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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: B
Rationale: The correct answer is the closure of the anterior fontanel. By 10 months of age, the anterior fontanel should be closed. The posterior fontanel should actually close by the age of 2 months, making choice A incorrect. Overlap of cranial bones is not a typical finding in a normal 10-month-old baby's skull, so choice C is incorrect. Ossification of the sutures is an ongoing process in skull development and should not be a definitive indicator at this age, making choice D incorrect.
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If Ms. Barrett's distance vision is 20/30, which of the following statements is true?
- A. The client can read from 20' what a person with normal vision can read at 30'.
- B. The client can read from 30' what a person with normal vision can read at 20'.
- C. The client can read the entire chart from 30'.
- D. The client can read the chart from 20' with the left eye and from 30' with the right eye.
Correct Answer: A
Rationale: When Ms. Barrett's distance vision is measured as 20/30, it means that she can read from 20 feet away what a person with normal vision can read at 30 feet. The numerator (20) represents the distance in feet between the chart and the client, while the denominator (30) indicates the distance at which a normal eye can read the chart. In this case, Ms. Barrett's vision is slightly worse than normal, as she needs to be closer to the chart to read it clearly. Therefore, choice A is correct. Choices B, C, and D are incorrect: Choice B reverses the distances, Choice C assumes the client can read the entire chart from 30 feet, and Choice D introduces information not related to the 20/30 measurement.
When assessing Mr. Lee's eye condition, what general information should the nurse seek?
- A. Type of employment.
- B. Burning or itchy sensation in the eyes.
- C. Position of the eyelids.
- D. Existence of floaters.
Correct Answer: A
Rationale: When assessing a patient's eye condition, the nurse should seek general information such as the type of employment, activities, allergies, medications, lenses, and protective devices used. This information helps in understanding potential exposures to irritants and risks related to activities. While the presence of burning or itchy sensation in the eyes, position of the eyelids, and existence of floaters are important aspects to assess during a focused eye examination, during the initial assessment, the type of employment is more relevant for understanding possible environmental factors affecting eye health.
A healthcare professional is reviewing the health care record of a client who has just undergone an examination of the internal genitalia. Which documented finding indicates an abnormality?
- A. The cervix is pink.
- B. The cervix is midline.
- C. The cervix is about 1 inch in diameter.
- D. Clear secretions with a foul odor are noted on the cervix.
Correct Answer: D
Rationale: The correct answer is 'Clear secretions with a foul odor are noted on the cervix.' Normally, the cervix is pink, midline, and about 1 inch in diameter. Depending on the day of the menstrual cycle, secretions may vary. However, they should always be odorless and nonirritating. Secretions with a foul odor are indicative of an infection, making this finding abnormal. Choices A, B, and C describe normal cervix characteristics, so they do not indicate an abnormality in this scenario.
While assisting with data collection regarding the neurological system, the nurse asks the client to puff out both cheeks. Which cranial nerve is the nurse assessing?
- A. Vagus
- B. Facial
- C. Abducens
- D. Oculomotor
Correct Answer: B
Rationale: The correct answer is B: Facial. Assessment of cranial nerve VII (facial nerve) involves noting mobility and symmetry as the client performs various facial movements, including puffing out the cheeks. Cranial nerve IX (glossopharyngeal nerve) and cranial nerve X (vagus nerve) are tested together for different functions. The abducens, oculomotor, and trochlear nerves are assessed together for eye movements and pupil reactions, not cheek puffing.
The home health nurse has made a visit to an 85-year-old female client's home who has recently had surgery to replace her left knee. The client has been discharged from a rehab facility and has been able to walk on her own. The nurse assesses the need for teaching related to fall prevention. What should the nurse include in this teaching plan?
- A. The client should remove all scatter rugs from the floor and minimize clutter.
- B. The client should not limit her movement within the home unless advised by the physician.
- C. The client should have a raised toilet seat and grab bars available in the bathroom.
- D. The client should not wear a robe and socks while walking in the house.
Correct Answer: A
Rationale: The correct answer is to instruct the client to remove all scatter rugs from the floor and minimize clutter. Rugs and clutter are common causes of falls in the home, especially for the elderly or those with gait issues. Removing them can significantly reduce the risk of falls. While having a raised toilet seat and grab bars in the bathroom is important for safety, it is not the priority in this scenario. The client should not limit her movement within the home unless specifically advised by the physician, as maintaining mobility is essential for recovery. Lastly, the client should avoid wearing robes and socks while walking in the house to prevent tripping, slipping, or falling on slippery floors.