Question

A nurse is assessing an adolescent who has type 1 diabetes mellitus. Which of the following findings is the nurse's priority?

Answer 1

Correct Answers:

HbA1c 11.5%

Rationale :

🔶 An HbA1c of 11.5% indicates very poor long-term glycemic control, reflecting an average blood glucose consistently above 280 mg/dL over the past 2–3 months.

🔶 This level places the adolescent at high risk for acute complications like diabetic ketoacidosis (DKA) and long-term complications such as retinopathy, nephropathy, and neuropathy.

🔶 In pediatric diabetes care, an HbA1c goal is typically <7.5%, and this result is significantly above that threshold, requiring urgent intervention in management, adherence, or insulin adjustment.

🔶 While glycosuria and slightly elevated preprandial glucose are concerning, they are expected in the setting of poor glucose control. However, the elevated HbA1c confirms that hyperglycemia is chronic and dangerous.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

A child who has a fractured left femur

Rationale :

✴️ A preschooler recovering from Wilms tumor removal (a type of kidney cancer) is immunocompromised due to recent surgery and possibly chemotherapy. They are highly susceptible to infections, so preventing exposure is critical.

✴️ Rooming with a child who has impetigo, viral pneumonia, or cellulitis would pose an infection risk, as these are all infectious conditions.

✴️ A child with a fractured femur, however, is not infectious and is medically stable, making them the safest and most appropriate roommate for a post-op immunocompromised patient.

✴️ This pairing minimizes infection risk and supports effective care without isolating the recovering child unnecessarily.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Diplopia

Rationale :

🌟 Diplopia (double vision) in a child with a brain tumor is a neurological red flag. It can signal increased intracranial pressure (ICP) or tumor progression affecting the cranial nerves—specifically those controlling eye movement.

🌟 Increased ICP can rapidly lead to herniation, which is life-threatening. Early signs such as visual disturbances, headache, vomiting, or altered consciousness must be immediately reported.

🌟 Unlike nightmares or pruritus, which are non-emergent, diplopia requires urgent assessment to prevent further neurological compromise or vision loss.

🌟 Prompt neuroimaging or intervention may be necessary based on the progression of tumor effects on the brain structures.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

Allergy to neomycin

Rationale :

✳️ A severe allergy to neomycin is a contraindication for receiving the MMR vaccine, as neomycin is used as a preservative or stabilizer in the vaccine.

✳️ Children with this allergy are at risk of experiencing a life-threatening anaphylactic reaction following administration.

✳️ The CDC specifically lists anaphylactic reactions to neomycin or gelatin as absolute contraindications to the MMR vaccine.

✳️ Other listed options, like a recent minor illness (URI), low-grade fever, or family history of seizures, are not contraindications and the vaccine may still be administered safely in those cases.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Weight loss 7%

Rationale :

🔶 Moderate dehydration in infants is typically characterized by a weight loss of 6% to 9% of total body weight.

🔶 A 7% weight loss falls within this range and is a reliable clinical indicator of moderate fluid deficit.

🔶 Infants with rotavirus are at high risk of dehydration due to profuse watery diarrhea and vomiting, making weight trends crucial for classification.

🔶 Other signs of moderate dehydration may include increased heart rate, irritability, decreased urine output, dry mucous membranes, and slightly delayed capillary refill.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Instruct the parent to ensure the pneumococcal vaccine is current.
Give oral hydroxyurea.
Monitor oxygen saturation continuously.

Rationale :

✅Instruct the parent to ensure the pneumococcal vaccine is current.

▪️ Sickle cell disease puts clients at high risk for invasive bacterial infections, particularly with encapsulated organisms such as Streptococcus pneumoniae.

▪️ These clients are functionally asplenic or may have autosplenectomy due to repeated splenic infarctions, reducing their ability to clear infections.

▪️ Ensuring up-to-date pneumococcal vaccination (both PCV13 and PPSV23) helps prevent life-threatening infections like sepsis and meningitis.

▪️ This intervention is a preventive health measure and part of long-term disease management, especially crucial during and after hospitalization.

✅ Give oral hydroxyurea.

▪️ Hydroxyurea is a disease-modifying medication that promotes the production of fetal hemoglobin (HbF), which inhibits the sickling of red blood cells.

▪️ It reduces the frequency of vaso-occlusive crises, hospitalizations, and the need for transfusions.

