which reflects correction of acidosis.

Answer 311

B. Correct dehydration and electrolyte imbalances Rationale: In the initial phase of DKA treatment, the priority is to correct dehydration and electrolyte imbalances, particularly potassium, which may be low. Insulin therapy and blood glucose reduction occur after these priorities are addressed.

Answer 312

D. Nausea and vomiting Rationale: Nausea and vomiting are common signs of diabetic ketoacidosis (DKA) and may indicate a worsening condition. Immediate medical attention is needed to prevent further complications.

Answer 313

D. Decreased blood pH Rationale: In DKA, the blood pH decreases due to the accumulation of ketones. This leads to metabolic acidosis, which is a key diagnostic indicator of DKA.

Answer 314

A. Ensuring the patient takes insulin as prescribed Rationale: Consistent insulin administration is essential for preventing diabetic ketoacidosis (DKA) in patients with Type 1 diabetes. Insulin helps control blood glucose levels and prevents ketone production that can lead to DKA.

Answer 315

B. Administer intravenous insulin and fluids to correct dehydration and acidosis Rationale: The priority treatment for DKA is to administer intravenous insulin to lower blood glucose levels and IV fluids to correct dehydration and acidosis. Potassium levels also need to be monitored and corrected, but fluid and insulin administration is the priority.

Answer 316

A. Administer 25 grams of glucose orally Rationale: For mild hypoglycemia in an alert patient who can swallow, the nurse should administer 15-20 grams of glucose or carbohydrate, which is equivalent to 25 grams of glucose. This helps rapidly raise blood glucose levels.

Answer 317

C. Administer 1 mg of glucagon intramuscularly or subcutaneously Rationale: In severe hypoglycemia with an unresponsive patient, glucagon should be administered intramuscularly or subcutaneously. Glucagon stimulates the liver to release glucose and raise blood glucose levels.

Answer 318

B. Blood pH of 7.35-7.45 Rationale: A blood pH of 7.35-7.45 is within the normal range and would indicate that the acidosis associated with DKA is improving. Blood glucose should also decrease, but the normalization of pH is a critical sign of recovery from DKA.

Answer 319

D. Blood glucose levels Rationale: Blood glucose levels must be closely monitored during insulin therapy in DKA to ensure they are decreasing appropriately. Additionally, potassium and other electrolytes should also be monitored, but blood glucose is the primary concern.

Answer 320

A. Wait 15 minutes and then reassess blood glucose levels Rationale: After administering glucagon, the nurse should wait approximately 15 minutes and reassess the patient’s blood glucose level. If the patient remains unresponsive or the blood glucose level is still low, additional measures, such as IV glucose, may be required.

Answer 321

A. Assess vital signs and urine output every hour Rationale: During the initial phase of DKA treatment, monitoring vital signs and urine output is critical to assess the patient’s response to fluid resuscitation and ensure that kidney function is adequate. Close observation for signs of fluid overload is important.

Answer 322

C. “Consume 15-20 grams of carbohydrate, such as glucose tablets or fruit juice.” Rationale: For mild hypoglycemia, the appropriate treatment is to consume 15-20 grams of a fast-acting carbohydrate, such as glucose tablets or fruit juice, to raise blood glucose levels quickly.

Answer 323

C. Treating dehydration with IV fluids Rationale: The first priority in treating DKA is fluid resuscitation to correct dehydration. This helps to improve circulation and kidney function. Insulin therapy and potassium replacement follow once the fluid status is corrected.

Answer 324

B. “I can skip my exercise routine if I feel like my blood sugar is stable.” Rationale: Exercise is an important part of diabetes management, even when blood sugar levels seem stable. Regular exercise helps control blood glucose, improve insulin sensitivity, and reduce cardiovascular risks associated with diabetes.

Answer 325

B. “Insulin should be kept in the refrigerator and never be frozen.” Rationale: Insulin should be stored in a cool, dry place such as the refrigerator. Freezing insulin reduces its effectiveness, and exposure to extreme heat or sunlight can degrade it.

