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A nurse is preparing to perform a physical assessment on a toddler. Which approach should the nurse use for this child?
- A. Always proceed in a head-to-toe direction.
- B. Perform traumatic procedures first.
- C. Use minimal physical contact initially.
- D. Demonstrate use of equipment.
Correct Answer: C
Rationale: When performing a physical assessment on a toddler, it is important for the nurse to use minimal physical contact initially. Toddlers are in a stage of development where they may be wary of strangers and new situations. By starting with minimal physical contact, such as by engaging the child in conversation or play first, the nurse can help establish trust with the toddler. This approach can help reduce the child's anxiety and resistance during the physical assessment, making the process smoother and more effective. It is essential to build rapport and establish a sense of safety and security before proceeding with the assessment to ensure the toddler's cooperation and comfort.
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Baby Ellie is diagnosed with gastroesophageal reflux (GER); which of the following nursing diagnoses would be inappropriate?
- A. Risk for aspiration
- B. Impaired oral mucous membrane
- C. Deficient fluid volume
- D. Imbalanced nutrition: Less than body requirements
Correct Answer: B
Rationale: Gastroesophageal reflux (GER) primarily involves issues with the digestive system, such as regurgitation of stomach contents into the esophagus. Impaired oral mucous membrane is not directly related to GER. The other nursing diagnoses are more relevant and applicable in a case of GER:
A client has been scheduled for a Schilling test. What instruction will the nurse give the client?
- A. Take nothing mouth fro 12 hours prior to the test
- B. Collect his urine for 12 hours
- C. Administer a fleet enema the evening before the test
- D. Empty his bladder immediately before the test
Correct Answer: B
Rationale: The correct instruction the nurse will give to the client scheduled for a Schilling test is to collect his urine for 12 hours. The Schilling test is a diagnostic test used to assess the body's ability to absorb vitamin B12. The test involves collecting urine samples over a period of 24 hours after the client ingests a small amount of radioactive vitamin B12. By collecting urine for 12 hours, the healthcare provider will be able to analyze the excretion of the vitamin and determine the client's ability to absorb vitamin B12. Instructions such as fasting, enema administration, or emptying the bladder before the test are not typically associated with the Schilling test procedure.
Which vein should be used first when initiating IV therapy?
- A. Jugular
- B. Basilic
- C. Brachiocephalic
- D. Axillary
Correct Answer: B
Rationale: When initiating IV therapy, the basilic vein is often used first due to its accessibility and size. The basilic vein is a common choice for venipuncture because it is located on the medial aspect of the arm and tends to be easily palpable. Additionally, the basilic vein is also less prone to complications such as nerve damage compared to other deeper veins like the jugular or brachiocephalic veins. Therefore, utilizing the basilic vein as the initial site for IV therapy is a safe and efficient choice.
Alveolar type of rhabdomyosarcoma accounts for approximately 1/3 of all cases of pediatric RMS and carries the poorest prognosis. Of the following, the MOST common site of involvement by alveolar type RMS is
- A. orbit
- B. middle ear
- C. extremities
- D. bladder
Correct Answer: C
Rationale: Extremities are the most common site for alveolar rhabdomyosarcoma.
The nurse is taking vital signs of a pregnant woman during her first prenatal visit. The patient asks the nurse if she has to have an HIV test. Which of the following is the nurse's best response?
- A. "Yes, all pregnant women must have the test."
- B. "If you do not have multiple sex partners or inject drugs, it is not necessary."
- C. "Governmental guidelines require an HIV test for all pregnant woman."
- D. "After voluntary pretest counseling, you decide whether HIV testing should be done."
Correct Answer: D
Rationale: The nurse's best response is D, "After voluntary pretest counseling, you decide whether HIV testing should be done." It is important for the pregnant woman to make an informed decision about HIV testing after receiving pretest counseling. The decision should be based on her individual risk factors, concerns, and preferences. The nurse should provide information about the importance of HIV testing during pregnancy, the benefits of knowing one's HIV status, and the available treatment options if the test is positive. Ultimately, the decision should be made by the pregnant woman after considering all the information provided.