Exhibits

Review H and P, nurse's note, and laboratory results.

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

Answer and Explanation

The Correct Answer is []

Potential Condition
Polycythemia

Tetralogy of Fallot, a congenital heart condition, often leads to decreased oxygenation, which triggers the body to produce more red blood cells to compensate, resulting in polycythemia.

Actions the nurse should take:

Take the child’s vital signs: Monitoring vital signs is essential to assess the child's overall stability and detect any signs of distress or hypoxia.

Ask the child’s parents about the frequency of tet spells: Tet spells (hypercyanotic episodes) are common in children with Tetralogy of Fallot, and understanding their frequency helps assess the child's current condition and plan interventions.

Parameters to monitor:

Oxygen saturation: Monitoring oxygen levels is crucial to determine how well the child is oxygenating and to detect any hypoxia or cyanosis.

Weight: Monitoring weight is important in this child, who is in the lower percentiles for growth, as poor weight gain may indicate the need for nutritional or medical intervention.

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Correct Answer is D

Explanation

A. Resuming normal physical activity is not advisable if the client is experiencing symptoms indicative of DKA.

B. Drinking electrolyte fluid replacements can be beneficial but does not address the underlying issue of hyperglycemia.

C. Measuring urine output may provide useful information but is not an immediate intervention for DKA.

D. Giving a dose of regular insulin as prescribed is crucial in managing DKA, as it helps to lower blood glucose levels and address the metabolic derangement.

A. Apply baby lotion to the skin twice daily. B. Keep the nails trimmed short. C. Allow the child to wear only 100% cotton clothing. D. Bathe the child daily with bath oil.

Correct Answer is B

Explanation

A. While applying lotion can help keep the skin moisturized, it may not prevent scratching or bleeding from lesions.

B. Keeping the nails trimmed short is essential to prevent the child from scratching the lesions, which can lead to further irritation and potential infection. Short nails reduce the risk of breaking the skin and causing bleeding.

C. While cotton clothing is less irritating and may help manage eczema, ensuring that the child does not scratch the lesions is more critical in this scenario.

D. Daily baths can be beneficial, but they should not be done excessively as they can further dry the skin. Bath oils may help, but they do not directly address the issue of scratching.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When developing a teaching plan for a client with newly diagnosed type 1 diabetes mellitus, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs?

Correct Answer is D

Explanation

The nurse is assessing a 4-year-old client with eczema. The child's skin is dry and scaly, and the parent reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child?

Correct Answer is B

Explanation

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