Nursing Elites

1. A child who is admitted to the hospital with anemia is anxious, fearful, and hyperventilating. The nurse anticipates the child developing which acid-base imbalance?

• A. Metabolic acidosis
• B. Respiratory acidosis
• C. Respiratory alkalosis
• D. Metabolic alkalosis

Correct answer: C

Rationale: In this scenario, the child is hyperventilating, which leads to excessive loss of carbon dioxide. This loss of carbon dioxide causes respiratory alkalosis due to a decrease in the partial pressure of carbon dioxide in the blood. Therefore, the correct answer is respiratory alkalosis. Choices A, B, and D are incorrect. Metabolic acidosis is characterized by a decrease in pH and bicarbonate levels due to conditions like kidney disease. Respiratory acidosis is caused by retention of carbon dioxide, leading to an increase in the partial pressure of carbon dioxide. Metabolic alkalosis results from a loss of acid or an increase in bicarbonate levels.

2. A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respirations. The nurse determines that the increased respiratory rate is a compensatory mechanism for which acid-base alteration?

• A. Metabolic alkalosis.
• B. Respiratory acidosis.
• C. Respiratory alkalosis.
• D. Metabolic acidosis.

Correct answer: D

Rationale: Kussmaul respirations are deep, rapid breathing patterns observed in metabolic acidosis, such as diabetic ketoacidosis. In this condition, the body tries to compensate for the acidic environment by increasing the respiratory rate to eliminate excess carbon dioxide (CO2) and decrease the acid levels, thereby helping to correct the acid-base imbalance. Therefore, the correct answer is metabolic acidosis.

3. When assessing a child with suspected meningitis, which finding is a characteristic sign of meningitis?

• A. High-pitched cry
• B. Tachycardia
• C. Photophobia
• D. Hypotension

Correct answer: C

Rationale: Photophobia, which is sensitivity to light, is a characteristic sign of meningitis in children. It commonly presents along with symptoms such as headache and neck stiffness. This symptom is important to recognize early for prompt diagnosis and treatment of meningitis.

4. Which assessment finding should the healthcare provider identify as most concerning in a child with acute glomerulonephritis?

• A. Hypertension.
• B. Gross hematuria.
• C. Proteinuria.
• D. Periorbital edema.

Correct answer: A

Rationale: In a child with acute glomerulonephritis, hypertension is the most concerning assessment finding as it can indicate worsening renal function. Hypertension is a common complication of glomerulonephritis and can lead to further kidney damage if not managed promptly. Monitoring and controlling blood pressure is crucial in these cases to prevent complications and preserve renal function. Gross hematuria, proteinuria, and periorbital edema are also common findings in acute glomerulonephritis but hypertension poses a higher risk for renal damage if left uncontrolled.

5. The mother of a 4-month-old asks the nurse for advice in preventing diaper rash. What suggestion should the nurse provide?

• A. At diaper change generously powder the baby's diaper area with talcum powder to promote dryness.
• B. Wash the diaper area every 2 hours with soap and water to help prevent skin breakdown.
• C. Use a barrier cream, such as zinc oxide, which does not have to be completely removed with each diaper change.
• D. Place a cloth diaper inside the disposable diaper for overnight periods when increased wearing time is likely.

Correct answer: C

Rationale: Using a barrier cream like zinc oxide protects the skin and helps prevent diaper rash.

Similar Questions