Nokea
A nurse is palpating a newborn's fontanels. The nurse documents the anterior fontanel is which shape?
- A. Circle
- B. Triangle
- C. Square
- D. Diamond
Correct Answer: A
Rationale: The anterior fontanel, also known as the bregma, is the larger of the two fontanels located on the baby's skull. It is diamond-shaped, with the sutures meeting in the center to create a space that is soft and slightly depressed. While it is diamond-shaped when looking at the intersection of the sutures, when palpated or touched by a nurse, it often feels more circular due to the softness of the fontanel. It is important for nurses to monitor the fontanels for normal closure and development in newborns.
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A child 2 years 6 months of age has arranged a play date with a neighbor's child aged 2 years 9 months. During the play date, which behavior is most typical for children of this age?
- A. Share and trade toys while playing.
- B. Play with one another with little or no conflict.
- C. Engage in parallel play (playing alongside but not directly with one another).
- D. Play with only one or two items, ignoring most of the other toys.
Correct Answer: C
Rationale: Toddlers typically engage in parallel play rather than cooperative play.
A 12-year-old male adolescent, recently diagnosed with Hodgkin lymphoma, shows left cervical and supraclavicular lymph node involvement and drenching night sweats. Based on Ann Arbor Classification, the patient is classified as
- A. stage IA
- B. stage IB
- C. stage IIA
- D. stage IIB
Correct Answer: D
Rationale: Involvement of two lymph node regions above the diaphragm with systemic symptoms corresponds to stage IIB.
The nurse is meeting a 5-year-old child for the first time and would like the child to cooperate during a dressing change. The nurse decides to do a simple magic trick using gauze. How should this action be interpreted?
- A. Inappropriate, because of child's age
- B. A way to establish rapport
- C. Too distracting, when cooperation is important
- D. Acceptable, if there is adequate time
Correct Answer: B
Rationale: Using a simple magic trick with gauze to engage a 5-year-old child during a dressing change is a way to establish rapport. This approach can help build trust and reduce anxiety by making the procedure more engaging and less intimidating for the child. By creating a positive interaction through a fun activity, the nurse can promote cooperation and make the dressing change a smoother experience for the child. Overall, the use of a magic trick in this context is appropriate and beneficial for enhancing the child's cooperation and comfort.
The nurse is caring for a client who is HIV positive. To prevent the spread of the HIV virus, what do the Centers for Disease Control and Prevention recommend?
- A. Universal blood and body fluid precautions
- B. Body systems isolation
- C. Laminar flow room during active infection
- D. Needle and syringe precautions
Correct Answer: A
Rationale: The Centers for Disease Control and Prevention (CDC) recommend universal blood and body fluid precautions for preventing the spread of the HIV virus. These precautions are designed to protect healthcare workers and patients from exposure to bloodborne pathogens. Universal precautions involve treating all blood and body fluids from all individuals as potentially infectious. This includes using personal protective equipment (such as gloves, gowns, and masks), proper handling and disposal of needles and other sharps, and following appropriate infection control practices. By implementing universal precautions, healthcare providers can minimize the risk of transmission of HIV and other bloodborne pathogens.
The nurse is developing a plan of care for marrow suppression, the major dose-limiting adverse reaction to floxuridine (FUDR). How long after drug administration does bone marrow suppression become noticeable?
- A. 24 hours
- B. 7 to 14 days
- C. 2 to 4 days
- D. 21 to 28 days
Correct Answer: C
Rationale: Marrow suppression is the major dose-limiting adverse reaction to floxuridine (FUDR). It typically becomes noticeable 2 to 4 days after drug administration. Floxuridine acts by interfering with DNA replication and is most toxic to rapidly dividing cells, such as those in the bone marrow. As a result, bone marrow suppression leading to decreased production of blood cells can occur relatively quickly after the administration of floxuridine. Monitoring for bone marrow suppression is essential in patients receiving this medication to ensure timely intervention and prevention of complications such as anemia, thrombocytopenia, and leukopenia.