Nokea
During a routine health assessment, the nurse notes that an 8-month-old infant has a significant head lag. Which is the most appropriate action?
- A. Recheck head control at the next visit
- B. Teach the parents appropriate exercises
- C. Schedule the child for further evaluation
- D. Refer the child for further evaluation if the anterior fontanel is still open
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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What is the appropriate placement of a tongue blade for assessment of the mouth and throat?
- A. On the lower jaw
- B. Side of the tongue
- C. Against the soft palate
- D. Center back area of the tongue
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is assessing a child's capillary refill time. This can be accomplished by doing what?
- A. Inspect the chest
- B. Auscultate the heart
- C. Palpate the apical pulse
- D. Palpate the nail bed with pressure to produce a slight blanching
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Pertussis vaccination should begin at which age?
- A. Birth
- B. 2 months
- C. 6 months
- D. 12 months
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A child is admitted with suspected pyloric stenosis. Which of the following should be included in the plan of care?
- A. Monitor for signs of metabolic acidosis
- B. Observe for projectile vomiting
- C. Provide large, infrequent feedings to allow for rest
- D. Place the infant in a supine position after feeding
Correct Answer: B
Rationale: The correct answer is B: 'Observe for projectile vomiting.' Projectile vomiting is a classic sign of pyloric stenosis, caused by obstruction at the pylorus. Choice A is incorrect as metabolic alkalosis, not acidosis, often occurs due to the loss of hydrochloric acid from persistent vomiting. Choice C is incorrect as frequent, small feedings are preferred to prevent overloading the stomach. Choice D is incorrect as placing the infant in an upright position after feeding can help reduce reflux.
Play activities of the preschool-age child include:
- A. Having imaginary playmates
- B. Selective collection of objects
- C. Complex board games
- D. Associative play
Correct Answer: A
Rationale: The correct answer is A, 'Having imaginary playmates.' Preschool-age children often engage in imaginative play, which includes creating imaginary friends or playmates. This type of play helps them develop creativity, social skills, and emotional expression. Choice B, 'Selective collection of objects,' may be more common in older children and is not a typical play activity for preschoolers. Choice C, 'Complex board games,' are usually beyond the developmental level of preschoolers as they require more advanced cognitive skills. Choice D, 'Associative play,' is a term used to describe a type of play where children play alongside each other but not necessarily together, which is different from the imaginative play involving imaginary playmates that preschoolers often engage in.