Chapter 30 My Nursing Test Banks

Ball/Bindler/Cowen, Principles of Pediatric Nursing: Caring for Children 5th Edition Test Bank
Chapter 30

Question 1

Type: MCSA

A child with diabetes insipidus (DI) has been admitted to the pediatric unit. The nurse would expect the childs lab value to demonstrate

1. Hyperglycemia.

2. Hypernatremia.

3. Hypercalcemia.

4. Hypoglycemia.

Correct Answer: 2

Rationale 1: In all forms of diabetes insipidus, serum sodium can increase to pathologic levels, so hypernatremia can occur and should be treated. The glucose level is not affected, so hypoglycemia or hyperglycemia is not caused by the diabetes insipidus. Hypercalcemia (high calcium) does not occur with this endocrine disorder.

Rationale 2: In all forms of diabetes insipidus, serum sodium can increase to pathologic levels, so hypernatremia can occur and should be treated. The glucose level is not affected, so hypoglycemia or hyperglycemia is not caused by the diabetes insipidus. Hypercalcemia (high calcium) does not occur with this endocrine disorder.

Rationale 3: In all forms of diabetes insipidus, serum sodium can increase to pathologic levels, so hypernatremia can occur and should be treated. The glucose level is not affected, so hypoglycemia or hyperglycemia is not caused by the diabetes insipidus. Hypercalcemia (high calcium) does not occur with this endocrine disorder.

Rationale 4: In all forms of diabetes insipidus, serum sodium can increase to pathologic levels, so hypernatremia can occur and should be treated. The glucose level is not affected, so hypoglycemia or hyperglycemia is not caused by the diabetes insipidus. Hypercalcemia (high calcium) does not occur with this endocrine disorder.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 01. Describe the anatomy and physiology of the endocrine system and pediatric differences.

Question 2

Type: MCSA

A nurse doing a daily weight on a child with diabetes insipidus notes the child has lost two pounds in 24 hours. The nurse should

1. Continue to monitor the child.

2. Notify the physician regarding the weight loss.

3. Chart the weight and report the loss to the next shift.

4. Do nothing more than chart the weight, as this would be a normal finding.

Correct Answer: 2

Rationale 1: With diabetes insipidus the child may have severe fluid-volume deficit. A weight loss of two pounds indicates a loss of one liter of fluid, so the physician should be notified and fluids replaced either orally or intravenously. This is a significant loss in a 24-hour period, so continuing to monitor, charting the weight and reporting to the next shift, and doing nothing would prolong treatment.

Rationale 2: With diabetes insipidus the child may have severe fluid-volume deficit. A weight loss of two pounds indicates a loss of one liter of fluid, so the physician should be notified and fluids replaced either orally or intravenously. This is a significant loss in a 24-hour period, so continuing to monitor, charting the weight and reporting to the next shift, and doing nothing would prolong treatment.

Rationale 3: With diabetes insipidus the child may have severe fluid-volume deficit. A weight loss of two pounds indicates a loss of one liter of fluid, so the physician should be notified and fluids replaced either orally or intravenously. This is a significant loss in a 24-hour period, so continuing to monitor, charting the weight and reporting to the next shift, and doing nothing would prolong treatment.

Rationale 4: With diabetes insipidus the child may have severe fluid-volume deficit. A weight loss of two pounds indicates a loss of one liter of fluid, so the physician should be notified and fluids replaced either orally or intravenously. This is a significant loss in a 24-hour period, so continuing to monitor, charting the weight and reporting to the next shift, and doing nothing would prolong treatment.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 07. Distinguish between the nursing care of the child with type 1 and type 2 diabetes.

Question 3

Type: MCMA

The nurse is caring for a child with syndrome of inappropriate antidiuretic hormone (SIADH) disorder. Which of the following interventions should the nurse implement for this child?

Standard Text: Select all that apply.

