Nokea
The practical nurse (PN) is collaborating with the registered nurse to conduct a developmental assessment of a 9-month-old client during a well-child visit. Which statement by the infant's parent should cause the PN concern?
- A. Our child needs help to grasp and bring teething toys to the mouth.
- B. Our child says 'mamama' to our dog.
- C. Our child screams when approached by unfamiliar people.
- D. Our child uses both hands for support to be able to sit upright.
Correct Answer: A
Rationale: By 9 months, infants should independently grasp objects. This indicates a potential fine motor delay requiring further evaluation.
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The nurse is reinforcing teaching about constipation prevention to a client. Which of the following client statements indicate appropriate understanding of the teaching? Select all that apply.
- A. Drinking more caffeinated drinks such as tea and soda helps to stimulate the bowel.
- B. Having a routine for bowel movements is important, but I should not wait if I feel the urge.
- C. I can use an over-the-counter laxative every other day if needed.
- D. I should try to eat more fruits and vegetables every day.
- E. Increasing my daily exercise level may help keep my bowel movements regular.
Correct Answer: B,D,E
Rationale: A routine, high-fiber diet, and exercise prevent constipation. Caffeine can dehydrate, and frequent laxative use is not recommended.
The nurse at an orthopedic joint clinic is assisting with the preparation of pre-operative teaching for clients scheduled for total hip replacement surgery. Which would be included in the teaching plan?
- A. Avoid sitting in a recliner
- B. Make sure that commode seats are at low levels
- C. Avoid crossing the legs when sitting
- D. Physical therapy will assist with adduction leg exercises
Correct Answer: C
Rationale: The client with joint hip replacement should avoid adduction of the legs and flexion of the hips greater than 90 degrees to ensure continued placement of the prosthetic joint. It is recommended for these clients to use recliners for seating instead of straight chairs, therefore A is incorrect. Commode seats will have to be raised and abduction of the legs is required, making B and D incorrect choices.
In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school age child for evaluation?
- A. Polyphagia
- B. Polyuria
- C. Bed wetting
- D. Weight loss
Correct Answer: C
Rationale: Bed wetting. In children, fatigue and bed wetting are the chief complaints that prompt parents to take their child for evaluation. Bed wetting in a school age child is readily detected by the parents.
Which of the following signs is highly suggestive of impaired hearing in an infant?
- A. The absence of the Moro reflex
- B. The absence of babbling by age 7 months
- C. A lack of eye contact when spoken to
- D. A lack of hand gesture to indicate wants
Correct Answer: B
Rationale: Absence of babbling by 7 months is a red flag for hearing impairment, as infants typically begin vocalizing in response to sounds. Other signs are less specific to hearing.
The nurse is to observe the client for shock. The client's admitting vital signs are blood pressure (BP)=116/70, pulse=86, and respirations=24. Which finding, if observed, would be most suggestive of shock?
- A. BP=140/60
- B. Pulse=100
- C. BP=114/68
- D. Pulse=60
Correct Answer: B
Rationale: Increased pulse (tachycardia) is a hallmark of shock, compensating for reduced volume. Stable or slightly varied BP and low pulse are less indicative.