▪️ Although it may not be used acutely for crisis management, continuation or initiation during hospitalization can be appropriate if prescribed, especially when the patient is stable.

▪️ Hydroxyurea is part of a long-term therapy plan and is important for overall crisis reduction.

✅ Monitor oxygen saturation continuously.

▪️ Hypoxia is a trigger for sickling, so maintaining adequate oxygenation is critical during a vaso-occlusive crisis.

▪️ Continuous pulse oximetry allows for early identification of desaturation, enabling prompt intervention to prevent complications such as acute chest syndrome.

▪️ Even a low-grade fever and vomiting, as in this case, can contribute to dehydration and acidosis, which increase oxygen demand and the risk of hypoxemia.

▪️ This measure supports early detection and proactive management of respiratory compromise.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Ataxia

Rationale :

🔷 Inhalant abuse (e.g., gasoline, glue, paint thinners) acts as a central nervous system depressant, leading to neurological impairment.

🔷 A key expected finding is ataxia, which is impaired coordination or unsteady gait due to cerebellar dysfunction.

🔷 Other possible signs include slurred speech, dizziness, confusion, and sometimes hallucinations or lethargy.

🔷 Inhalants can also sensitize the myocardium to catecholamines, increasing risk of sudden cardiac death even in healthy adolescents.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

"You can apply gloves to your child's hands."
"You should cut and file your child's fingernails frequently."
"Your child will experience occasional flare-ups of this condition."
"You should apply emollients to your child's skin after bathing."

Rationale :

✅"You can apply gloves to your child's hands."

▪️ Applying soft gloves or mittens to the child’s hands—especially during sleep—can help reduce scratching, which minimizes skin trauma, bleeding, and risk of secondary infection.

▪️ Scratching worsens inflammation and can lead to lichenification (thickened skin), which is common in atopic dermatitis.

▪️ This non-pharmacological method is a safe and practical intervention for toddlers who may not respond to redirection.

▪️ It also helps support skin healing and improves comfort and sleep quality.

✅ "You should cut and file your child's fingernails frequently."

▪️ Keeping the child’s nails short and smooth decreases the damage caused by scratching.

▪️ Long nails can harbor bacteria, increasing the risk of secondary infection from open lesions.

▪️ Filing helps remove sharp edges that can worsen skin breakdown, especially when the child scratches subconsciously.

▪️ This is a key preventive strategy recommended for all children with atopic dermatitis.

✅"Your child will experience occasional flare-ups of this condition."

▪️ Atopic dermatitis is a chronic relapsing inflammatory condition, often triggered by allergens, irritants, stress, or weather changes.

▪️ Guardians should be informed that flare-ups are expected, but proper skin care and trigger avoidance can reduce their frequency and severity.

▪️ This guidance prepares caregivers emotionally and encourages consistency with long-term management, including moisturizing and trigger control.

✅"You should apply emollients to your child's skin after bathing."

▪️ Applying emollients (moisturizers) immediately after bathing (within 3 minutes) helps lock in moisture and restore the skin barrier.

▪️ This is a first-line treatment for atopic dermatitis and significantly reduces itching and flare-ups.

▪️ Thick, unscented emollients like petroleum jelly or Eucerin are preferred over lotions.

▪️ Regular use of emollients improves skin hydration, which is essential in minimizing skin inflammation and discomfort.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

The child is curious about what happened to the sibling's body.

Rationale :

🟣 Preschool-age children (3–6 years) are in Piaget’s preoperational stage, where thinking is magical, egocentric, and often not logical.

🟣 At this age, children often exhibit curiosity about death, particularly about the physical aspects, such as what happens to the body or burial process.

🟣 They may not understand the permanence or universality of death and may even ask repetitive or concrete questions.

🟣 Curiosity is a normal developmental reaction and can be addressed with simple, honest, and age-appropriate explanations.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Tachypnea

Rationale :

🔴 Tachypnea in an infant with respiratory syncytial virus (RSV) is a priority finding that should be reported immediately, as it may indicate worsening respiratory distress or impending respiratory failure.

🔴 A rapid respiratory rate can lead to fatigue, decreased ability to maintain effective ventilation, and hypoxemia.

🔴 Early recognition allows for prompt intervention, such as oxygen support or hospitalization, to prevent severe complications.