1. Encouragement of fluids.

2. Strict intake and output.

3. Administration of ordered diuretics.

4. Specific gravity of urine.

5. Weight only on admission but not daily.

Correct Answer: 2,3,4

Rationale 1: SIADH results from an excessive amount of serum antidiuretic hormone, causing water intoxication and hyponatremia. Intake and output should be monitored strictly. Diuretics such as furosemide (Lasix) are administered to eliminate excess body fluid, and urine specific gravity is monitored. Fluids are restricted to prevent further hemodilution. Daily weights should be obtained to monitor fluid balance.

Rationale 2: SIADH results from an excessive amount of serum antidiuretic hormone, causing water intoxication and hyponatremia. Intake and output should be monitored strictly. Diuretics such as furosemide (Lasix) are administered to eliminate excess body fluid, and urine specific gravity is monitored. Fluids are restricted to prevent further hemodilution. Daily weights should be obtained to monitor fluid balance.

Rationale 3: SIADH results from an excessive amount of serum antidiuretic hormone, causing water intoxication and hyponatremia. Intake and output should be monitored strictly. Diuretics such as furosemide (Lasix) are administered to eliminate excess body fluid, and urine specific gravity is monitored. Fluids are restricted to prevent further hemodilution. Daily weights should be obtained to monitor fluid balance.

Rationale 4: SIADH results from an excessive amount of serum antidiuretic hormone, causing water intoxication and hyponatremia. Intake and output should be monitored strictly. Diuretics such as furosemide (Lasix) are administered to eliminate excess body fluid, and urine specific gravity is monitored. Fluids are restricted to prevent further hemodilution. Daily weights should be obtained to monitor fluid balance.

Rationale 5: SIADH results from an excessive amount of serum antidiuretic hormone, causing water intoxication and hyponatremia. Intake and output should be monitored strictly. Diuretics such as furosemide (Lasix) are administered to eliminate excess body fluid, and urine specific gravity is monitored. Fluids are restricted to prevent further hemodilution. Daily weights should be obtained to monitor fluid balance.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 02. Identify the function of important hormones of the endocrine system.

Question 4

Type: MCSA

An adolescent girl with Graves disease is admitted to the hospital. What clinical manifestations would the nurse expect on assessment?

1. Weight gain, hirsutism, and muscle weakness.

2. Dehydration, metabolic acidosis, and hypertension.

3. Tachycardia, fatigue, and heat intolerance.

4. Hyperglycemia, ketonuria, and glucosuria.

Correct Answer: 3

Rationale 1: Graves disease occurs when thyroid hormone levels are increased, resulting in excessive levels of circulating thyroid hormones. Clinical manifestations include tachycardia, fatigue, and heat intolerance. Weight gain, hirsutism, and muscle weakness are signs of Cushings syndrome. Dehydration, metabolic acidosis, and hypertension are signs of congenital adrenal hyperplasia. Hyperglycemia, ketonuria, and glucosuria are signs of diabetes.

Rationale 2: Graves disease occurs when thyroid hormone levels are increased, resulting in excessive levels of circulating thyroid hormones. Clinical manifestations include tachycardia, fatigue, and heat intolerance. Weight gain, hirsutism, and muscle weakness are signs of Cushings syndrome. Dehydration, metabolic acidosis, and hypertension are signs of congenital adrenal hyperplasia. Hyperglycemia, ketonuria, and glucosuria are signs of diabetes.

Rationale 3: Graves disease occurs when thyroid hormone levels are increased, resulting in excessive levels of circulating thyroid hormones. Clinical manifestations include tachycardia, fatigue, and heat intolerance. Weight gain, hirsutism, and muscle weakness are signs of Cushings syndrome. Dehydration, metabolic acidosis, and hypertension are signs of congenital adrenal hyperplasia. Hyperglycemia, ketonuria, and glucosuria are signs of diabetes.

Rationale 4: Graves disease occurs when thyroid hormone levels are increased, resulting in excessive levels of circulating thyroid hormones. Clinical manifestations include tachycardia, fatigue, and heat intolerance. Weight gain, hirsutism, and muscle weakness are signs of Cushings syndrome. Dehydration, metabolic acidosis, and hypertension are signs of congenital adrenal hyperplasia. Hyperglycemia, ketonuria, and glucosuria are signs of diabetes.

