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During a routine health assessment, the nurse notes that an 8-month-old infant has significant head lag. Which is the nurse's most appropriate action?
- A. Teach parents appropriate exercises.
- B. Recheck head control at next visit.
- C. Refer child for further evaluation.
- D. Refer child for further evaluation if anterior fontanel is still open. TestBankWorld.org
Correct Answer: C
Rationale: Significant head lag in an 8-month-old infant can be a concerning sign indicating potential developmental delays or muscle weakness. The most appropriate action for the nurse in this situation is to refer the child for further evaluation by a healthcare provider, such as a pediatrician or developmental specialist, to assess and address the underlying cause of the head lag. It is important to rule out any potential developmental issues early on to provide the necessary interventions and support for the infant's optimal growth and development.
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Constellation of aniridia and hemihypertrophy is strongly associated with increased risk of which of the following tumors?
- A. rhabdomyosarcoma
- B. hepatoblastoma
- C. Wilms tumor
- D. medulloblastoma
Correct Answer: C
Rationale: Aniridia and hemihypertrophy are features of WAGR syndrome, which increases the risk of Wilms tumor.
Total parenteral nutrition (TPN) is ordered for an adult client. Which nutrient is not likely to be in the solution?
- A. dextrose
- B. electrolytes
- C. trace minerals
- D. amino acids
Correct Answer: C
Rationale: Total parenteral nutrition (TPN) is a method of providing nutrition intravenously to individuals who are unable to obtain adequate nutrition through oral or enteral routes. The components of a TPN solution typically include dextrose (a source of carbohydrates for energy), amino acids (building blocks of proteins), electrolytes (such as sodium, potassium, and magnesium to maintain proper balance), vitamins, and trace elements (such as zinc and selenium). Trace minerals are essential for various metabolic functions in the body, and their inclusion in TPN solutions is crucial to prevent deficiencies. Therefore, trace minerals are likely to be present in TPN solutions, making them an essential component, unlike the other options provided in the question.
Which of the following communication methods is not an option for a patient following laryngectomy surgery?
- A. Placing a finger over the stoma
- B. Using a picture board
- C. Using a special valve that diverts air into
- D. Learning esophageal speech the oesophagus
Correct Answer: B
Rationale: Following laryngectomy surgery, the larynx (voice box) is removed, making it impossible for the patient to produce sound for speech. The options listed are alternative communication methods for patients post-surgery, except for using a picture board. Placing a finger over the stoma can help redirect air for speech, using a special valve can help divert air for speech as well, and learning esophageal speech involves speaking by swallowing air into the esophagus and then releasing it to create sound. Picture boards are not a common method of communication for patients following laryngectomy surgery.
The statement about sleep which is NOT true is
- A. melatonin is secreted in dark-light cycle
- B. slow-wave sleep is needed for brain injury protection
- C. rapid eye movement (REM) sleep is responsible for dreams
- D. both REM and non-REM cycles are sufficient for sleep
Correct Answer: B
Rationale: Slow-wave sleep is primarily restorative, not protective against brain injury.
The patient is dangling at the bedside and states, "Oh, my stomach is tearing open." Which of the following actions should the nurse immediately take when dehiscence occurs?
- A. Have patient sit upright in a chair.
- B. Have patient lie down.
- C. Slow IV fluids.
- D. Obtain a sterile suture set.
Correct Answer: B
Rationale: When dehiscence, which is the separation of the layers of a surgical incision, occurs in a patient, it is important to have the patient lie down. This position will help decrease intra-abdominal pressure and reduce the risk of further complications. Having the patient sit upright in a chair can increase intra-abdominal pressure, worsening the dehiscence. Slowing IV fluids may be necessary to prevent fluid overload in certain situations, but it is not the immediate action required when dehiscence occurs. Obtain a sterile suture set may eventually be needed, but the priority in this situation is to stabilize the patient by having them lie down.