Findings that indicate a developmental delay:

Language: uses one word sentences, can say 5 words- At age 2, toddlers are expected to use at least two-word phrases and have a vocabulary of about 50 words. This finding suggests a delay in expressive language development.

Play: does not notice when others are upset- At this age, toddlers begin to show empathy or awareness of others' emotions. Not noticing when others are upset could indicate a delay in social-emotional development.

Rationale for incorrect findings:

Fine motor: rotates utensils to bring them to their mouth- This is an age-appropriate fine motor skill.

Gross motor: scoots on bottom up and down stairs- Although some toddlers may walk up stairs by 2 years, scooting is still within developmental range.

A. Fruity breath odor: Expected during hyperglycemia or diabetic ketoacidosis; useful to teach for early recognition of complications.

B. Excessive thirst: Expected in diabetes; teaching should reinforce fluid needs and early symptom identification.

C. Negative ketones: Not expected to teach, as it is a lab result, not a symptom.

D. Abdominal pain: Expected in hyperglycemia or ketoacidosis.

E. Sweating: Expected in hypoglycemia, important for future recognition.

F. Nightmares: Unrelated to diabetes.

G. Double vision: More typical of severe hyperglycemia or other neurological issues.

H. Headache: Expected symptom of hypoglycemia.

The nurse should first: Notify the surgeon due to the child's: Throat clearing

Rationale for correct answer:

Frequent swallowing and throat clearing after tonsillectomy are early signs of bleeding, a serious postoperative complication. This requires immediate attention.

Rationale for incorrect answers:

Provide a diversional activity: Not priority in this urgent context.

Administer PRN pain medication: Important, but not first given the concern for bleeding.

Offer the child a popsicle: Contraindicated if bleeding is suspected.

Provide discharge education: Not appropriate until the child is stable.

Cold compresses to painful areas: Expected

Nonpharmacologic method to help reduce pain and inflammation during vaso-occlusive crisis.

Bed rest: Expected

Conserves oxygen and prevents further sickling.

Blood type and cross match: Expected

Anticipated if anemia is severe or if transfusion is needed (Hemoglobin 7.6 g/dL).

NPO status: Unexpected

No GI procedures planned; child should stay hydrated to prevent sickling.

Morphine IV: Expected

Opioids are often necessary for severe sickle cell pain management.

When planning care for the infant, the nurse should prepare the infant for a rectal biopsy and frequently measure abdominal circumference.

Rationale for correct answers:

Prepare the infant for a rectal biopsy: Confirms diagnosis of Hirschsprung disease, which is suspected based on symptoms and enema findings.

Frequently measure abdominal circumference: Monitors abdominal distension, a key sign in bowel obstruction or worsening condition.

Rationale for incorrect answers:

Explain the purpose of the pyloromyotomy: This procedure is for pyloric stenosis, not Hirschsprung disease.

Transport the client for a radiologist guided gas enema: Contrast enema already performed.

Administer oral laxatives: Contraindicated in suspected bowel obstruction like Hirschsprung disease.

Correct answers: The nurse should recognize that the findings in the EMR are consistent with acute glomerulonephritis as evidenced by urinalysis.

Rationale for correct answers:

Acute Glomerulonephritis (AGN): AGN is a known complication that can occur 1–2 weeks after a streptococcal infection (positive strep test a week ago). The child now has periorbital edema, hypertension (BP 141/88), lethargy, and tea-colored urine- all classic signs.

The urinalysis shows proteinuria, hematuria, and cloudy tea-colored urine, which are hallmark findings in AGN.

Rationale for incorrect answers:

Urinary tract infection: Typically causes dysuria, urgency, frequency, and often a positive leukocyte esterase or nitrites.

Mononucleosis: Would show lymphadenopathy, sore throat, and fatigue but is not consistent with current urinary findings or hypertension.

A delayed allergic reaction: Would be more likely to present with urticaria, pruritus, or respiratory compromise.

Congestive heart failure: Rare in children with no cardiac history and wouldn't explain the urinalysis findings.

The toddler is at risk for developing hearing loss as evidenced by the toddler’s bone biopsy results.

Rationale for correct answers:

Osteogenesis Imperfecta (OI): Confirmed by bone biopsy showing decreased trabecular and cortical bone volume. Classic features: recurrent fractures with minimal trauma, blue sclera, dentinogenesis imperfecta (grey teeth). OI can cause conductive hearing loss due to abnormalities in the bones of the middle ear.

Rationale for incorrect answers:

Hyperkalemia and hypercalcemia: Not supported by findings; there's no lab evidence or indication for this.

Compartment syndrome: No signs like severe pain, pallor, paresthesia, pulselessness, or pressure; capillary refill is normal (<3 seconds).

A. Steatorrhea

This refers to fatty, foul-smelling stools and is associated with malabsorption syndromes (e.g., celiac disease), not UTIs.

B. Jaundice

Jaundice is typically associated with liver or hemolytic conditions. It is not a symptom of a urinary tract infection.

C. Incontinence

In a toilet-trained toddler, new or increased episodes of incontinence may indicate a UTI. Toddlers may have difficulty expressing pain or urinary urgency, so regression in toilet habits is often a key indicator.

D. Rebound tenderness

Rebound tenderness indicates peritoneal irritation, seen in conditions like appendicitis—not in uncomplicated UTIs.

A. "Expect the medication to cause constipation for the first few days of therapy."

Metformin more commonly causes diarrhea, nausea, and abdominal discomfort, not constipation.

B. "Take the medication at the same time each day."

Consistent dosing helps maintain stable blood glucose levels. Metformin is usually taken once or twice daily with meals.

C. "This medication is used for short-term therapy until your symptoms improve."

Type 2 diabetes is a chronic condition. Metformin is often used as a long-term maintenance therapy.

D. "Take this medication 1 hour before meals."

Metformin should be taken with meals to reduce gastrointestinal side effects, not on an empty stomach.