Question

A nurse is assessing an adolescent who has type 1 diabetes mellitus. Which of the following findings is the nurse's priority?

Answer 1

Correct Answers:

HbA1c 11.5%

Rationale :

🩸An HbA1c of 11.5% is critically high and reflects chronic poor glycemic control over the past 2–3 months.

⚠️This finding is more concerning than cholesterol 189 mg/dL, which is near normal, and more urgent than glycosuria, which is common in diabetes but not always critical.

🧪The preprandial blood glucose of 124 mg/dL is within the acceptable range for adolescents with type 1 diabetes, so it is not the priority.

✅The extremely elevated HbA1c indicates prolonged hyperglycemia, making it the nurse’s priority to address to prevent severe complications.

📌Core Message

The priority is option B (HbA1c 11.5%), showing chronic poor glucose control and risk for complications.

Answer 2

Correct Answers:

A child who has a fractured left femur

Rationale :

🏥A preschooler recovering from a Wilms tumor removal is at high risk for infection due to surgery and immunocompromise.

🦠Children with impetigo, viral pneumonia, or cellulitis have infectious conditions that could spread to the recovering child.

🛏️A child with a fractured femur has a non-infectious condition, making them a safe roommate choice.

💡Room assignment decisions must always prioritize infection control in pediatric patients.

📌Core Message

The safe roommate is a child with a fractured femur because there is no infection risk.

Answer 3

Correct Answers:

Diplopia

Rationale :

👁️Diplopia (double vision) in a child with a brain tumor suggests increased intracranial pressure and cranial nerve involvement.

⚠️This is a critical finding because it can rapidly progress to brain herniation.

😴Nightmares, hyperactivity, and pruritus are not signs of acute neurological compromise.

📊The nurse must report neurological changes immediately, as they reflect worsening tumor effects.

📌Core Message

The priority finding is diplopia, which indicates increased intracranial pressure.

Answer 4

Correct Answers:

Allergy to neomycin

Rationale :

💉The MMR vaccine is contraindicated in children with neomycin allergy, due to the risk of anaphylaxis.

🤧A mild upper respiratory infection and a low-grade temperature are not reasons to delay vaccination.

👨‍👩‍👦A family history of seizures does not prevent vaccination but requires monitoring afterward.

⚠️Checking for allergies to vaccine components is the most critical safety step.

📌Core Message

A history of neomycin allergy is a true contraindication to the MMR vaccine.

Answer 5

Correct Answers:

Weight loss 7%

Rationale :

⚖️Moderate dehydration in infants is defined as 6–9% weight loss.

💨A respiratory rate of 28/min is within normal range for infants.

⏱️Capillary refill of 1 second indicates good circulation, not dehydration.

❤️Bradycardia is a late sign of severe dehydration, not moderate.

📌Core Message

Weight loss of 7% reflects moderate dehydration in infants.

Answer 6

Correct Answers:

Instruct the parent to ensure the pneumococcal vaccine is current.
Give oral hydroxyurea.
Monitor oxygen saturation continuously.
Apply cold compresses to the affected joints.
Administer meperidine IV for pain.

Rationale :

💉Hydroxyurea helps reduce crises by increasing fetal hemoglobin.

📈Continuous oxygen monitoring ensures early detection of hypoxemia.

🩹Vaccinations such as pneumococcal are essential because sickle cell patients are prone to infections.

🔥Heat promotes vasodilation and relieves pain, while cold compresses worsen sickling.

⚠️Meperidine is avoided due to risk of seizures; safer opioids like morphine are used.

📌Core Message

Care includes vaccination, hydroxyurea, oxygen monitoring, heat application, and safe opioid use.

Answer 7

Correct Answers:

Ataxia

Rationale :

🧠Inhalant abuse like gasoline affects the central nervous system, leading to symptoms such as ataxia, confusion, and poor coordination.

👀Pinpoint pupils are related to opioids, not inhalants.

⚡Hyperactive reflexes are not typical findings; reflexes are usually depressed.

❄️Hypothermia can occur but is not as expected as ataxia.

📌Core Message

Ataxia is the expected finding with gasoline inhalation.

Answer 8

Correct Answers:

"You can apply gloves to your child's hands."
"You should cut and file your child's fingernails frequently."
"Your child will experience occasional flare-ups of this condition."
"You should apply emollients to your child's skin after bathing."

Rationale :

✋Gloves reduce scratching and protect damaged skin.

💅Keeping nails short and smooth reduces risk of injury from scratching.

🔄Atopic dermatitis has flare-ups, so the guardian should be prepared for recurrent symptoms.

🧴Emollients after bathing help keep the skin hydrated and reduce irritation.

⚠️Pimecrolimus cream is not for widespread use, and atopic dermatitis is not contagious.

📌Core Message

Best care includes gloves, nail care, anticipating flare-ups, and using emollients.

Answer 9

Correct Answers:

The child is curious about what happened to the sibling's body.

