Patient Data

Exhibits

The nurse identifies that the client is experiencing
dropdown
as evidenced by
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Rationale for Correct Choices

Diabetic ketoacidosis (DKA): The client exhibits classic signs of DKA, including nausea, abdominal pain, polyuria, polydipsia, and extreme fatigue. DKA is a serious complication of type 1 diabetes caused by insulin deficiency and requires urgent management.
Blood glucose 224 mg/dL, acetone odor on breath: Hyperglycemia combined with ketone production leads to acetone breath, deep rapid respirations (Kussmaul respirations), and dehydration. These laboratory and physical findings support the diagnosis of DKA.

Rationale for Incorrect Choices

Hyperosmolar hyperglycemic state (HHS): HHS is more common in type 2 diabetes and usually presents with much higher blood glucose levels (>600 mg/dL) without significant ketone production. The presence of acetone breath indicates ketones, which points to DKA instead.
Hypoglycemia: Hypoglycemia presents with low blood glucose (<70 mg/dL), diaphoresis, tremors, and possible confusion or seizures. This client’s glucose is elevated, making hypoglycemia unlikely.
Preeclampsia: Preeclampsia is characterized by hypertension, proteinuria, and sometimes edema. This client’s blood pressure is not elevated, and there is no proteinuria, so preeclampsia is not indicated.
Hemoglobin A1C 6.2%: A normal HbA1c indicates overall good glycemic control over the past 2–3 months but does not rule out acute hyperglycemic emergencies such as DKA.
Blood glucose 60 mg/dL, diaphoresis, tremors: These findings indicate hypoglycemia rather than DKA and do not match the client’s current symptoms.
Blood pressure 150/100 mmHg: Elevated BP is associated with hypertensive disorders like preeclampsia, not DKA, and is not present in this client.

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

Explanation

Rationale:

Weight 35 lbs (15.87 kg): Weight is appropriate for a 24-month-old, indicating adequate growth and nutrition. Growth trends should continue to be monitored but currently show no concern.
Toddler speaks in 3 to 4 word sentences: Speech is appropriate for developmental age, indicating normal language and cognitive development. Age-appropriate communication supports healthy social and cognitive growth.
Bottle habit: Bottle provided at nap and bedtime: Prolonged bottle use increases the risk of dental caries and otitis media. Nighttime bottles contribute to poor oral hygiene and may worsen ear infections. Intervention includes education on limiting bottles and transitioning to cups.
Blood pressure 90/40 mm Hg: Blood pressure falls within expected range for a toddler. No signs of hypotension or cardiovascular compromise are present. Routine monitoring is sufficient.
Temperature 102.6° F (39.7° C) axillary: Fever indicates an active infection requiring monitoring and possible treatment. High temperatures can increase metabolic demand and dehydration risk. Nurse should assess for signs of worsening illness and educate parents on fever management.
Diaper count in 24 hour period 6 to 8 with urine: This indicates adequate hydration and normal renal function. Urine output is within expected limits for age and fluid intake. No interventions are required related to hydration status.

A. A full-term infant who has a 98.2° F (36.8° C) axillary temperature and needs a bath. B. An infant with tachypnea, tachycardia, and a meconium stained cord, C. A 38-week gestation infant whose mother wants to breastfeed now. D. Infant of a diabetic mother who has a blood glucose level of 60 mg/dL (3.3 mmol/L).

Correct Answer is B

Explanation

Rationale:

A. A full-term infant who has a 98.2° F (36.8° C) axillary temperature and needs a bath: A temperature within the normal neonatal range is not concerning, and the bath can be safely delayed. This infant is stable and does not require immediate assessment.

B. An infant with tachypnea, tachycardia, and a meconium stained cord: Respiratory distress in the presence of meconium raises concern for meconium aspiration syndrome, which can rapidly compromise oxygenation. This infant is at the greatest risk for airway obstruction and requires prompt assessment and intervention.

C. A 38-week gestation infant whose mother wants to breastfeed now: A term infant initiating breastfeeding is expected and appropriate, and while feeding support is important, there are no urgent physiologic concerns requiring immediate assessment in this situation.

D. Infant of a diabetic mother who has a blood glucose level of 60 mg/dL (3.3 mmol/L): A blood glucose level of 60 mg/dL is within the acceptable neonatal range of 30–60 mg/dL. Although infants of diabetic mothers require close glucose monitoring, this value is stable and does not require urgent intervention at this time.

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Patient Data Exhibits The nurse identifies that the client is experiencing dropdown as evidenced by dropdown.

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits The nurse is performing an assessment on the toddler. For each assessment finding, click to indicate whether the findings from the assessment should be a concern or not a concern to the nurse. Each row must have only one response option selected.

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

Explanation

A nurse in the transition nursery is assigned to care for four recently delivered infants. Which infant should the nurse assess first? Reference Range: Blood glucose/neonate [30 to 60 mg/dL (1.7 to 3.3 mmol/L)]

Correct Answer is B

Explanation

The nurse is preparing to administer oxytocin IV to a client after the delivery of her infant. Which outcome should the nurse expect from the administration of oxytocin?

A newborn infant diagnosed with developmental dysplasia of the hip must wear a Pavlik harness 23 hours a day. Which behavior by the mother best indicates that discharge teaching was effective?

A client who is at 10-weeks gestation calls the clinic because she has been vomiting for the past 24 hours. The nurse determines that the client has no fever. Which instruction should the nurse give to this client?

Albumin 25% IV is prescribed for a child with nephrotic syndrome. Which assessment finding indicates to the nurse that the medication is having the desired effect?

Patient Data Exhibits The nurse identifies that the client is experiencing dropdown as evidenced by dropdown.

A child who has been vomiting for 3 days is admitted for correction of fluid and electrolyte imbalances. Which acid-base imbalance is this child likely to exhibit?

Patient Data

Exhibits

The nurse identifies that the client is experiencing
dropdown
as evidenced by
dropdown
.