Global Rationale:

Cognitive Level: Evaluating

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 03. Summarize signs and symptoms that may indicate a disorder of the endocrine system.

Question 5

Type: MCSA

A nurse is planning care for a child with adrenal insufficiency (Addisons disease). The priority nursing diagnosis is

1. Risk for Deficient Fluid Volume.

2. Risk for Injury Secondary to Hypertension.

3. Acute Pain.

4. Imbalanced Nutrition: More than Body Requirements.

Correct Answer: 1

Rationale 1: Adrenal insufficiency can cause fluid deficit. The goal of care is to maintain fluid and electrolyte balance while normal levels of corticosteroids and mineral corticoids are established. Therefore, Acute Pain and Imbalanced Nutrition: More than Body Requirements are not priority nursing diagnoses. A symptom of adrenal insufficiency is hypotension, not hypertension.

Rationale 2: Adrenal insufficiency can cause fluid deficit. The goal of care is to maintain fluid and electrolyte balance while normal levels of corticosteroids and mineral corticoids are established. Therefore, Acute Pain and Imbalanced Nutrition: More than Body Requirements are not priority nursing diagnoses. A symptom of adrenal insufficiency is hypotension, not hypertension.

Rationale 3: Adrenal insufficiency can cause fluid deficit. The goal of care is to maintain fluid and electrolyte balance while normal levels of corticosteroids and mineral corticoids are established. Therefore, Acute Pain and Imbalanced Nutrition: More than Body Requirements are not priority nursing diagnoses. A symptom of adrenal insufficiency is hypotension, not hypertension.

Rationale 4: Adrenal insufficiency can cause fluid deficit. The goal of care is to maintain fluid and electrolyte balance while normal levels of corticosteroids and mineral corticoids are established. Therefore, Acute Pain and Imbalanced Nutrition: More than Body Requirements are not priority nursing diagnoses. A symptom of adrenal insufficiency is hypotension, not hypertension.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 05. Develop a nursing care plan for each type of acquired metabolic disorder.

Question 6

Type: MCSA

A child has been admitted to the hospital unconscious. The child has a history of type 1 diabetes, and according to the childs mother, he has been to two birthday parties in the last few days and has resisted taking his insulin. At school the child had two more pieces of birthday cake and some ice cream at a class birthday party. What is the likely reason for this childs unconscious state?

1. Metabolic alkalosis.

2. Metabolic ketoacidosis.

3. Insulin shock.

4. Insulin reaction.

Correct Answer: 2

Rationale 1: Metabolic acidosis or ketoacidosis could have occurred because of the excessive intake of sugar with no additional insulin. The body burns fat and protein stores for energy when no insulin is available to metabolize glucose. Altered consciousness occurs as symptoms progress. Metabolic alkalosis, insulin shock, or insulin reaction would not be happening in this case.

Rationale 2: Metabolic acidosis or ketoacidosis could have occurred because of the excessive intake of sugar with no additional insulin. The body burns fat and protein stores for energy when no insulin is available to metabolize glucose. Altered consciousness occurs as symptoms progress. Metabolic alkalosis, insulin shock, or insulin reaction would not be happening in this case.

Rationale 3: Metabolic acidosis or ketoacidosis could have occurred because of the excessive intake of sugar with no additional insulin. The body burns fat and protein stores for energy when no insulin is available to metabolize glucose. Altered consciousness occurs as symptoms progress. Metabolic alkalosis, insulin shock, or insulin reaction would not be happening in this case.

Rationale 4: Metabolic acidosis or ketoacidosis could have occurred because of the excessive intake of sugar with no additional insulin. The body burns fat and protein stores for energy when no insulin is available to metabolize glucose. Altered consciousness occurs as symptoms progress. Metabolic alkalosis, insulin shock, or insulin reaction would not be happening in this case.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 07. Distinguish between the nursing care of the child with type 1 and type 2 diabetes.

