Nokea
An assessment of the skull of a normal 10-month-old baby should identify which of the following?
- A. closure of the posterior fontanel.
- B. closure of the anterior fontanel.
- C. overlap of cranial bones.
- D. ossification of the sutures.
Correct Answer: A
Rationale: The posterior fontanel should close by the age of 2 months.
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The advanced directive in a client's chart is dated August 12, 1998. The client's daughter produces a Power of Attorney for Health Care, dated 2003, which contains different care direction(s). The nurse is supposed to:
- A. follow the 1998 version because it's part of the legal chart.
- B. follow the 1998 version because the physician's code order is based on it.
- C. follow the 2003 version, place it in the chart, and communicate the update appropriately.
- D. follow neither until clarified by the unit manager.
Correct Answer: C
Rationale: The document dated 2003 supersedes the previous version and should be used as a basis for care direction. Choices 1 and 2 are incorrect because the 1998 version is now outdated. Choice 4 is incorrect because the nurse can be held negligent for not responding to the 2003 document as directed.
In conducting a health screening for 12-month-old children, the nurse expects them to have been immunized against which of the following diseases?
- A. measles, polio, pertussis, hepatitis B
- B. diptheria, pertussis, polio, tetanus
- C. rubella, polio, pertussis, hepatitis A
- D. measles, mumps, rubella, polio
Correct Answer: B
Rationale: By 12 months, children should have received DTaP (diphtheria, tetanus, pertussis) and polio vaccines. MMR (measles, mumps, rubella) is given after 12 months, and hepatitis A is not routine at this age.
A gastroenterologist should be consulted for clients suffering from:
- A. digestive system diseases.
- B. urinary system diseases.
- C. female reproductive system diseases.
- D. nervous system diseases.
Correct Answer: A
Rationale: A gastroenterologist cares for clients with digestive system diseases. A urologist cares for clients with urinary system diseases. A gynecologist cares for clients with female reproductive system diseases. A neurologist cares for clients with nervous system diseases.
All of the following tasks could be delegated to a nursing assistant or unlicensed assistive personnel (UAP) except:
- A. monitoring intravenous infusion.
- B. assisting a client to the bathroom.
- C. offering fluid intake every 1-2 hours.
- D. monitoring/recording the amount of fluid taken.
Correct Answer: A
Rationale: Monitoring an intravenous infusion must be performed by an RN or LPN. Assisting during activity, offering fluids and recording intake are in the job scope of the nursing assistant.
Which of the following is not an advanced directive?
- A. informed consent
- B. living will
- C. durable power of attorney for health care
- D. health care proxy
Correct Answer: A
Rationale: Informed consent is not a type of advanced directive but is a process for obtaining consent to care or treatment.