Nokea
During a routine health assessment, the nurse notes that an 8-month-old infant has a significant head lag. Which is the most appropriate action?
- A. Recheck head control at the next visit
- B. Teach the parents appropriate exercises
- C. Schedule the child for further evaluation
- D. Refer the child for further evaluation if the anterior fontanel is still open
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The nurse is aware that skin turgor best estimates what?
- A. Perfusion
- B. Adequate hydration
- C. Amount of body fat
- D. Amount of anemia
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Examination of the abdomen is performed correctly by the nurse in which order?
- A. Inspection, palpation, percussion, and auscultation
- B. Inspection, percussion, auscultation, and palpation
- C. Palpation, percussion, auscultation, and inspection
- D. Inspection, auscultation, percussion, and palpation
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What interventions should be implemented to maintain the skin integrity of a preterm infant born at 30 weeks?
- A. Avoid cleaning the skin
- B. Bathe the infant with sterile water
- C. Cleanse the skin with a gentle alkaline-based soap and water
- D. Thoroughly rinse the skin with plain water after bathing
Correct Answer: B
Rationale: The correct intervention to maintain the skin integrity of a preterm infant born at 30 weeks is to bathe the infant with sterile water. Bathing with sterile water or a neutral pH solution is recommended to protect the delicate skin of preterm infants, which is more permeable and prone to damage. Choices A, C, and D are incorrect as avoiding cleaning the skin may lead to hygiene issues, cleansing with alkaline-based soap can be harsh on the delicate skin, and thoroughly rinsing with plain water after bathing may not be as gentle and protective for preterm infants.
When the nurse interviews an adolescent, which is especially important?
- A. Focus the discussion on the peer group
- B. Allow an opportunity to express feelings
- C. Use the same type of language as the adolescent
- D. Emphasize that confidentiality will always be maintained
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What is an appropriate screening test for hearing that the nurse can administer to a 5-year-old child?
- A. Rinne test
- B. Weber test
- C. Pure tone audiometry
- D. Eliciting the startle reflex
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.