Nokea
An infant is hospitalized for treatment of nonorganic failure to thrive. Which nursing action is most appropriate for this infant?
- A. Encouraging the infant to hold a bottle
- B. Keeping the infant on bed rest to conserve energy
- C. Rotating caregivers to provide more stimulation
- D. Maintaining a consistent, structured environment
Correct Answer: D
Rationale: A consistent, structured environment helps build trust and security, which is essential for an infant with nonorganic failure to thrive.
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A male client with diabetes mellitus (DM) is transferred from the hospital to a rehabilitation facility following treatment for a stroke with resulting right hemiplegia. He tells the nurse that his feet are always uncomfortably cool at night, preventing him from falling asleep. Which action should the nurse implement.
- A. Provide a warming pad (Aqua-pad or K-pad) to feet
- B. Medicate the client with a prescribed sedative
- C. Use a bed cradle to hold the covers off the feet
- D. Place warm blankets next to the client's feet
Correct Answer: D
Rationale: Warm blankets can help improve circulation and provide comfort without the risk of burns associated with heating pads.
A fair-skinned female client who is an avid runner is diagnosed with malignant melanoma, located on the lateral surface of the lower leg. After wide margin resection, the nurse provides discharge teaching. It is most important for the nurse to emphasize the need to observe for changes in which characteristic?
- A. Elasticity of the skin
- B. Appearance of any moles
- C. Muscle aches and pains
- D. Pigmentation of the skin
Correct Answer: B
Rationale: Monitoring for changes in moles is critical for early detection of new or recurrent melanoma, which is essential for timely intervention.
Recognised causes of delayed speech include:
- A. Hypothyroidism
- B. PKU
- C. Cystinuria
- D. Twins
Correct Answer: A
Rationale: Hypothyroidism is a known cause of delayed speech. PKU and deafness can also cause speech delays, but cystinuria is not associated with speech delay.
Distal occlusion of the posterior cerebral artery may produce:
- A. Contralateral hemiplegia
- B. Homonymous hemianopia
- C. Dysarthria
- D. Cerebellar ataxia
Correct Answer: B
Rationale: Homonymous hemianopia is a classic finding in posterior cerebral artery occlusion. Hemiplegia, dysarthria, and ataxia are not typical.
Histochemical staining used for diagnosing Hirschsprung's disease is
- A. Acetyl choline esterase
- B. Dopamine
- C. Glutamate
- D. Chromogranin and synaptophysin
Correct Answer: A
Rationale: Acetylcholine esterase staining is used to diagnose Hirschsprung's disease by identifying the absence of ganglion cells.