Question 7

Type: MCSA

A child has been diagnosed with type 1 diabetes. The nurse has taught the child the difference between insulin shock and diabetic hyperglycemia. The nurse knows that the child understands the teaching when the child states that the characteristics of diabetic hyperglycemia are

1. Tremors and lethargy.

2. Hunger and hypertension.

3. Thirst and flushed skin.

4. Shakiness and pallor.

Correct Answer: 3

Rationale 1: Thirst and flushed skin are characteristic of diabetic hyperglycemia. Tremors, lethargy, hunger, shakiness, and pallor are characteristic of hypoglycemia. Hypertension is not a sign associated with hyperglycemia or hypoglycemia.

Rationale 2: Thirst and flushed skin are characteristic of diabetic hyperglycemia. Tremors, lethargy, hunger, shakiness, and pallor are characteristic of hypoglycemia. Hypertension is not a sign associated with hyperglycemia or hypoglycemia.

Rationale 3: Thirst and flushed skin are characteristic of diabetic hyperglycemia. Tremors, lethargy, hunger, shakiness, and pallor are characteristic of hypoglycemia. Hypertension is not a sign associated with hyperglycemia or hypoglycemia.

Rationale 4: Thirst and flushed skin are characteristic of diabetic hyperglycemia. Tremors, lethargy, hunger, shakiness, and pallor are characteristic of hypoglycemia. Hypertension is not a sign associated with hyperglycemia or hypoglycemia.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 08. Describe collaborative management for the child with type 1 and type 2 diabetes.

Question 8

Type: MCSA

During the summer many children are more physically active. What changes in the management of the child with diabetes should be taught as a result of more exercise?

1. Increased food intake.

2. Decreased food intake.

3. Increased need for insulin.

4. Decreased risk of insulin reaction.

Correct Answer: 1

Rationale 1: Increased physical activity requires adequate caloric intake to prevent hypoglycemia, so food intake should be increased. Increased activity would not require decreased food intake, and it would not result in a decreased risk of insulin reaction. Exercise causes the insulin to be used more efficiently, so increased insulin would not be needed.

Rationale 2: Increased physical activity requires adequate caloric intake to prevent hypoglycemia, so food intake should be increased. Increased activity would not require decreased food intake, and it would not result in a decreased risk of insulin reaction. Exercise causes the insulin to be used more efficiently, so increased insulin would not be needed.

Rationale 3: Increased physical activity requires adequate caloric intake to prevent hypoglycemia, so food intake should be increased. Increased activity would not require decreased food intake, and it would not result in a decreased risk of insulin reaction. Exercise causes the insulin to be used more efficiently, so increased insulin would not be needed.

Rationale 4: Increased physical activity requires adequate caloric intake to prevent hypoglycemia, so food intake should be increased. Increased activity would not require decreased food intake, and it would not result in a decreased risk of insulin reaction. Exercise causes the insulin to be used more efficiently, so increased insulin would not be needed.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 08. Describe collaborative management for the child with type 1 and type 2 diabetes.

Question 9

Type: MCSA

The nurse is teaching the parent of a type 1 diabetic preschool child about management of the disease. The parent should be told to allow the preschool child to

1. Administer all the insulin injections.

2. Pick which finger to stick for glucose testing.

3. Draw up the insulin dose.

4. Test blood glucose.

Correct Answer: 2

Rationale 1: The preschool childs need for autonomy and control can be met by allowing the child to pick which finger to stick for glucose testing. Administering the insulin, drawing up the dose, and testing blood glucose should not be done by the child until he or she is middle-school age or older.

Rationale 2: The preschool childs need for autonomy and control can be met by allowing the child to pick which finger to stick for glucose testing. Administering the insulin, drawing up the dose, and testing blood glucose should not be done by the child until he or she is middle-school age or older.

Rationale 3: The preschool childs need for autonomy and control can be met by allowing the child to pick which finger to stick for glucose testing. Administering the insulin, drawing up the dose, and testing blood glucose should not be done by the child until he or she is middle-school age or older.

