A nurse is caring for a school-age child who has diabetes mellitus and was admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the following findings should the nurse expect?

Periods of apnea for 20 seconds

Paradoxic respirations of 26/min

Shallow respirations of 10/min

Deep respirations of 32/min

Answer and Explanation

The Correct Answer is D

A. Periods of apnea are not typical for DKA and may indicate other respiratory issues.

B. Paradoxic respirations are abnormal and occur when chest and abdomen move in opposite directions, which is not typically associated with DKA.

C. Shallow respirations are not typical of DKA; they would indicate respiratory depression or other issues.

D. Deep, rapid respirations (Kussmaul respirations) are characteristic of diabetic ketoacidosis (DKA). They occur as the body tries to compensate for acidosis by exhaling more carbon dioxide.

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Correct Answer is D

Explanation

A. Asking the client to look away may reduce anxiety for some, but it does not minimize discomfort or promote understanding.

B. Using a larger needle would likely increase discomfort and is not consistent with atraumatic care, which aims to minimize pain.

C. Administering the injection quickly might reduce discomfort but does not address the child’s emotional needs or ensure proper understanding of the procedure.

D. Explaining the procedure in simple terms helps the child understand what will happen, reducing fear and promoting cooperation. This is an important aspect of atraumatic care.

A. "Award the child with a sticker when he sits on the potty chair." B. "Play the child's favorite song while teaching him to use the potty chair." C. "Teach multiple steps of the skill at the same time." D. "Scold the child when he has a toileting accident."

Correct Answer is A

Explanation

A. Positive reinforcement, such as giving stickers for sitting on the potty, is an effective way to encourage toilet training in toddlers, especially those with cognitive impairments.

B. Playing a favorite song can help with the process but is not as effective as a structured reinforcement like rewarding the child for participating in the activity.

C. Teaching multiple steps at once can be overwhelming for a toddler with cognitive impairments. It is better to break the task into simple, manageable steps.

D. Scolding the child for accidents can cause shame and hinder progress. Positive reinforcement is more effective than punishment.

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A nurse is caring for a school-age child who has diabetes mellitus and was admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An acute care nurse is caring for a pediatric client diagnosed with diabetes mellitus who receives insulin injections. Which of the following actions by the nurse demonstrates atraumatic care?

Correct Answer is D

Explanation

A nurse is teaching the parents of a toddler who has a cognitive impairment about toilet training. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

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