A nurse in an emergency department is assisting with the care of a 2- year-old toddler.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the toddler is most likely experiencing 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the toddler's progress.

Answer and Explanation

The Correct Answer is []

Rationale for Correct Choices:

Intussusception: The toddler's sudden onset of crying, drawing knees to the chest, and high-pitched cry are classic signs of intussusception. The "red jelly" stool (currant jelly stool) is also a hallmark symptom of this condition.
Reinforce teaching with the guardian about hydrostatic reduction: Hydrostatic reduction is the treatment for intussusception, where a contrast material is used to reduce the telescoped bowel. It's an important intervention that should be discussed with the guardian.
Palpate the toddler's abdomen for a mass in the upper quadrant: A palpable abdominal mass is a classic sign of intussusception, and the nurse should assess for this to help confirm the diagnosis.
Abdominal pain: Monitoring abdominal pain is essential because it can be a significant indicator of worsening intussusception or any complications. The child is showing signs of severe pain, so it needs to be closely watched.
Stool consistency: The "red jelly" stool is a key finding of intussusception, and the nurse should continue to monitor for this, as it is a clear indicator of bowel obstruction.

Rationale for Incorrect Choices:

Prepare the toddler for an upper endoscopy with possible biopsy : An upper endoscopy with biopsy is used to assess gastrointestinal conditions like Celiac disease or gastroesophageal reflux. Intussusception is diagnosed through imaging techniques like ultrasound or a contrast enema, not an upper endoscopy.
Request a prescription for a fat-soluble vitamin supplement: Vitamin supplements are more relevant to conditions like Celiac disease or other chronic malabsorption syndromes.
Obtain a prescription for blood transglutaminase antibody testing: This test is relevant for diagnosing Celiac disease but is not needed for diagnosing intussusception, which requires imaging and clinical assessment for bowel obstruction.
Gastroesophageal reflux: Gastroesophageal reflux does not typically present with the acute abdominal pain, "red jelly" stool, or the high-pitched crying observed in this toddler. It's more of a chronic condition associated with spitting up or regurgitation.
Celiac disease: Celiac disease typically presents with gastrointestinal issues like diarrhea, abdominal distension, and failure to thrive, rather than acute symptoms like crying and "red jelly" stools.
Gastroenteritis: While gastroenteritis may present with vomiting, diarrhea, and irritability, it does not explain the specific findings of a high-pitched cry, drawing knees to the chest, or the characteristic stool.
Bone mineral densit: Bone mineral density is relevant to conditions like osteoporosis or rickets but is not related to intussusception. The focus here should be on monitoring gastrointestinal symptoms, particularly abdominal pain and stool consistency, not bone health.
Sleep pattern: While sleep pattern can be affected by various conditions, it is not a primary concern in the management of intussusception. The toddler's acute symptoms (pain, vomiting, stool changes) should take precedence over monitoring sleep.
Urine specific gravity: Urine specific gravity is typically monitored for dehydration or kidney function, but intussusception is not primarily associated with these issues.
Request a prescription for blood transglutaminase antibody testing: This test is relevant for diagnosing Celiac disease but is not needed for diagnosing intussusception, which requires imaging and clinical assessment for bowel obstruction.

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Correct Answer is B

Explanation

A. Monitor vital signs every 8 hr: Vital signs should be monitored more frequently in a child with diabetic ketoacidosis (DKA) than every 8 hours. Monitoring every 1-2 hours is typically recommended in order to detect any signs of deterioration or complications early.
B. Initiate continuous cardiac monitoring: Cardiac monitoring is important in the management of DKA because the condition can lead to electrolyte imbalances (especially hypokalemia), which can affect heart rhythm and potentially cause arrhythmias.
C. Administer subcutaneous insulin 30 min before meals: In SKA, insulin should not be administered subcutaneously until the child’s condition is stabilized, as intravenous (IV) insulin is typically used initially to correct acidosis and hyperglycemia in DKA.
D. Implement fluid restrictions: Fluid restrictions are not appropriate in DKA. Aggressive fluid resuscitation is necessary to correct dehydration and restore proper electrolyte balance. Fluid restrictions could worsen dehydration and acidosis.

A. "You should chill your medication before administration” B. "You should rotate sites when administering the medication." C. "You should administer your medication at a 45-degree angle” D. "You should administer your insulin into a muscle.”

Correct Answer is B

Explanation

A. "You should chill your medication before administration." Insulin should not be chilled before administration. It should be stored in a cool place, but administering insulin directly from the refrigerator can cause discomfort.

B. "You should rotate sites when administering the medication." Rotating injection sites helps prevent tissue damage and the formation of lumps or scar tissue. It is recommended to rotate sites within the same area (e.g., abdomen, thigh, etc.) to ensure absorption and prevent complications.

C. "You should administer your medication at a 45-degree angle." Insulin should generally be administered at a 90-degree angle for subcutaneous injection, not a 45-degree angle. A 45-degree angle may be appropriate.

D. "You should administer your insulin into a muscle." Insulin should be administered subcutaneously (into the fat layer just under the skin), not into the muscle. Injecting insulin into a muscle can alter its absorption rate and may cause irritation or pain.

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Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a school-age child who is being admitted for diabetic ketoacidosis. Which of the following interventions should the nurse recommend?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with an adolescent about self-administration of insulin. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

Exhibits Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Exhibits Complete the following sentence by using the lists of options. The nurse should plan to dropdownanddropdown.

A nurse is reinforcing teaching with the parents of a 2-month-old infant who has gastroesophageal reflux. The parents are feeding the infant formula. Which of the following instructions should the nurse include in the teaching?

Exhibits Complete the following sentence by using the lists of options. The nurse should first recommend to address the infant's dropdownfollowed by the infant'sdropdown.

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