Rationale 4: The preschool childs need for autonomy and control can be met by allowing the child to pick which finger to stick for glucose testing. Administering the insulin, drawing up the dose, and testing blood glucose should not be done by the child until he or she is middle-school age or older.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 08. Describe collaborative management for the child with type 1 and type 2 diabetes.

Question 10

Type: MCSA

A child is being seen in the clinic with a possible diagnosis of type 2 diabetes. The mother asks what the physician uses to make the diagnosis. The nurse would explain that type 2 diabetes is suspected if the child has obesity, acanthosis nigricans, and two non-fasting blood-glucose levels above

1. 120.

2. 80.

3. 200.

4. 50.

Correct Answer: 3

Rationale 1: Blood-glucose levels at or above 200 mg/dL without fasting is diagnostic of diabetes.

Rationale 2: Blood-glucose levels at or above 200 mg/dL without fasting is diagnostic of diabetes.

Rationale 3: Blood-glucose levels at or above 200 mg/dL without fasting is diagnostic of diabetes.

Rationale 4: Blood-glucose levels at or above 200 mg/dL without fasting is diagnostic of diabetes.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 03. Summarize signs and symptoms that may indicate a disorder of the endocrine system.

Question 11

Type: MCSA

A child with Turner syndrome tells the nurse that she feels different from her peers. The nurse should respond with

1. Tell me more about the feelings you are experiencing.

2. These feelings are not unusual and should pass soon.

3. Youll start to grow soon, so dont worry.

4. You seem to be upset about your disease.

Correct Answer: 1

Rationale 1: The lack of growth and sexual development associated with Turner syndrome presents problems with psychosocial development. Self-image, self-consciousness, and self-esteem are affected by the girls perception of her body and how she differs from peers. The nurse should encourage more expression of the girls feelings. Responding that the feelings will pass, that shell start to grow, or that she is upset about the disease would not be therapeutic.

Rationale 2: The lack of growth and sexual development associated with Turner syndrome presents problems with psychosocial development. Self-image, self-consciousness, and self-esteem are affected by the girls perception of her body and how she differs from peers. The nurse should encourage more expression of the girls feelings. Responding that the feelings will pass, that shell start to grow, or that she is upset about the disease would not be therapeutic.

Rationale 3: The lack of growth and sexual development associated with Turner syndrome presents problems with psychosocial development. Self-image, self-consciousness, and self-esteem are affected by the girls perception of her body and how she differs from peers. The nurse should encourage more expression of the girls feelings. Responding that the feelings will pass, that shell start to grow, or that she is upset about the disease would not be therapeutic.

Rationale 4: The lack of growth and sexual development associated with Turner syndrome presents problems with psychosocial development. Self-image, self-consciousness, and self-esteem are affected by the girls perception of her body and how she differs from peers. The nurse should encourage more expression of the girls feelings. Responding that the feelings will pass, that shell start to grow, or that she is upset about the disease would not be therapeutic.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 09. Plan care for the child with an inherited metabolic disorder.

Question 12

Type: MCSA

A parent of a newborn asks the nurse why a heel stick is being done on the baby to test for phenylketonuria (PKU). The nurse responds that

1. Screening for PKU is required and detection can be done before symptoms develop.

2. The infant has high-risk characteristics.

3. Because the infant was born by cesarean, a PKU test is necessary.

4. Because the infant was born by vaginal delivery, a PKU is recommended.

Correct Answer: 1

Rationale 1: Screening for phenylketonuria is required by law in every state. It is not done according to high-risk characteristics or type of delivery.

Rationale 2: Screening for phenylketonuria is required by law in every state. It is not done according to high-risk characteristics or type of delivery.

Rationale 3: Screening for phenylketonuria is required by law in every state. It is not done according to high-risk characteristics or type of delivery.

Rationale 4: Screening for phenylketonuria is required by law in every state. It is not done according to high-risk characteristics or type of delivery.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 03. Summarize signs and symptoms that may indicate a disorder of the endocrine system.

