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Questions 158

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Question 1 of 5

Which of the following blood values would require further nursing action in a newborn who is 4 hours old?

Correct Answer: C

Rationale: A serum glucose of 30 mg/dL in the first 72 hours of life is indicative of hypoglycemia and warrants further intervention.

Question 2 of 5

Which of the following nursing diagnoses is of highest priority for the patient with hypothyroidism?

Correct Answer: D

Rationale: Hypothyroidism reduces metabolic rate potentially decreasing cardiac output which can lead to life-threatening complications like heart failure. While hypothermia and other diagnoses are relevant decreased cardiac output is the most critical.

Question 3 of 5

The nurse is evaluating teaching effectiveness on a client with a gastrointestinal disorder prescribed a gluten-free diet. Which diet choice indicates that the client understands the instructions given?

Correct Answer: A

Rationale: Steamed broccoli is naturally gluten-free, indicating understanding of a gluten-free diet. Wheat toast (
B), chocolate chip cookies (
C), and bran cereal (
D) contain gluten.

Question 4 of 5

The most important goal in the care plan for a child who was hospitalized with an accidental overdose would be to:

Correct Answer: D

Rationale: This goal is not the most important. There is always some guilt when an accident occurs; however, the priority is to be sure future accidents are prevented. Ipecac is not used for caustic alkali and acid ingestions. Determining the parent's knowledge about safety hazards and teaching appropriate preventive measures are likely to prevent recurrence of accidents.

Question 5 of 5

A 3-year-old child is admitted with a diagnosis of possible noncommunicating hydrocephalus. What is the first symptom that indicates increased intracranial pressure?

Correct Answer: C

Rationale: Headache is the earliest symptom of increased intracranial pressure in children, preceding other signs like seizures or ataxia.

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