Nokea
A nurse is assisting with data collection regarding the motor development of a 24-month-old child. Which activities would the nurse expect the mother to report that the child can perform?
- A. Go to the bathroom without help
- B. Dress himself appropriately
- C. Put on and tie his shoes
- D. Align two or more blocks
Correct Answer: A
Rationale: By 24 months of age, a child can perform various activities. While the child may be able to put on simple items of clothing, distinguishing front from back might still be a challenge. They may also be able to zip large zippers, put on shoes, wash and dry their hands, align two or more blocks, and turn book pages one at a time. However, the fine motor skill required to tie shoes is usually not developed at this age. Full independence in dressing, using the bathroom, and eating typically occurs around 4 to 5 years of age. Therefore, the correct expectation for a 24-month-old child would be aligning two or more blocks. Choices A, B, and C are incorrect as they represent skills that are usually achieved at a later age.
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A nurse is determining the fetal heart rate (FHR) and places the fetoscope on the mother's abdomen to count the FHR. The nurse simultaneously palpates the mother's radial pulse and notes that it is synchronized with the sounds heard through the fetoscope. Which action should the nurse take?
- A. Count the FHR for 60 seconds, ensuring that it is synchronized consistently with the mother's radial pulse.
- B. Move the fetoscope to another area on the mother's abdomen to locate the fetal heart.
- C. Ask the mother to lie still while both the FHR and the radial pulse rate are counted.
- D. Count the FHR for 30 seconds and then count the radial pulse rate of the mother for 30 seconds.
Correct Answer: B
Rationale: When auscultating the fetal heart rate, the nurse would place the fetoscope on the maternal abdomen, over the fetal back. The nurse would then palpate the mother's radial pulse. If her pulse is synchronized with the sounds from the fetoscope, the nurse would move the fetoscope to another area on the mother's abdomen to locate the FHR. The nurse needs to be sure that the FHR is what is actually being heard. Other sounds that may be heard are the funic sound (blood flowing through the umbilical cord) and the uterine sound (blood flowing through the uterine vessels). The funic sound is synchronized with the FHR; the uterine sound is synchronized with the mother's pulse. Therefore, moving the fetoscope to a different area will help in accurately locating and counting the fetal heart rate. Choice A is incorrect because counting for 60 seconds without changing the position may not address the issue of accurately locating the FHR. Choice C is incorrect as it does not address the need to reposition the fetoscope to locate the fetal heart. Choice D is incorrect because counting the FHR and the radial pulse rate separately may not help in differentiating the two sounds.
A nurse is interviewing an older adult while assisting with data collection. Which client comment regarding vision requires immediate discussion with the health care provider?
- A. "If I go from a very bright room to a very dark room, I have some trouble adjusting."
- B. "I have to hold my newspaper farther and farther away from me when I read."
- C. "I have a little trouble telling if my same-colored shirts and blouses actually match; the colors seem the same to me."
- D. "It looks like I have a blank spot in the middle of what I'm trying to see."
Correct Answer: D
Rationale: The correct answer is "It looks like I have a blank spot in the middle of what I'm trying to see." Seeing blank spots in the middle of an object is a sign of central vision loss, which is a symptom of macular degeneration. Macular degeneration is a serious condition that requires immediate discussion with a healthcare provider to prevent further vision loss. Choice A, mentioning difficulty adjusting between bright and dark rooms, is a common issue related to changes in lighting and not a cause for immediate concern. Choice B, having to hold objects farther away when reading, is indicative of presbyopia, a normal age-related change in vision. Choice C, experiencing slight changes in color perception, is also a common age-related change and not an urgent issue that necessitates immediate discussion with a healthcare provider.
When assisting with data collection on language development in a toddler from a bilingual family, what characteristic would a nurse expect?
- A. Is more advanced than expected
- B. Is developing as expected
- C. Is slower than expected
- D. Will require assistance from a speech therapist
Correct Answer: C
Rationale: When assessing language development in a toddler from a bilingual family, a nurse would expect the child's language development to be slower than expected. Various factors, such as physical maturity and reinforcement received, can influence the pace of language development. Children from bilingual families, twins, and non-firstborn children may exhibit slower language development. Therefore, it is common for the language development of a toddler from a bilingual family to be slower than expected. This characteristic does not necessarily imply a need for speech therapy. Choices A, B, and D are incorrect because, in this context, the language development of the child is more likely to be slower than expected rather than more advanced, developing as expected, or requiring speech therapy.
When preparing a client for surgery, the graduate nurse realizes the operative permit has not been signed. The client tells the nurse he understands the procedure but received his preoperative medication approximately 10 minutes prior. The appropriate action would be:
- A. Have the client sign the permit, as he verbalizes understanding.
- B. Witness the form after having the client sign it.
- C. Have his wife sign the form as she witnessed him saying he wants the surgery.
- D. Call the surgical area and explain the surgery will have to be cancelled.
Correct Answer: D
Rationale: The correct action in this scenario is to call the surgical area and explain that the surgery will have to be cancelled. The client must sign the operative permit or any other legal document before receiving preoperative medication. Without the signed permit, the surgery cannot proceed to ensure the client's safety and legal compliance. Having the client sign the permit, witnessing the form after the client signs it, or having someone else sign the form are all inappropriate actions and do not address the legal requirement of the client's signature before receiving preoperative medication.
Which of the following vaccines contains a live virus?
- A. varicella
- B. IPV
- C. DTaP
- D. hepatitis B
Correct Answer: A
Rationale: The correct answer is varicella. Varicella vaccine contains a live, weakened form of the varicella-zoster virus. Choice B, IPV (inactivated poliovirus vaccine), is an inactivated vaccine, not a live virus vaccine. Choices C and D, DTaP (diphtheria, tetanus, and acellular pertussis vaccine) and hepatitis B vaccine, respectively, do not contain live viruses. Varicella is the only live virus vaccine among the options.