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 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: Significant head lag after age 6 months strongly indicates cerebral injury and is referred for further evaluation. Head control is part of normal development. Exercises will not be effective. The lack of achievement of this developmental milestone must be evaluated.
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The nurse is interviewing the mother of an infant. The mother reports, I had a difficult delivery, and my baby was born prematurely. This information should be recorded under which heading?
- A. History
- B. Present illness
- C. Chief complaint
- D. Review of systems
Correct Answer: A
Rationale: The history refers to information that relates to previous aspects of the childs health, not to the current problem. The difficult delivery and prematurity are important parts of the infants history. The history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present. Unless the chief complaint is directly related to the prematurity, this information is not included in the history of the present illness. The chief complaint is the specific reason for the childs visit to the clinic, office, or hospital. It should not include the birth information. The review of systems is a specific review of each body system. It does not include the premature birth but might include sequelae such as pulmonary dysfunction.
Which is the most frequently used test for measuring visual acuity?
- A. Snellen letter chart
- B. Ishihara vision test
- C. Allen picture card test
- D. Denver eye screening test
Correct Answer: A
Rationale: The Snellen letter chart, which consists of lines of letters of decreasing size, is the most frequently used test for visual acuity. The Ishihara Vision Test is used for color vision. The Allen picture card test and Denver eye screening test involve single cards for children ages 2 years and older who are unable to use the Snellen letter chart.
When the nurse interviews an adolescent, which is especially important?
- A. Focus the discussion on the peer group.
- B. Allow an opportunity to express feelings.
- C. Use the same type of language as the adolescent.
- D. Emphasize that confidentiality will always be maintained.
Correct Answer: B
Rationale: Adolescents, like all children, need opportunities to express their feelings. Often they interject feelings into their words. The nurse must be alert to the words and feelings expressed. The nurse should maintain a professional relationship with adolescents. To avoid misunderstanding or misinterpretation of words and phrases used, the nurse should clarify the terms used, what information will be shared with other members of the health care team, and any limits to confidentiality. Although the peer group is important to this age group, the interview should focus on the adolescent.
Which data should be included in a health history?
- A. Review of systems
- B. Physical assessment
- C. Growth measurements
- D. Record of vital signs
Correct Answer: A
Rationale: A review of systems is done to elicit information concerning any potential health problems. This further guides the interview process. Physical assessment, growth measurements, and a record of vital signs are components of the physical examination.
The nurse is seeing an adolescent and the parents in the clinic for the first time. Which should the nurse do first?
- A. Introduce him- or herself.
- B. Make the family comfortable.
- C. Give assurance of privacy.
- D. Explain the purpose of the interview.
Correct Answer: A
Rationale: The first thing that nurses must do is to introduce themselves to the patient and family. Parents and other adults should be addressed with appropriate titles unless they specify a preferred name. Clarification of the purpose of the interview and the nurses role is the second thing that should be done. During the initial part of the interview, the nurse should include general conversation to help make the family feel at ease. The interview also should take place in an environment as free of distraction as possible. In addition, the nurse should clarify which information will be shared with other members of the health care team and any limits to the confidentiality.