The practical nurse (PN) caring for a 3-month-old boy one day after a pyloromyotomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should the PN take?

Feed one ounce of formula to correct hypoglycemia.

Administer a prescribed analgesia for pain.

Provide additional blankets to increase body temperature.

Increase IV infusion rate for rehydration.

Answer and Explanation

The Correct Answer is B

The infant's symptoms are consistent with postoperative pain, which can be expected following a surgical procedure like pyloromyotomy. The PN should administer the prescribed analgesic medication to relieve the infant's discomfort and pain. It is crucial to manage pain appropriately in infants to promote healing, improve feeding tolerance, and prevent complications.

Option A is not appropriate as the infant's symptoms are not indicative of hypoglycemia.

Option C is not appropriate as the infant's symptoms do not indicate hypothermia.

Option D is not appropriate as the infant's symptoms do not indicate dehydration.

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Correct Answer is A

Explanation

The practical nurse (PN) should obtain a serum glucose level to assess the client's blood sugar level, which can help to determine if the client is experiencing hyperglycemia or diabetic ketoacidosis (DKA). Anorexia, drowsiness, and polydipsia, along with the reported frequent urination and bedwetting, are symptoms of hyperglycemia or DKA.

Oﬀering age-appropriate toys (B) or suggesting diapers for bedtime use (C) are not appropriate actions for the PN to take in this situation.

Bringing orange juice and crackers (D) may help to increase the client's blood sugar level in the short term, but it does not address the underlying issue and may exacerbate the client's symptoms if she is experiencing hyperglycemia or DKA.

A. "Are you planning to obey the voices?" B. "When did these voices begin?" C. "Have you taken any hallucinogens?" D. "Do you believe the voices are real?"

Correct Answer is A

Explanation

The practical nurse (PN) should ask the client if he is planning to obey the voices, as this will help determine the client's risk for harming himself or others. The PN should also ask about the onset and duration of the symptoms and any factors that may have triggered them, such as drug use or recent stressors. Additionally, the PN should assess the client's perception of the voices, as some individuals may recognize them as a symptom of a mental illness, while others may believe them to be real. It is important for the PN to remain non-judgmental and supportive during the assessment, while prioritizing the client's safety.

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The practical nurse (PN) caring for a 3-month-old boy one day after a pyloromyotomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should the PN take?

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Naxlex Comprehensive Predictor Exams

A 6-year-old female client who was recently diagnosed with type 1 diabetes mellitus (DM) comes to the clinic with anorexia, drowsiness, and polydipsia. Her parents report frequent urination and bedwetting episodes almost nightly. Which action should the practical nurse (PN) take?

Correct Answer is A

Explanation

A male college student brings his roommate to the clinic because the roommate has been talking to someone who is not present. The client tells the practical nurse (PN) that the voices are saying, "Kill, kill." Which question should the PN ask the client next?

Correct Answer is A

Explanation

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