Answer 326

D. “You should check your blood glucose levels before meals and at bedtime.” Rationale: Checking blood glucose before meals and at bedtime is recommended to monitor the patient’s blood glucose levels, adjust insulin doses, and prevent hypoglycemia or hyperglycemia.

Answer 327

B. Assess the patient’s adherence to diet, exercise, and medication plan Rationale: The priority is to assess the patient’s adherence to their treatment plan, including diet, exercise, and medications. If there are gaps in adherence, addressing them can improve glycemic control and help the patient achieve a better A1C level.

Answer 328

A. “Exercise can lower blood glucose levels, so it’s important to monitor blood glucose before, during, and after exercise.” Rationale: Physical activity can lower blood glucose levels, so it is essential to monitor blood glucose before, during, and after exercise to prevent hypoglycemia. Mild to moderate exercise is encouraged as part of diabetes management.

Answer 329

C. Sweating and shaking Rationale: Early signs of hypoglycemia include sweating, shaking, and feelings of nervousness or anxiety. Recognizing these symptoms early allows for prompt treatment, such as consuming carbohydrates to raise blood glucose levels.

Answer 330

D. “The CGM provides real-time glucose trends, but you should still check your blood glucose regularly as needed.” Rationale: A continuous glucose monitor provides real-time glucose trends but should not replace traditional blood glucose checks, especially when readings are abnormal. Fingerstick tests may still be necessary to confirm the CGM readings.

Answer 331

B. Weight gain, cold intolerance, and fatigue Rationale: Hypothyroidism typically presents with symptoms such as weight gain, cold intolerance, fatigue, and depression due to reduced metabolic rate. These clinical manifestations are common as the thyroid hormone levels are insufficient.

Answer 332

B. Weight loss, heat intolerance, and tachycardia Rationale: Hyperthyroidism is characterized by increased metabolic rate, leading to weight loss, heat intolerance, tachycardia, and sometimes palpitations. These symptoms occur due to excess thyroid hormones.

Answer 333

D. Thyroid-stimulating hormone (TSH) Rationale: In hypothyroidism, the thyroid gland does not produce enough thyroid hormones, so the pituitary gland compensates by increasing the production of TSH. Elevated TSH levels are commonly seen in hypothyroidism.

Answer 334

C. Hypothyroidism Rationale: In primary hyperthyroidism, TSH levels are usually low due to negative feedback from elevated thyroid hormones. However, in hypothyroidism, the TSH level is elevated as the pituitary gland tries to stimulate the thyroid to produce more hormones.

Answer 335

D. Increased thyroid hormone production Rationale: A goiter is often caused by the enlargement of the thyroid gland due to overstimulation, as seen in hyperthyroidism. This can occur with conditions such as Graves’ disease, where there is excessive thyroid hormone production.

Answer 336

B. Puffy face, dry skin, and slow reflexes Rationale: Hypothyroidism slows the metabolism, resulting in physical findings such as a puffy face, dry skin, and delayed reflexes. These are common characteristics of the condition due to reduced thyroid hormone levels.

Answer 337

A. Serum TSH Rationale: In hyperthyroidism, the high levels of thyroid hormones inhibit the release of TSH from the pituitary gland, leading to decreased levels of serum TSH as part of the negative feedback mechanism.

Answer 338

D. “I will stop taking my antithyroid medication if I feel any discomfort.” Rationale: Antithyroid medications should not be stopped abruptly. Discontinuing the medication can cause a resurgence of symptoms. The patient should take the medication as prescribed and notify the healthcare provider if any issues arise.

Answer 339

B. Levothyroxine to replace thyroid hormones Rationale: Levothyroxine is a synthetic form of thyroid hormone that is used to replace the thyroid hormones in patients with hypothyroidism, thereby normalizing metabolic function and reducing symptoms.

