A nurse in the emergency department is caring for a toddler.

Exhibits
The nurse is reviewing the toddler's nurses' notes, vital signs, and intake and output record. For each clinical finding, click to specify if the finding indicates the condition has improved, has not changed, or has declined.

Heart rate

Respiratory rate

Urine output

Mucous membranes

Abdominal examination

Vomiting frequency

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Heart rate: Not changed

No specific mention of heart rate changes, so it remains unchanged.

Respiratory rate: Not changed

Respirations are described as clear and shallow, with no significant change noted over time. The child's respiratory rate appears stable.

Urine output: Improved

Initially, the output was 8 mL of concentrated urine over 2 hours, and by 1600, the output increased to 30 mL of yellow urine over 2 hours. The improvement in both the volume and color indicates that hydration status is improving.

Mucous membranes: Improved

At 1000, the mucous membranes were described as pale and dry. By 1200, they were pale and sticky, which is still a sign of dehydration, but by 1600, they are likely improving as the child is receiving intravenous fluids and hydration.

Abdominal examination: Not changed

The abdominal examination remains consistent, with mild tenderness on palpation and hyperactive bowel sounds observed throughout the shift. These findings indicate that the child is still experiencing gastrointestinal upset but without significant worsening.

Vomiting frequency: Improved

Vomiting frequency decreased from 8 times in the previous 24 hours to just 1 episode in the past 2 hours, indicating a significant improvement in vomiting control.

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Correct Answer is ["B","D","E"]

Explanation

A. While age is considered in growth charts, it is not an anthropometric measurement.

B. BMI is an important indicator of nutritional status and helps assess underweight, healthy weight, or overweight status.

C. Vital signs are not part of anthropometric measurements.

D. Height is a key anthropometric measure used to assess growth and development.

E. Weight is a fundamental anthropometric measure for assessing nutritional status.

F. Routine laboratory tests are not part of anthropometric measurements but may complement the assessment.

A. “children are expected to count backwards from 20 to 1 by age 7." B. “By age most children can dress and groom themselves." C. "By age 6, most children can use tools such as a screwdriver or hammer." D. "Children engage in motor activities that require balance such as jumping rope by age 6."

Correct Answer is D

Explanation

A. Counting backward from 20 to 1 is typically expected around age 8, not age 7.

B. Dressing and grooming independently are typically expected by age 5 to 6, not exclusive to school age.

C. Using tools like a screwdriver is more characteristic of older school-age children, not typical at age 6.

D. By age 6, children develop balance and coordination, allowing them to perform activities like jumping rope.

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A nurse in the emergency department is caring for a toddler. Exhibits The nurse is reviewing the toddler's nurses' notes, vital signs, and intake and output record. For each clinical finding, click to specify if the finding indicates the condition has improved, has not changed, or has declined.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing the nutritional status of a child using anthropometric evaluations. Which of the following should the nurse include in the assessment? (Select All that Apply.)

Correct Answer is ["B","D","E"]

Explanation

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Correct Answer is D

Explanation

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A nurse in the emergency department is caring for a toddler.

Exhibits
The nurse is reviewing the toddler's nurses' notes, vital signs, and intake and output record. For each clinical finding, click to specify if the finding indicates the condition has improved, has not changed, or has declined.