An elderly nursing home resident who has always been alert and oriented is now showing signs of dehydration and has become confused. Which electrolyte imbalance is most likely involved?

Correct Answer: A

Rationale: Hyponatremia is an electrolyte imbalance characterized by low sodium levels in the blood. Sodium plays a crucial role in regulating the body's fluid balance and is essential for nerve and muscle function. Elderly individuals are at a higher risk of developing hyponatremia due to various factors, including medication use, reduced thirst sensation, and impaired kidney function.

Correct Answer: C

Rationale: The primary reason a type II diabetic does not usually develop diabetic ketoacidosis is that there is no sufficient insulin to prevent the breakdown of protein and fatty acids for metabolic needs. In type II diabetes, the body still produces some insulin, unlike in type I diabetes where there is a complete lack of insulin. However, the insulin that is produced in type II diabetes may not be enough to effectively lower blood sugar levels and prevent the breakdown of protein and fatty acids for energy. This imbalance can lead to high blood sugar levels, known as hyperglycemia, but not to the extent of causing diabetic ketoacidosis, which typically occurs in the absence of sufficient insulin to prevent the breakdown of fats into ketones.

Correct Answer: B

Rationale: By the age of 8 months, most infants are able to pull themselves up to a standing position by holding onto furniture or other support. This milestone signifies the development of leg strength and coordination required for standing. While some infants may achieve this skill earlier or later, on average, 8 months is a common age for this milestone to be reached.

Correct Answer: C

Rationale: Rectal temperatures are not recommended in newborns because they can potentially cause perforation of the rectal mucosa. Newborns have fragile, delicate tissues in the rectal area, and the insertion of a rectal thermometer may lead to injury or damage to the mucosal lining. It is important to exercise caution and use alternative methods for taking temperatures in newborns to avoid any harm or discomfort.

Correct Answer: C

Rationale: Administering analgesics before removing chest tubes from a child is an important nursing consideration because the procedure may cause pain or discomfort. While it is ideal to minimize pain during and after the removal, it is essential to anticipate the possibility of discomfort and provide appropriate pain management to ensure the child's comfort and well-being. By administering analgesics before the procedure, nurses can help alleviate any potential pain and promote a more positive experience for the child.