Question 13

Type: MCSA

The nurse is administering a dose of rapid-acting insulin at 0800 to an insulin-dependent diabetic child. Based on when the insulin peaks, the child would be at greatest risk for a hypoglycemic episode:

1. At about noon.

2. Between bedtime and breakfast the next morning.

3. Between lunch and dinner.

4. Around 0930.

Correct Answer: 4

Rationale 1: Rapid-acting insulin peaks 3090 minutes after administration. An injection given at 0800 would peak around 0930.

Rationale 2: Rapid acting insulin peaks 3090 minutes after administration. An injection given at 0800 would peak around 0930.

Rationale 3: Rapid acting insulin peaks 3090 minutes after administration. An injection given at 0800 would peak around 0930.

Rationale 4: Rapid acting insulin peaks 3090 minutes after administration. An injection given at 0800 would peak around 0930.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 07. Distinguish between the nursing care of the child with type 1 and type 2 diabetes.

Question 14

Type: MCMA

What teaching tips should be included when instructing parents on hydrocortisone administration?

Standard Text: Select all that apply.

1. Maintain prescribed administration times.

2. Never discontinue medication abruptly.

3. Injections might be necessary when unable to take by mouth.

4. Lower doses are needed during illness.

5. Keep an emergency kit with the child at all times.

Correct Answer: 1,2,3,5

Rationale 1: Maintaining prescribed administration times is important, as they follow the normal body release of cortisol. Abruptly discontinuing a steroid is not recommended. Giving injections when unable to take by mouth and during emergencies is important to maintain cortisol levels. Higher, not lower, doses are needed during illness.

Rationale 2: Maintaining prescribed administration times is important, as they follow the normal body release of cortisol. Abruptly discontinuing a steroid is not recommended. Giving injections when unable to take by mouth and during emergencies is important to maintain cortisol levels. Higher, not lower, doses are needed during illness.

Rationale 3: Maintaining prescribed administration times is important, as they follow the normal body release of cortisol. Abruptly discontinuing a steroid is not recommended. Giving injections when unable to take by mouth and during emergencies is important to maintain cortisol levels. Higher, not lower, doses are needed during illness.

Rationale 4: Maintaining prescribed administration times is important, as they follow the normal body release of cortisol. Abruptly discontinuing a steroid is not recommended. Giving injections when unable to take by mouth and during emergencies is important to maintain cortisol levels. Higher, not lower, doses are needed during illness.

Rationale 5: Maintaining prescribed administration times is important, as they follow the normal body release of cortisol. Abruptly discontinuing a steroid is not recommended. Giving injections when unable to take by mouth and during emergencies is important to maintain cortisol levels. Higher, not lower, doses are needed during illness.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 06. Develop a family education plan for the child that needs lifelong cortisol replacement.

Question 15

Type: MCSA

In planning care for a child with adrenal hyperplasia, the nursing diagnosis most appropriate would be:

1. Impaired social interaction related to unnatural facial features.

2. Nutrition: Less than body requirements due to nausea and vomiting.

3. Depression related to inability to take in oral fluids.

4. Risk for deficient fluid volume related to failure of regulatory mechanisms.

Correct Answer: 4

Rationale 1: Adrenal hyperplasia alters the regulatory mechanisms, creating a fluid volume deficit. There is no major nutritional deficit, social interaction, or depression related directly to the diagnosis of adrenal hyperplasia.

Rationale 2: Adrenal hyperplasia alters the regulatory mechanisms, creating a fluid volume deficit. There is no major nutritional deficit, social interaction, or depression related directly to the diagnosis of adrenal hyperplasia.

Rationale 3: Adrenal hyperplasia alters the regulatory mechanisms, creating a fluid volume deficit. There is no major nutritional deficit, social interaction, or depression related directly to the diagnosis of adrenal hyperplasia.

Rationale 4: Adrenal hyperplasia alters the regulatory mechanisms, creating a fluid volume deficit. There is no major nutritional deficit, social interaction, or depression related directly to the diagnosis of adrenal hyperplasia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 09. Plan care for the child with an inherited metabolic disorder.

Ball/Bindler/Cowen, Principles of Pediatric Nursing 5th Ed. Test Bank

Copyright 2012 by Pearson Education, Inc.

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