🔴 While symptoms like rhinorrhea, pharyngitis, and coughing are common with RSV, tachypnea signals a serious decline in respiratory function and needs urgent attention.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

1 :
A nurse is assessing an adolescent who has type 1 diabetes mellitus. Which of the following findings is the nurse's priority?

2 :
A nurse is planning to admit a preschooler from the PACU following the removal of a Wilms tumor. Which of the following children should the nurse identify as an appropriate roommate for the preschooler?

3 :
A nurse is caring for a preschooler who has a brain tumor. Which of the following findings is the priority for the nurse to report to the provider?

4 :
A nurse is reviewing the medical record of a 15-month-old child who is scheduled to receive the measles, mumps, and rubella (MMR) vaccine. Which of the following findings should the nurse identify as a contraindication for receiving this vaccine?

5 :
A nurse is caring for an infant who has rotavirus. Which of the following findings indicates that the infant is moderately dehydrated?

6 :
A nurse is caring for an adolescent who is admitted with a vaso-occlusive crisis.

Answer Options

7 :
A nurse in an emergency department is assessing an adolescent who reports inhalation of gasoline. Which of the following findings should the nurse expect?

8 :
A nurse in the emergency department is preparing to discharge a 3-year- old child.

Answer Options

9 :
A nurse in a family practice clinic is assessing a preschool-age child who recently experienced the death of a sibling. Which of the following reactions is an age-appropriate response to death?

10 :
A nurse is assessing a 6-month-old infant who has respiratory syncytial virus. The nurse should immediately report which of the following findings to the provider?

QLexNursing

1 : A nurse is assessing an adolescent who has type 1 diabetes mellitus. Which of the following findings is the nurse's priority?

2 : A nurse is planning to admit a preschooler from the PACU following the removal of a Wilms tumor. Which of the following children should the nurse identify as an appropriate roommate for the preschooler?

3 : A nurse is caring for a preschooler who has a brain tumor. Which of the following findings is the priority for the nurse to report to the provider?

4 : A nurse is reviewing the medical record of a 15-month-old child who is scheduled to receive the measles, mumps, and rubella (MMR) vaccine. Which of the following findings should the nurse identify as a contraindication for receiving this vaccine?

5 : A nurse is caring for an infant who has rotavirus. Which of the following findings indicates that the infant is moderately dehydrated?

6 : A nurse is caring for an adolescent who is admitted with a vaso-occlusive crisis.

Answer Options

7 : A nurse in an emergency department is assessing an adolescent who reports inhalation of gasoline. Which of the following findings should the nurse expect?

8 : A nurse in the emergency department is preparing to discharge a 3-year- old child.

Answer Options

9 : A nurse in a family practice clinic is assessing a preschool-age child who recently experienced the death of a sibling. Which of the following reactions is an age-appropriate response to death?

10 : A nurse is assessing a 6-month-old infant who has respiratory syncytial virus. The nurse should immediately report which of the following findings to the provider?

1 :
A nurse is assessing an adolescent who has type 1 diabetes mellitus. Which of the following findings is the nurse's priority?

2 :
A nurse is planning to admit a preschooler from the PACU following the removal of a Wilms tumor. Which of the following children should the nurse identify as an appropriate roommate for the preschooler?

3 :
A nurse is caring for a preschooler who has a brain tumor. Which of the following findings is the priority for the nurse to report to the provider?

4 :
A nurse is reviewing the medical record of a 15-month-old child who is scheduled to receive the measles, mumps, and rubella (MMR) vaccine. Which of the following findings should the nurse identify as a contraindication for receiving this vaccine?

5 :
A nurse is caring for an infant who has rotavirus. Which of the following findings indicates that the infant is moderately dehydrated?

6 :
A nurse is caring for an adolescent who is admitted with a vaso-occlusive crisis.

7 :
A nurse in an emergency department is assessing an adolescent who reports inhalation of gasoline. Which of the following findings should the nurse expect?

8 :
A nurse in the emergency department is preparing to discharge a 3-year- old child.

9 :
A nurse in a family practice clinic is assessing a preschool-age child who recently experienced the death of a sibling. Which of the following reactions is an age-appropriate response to death?

10 :
A nurse is assessing a 6-month-old infant who has respiratory syncytial virus. The nurse should immediately report which of the following findings to the provider?