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 motions is identified with the corresponding action? (Action: Turning palm of hand over to face in the anterior direction, dorsum of the hand is pointed downward toward the floor.)
- A. Pronation
- B. Supination
- C. Abduction
- D. Adduction
Correct Answer: B
Rationale: Supination is described as 'Holding a bowl of soup in your hand,' which matches the action of turning the palm to face anteriorly.
A patient has been admitted to the hospital with a HNP L4-5 segment diagnosis. After 24 hours the patient is able to ambulate with assistance with reduced muscle spasms. Which of the following medications was the most beneficial in changing the patient's mobility status?
- A. Mivacron
- B. Atropine
- C. Bethanechol
- D. Flexeril
Correct Answer: D
Rationale: Flexeril is a muscle relaxant for acute muscle pain and spasms.
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.
Which of the following developmental milestones for a 6-month-old child should be screened by the nurse during a routine office visit?
- A. standing while holding something
- B. rolling over
- C. sitting up
- D. creeping
Correct Answer: B
Rationale: Rolling over occurs between 4 and 6 months of age. Sitting up occurs between 7 and 8 months, creeping between 9 and 10 months, and standing between 8 and 10 months.
A 50 milliliter (ml) bolus of normal saline fluid is ordered by the physician. The physician wants it to infuse in 30 minutes. The nurse should set the pump rate at:
- A. 100 ml per hour for one hour.
- B. 60 ml per hour for one-half hour.
- C. 120 ml per hour for one hour.
- D. 50 ml per hour for one hour.
Correct Answer: A
Rationale: One hundred ml in one hour equals 50 ml in 30 minutes, which is what the physician prescribed. Choice 2 is 10 ml more than the physician prescribed for 30 minutes. Choice 3 is the same as Choice 2; it is 10 ml more than the physician prescribed for 30 minutes. Choice 4 only provides 25 ml over 30 minutes, or half the volume prescribed.