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By which age should the nurse expect an infant to be able to pull to a standing position?
- A. 6 months
- B. 8 months
- C. 11 to 12 months
- D. 14 to 15 months
Correct Answer: B
Rationale: By the age of 8 months, most infants are able to pull themselves up to a standing position by holding onto furniture or other support. This milestone signifies the development of leg strength and coordination required for standing. While some infants may achieve this skill earlier or later, on average, 8 months is a common age for this milestone to be reached.
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Nursing measures in hemodynamic monitoring include assessing for localized ischemia owing to inadequate arterial flow. The nurse should:
- A. Assess the involved extremity for color and temperature
- B. Check for capillary refill
- C. Evaluate pulse rate
- D. Do all of the above
Correct Answer: D
Rationale: When assessing for localized ischemia owing to inadequate arterial flow, it is important for the nurse to perform all of the mentioned actions:
Molly, with suspected rheumatic fever, is admitted to the pediatric unit. When obtaining the child's history, the nurseconsiders which information to be most important?
- A. A fever that started 3 days ago
- B. Lack of interest in food
- C. A recent episode of pharyngitis
- D. Vomiting for 2 days
Correct Answer: C
Rationale: A recent episode of pharyngitis is most important when obtaining the history of a child suspected of having rheumatic fever because rheumatic fever often develops as a complication of inadequately treated streptococcal pharyngitis. It is crucial to determine if there was a recent streptococcal infection to assess the likelihood of rheumatic fever developing. The other symptoms mentioned, such as fever, lack of interest in food, and vomiting, are important as well, but the connection with the recent episode of pharyngitis is more specifically related to the potential development of rheumatic fever in this case.
Which of the following is MOST likely considered a risk factor for extraneural metastasis in primary brain tumors?
- A. age less than 10 year
- B. female gender
- C. ventriculoperitoneal (VP) shunt insertion
- D. supratentorial tumor
Correct Answer: A
Rationale: Younger age is a significant risk factor for extraneural metastasis in pediatric brain tumors.
When palpating the brachial, radial, and femoral pulses of a neonate, the nurse notes a difference in pulse amplitude between the femoral and radial pulses bilaterally. This difference suggests:
- A. Patent ductus arteriosus
- B. Coarctation of the aorta
- C. Diminished cardiac output
- D. Left to right shunting in the heart. 104 Practice Exam I
Correct Answer: B
Rationale: Coarctation of the aorta is a congenital heart defect in which there is a narrowing of the aorta leading to differential pulses in the upper and lower extremities. In neonates, this can manifest as weaker femoral pulses compared to radial pulses due to decreased blood flow to the lower body. This difference in pulse amplitude between the femoral and radial pulses bilaterally is a classic finding in coarctation of the aorta, making it the most likely cause in this scenario. Other conditions like patent ductus arteriosus, diminished cardiac output, or left to right shunting in the heart may not specifically present with this particular pulse amplitude difference.
The nurse is interviewing a client about his past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer?
- A. Duodenal ulcer
- B. Weight gain
- C. Hemorrhoids
- D. Polyps
Correct Answer: D
Rationale: The presence of polyps in the colon is a significant risk factor for developing colorectal cancer. Polyps are abnormal growths in the inner lining of the colon or rectum that can potentially become cancerous over time if left untreated. Therefore, if a client has a history of polyps, the nurse may suspect the possibility of colorectal cancer and should closely monitor the client for any signs or symptoms. While the other conditions listed may sometimes be associated with colorectal cancer, having a history of polyps is the most concerning in this context.