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An infant presents with poor feeding and a blood glucose level of 50 mg/dL. A nurse should assess for which of the following symptoms?
A. Hyperthermia and tachycardia
B. Flushed skin and tachycardia
C. Hyperthermia and irritability
D. Hypothermia and apnea
Answer: D
Explanation:
In neonates and infants, hypoglycemia is oftensymptomatically silentor presents withnonspecific signs, includinghypothermia, lethargy, and apnea. These can quickly progress to seizures or coma if not corrected.
"Hypoglycemia in infants may manifest as apnea, poor feeding, jitteriness, or hypothermia. Immediate intervention is required to prevent neurological injury." (Referenced from CCRN Pediatric - Direct Care: Endocrine Function and Metabolic Monitoring)
NEW QUESTION # 100
During the morning rounds, a toddler client with autism starts to run and he head bangs in the all. What would be the best initial action of the nurse:
A. allow the child to act out his feelings.
B. ask the toddler to stop to avoid injury.
C. restrain the toddler to avoid injury.
D. explain to the toddler that his behavior is not acceptable.
Answer: C
Explanation:
Explanation: Children with autism needs protection from self-injury. Option D is permitted but do it if doesn't put the child in jeopardy. Options A and B is incorrect because the child has difficulty in following instructions especially if when out of control.
NEW QUESTION # 101
The mother of a 16-month-old child who is coughing and having trouble breathing calls the clinic to ask advice because she suspects that her child has croup. Which of the following instructions would be most appropriate?
A. Administer acetaminophen (Tylenol) every 4 hours
B. Give over-the-counter cough syrup every 6 hours
C. Take the child into the bathroom and run the hot water
D. Get the child to take as much fluid as possible
Answer: C
Explanation:
Explanation: For a child with croup who is coughing and having difficulty breathing, the child should be taken into the shower where hot water is running to make the bathroom steamy. Steam helps to loosen secretion and relieve some of the respiratory distress. Giving acetaminophen is helpful but will not ease difficult breathing. Giving over-the-counter cough syrup is inappropriate because the underlying problem is airway inflammation and subsequent mucus accumulation and bronchoconstriction. Getting the child to take as much fluid as possible is important but it will not be effective in easing difficult breathing.
NEW QUESTION # 102
Which of the following reflects the child's level of moral development when a 2 1/2-year-old child states that the nurse is "a bad girl" after she administers an injection:
A. Preconventional/naive instrumentation
B. Conventional/"law and order"
C. Preconventional/punishment-obedience
D. Conventional/interpersonal concordance
Answer: C
Explanation:
Explanation: Children between ages 1 and 3 are at the Preconventional/punishment-obedience stage and determine the goodness or badness of an action in terms of its consequences.
NEW QUESTION # 103
A 3-year-old heart transplant patient is experiencing signs of rejection. Which of the following best supports this?
A. Serum glucose of 230 mg/dL and LDL of 184
B. Bilaterally diminished breath sounds
C. HR of 145 and urine output of 0.5/kg/hr
D. BP of 98/55 and RR of 34
Answer: C
Explanation:
Tachycardiaanddecreased urine outputare early clinical signs ofcardiac allograft rejectionin pediatric transplant recipients. Because transplanted hearts aredenervated,tachycardiais often thefirst compensatory responseto decreased cardiac output, while low urine output reflectsend-organ hypoperfusion.
"Rejection may present subtly with signs like persistent tachycardia, fatigue, or poor perfusion. Urine output is a sensitive measure of systemic perfusion." (Referenced from CCRN Pediatric - Direct Care: Cardiovascular, Heart Transplant Rejection Indicators)
NEW QUESTION # 104
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