A nurse is caring for a 7-year-old in the emergency department (ED).
Which of the following findings should the nurse include in today's teaching?
Select All That Apply.
Fruity breath odor
Excessive thirst
Negative ketones
Abdominal pain
Sweating
Nightmares
Double vision
Headache
Correct Answer : A,B,D,E,H
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I should place the shoulder harness above the level of my baby's shoulders.":
For rear-facing seats, the harness straps should be at or just below shoulder level.
B. "I should place the car seat rear-facing until my baby is 2 years old.":
The American Academy of Pediatrics recommends that children remain in a rear-facing car seat until at least age 2 or until they exceed the height and weight limit set by the manufacturer.
C. "I will place the retainer clip over my baby's abdomen.":
The retainer clip should be positioned at armpit level (mid-chest) to protect vital organs.
D. "I should position my baby at a 30-degree angle in the car seat.":
The infant should be positioned at a 45-degree angle to prevent airway obstruction.
Correct Answer is D
Explanation
A. Asking the toddler's parents to go to the waiting room:
Parents should stay with the child to reduce anxiety and support cooperation.
B. Palpating the child's abdomen:
Abdominal palpation is contraindicated in Wilms tumor because it can cause tumor rupture and spread cancer cells.
C. Discontinuing clear liquids 1 hr prior to surgery:
Clear liquids are usually stopped at least 2-6 hours before surgery depending on hospital protocols-not just 1 hour prior.
D. Monitoring the child's blood pressure continuously
Wilms tumor often affects kidney function, and blood pressure monitoring is crucial because of the risk of hypertension due to renal involvement.
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