Answer 340

A. Encourage the patient to increase fluid intake and fiber to relieve constipation Rationale: Constipation is a common symptom of hypothyroidism due to slowed metabolism. Increasing fiber and fluid intake, along with other lifestyle changes, can help relieve constipation and improve the patient’s overall comfort.

Answer 341

C. Tachycardia and tremors Rationale: Hyperthyroidism increases metabolic rate, leading to symptoms such as tachycardia, tremors, weight loss, and heat intolerance. These are common signs of excessive thyroid hormone production.

Answer 342

B. “Take levothyroxine at the same time every day, preferably on an empty stomach.” Rationale: Levothyroxine should be taken at the same time each day to maintain consistent levels of thyroid hormone in the body. Taking it on an empty stomach improves absorption. Patients should not stop taking it without consulting a healthcare provider.

Answer 343

C. Rash and fever Rationale: Antithyroid medications can cause allergic reactions, including rash and fever. The nurse should monitor for these side effects and notify the healthcare provider if they occur.

Answer 344

Growth hormone deficiency is treated with recombinant human growth hormone (rhGH) to promote normal growth and development in children. It is typically prescribed when a child has a confirmed deficiency in growth hormone, which leads to growth failure and short stature. The treatment helps stimulate growth, increase height, and improve overall development. In adults, rhGH may be used to treat symptoms of growth hormone deficiency such as decreased muscle mass, increased fat, and low energy levels. The goal is to restore normal growth patterns and enhance quality of life.

Answer 345

A) Increased urine output with low specific gravity Rationale: Diabetes Insipidus is characterized by large amounts of dilute urine due to a deficiency of antidiuretic hormone (ADH), which leads to decreased water reabsorption in the kidneys. This results in increased urine output and a low specific gravity.

Answer 346

C) Hypertension and edema Rationale: SIADH results in excessive release of ADH, causing the kidneys to retain water. This leads to fluid retention, hypertension, and edema.

Answer 347

B) Monitoring urine output and specific gravity Rationale: The priority assessment for a patient with DI is to monitor urine output and specific gravity. The patient will produce large amounts of dilute urine, so monitoring helps assess the severity of the condition and ensure hydration status.

Answer 348

A) Serum sodium levels Rationale: SIADH causes water retention and dilution of sodium in the body, leading to hyponatremia. Monitoring serum sodium levels is crucial to prevent complications like seizures or coma due to severe hyponatremia.

Answer 349

A) Increase fluid intake to prevent dehydration Rationale: Since patients with DI lose large amounts of water in the urine, increasing fluid intake is essential to prevent dehydration and maintain fluid balance.

Answer 350

C) Weight gain and a decrease in serum sodium Rationale: In SIADH, fluid retention can lead to weight gain and dilution of serum sodium levels, resulting in hyponatremia. This is a serious complication and requires prompt intervention.

Answer 351

A) Hypertension and fluid overload Rationale: SIADH leads to excessive water retention, which can result in fluid overload, increasing the risk for hypertension and edema.

Answer 352

D) Encouraging the child to drink fluids to replace lost water Rationale: The primary intervention for Diabetes Insipidus is to encourage fluid intake to replace the water lost through excessive urine output. Monitoring for dehydration is key to maintaining fluid balance.

Answer 353

C) Tinea capitis Rationale: Tinea capitis is a fungal infection of the scalp, presenting as a circular, scaly, itchy rash with raised borders. It commonly affects children and can spread if untreated.

Answer 354

B) Topical antifungal cream Rationale: Tinea corporis is a superficial fungal infection treated with topical antifungal agents like clotrimazole or terbinafine. Oral antifungals may be necessary for more severe or extensive cases.

Answer 355

D) Ensuring the child’s feet are kept clean and dry Rationale: Tinea pedis (athlete’s foot) thrives in warm, moist environments. Keeping the feet clean and dry, along with avoiding sharing footwear, can help prevent the spread of the infection.

Answer 356

A) Tinea cruris Rationale: Tinea cruris (jock itch) is a fungal infection that commonly affects the groin area, characterized by a ring-shaped lesion with a raised border and clear skin in the center.

