the nurse is caring for a child with hypernatremia the nurse evaluates the child for which signs and symptoms of hypernatremia select all that apply

ATI RN

RN Nursing Care of Children Online Practice 2019 A

1. The nurse is caring for a child with hypernatremia. The nurse evaluates the child for which signs and symptoms of hypernatremia? (Select all that apply.)

A. All below
B. Lethargy
C. Oliguria
D. Intense thirst

Correct answer: A

Rationale: Hypernatremia typically presents with lethargy, oliguria, and intense thirst due to the body's attempt to conserve water. Apathy can also occur, but lethargy and thirst are more consistent indicators.

2. When auscultating an infant's lungs, the nurse detects diminished breath sounds. What should the nurse interpret this as?

A. Suggestive of chronic pulmonary disease
B. Suggestive of impending respiratory failure
C. An abnormal finding warranting investigation
D. A normal finding in infants younger than 1 year of age

Correct answer: C

Rationale: Diminished breath sounds in an infant are an abnormal finding and warrant further investigation to rule out conditions like atelectasis or pneumonia.

3. Rectal temperatures are indicated in which situation?

A. In the newborn period
B. Whenever accuracy is essential
C. Rectal temperatures are never indicated
D. When rapid temperature changes are occurring

Correct answer: B

Rationale: Rectal temperatures provide the most accurate measurement of core body temperature and are therefore indicated when accuracy is essential.

4. What is the recommended method to assess hydration status in infants?

A. Capillary refill time
B. Skin turgor
C. Urine output
D. Mucous membranes

Correct answer: C

Rationale: The correct answer is C: Urine output. Assessing urine output is a recommended method to determine hydration status in infants. Adequate urine output indicates good hydration, while decreased urine output may suggest dehydration. Capillary refill time (Choice A) is more indicative of circulatory status rather than hydration. Skin turgor (Choice B) is a useful assessment in adults but can be less reliable in infants. Checking mucous membranes (Choice D) can provide some information on hydration, but it is not as reliable as assessing urine output in infants.

5. The nurse is assessing a 3-year-old child. Which assessment finding would the nurse identify as abnormal?

A. Pedals tricycle without assistance
B. Unscrews a bolt on a toy
C. Falls when bending over to touch toes
D. Builds a tower of 10 cubes

Correct answer: C

Rationale: The correct answer is C. Falling when bending over to touch toes could indicate a developmental delay or a balance issue that may need further assessment. Choices A, B, and D are typical developmental milestones for a 3-year-old child. Pedaling a tricycle without assistance, unscrewing a bolt on a toy, and building a tower of 10 cubes are all age-appropriate activities for a child of this age.