Nokea
A 13-month-old child is admitted to the pediatric unit with diarrhea and vomiting. The mother tells the nurse that she is worried because her son does not yet walk. She says her other children walked at eight and nine months and asks what could be wrong with this child. How should the nurse respond?
- A. All babies are different. It is not abnormal that the baby is not yet walking.'
- B. The baby should be walking. I'll let the doctor know he is behind developmentally.'
- C. Your son is probably enjoying being the baby and is not eager to grow up and walk.'
- D. Walking requires complex coordination. Your son is probably just a little slow to develop this. Don't worry.'
Correct Answer: A
Rationale: Walking typically occurs between 9-18 months; at 13 months, not walking is within normal variation, reassuring the mother without dismissing concerns.
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The nurse is caring for a 3-month-old infant who has bacterial meningitis. Which of the following clinical findings support this diagnosis? Select all that apply.
- A. Depressed anterior fontanelle
- B. High-pitched cry
- C. Poor feeding
- D. Presence of the Babinski sign
- E. Vomiting
Correct Answer: B, C, E
Rationale: High-pitched cry (B), poor feeding (C), and vomiting (E) are signs of bacterial meningitis in infants. A depressed fontanelle (A) suggests dehydration, not meningitis, and Babinski sign (D) is normal in infants.
Which therapeutic communication skill used by the nurse is most likely to encourage a depressed client to vent feelings?
- A. Direct confrontation
- B. Reality orientation
- C. Projective identification
- D. Active listening
Correct Answer: D
Rationale: Active listening. This skill, along with silence, encourages the client to verbalize feelings.
A 78 year-old client with pneumonia has a productive cough, but is confused. Safety protective devices (restraints) have been ordered for this client. How can the nurse prevent aspiration?
- A. Suction the client frequently while restrained
- B. Secure all 4 restraints to 1 side of bed
- C. Obtain a sitter for the client while restrained
- D. Request an order for a cough suppressant
Correct Answer: C
Rationale: Obtain a sitter for the client while restrained. The plan to use safety devices (restraints) should be rethought. Restraints are used to protect the client from harm caused by removing tubes or getting out of bed. In the event that this restricted movement could cause more harm, such as aspiration, then a sitter should be requested. These are to be provided by the facility in the event the family cannot do so. This client needs to cough and be watched rather than restricted. Suctioning will not prevent aspiration in this situation. Cough suppressants should be avoided for this client.
A client diagnosed with cirrhosis is experiencing pruritus. Which strategies are appropriate for the nurse to teach the client to promote comfort and skin integrity? Select all that apply.
- A. Maintain short fingernails to minimize excoriating the skin
- B. Take a bath or shower in hot water to alleviate itching sensations
- C. Take prescribed cholestyramine 1 hour after other medications
- D. Use a moisturizing cream on unbroken skin daily
- E. Wear wool gloves and tight stockings to avoid scratching
Correct Answer: A, C, D
Rationale: Short fingernails (A), cholestyramine timing (C), and moisturizing cream (D) reduce itching and protect skin. Hot water (B) worsens itching, and wool gloves/tight stockings (E) may irritate skin.
Laboratory reference ranges
Glucose (fasting)
Infant – Within 24 hours after birth
≥40 mg/dL (2.2 mmol/L)
The nurse is caring for assigned newborns. Which of the following newborns should the nurse check first?
- A. a newborn who was delivered 30 minutes ago and has bilateral crackles
- B. a newborn who was delivered 45 minutes ago and has asymmetric arm movement when the Moro reflex is tested
- C. a newborn who was delivered 6 hours ago and has a respiratory rate of 52/min
- D. a newborn who was delivered 12 hours ago, is jittery, and has a serum glucose level of 38 mg/dL (2.1 mmol/L)
Correct Answer: D
Rationale: A glucose level of 38 mg/dL with jitteriness (D) indicates hypoglycemia, a critical condition requiring immediate intervention. Crackles (A), asymmetric Moro reflex (B), and respiratory rate of 52 (C) are less urgent.