Answer 357

B) Oral antifungal medication Rationale: Tinea capitis, a fungal infection of the scalp, requires oral antifungal treatment such as griseofulvin or terbinafine due to its deep tissue involvement and resistance to topical therapy.

Answer 358

C) “Avoid sharing towels, clothing, or hats until the infection is cleared.” Rationale: Tinea corporis is contagious, and sharing personal items like towels, clothing, or hats can lead to the spread of the infection. It’s important to avoid close contact with others until the infection resolves.

Answer 359

A) “Avoid sweating and keep the skin dry.” Rationale: Tinea versicolor is caused by a yeast that thrives in warm, moist environments. Reducing sweating and keeping the skin dry can help prevent recurrence.

Answer 360

C) “Wash the affected area with soap and water, dry it thoroughly, then apply the cream.” Rationale: The area should be cleaned and dried before applying the antifungal cream to maximize its effectiveness. It is important to follow the full course of treatment, even if symptoms improve.

Answer 361

B) Administer oral antifungal therapy as prescribed Rationale: Tinea capitis requires oral antifungal treatment (such as griseofulvin or terbinafine), as topical therapies are ineffective for deeper fungal infections of the scalp.

Answer 362

D) Instruct the child to avoid walking barefoot in public areas such as pools and gyms. Rationale: Tinea pedis is highly contagious and can be spread in warm, damp environments like public pools and gyms. Wearing protective footwear can help prevent transmission to others.

Answer 363

A) First-degree burn Rationale: First-degree burns involve only the epidermis, causing redness, pain, and mild swelling without blistering. These burns are typically superficial and heal within a few days.

Answer 364

A) Apply a topical antibiotic ointment and cover the burn with a sterile dressing. Rationale: Second-degree burns involve both the epidermis and dermis, causing blisters, redness, and swelling. It is important to prevent infection by applying a topical antibiotic and covering the area with a sterile dressing.

Answer 365

D) Assess the child’s airway, breathing, and circulation. Rationale: Third-degree burns involve full-thickness injury, damaging all layers of the skin. The nurse’s priority is to assess the child’s ABCs (airway, breathing, circulation), as severe burns may lead to respiratory distress or circulatory shock.

Answer 366

D) Monitor for signs of respiratory distress and shock. Rationale: Fourth-degree burns involve tissue destruction down to the muscle or bone. The nurse must prioritize monitoring for signs of shock, respiratory distress, and other life-threatening complications due to the extent of the injury.

Answer 367

B) Apply a cold compress and administer acetaminophen for pain relief. Rationale: First-degree burns are typically superficial and can be managed with cold compresses for comfort and acetaminophen for pain relief. Avoid applying petroleum jelly or hot compresses, which could worsen the burn.

Answer 368

C) Prevent infection by keeping the burn area clean and dry. Rationale: Preventing infection is a priority for second-degree burns, as they involve the dermis and may have open blisters. Keeping the area clean and dry helps prevent bacterial contamination and promotes healing.

Answer 369

B) Second-degree burn Rationale: Second-degree burns affect both the epidermis and dermis, causing redness, pain, blisters, and swelling. This classification is consistent with the described symptoms.

Answer 370

A) Fluid and electrolyte imbalance due to massive fluid loss. Rationale: Third-degree burns cause significant damage to the skin, leading to fluid loss, electrolyte imbalances, and hypovolemia. Fluid resuscitation is the primary concern in the early post-burn phase.

Answer 371

A) Redness and swelling have subsided. Rationale: In a first-degree burn, the skin should heal within a few days with the subsidence of redness and swelling. The absence of blisters or severe pain suggests appropriate healing.

Answer 372

B) Manage pain and prevent infection by applying appropriate dressings. Rationale: For second-degree burns, the focus is on managing pain and preventing infection. This is done by applying appropriate dressings and monitoring for signs of infection or complications.