with 100% Correct Answers
What clinical finding should a nurse expect a child with nephrosis to exhibit?
A. Elevated blood pressure
B. Blood-tinged urine
C. Elevated temperature
D. Urine protein 3+ to 4+
D. Urine protein 3+ to 4+
When plotting a 20 week-old infant's weight on a standardized growth chart, the nurse determines
that the child's weight is between the 2nd and 3rd percentile. Based on this finding what action
should the nurse take?
A. Teach the parents about interventions for failure to thrive syndrome
B. Compare this weight with previous weights recorded in the child's record
C. Evaluate the parent's body build in relation to the infant's weight
D. Obtain a 24 hour nutritional history before making any conclusions
Compare this weight with previous weights recorded in the child's record
A 12-year-old male client tells the nurse that he is happy to be taking growth hormones because now
he can expect to grow and be just as tall as all of his friends. What response is best for the nurse to
provide?
A"You must remember that this treatment regimen is not always effective."
B."Although being tall is important to you, remember there are far more important characteristics
than height."
C."You will grow with this medicine, and are likely to be taller than anyone in your family."
D."Being taller is important to you and taking your injections will help achieve that goal."
"Being taller is important to you and taking your injections will help achieve that goal."
A 3-year-old boy is brought to the emergency room because of a possible diazepam (Valium)
overdose. He is lethargic and confused, and his vital signs are: pulse rate 100 beats/minute,
respiratory rate 20 breaths/minute, and blood pressure 70/30. Which nursing intervention has the
highest priority?
A. Insert an orogastric tube for gastric lavage.
B. Prepare a set-up for an endotracheal intubation.
C. Draw blood for stat chemistries and blood gases.
D. Insert a Foley catheter to monitor renal functioning.
B. Prepare a set-up for an endotracheal intubation.
The nurse is preparing to catheterize an 8-year-old child. Before starting the procedure, which action
should the nurse take first?
A. Obtain the parent's cooperation before initiating the procedure.
B. Explain to the child and the parents that the procedure needs to be done.
C. After talking with the parents about the procedure, ask them to leave the room.
D. Provide the child with privacy by conducting the procedure in the treatment room.
Explain to the child and the parents that the procedure needs to be done.
The nurse is developing a plan of care for a newborn with a colostomy due to anal agenesis, and the
infant has had three loose stools since surgery yesterday. Which nursing diagnosis has the highest
priority?
Potential for fluid volume deficit.