Nokea
A nurse is preparing to assess a 3-year-old child. What communication technique should the nurse use for this child?
- A. Focus communication on child.
- B. Explain experiences of others to child.
- C. Use easy analogies when possible.
- D. Assure child that communication is private.
Correct Answer: A
Rationale: When assessing a young child, it is important for the nurse to focus communication on the child by using simple language, asking direct questions, and using play-based approaches to facilitate communication. By engaging the child directly and adapting communication techniques to their developmental level, the nurse can establish rapport, gain the child's trust, and obtain accurate information during the assessment process. This approach helps create a positive and supportive environment for the child, making them feel comfortable and understood.
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The nurse would expect which of the following would be included in the plan of care/
- A. Have the client drink at least 8 glases of water in the first day
- B. Administer NaHCO3 IV as per physician's orders
- C. Continue sodium bicarbonate for nausea
- D. Monitor electrolytes for hypokalemia and hypocalcemia
Correct Answer: D
Rationale: Monitoring electrolytes for hypokalemia (low potassium levels) and hypocalcemia (low calcium levels) is essential in the plan of care for a client. These electrolyte imbalances can be common in cases of dehydration and vomiting, and they can lead to serious complications if not detected and managed promptly. Hypokalemia can cause cardiac arrhythmias and muscle weakness, while hypocalcemia can lead to neuromuscular irritability and seizures. By monitoring electrolyte levels, the nurse can identify any imbalances early and take necessary interventions to prevent adverse outcomes.
What is the best age for solid food to be introduced into the infant's diet?
- A. 2 to 3 months
- B. 4 to 6 months
- C. When birth weight has tripled
- D. When tooth eruption has started
Correct Answer: B
Rationale: The American Academy of Pediatrics recommends introducing solid foods into an infant's diet between 4 to 6 months of age. At this stage, most infants have developed the necessary motor skills to start eating solid foods, such as being able to sit up and hold their head steady. Additionally, their digestive system has matured enough to handle solid foods. Introducing solid foods too early, such as at 2 to 3 months (Option A), can increase the risk of digestive issues and allergies. Waiting for tooth eruption (Option D) is not a reliable indicator as some infants may begin teething earlier or later than others. Waiting for the birth weight to triple (Option C) is not necessary as infants can start on solid foods once they reach the appropriate developmental stage around 4 to 6 months.
Which of the following guidekines does not observe surgical asepisi in the operating room?
- A. sterile articles may touch other sterile articles or surface and remain sterile
- B. gowns of surgical team are considered sterile in front from the chest down to the bottom of the gown
- C. whenever a sterile barrier is breached, the area must be considered contaminated
- D. sterile drapes are used to create a sterile field
Correct Answer: A
Rationale: This statement is incorrect and does not observe surgical asepsis in the operating room. In surgical asepsis, it is crucial that sterile articles do not touch other sterile articles or surfaces to prevent contamination. Any contact between sterile items or surfaces can lead to the transfer of microorganisms, compromising the sterility of the environment. Maintaining a sterile field is essential to prevent surgical site infections and ensure the safety of the patient undergoing the procedure.
At a public health fair, a nurse discusses the dangers of sun exposure. Prolonged sun exposure has been blamed for which form of cancer?
- A. Malignant melanoma
- B. Basal cell epithelioma
- C. Squamous cell carcinoma
- D. All of the above
Correct Answer: D
Rationale: Prolonged sun exposure is indeed a known risk factor for all three types of skin cancer listed in the choices. Malignant melanoma is a serious form of skin cancer that develops in the melanocytes, the cells that produce skin pigment. Basal cell epithelioma and squamous cell carcinoma are two other common types of skin cancer that are largely attributed to sun exposure. It is crucial to protect your skin from the harmful effects of the sun by applying sunscreen, wearing protective clothing, and seeking shade when necessary to reduce the risk of developing skin cancer.
The nurse is using calipers to measure skinfold thickness over the triceps muscle in a school- age child. What is the purpose of doing this?
- A. To measure body fat
- B. To measure muscle mass
- C. To determine arm circumference
- D. To determine accuracy of weight measurement
Correct Answer: A
Rationale: Skinfold thickness measurements using calipers are commonly used in assessing body composition, specifically to estimate body fat percentage. By measuring skinfold thickness over the triceps muscle in combination with measurements from other sites on the body, healthcare professionals can estimate the amount of subcutaneous fat present. This information is valuable in evaluating an individual's overall body composition and health status. The triceps skinfold measurement is a commonly included site in body fat calculations, especially in school-age children, where it can provide insights into growth and development.