Nokea
A mother brings her 1-year-old child to the clinic. The child has no record of previous immunizations, and the mother confirms the child has not been immunized. Teaching by the nurse should include which of the following?
- A. Immunizations may be started at any age.
- B. The recommended immunization schedule must be followed exactly.
- C. If a primary series of immunizations is interrupted, the series must be restarted.
- D. This child is at increased risk for reaction to the vaccines, when they are started.
Correct Answer: A
Rationale: While a recommended immunization schedule exists, immunizations may be started at any age. An interrupted series may be continued and need not be restarted. There is no increased risk for reaction to vaccines due to delay.
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Which of the following infant behaviors demonstrates the concept of object permanence?
- A. The infant cries when his mother leaves the room.
- B. The infant looks at the floor to find a toy that he was playing with and dropped.
- C. The infant picks up another toy after the one he was playing with rolls under the couch.
- D. The infant participates in a game of patty-cake.
Correct Answer: B
Rationale: Object permanence occurs when the infant learns that something/someone still exists even though they might not be able to see it/them. This develops between 9 and 10 months of age. If the infant cries when his mother leaves the room, it might be because he believes she is no longer in the house when he can't see her. If an infant picks up another toy after the one he is playing with rolls under the couch and the infant fails to look for it, he believes the toy that rolled under the couch no longer exists. Patty-cake is a game infants engage in but, it has nothing to do with object permanence. An infant game that does show object permanence is peek-a-boo. In this game, an infant continues to hunt for a hidden face because he believes it is still there.
Which of the following substances need to be assessed when completing a family health assessment?
- A. coffee, tea, cola, and cocoa
- B. alcohol, tobacco, and illegal substances
- C. medicines prescribed by a physician
- D. all of the above
Correct Answer: D
Rationale: When assessing drug, alcohol, and tobacco practices among family members, a thorough investigation of prescribed, over-the-counter, and illegal substance-use practices should be made.
After 12 months of cessation of menses, which of the following assessment findings in a client who is taking hormone replacement therapy should the nurse report to the physician immediately?
- A. breast tenderness
- B. weight gain
- C. fluid retention
- D. uterine bleeding
Correct Answer: D
Rationale: Uterine bleeding on combination hormone replacement therapy, after 12 months of menses cessation, indicates an increased risk of carcinoma and should be reported to the physician immediately. Breast tenderness, weight gain, and fluid retention are all routine side effects of hormone replacement therapy. They should be noted in the record and reported to the physician, but they are not urgent.
The school nurse is conducting health screenings on schoolchildren. During the screening, she identifies a child with the behavioral characteristics of attention deficit disorder. Which of the following behaviors is consistent with this disorder?
- A. slow speech development
- B. overreaction to stimuli from the surroundings
- C. inability to carry on a conversation
- D. concrete thinking
Correct Answer: B
Rationale: Children with attention deficit disorder are easily distracted but are able to carry on a conversation. Concrete thinking is more indicative of age, and slow speech development has more to do with other learning disabilities.
An appraisal of self-care practices involves an assessment of:
- A. all diagnostic tests.
- B. home treatment practices, including nurse visits for the sick or disabled.
- C. the family's capability to get health insurance.
- D. caregiving needs and the potential for strain.
Correct Answer: D
Rationale: Short-term stressors impinging on a family include unemployment, being on welfare, the threat of termination, health, hospitalization, convalescence, depression, and suicidal thoughts. Long-term stressors impinging on the family include emotional distance, lack of communication in families (especially within marital relationships), continual geographical movement from one community to the next (so that no stable and sufficient social network is established), a spouse's minimal participation in family life, and excessive and frequent drinking bouts. Family strengths include the presence of a social support system, interest in and capability to provide child care, motivation for employment, and financial self-sufficiency, self-care beliefs, values, health-seeking behaviors, and realistic goals and limitations.