At 7 AM, a nurse receives the information that an adolescent with diabetes has a 6:30 AM fasting blood glucose level of 180 mg/dL. What is the priority nursing action at this time?

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Question 1 of 9

At 7 AM, a nurse receives the information that an adolescent with diabetes has a 6:30 AM fasting blood glucose level of 180 mg/dL. What is the priority nursing action at this time?

Correct Answer: D

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 2 of 9

An additional defect is associated with exstrophy of the bladder. For what anomaly should the nurse assess the infant?

Correct Answer: D

Rationale: The correct answer is D, pubic bone malformation. Exstrophy of the bladder is commonly associated with pubic bone malformation because the condition involves a defect in the pelvic region. Choices A, B, and C are incorrect. Imperforate anus, absence of one kidney, and congenital heart disease are not typically associated with exstrophy of the bladder.

Question 3 of 9

A healthcare professional plans to discuss childhood nutrition with a group of parents whose children have Down syndrome in an attempt to minimize a common nutritional problem. What problem should be addressed?

Correct Answer: B

Rationale: Childhood obesity is a prevalent issue in children with Down syndrome due to factors such as decreased physical activity, slower metabolism, and potential overeating tendencies. Addressing obesity is crucial to promoting healthy lifestyles and preventing associated health complications. Rickets, a condition caused by a deficiency of vitamin D, is not commonly associated with Down syndrome. While anemia can occur in individuals with Down syndrome, obesity is a more common concern. Rumination, the regurgitation of food without nausea, is not a typical nutritional problem in children with Down syndrome.

Question 4 of 9

The nurse is counseling a young couple who in 2 months are having their third baby. The nurse uses Von Bertalanffy's general system theory applied to families to analyze the family structure. Which best describes the main emphasis of this theory and its application to family dynamics?

Correct Answer: A

Rationale: Von Bertalanffy's general system theory applied to families emphasizes the family as a system with interdependent, interacting parts that endure over time to ensure the survival, continuity, and growth of its components. This theory focuses on viewing the family as a dynamic system where each member's actions and behaviors impact the whole family unit. Choice B is incorrect as it focuses solely on the social system of the family, while Von Bertalanffy's theory looks at the family as a whole system. Choice C is incorrect as it discusses family developmental stages, which is not the main emphasis of Von Bertalanffy's theory. Choice D is also incorrect as it only addresses how families respond to stress, which is a narrower focus compared to the broader system view of Von Bertalanffy's theory.

Question 5 of 9

What should the nurse include in the preoperative teaching for a 4-year-old child scheduled for a myringotomy?

Correct Answer: A

Rationale: For a 4-year-old child scheduled for a myringotomy, explaining the procedure in simple terms is essential in helping the child understand what will happen during the surgery and reducing anxiety. Encouraging fluid intake, allowing the child to play with medical equipment, and using play therapy are not directly related to preparing the child for the myringotomy procedure. Therefore, these options are incorrect and not as beneficial as explaining the procedure in simple terms.

Question 6 of 9

When evaluating a child with a diagnosis of attention-deficit/hyperactivity disorder (ADHD) for medication management, what is an important assessment for the nurse to perform?

Correct Answer: B

Rationale: Assessing the child's dietary intake is crucial as certain foods and additives can affect ADHD symptoms. Ensuring a balanced diet can help manage symptoms and provide proper nutrition. Assessing sleep patterns (Choice A) is also important, but dietary intake is more directly linked to symptom management in ADHD. Academic performance (Choice C) and behavior at home (Choice D) may be affected by ADHD but are not as directly related to medication management as dietary intake.

Question 7 of 9

At 0345, you receive a call for a woman in labor. Upon arriving at the scene, you are greeted by a very anxious man who tells you that his wife is having her baby 'now.' This man escorts you into the living room where a 25-year-old woman is lying on the couch in obvious pain. After determining that delivery is not imminent, you begin transport. While en route, the mother tells you that she feels the urge to push. You assess her and see the top of the baby's head bulging from the vagina. What is your most appropriate first action?

Correct Answer: B

Rationale: The correct action in this scenario is to advise your partner to stop the ambulance and assist with the delivery. When the mother feels the urge to push and you see the baby's head bulging from the vagina, it indicates an imminent delivery. Stopping the ambulance allows for a safer environment for the delivery of the baby and ensures that immediate assistance can be provided to both the mother and the newborn. Allowing the head to deliver before checking for the cord (Choice A) may delay necessary interventions in case of complications. Instructing the mother to take short, quick breaths (Choice C) is not appropriate when the baby's head is already visible. Preparing for an emergency delivery and opening the obstetrics kit (Choice D) is important but should come after stopping the ambulance and assisting with the imminent birth.

Question 8 of 9

At 0345, you receive a call for a woman in labor. Upon arriving at the scene, you are greeted by a very anxious man who tells you that his wife is having her baby 'now.' This man escorts you into the living room where a 25-year-old woman is lying on the couch in obvious pain. After determining that delivery is not imminent, you begin transport. While en route, the mother tells you that she feels the urge to push. You assess her and see the top of the baby's head bulging from the vagina. What is your most appropriate first action?

Correct Answer: B

Rationale: In this scenario, the most appropriate first action is to advise your partner to stop the ambulance and assist with the delivery. When the baby's head is visible and delivery is imminent, it is crucial to provide immediate assistance to ensure the safety of both the mother and the baby. Allowing the head to deliver and checking for the location of the cord (Choice A) may delay necessary actions during an imminent delivery. Instructing the mother to take short, quick breaths (Choice C) is not suitable as active delivery is already in progress. Preparing the mother for an emergency delivery and opening the obstetrics kit (Choice D) is not the most immediate action needed when the baby's head is already visible and delivery is imminent.

Question 9 of 9

What is an essential nursing action when caring for a young child with severe diarrhea?

Correct Answer: D

Rationale: Promoting perianal skin integrity is crucial when caring for a young child with severe diarrhea to prevent skin breakdown from the irritation caused by frequent bowel movements. Maintaining the IV (Choice A) may be important for hydration but is not directly related to managing skin integrity. Taking daily weights (Choice B) is important for monitoring fluid balance but does not address the immediate need to prevent skin breakdown. While replacing lost calories (Choice C) is important, it is not the priority when a child is experiencing severe diarrhea and skin integrity is at risk.

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