Rationale :

👶Preschoolers view death as temporary or reversible.

🧠They are naturally curious about the body, showing interest in what happens physically.

⚠️Preschoolers cannot give logical explanations or fully grasp permanence.

😢Feelings of responsibility usually occur in school-aged children, not preschoolers.

📌Core Message

Preschoolers often show curiosity about the body, not an understanding of death’s permanence.

Answer 10

Correct Answers:

Tachypnea

Rationale :

💨With RSV, tachypnea is an early sign of respiratory distress.

🤧Rhinorrhea, cough, and pharyngitis are common but not urgent.

⚠️Tachypnea requires prompt attention to prevent progression to respiratory failure.

📊This finding must be reported immediately to the provider.

📌Core Message

Tachypnea is the urgent finding in infants with RSV.

1 :
A nurse is assessing an adolescent who has type 1 diabetes mellitus. Which of the following findings is the nurse's priority?

2 :
A nurse is planning to admit a preschooler from the PACU following the removal of a Wilms tumor. Which of the following children should the nurse identify as an appropriate roommate for the preschooler?

3 :
A nurse is caring for a preschooler who has a brain tumor. Which of the following findings is the priority for the nurse to report to the provider?

4 :
A nurse is reviewing the medical record of a 15-month-old child who is scheduled to receive the measles, mumps, and rubella (MMR) vaccine. Which of the following findings should the nurse identify as a contraindication for receiving this vaccine?

5 :
A nurse is caring for an infant who has rotavirus. Which of the following findings indicates that the infant is moderately dehydrated?

6 :
A nurse is caring for an adolescent who is admitted with a vaso-occlusive crisis.

Answer Options

7 :
A nurse in an emergency department is assessing an adolescent who reports inhalation of gasoline. Which of the following findings should the nurse expect?

8 :
A nurse in the emergency department is preparing to discharge a 3-year- old child.

Answer Options

9 :
A nurse in a family practice clinic is assessing a preschool-age child who recently experienced the death of a sibling. Which of the following reactions is an age-appropriate response to death?

10 :
A nurse is assessing a 6-month-old infant who has respiratory syncytial virus. The nurse should immediately report which of the following findings to the provider?

1 : A nurse is assessing an adolescent who has type 1 diabetes mellitus. Which of the following findings is the nurse's priority?

2 : A nurse is planning to admit a preschooler from the PACU following the removal of a Wilms tumor. Which of the following children should the nurse identify as an appropriate roommate for the preschooler?

3 : A nurse is caring for a preschooler who has a brain tumor. Which of the following findings is the priority for the nurse to report to the provider?

4 : A nurse is reviewing the medical record of a 15-month-old child who is scheduled to receive the measles, mumps, and rubella (MMR) vaccine. Which of the following findings should the nurse identify as a contraindication for receiving this vaccine?

5 : A nurse is caring for an infant who has rotavirus. Which of the following findings indicates that the infant is moderately dehydrated?

6 : A nurse is caring for an adolescent who is admitted with a vaso-occlusive crisis.

Answer Options

7 : A nurse in an emergency department is assessing an adolescent who reports inhalation of gasoline. Which of the following findings should the nurse expect?

8 : A nurse in the emergency department is preparing to discharge a 3-year- old child.

Answer Options

9 : A nurse in a family practice clinic is assessing a preschool-age child who recently experienced the death of a sibling. Which of the following reactions is an age-appropriate response to death?

10 : A nurse is assessing a 6-month-old infant who has respiratory syncytial virus. The nurse should immediately report which of the following findings to the provider?

1 :
A nurse is assessing an adolescent who has type 1 diabetes mellitus. Which of the following findings is the nurse's priority?

2 :
A nurse is planning to admit a preschooler from the PACU following the removal of a Wilms tumor. Which of the following children should the nurse identify as an appropriate roommate for the preschooler?

3 :
A nurse is caring for a preschooler who has a brain tumor. Which of the following findings is the priority for the nurse to report to the provider?

4 :
A nurse is reviewing the medical record of a 15-month-old child who is scheduled to receive the measles, mumps, and rubella (MMR) vaccine. Which of the following findings should the nurse identify as a contraindication for receiving this vaccine?

5 :
A nurse is caring for an infant who has rotavirus. Which of the following findings indicates that the infant is moderately dehydrated?

6 :
A nurse is caring for an adolescent who is admitted with a vaso-occlusive crisis.

7 :
A nurse in an emergency department is assessing an adolescent who reports inhalation of gasoline. Which of the following findings should the nurse expect?

8 :
A nurse in the emergency department is preparing to discharge a 3-year- old child.

9 :
A nurse in a family practice clinic is assessing a preschool-age child who recently experienced the death of a sibling. Which of the following reactions is an age-appropriate response to death?

10 :
A nurse is assessing a 6-month-old infant who has respiratory syncytial virus. The nurse should immediately report which of the following findings to the provider?