Nokea
Parents tell the nurse that their 1-year-old son often sleeps with them. They seem unconcerned about this. The nurse's response should be based on which statement?
- A. Children should not sleep with their parents.
- B. Separation from parents should be completed by this age.
- C. Daytime attention should be increased.
- D. This is a common and accepted practice, especially in some cultural groups.
Correct Answer: D
Rationale: The correct response is D because it acknowledges that co-sleeping with children, especially infants and toddlers, is a common and accepted practice in various cultural groups. Co-sleeping can have benefits such as promoting bonding and facilitating breastfeeding. However, it is essential for the nurse to educate the parents on safe sleep practices to reduce the risk of Sudden Infant Death Syndrome (SIDS) or other sleep-related accidents. It is important to provide guidance on creating a safe sleep environment for the child if they continue co-sleeping.
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An adult has and IV line in the right forearm infusing D5 ½ NS with 20 mEq of potassium at 75 ml/h. which statement would be a correct report from the RN?
- A. The potassium bag is piggybacked into the dextrose at 75ml/h
- B. The clamp should be closed below the D5 ½ NS bag
- C. Potassium is on the secondary line
- D. 75 ml infuse in one hour
Correct Answer: A
Rationale: The correct report from the RN in this situation would be option A. This report accurately describes the situation by mentioning that the potassium bag is piggybacked into the dextrose at 75 ml/h, stating that the clamp should be closed below the D5 ½ NS bag, and clarifying that potassium is on the secondary line. Additionally, the statement that 75 ml will infuse in one hour is also correct based on the infusion rate provided in the question. Therefore, option A is the most appropriate and accurate report to provide in this scenario.
Which defect results in increased pulmonary blood flow?
- A. Pulmonic stenosis
- B. Tricuspid atresia
- C. Atrial septal defect
- D. Transposition of the great arteries
Correct Answer: C
Rationale: Atrial septal defect (ASD) is a congenital heart defect where there is an abnormal opening in the atrial septum, leading to a left-to-right shunt of blood. This shunt causes increased pulmonary blood flow, as oxygenated blood from the left atrium is shunted back into the right atrium and then into the pulmonary circulation. Over time, this increased pulmonary blood flow can lead to pulmonary hypertension and potentially Eisenmenger syndrome if left untreated. Pulmonic stenosis, tricuspid atresia, and transposition of the great arteries all typically result in decreased pulmonary blood flow rather than increased pulmonary blood flow.
Which food choice contains the highest kilocalorie?
- A. Apple
- B. Chicken
- C. Bacon
- D. Bread
Correct Answer: C
Rationale: Bacon contains the highest kilocalories among the food choices provided. Bacon is high in fat, with approximately 42 kilocalories per slice (8 grams) compared to other options like an apple (52 kilocalories), chicken (231 kilocalories), and bread (79 kilocalories). The high fat content in bacon contributes to its higher caloric value compared to the other choices listed. As such, bacon is the food choice with the highest kilocalorie content in this selection.
The nurse is assessing a 3-month-old during a well-baby visit. Which of the following findings would warrant the nurse to recommend that the baby have an ultrasound for a possible diagnosis of developmental dysplasia of the hip (DDH)?
- A. Bilateral plantar flexion
- B. Unequal knee heights
- C. Bilateral polydactyly
- D. Positive Babinski test 113
Correct Answer: B
Rationale: Developmental dysplasia of the hip (DDH) is a condition where the hip joint does not develop normally. It is important to detect DDH early in infants as it can lead to long-term hip problems. One of the key physical exam findings that may suggest DDH is unequal knee heights when the infant's legs are flexed. This is known as the Galeazzi sign, and it can indicate hip dysplasia or dislocation. Therefore, if a nurse observes this finding during an assessment of a 3-month-old infant, it would warrant recommending an ultrasound to further evaluate for possible DDH. Bilateral plantar flexion, bilateral polydactyly, and a positive Babinski test are not typically associated with DDH.
A 3-year-old child from a suburban community presents with vomiting, diarrhea, and blurred vision. Physical examination reveals an afebrile child with pinpoint pupils, salivation, and muscular fasciculations. The child's lawn was treated yesterday for insects. Which of the following tests will establish the correct diagnosis?
- A. Blood-lead level
- B. 24-hour urine mercury level
- C. Plasma cholinesterase level
- D. Urine malathion level
Correct Answer: C
Rationale: The symptoms suggest organophosphate poisoning, which can be confirmed by measuring plasma cholinesterase levels, as organophosphates inhibit this enzyme.