Betty is a 9-year-old girl diagnosed with cystic fibrosis. Which of the following must Nurse Archie keep in mind when developing a care plan for the child?

Correct Answer: A

Rationale: Cystic fibrosis (CF) is a genetic disorder that primarily affects the lungs and digestive system. One of the key characteristics of CF is the production of abnormally thick and sticky mucus in the respiratory system. This thick mucus can obstruct the airways, leading to recurrent lung infections, difficulty breathing, and other respiratory complications. Therefore, Nurse Archie must keep in mind the need to address and manage the thick pulmonary secretions when developing a care plan for Betty, the 9-year-old girl with cystic fibrosis.

Correct Answer: B

Rationale: Tetralogy of Fallot is a congenital heart defect that affects the flow of blood through the heart. In this condition, there is decreased pulmonary blood flow leading to reduced oxygenation of the blood. To compensate for the low oxygen levels in the blood, the body may increase the production of red blood cells, resulting in polycythemia (an increased red blood cell count). This is the body's way of trying to ensure that enough oxygen is carried to the tissues despite the heart defect. Therefore, in a 5-month-old infant with tetralogy of Fallot, the nurse would expect the blood workup to show polycythemia.

Correct Answer: A

Rationale: The Ortolani maneuver is a physical examination test specifically used to assess for hip instability in infants with suspected developmental dysplasia of the hip (DDH). This maneuver helps the healthcare provider determine if the femoral head can be gently relocated into the acetabulum, which can indicate the presence of hip dysplasia in newborns. Hip instability may be a sign of DDH, which is a condition where the hip joint has not developed properly. It is crucial to detect DDH early to prevent long-term complications such as hip dysplasia or dislocations.

Correct Answer: B

Rationale: Diaphoresis, which refers to excessive sweating, is a common clinical feature seen in a hypoglycemic reaction. Hypoglycemia occurs when the blood sugar level drops too low, leading to symptoms like sweating, shakiness, confusion, and rapid heartbeat. On the other hand, ketoacidosis is a serious complication of diabetes that occurs when there is a lack of insulin, causing high blood sugar levels and the body to break down fat for energy. Symptoms of ketoacidosis include nausea, vomiting, abdominal pain, and fruity-smelling breath, but diaphoresis is not typically a prominent feature. Therefore, diaphoresis can help clinicians differentiate between hypoglycemic and ketoacidosis reactions.

Correct Answer: B

Rationale: Acute glomerulonephritis is an inflammatory kidney disease that typically follows a streptococcal infection, such as strep throat or skin infection caused by group A beta-hemolytic streptococcus. The infection triggers the body's immune response, leading to the deposition of immune complexes in the glomeruli of the kidneys. This results in inflammation, damage to the glomeruli, and impaired kidney function. Symptoms of acute glomerulonephritis may include hematuria (blood in the urine), proteinuria (protein in the urine), edema, hypertension, and decreased urine output. It is important to diagnose and manage acute glomerulonephritis promptly to prevent complications and promote recovery. Other answer choices do not accurately describe the typical etiology or presentation of acute glomerulonephritis.