Nokea
A nurse notes that a 10-month-old infant has a larger head circumference than chest. The nurse interprets this as a normal finding because the head and chest circumference become equal at which age?
- A. 1 month
- B. 6 to 9 months
- C. 1 to 2 years
- D. to 3 years
Correct Answer: B
Rationale: It is considered normal for a baby's head circumference to be larger than their chest circumference during the first few months of life. Generally, a baby's head grows more rapidly than their chest, which causes the head circumference to be larger. By around 6 to 9 months of age, the head and chest circumference measurements typically become equal. This is part of the normal growth and development pattern in infants.
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Another girl was bitten by a poisonous snake. All of the following are true except
- A. The victim of a snake bite should be made to exercise the bitten extremity to hasten circulation
- B. The bite of a poisonous snake is distinguished by two fang marks
- C. Immediate severe pain and swelling distinguished the bite of a poisonous snake
- D. The tourniquet should be tight enough to prevent superficial circulation of blood thus stopping absorption of the poison
Correct Answer: A
Rationale: When it comes to snake bites, one should not exercise the bitten extremity as it can increase the spread of venom in the body. Moving the affected limb can potentially lead to the venom spreading more quickly through the lymphatic system and into the bloodstream. Therefore, it is essential to keep the victim as calm and still as possible to minimize the effects of the venom. Proper first aid for snake bites includes keeping the victim calm, immobilizing the bitten limb, and seeking immediate medical attention.
Matthew, age 18 months, has just been admitted with croup. His parent is tearful and tells the nurse, "This is all my fault. I should have taken him to the doctor sooner so he wouldn't have to be here." Which is appropriate in the care plan for this parent who is experiencing guilt?
- A. Clarify misconception about the illness.
- B. Explain to the parent that the illness is not serious.
- C. Encourage the parent to maintain a sense of control.
- D. Assess further why the parent has excessive guilt feelings.
Correct Answer: A
Rationale: In this situation, it is important to clarify the parent's misconception about the illness. By providing information about croup, the nurse can help the parent understand that seeking medical care promptly is essential in managing the condition but that it is not solely the parent's fault. This can help alleviate the parent's guilt and provide reassurance that they are doing their best for their child. It is essential to provide education and support to empower the parent in caring for their child effectively.
Which is an important nursing consideration when suctioning a young child who has had heart surgery?
- A. Perform suctioning at least every hour.
- B. Suction for no longer than 30 seconds at a time.
- C. Administer supplemental oxygen before and after suctioning.
- D. Expect symptoms of respiratory distress when suctioning.
Correct Answer: B
Rationale: Suctioning for no longer than 30 seconds at a time is an important nursing consideration when suctioning a young child who has had heart surgery. Prolonged suctioning can cause hypoxemia and decrease the child's oxygen saturation, which can be detrimental, especially in postoperative patients who may have compromised cardiopulmonary reserves. It is crucial to minimize the duration of suctioning to prevent potential complications. Additionally, hyperoxygenation before and after suctioning may help maintain adequate oxygen levels and minimize the risk of hypoxemia in these vulnerable patients.
A newborn's mother is alarmed to find small amounts of blood on her infant girl's diaper. When the nurse checks the infant's urine it is straw colored and has no offensive odor. Which explanation to the newborn's mother is most appropriate?
- A. "It appears your baby has a kidney infection"
- B. "Breast-fed babies often experience this type of bleeding problem due to lack of vitamin C in the breast milk"
- C. "The baby probably passed a small kidney stone"
- D. "Some infants experience menstruation like bleeding when hormones from the mother are not available"
Correct Answer: D
Rationale: The most appropriate explanation to the newborn's mother is option D, "Some infants experience menstruation-like bleeding when hormones from the mother are not available." This condition is known as neonatal menstrual-like bleeding or pseudo-menstruation. During pregnancy, babies are exposed to the mother's hormones in the womb. After birth, when the hormonal influence from the mother decreases, some female infants may experience vaginal bleeding, which can be seen in their diapers. This type of bleeding is usually benign and resolves on its own without any intervention. It is not a cause for concern and does not indicate any serious health issue. The straw-colored urine with no offensive odor is a normal finding and further supports the explanation of neonatal menstrual-like bleeding in this case.
Which of the ff is an important nursing intervention for HIV positive clients?
- A. Suggesting the use of herbal medications and alternative therapies
- B. Suggesting the use of psychostimulants such as methamphetamine
- C. Advising the client to avoid clinical drug trials
- D. Providing referral to support groups and resources for information
Correct Answer: D
Rationale: For HIV positive clients, one of the most important nursing interventions is to provide referral to support groups and resources where they can find emotional support, information, and guidance. Support groups can offer a sense of community, a safe space to share experiences, and practical advice on living with HIV. These groups can also provide valuable resources on managing HIV, accessing treatment, and coping with any associated stigma or discrimination. By connecting HIV positive clients to support groups and resources, nurses can help them navigate the challenges of living with HIV and promote their overall well-being and quality of life. This intervention fosters a holistic approach to care that goes beyond just medical treatment to address the social, emotional, and psychological needs of the client.