Nokea
A mother calls the clinic to report that her otherwise healthy newborn has a rash on his forehead and face. The nurse should tell the mother:
- A. To use a mild soap when washing the newborn's face
- B. That many newborns have a rash that will go away by one month of life
- C. That the rash indicates illness and she needs to bring the newborn in immediately
- D. To check for signs of illness among family members
Correct Answer: B
Rationale: Many newborns develop erythema toxicum or milia benign rashes that resolve within a month. This is the most likely explanation for a healthy newborn’s facial rash. Immediate evaluation or family illness checks are unnecessary unless other symptoms are present.
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What information should the nurse give a new mother regarding the introduction of solid foods for her infant?
- A. Solid foods should not be given until the extrusion reflex disappears at 8-10 months of age.
- B. Solid foods should be introduced one at a time, with 4- to 7-day intervals.
- C. Solid foods can be mixed in a bottle or infant feeder, to make feeding easier.
- D. Solid foods should begin with fruits and vegetables.
Correct Answer: B
Rationale: Introducing solid foods one at a time with 4-7 day intervals allows identification of allergies. The extrusion reflex fades by 4-6 months, and mixing in bottles or starting with fruits is not recommended.
Which behaviors are expected to be observed in the 18-month old?
- A. Has a vocabulary of 900 words
- B. Removes clothes
- C. Points to at least one named body part
- D. Asks many questions
- E. Can kick a ball forward
Correct Answer: B, C, E
Rationale: At 18 months, children remove clothes (B), point to body parts (C), and kick balls (E). Vocabulary is ~20-50 words (A), and questioning (D) emerges later (~2-3 years).
A 5-year-old child is hospitalized for an acute illness. The nurse encourages the family to bring her favorite objects from home. What is the nurse's rationale?
- A. To reduce fear of the unknown
- B. To keep the child calm
- C. To establish a trusting relationship
- D. To prevent or minimize separation anxiety
Correct Answer: D
Rationale: Favorite objects from home assist in creating a familiar setting, preventing or minimizing separation anxiety.
An 18-year-old girl is admitted to the hospital with a depressed skull fracture as a result of a car accident. If the nurse were to observe a rising pulse rate and lowering blood pressure, the nurse would suspect that the client:
- A. Has a sudden and severe increase in intracranial pressure
- B. Has sustained an internal injury in addition to the head injury
- C. Is beginning to experience a dangerously high level of anxiety
- D. Is having intracranial bleeding
Correct Answer: B
Rationale: Rising pulse rate and lowering blood pressure are indicative of hypovolemia, which is consistent with an internal injury causing blood loss.
In an interview for suspected child abuse, the child's mother openly discusses her feelings. She feels her husband is too aggressive in disciplining their child. The child's father states, 'Being a school custodian, I see kids every day that are bad because they did not get enough discipline at home. That will not happen to our child.' Based on this remark, the nurse would make the following nursing diagnosis:
- A. Fear related to retaliation by the father
- B. Actual injury related to poor impulse control by the father
- C. Ineffective coping
- D. Altered family process related to physical abuse
Correct Answer: D
Rationale: There is no evidence of fear as the child is unable to communicate. There is actual injury, but the parents have not yet admitted causing the child's injuries. This diagnosis is incomplete. There is no specific ineffective coping behavior identified in this nursing diagnosis. Altered family process best describes the family dynamics in this situation. The parents have admitted severe disciplinary action.