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A 13-year-old boy is hospitalized for a femur fracture after being hit by a car while racing bikes. The parents are concerned about his judgment. The nurse should tell the parents that this behavior is:
- A. Typical of young teens.
- B. Related to hormonal surges during adolescence.
- C. An isolated incident that will not likely happen again.
- D. Related to underdeveloped judgment and impulse control in adolescence.
Correct Answer: D
Rationale: The adolescent brain is still developing, which can lead to poor judgment and impulsive behavior.
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Which is a common, serious complication of rheumatic fever?
- A. Seizures
- B. Cardiac arrhythmias
- C. Pulmonary hypertension
- D. Cardiac valve damage
Correct Answer: D
Rationale: Rheumatic fever is an inflammatory disease that can develop after a streptococcal infection, such as strep throat. One of the most serious complications of rheumatic fever is cardiac involvement, specifically damage to the heart valves. This occurs due to the body's immune response attacking the heart valves as a result of molecular mimicry between streptococcal antigens and human tissues. The damage to the heart valves can result in conditions like mitral valve stenosis or regurgitation, which can lead to heart failure if not managed appropriately. Therefore, cardiac valve damage is a common and serious complication of rheumatic fever that requires monitoring and treatment to prevent long-term consequences.
The MOST common type of cerebral palsy is
- A. ataxic cerebral palsy
- B. spastic cerebral palsy
- C. dystonic cerebral palsy
- D. dyskinetic cerebral palsy
Correct Answer: B
Rationale: Spastic cerebral palsy is the most common type.
The nurse is planning care for a low birth weight newborn. Which is an appropriate nursing intervention to promote adequate oxygenation?
- A. Place in Trendelenburg position periodically.
- B. Suction at least every 2 to 3 hours.
- C. Maintain neutral thermal environment.
- D. Hyperextend neck with nose pointing to ceiling.
Correct Answer: C
Rationale: Maintaining a neutral thermal environment is an appropriate nursing intervention to promote adequate oxygenation in a low birth weight newborn. Newborns, especially those with low birth weight, have limited capacity to regulate their body temperature. Keeping the baby warm helps prevent cold stress, which can lead to increased metabolic demands and oxygen consumption. By maintaining a neutral thermal environment, the newborn's energy can be directed towards growth and development, rather than compensating for temperature fluctuations. This intervention helps optimize oxygenation and overall well-being of the low birth weight newborn. The other options (A, B, D) do not directly address the need for adequate oxygenation in a low birth weight newborn.
Which of the following would indicate that the patient has a normal corneal light reflex?
- A. The eye focuses the image in the center of the pupil.
- B. The eyes converge to focus on the light.
- C. Constriction of both pupils occurs in response to bright light.
- D. Light is reflected at the same spot in both eyes.
Correct Answer: D
Rationale: A normal corneal light reflex, also known as the Hirschberg test, is assessed by shining a light into the patient's eyes and observing the reflection of the light on the corneas. In a normal response, the light should be reflected at the same spot in both eyes. If the light is off-center in one eye compared to the other, it could indicate a deviation in the alignment of the eyes, known as strabismus. Therefore, choice D, "Light is reflected at the same spot in both eyes," is the correct indicator of a normal corneal light reflex.
A 4-month-old was born at 35 weeks of gestation. She seems to be developing normally, but her parents are concerned because she is a "more difficult" baby than their other child, who was term. What should the nurse's explanation include?
- A. Infants' temperaments are part of their unique characteristics.
- B. Infants become less difficult if they are not kept on scheduled feedings and structured routines.
- C. The infant's behavior is suggestive of failure to bond completely with her parents.
- D. The infant's difficult temperament is the result of painful experiences in the neonatal period.
Correct Answer: A
Rationale: The nurse should explain to the parents that infants' temperaments are part of their unique characteristics. Temperament refers to an individual's natural predisposition towards certain behaviors and emotional responses. It is not uncommon for babies to have different temperaments, even within the same family. This 4-month-old baby may simply have a more difficult temperament compared to her sibling who was born at term. It is important for parents to understand and accept their baby's temperament as part of her individuality, rather than attributing it to other factors such as failure to bond or painful experiences in the neonatal period. While schedules and routines can help with managing challenging behaviors, it is essential for the parents to recognize and appreciate the uniqueness of their baby's temperament.