Nokea
During a well-baby check, the nurse hides a block under the baby's blanket, and the baby looks for the block. Which normal growth and development milestone is the baby developing?
- A. Separation anxiety.
- B. Associative play.
- C. Object prehension.
- D. Object permanence.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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When assessing the breath sounds of an 18-month-old child who is crying, what action should the healthcare professional take?
- A. Document that the assessment is not available because the child is crying.
- B. Ask the caregiver to quiet the child so breath sounds can be auscultated.
- C. Allow the child to play with a stethoscope to distract them during auscultation.
- D. Auscultate and document breath sounds, noting that the child was crying at the time.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When developing a behavior modification program for an extremely aggressive 10-year-old boy, what should the nurse do first?
- A. Determine what activities, foods, and toys the child enjoys
- B. Evaluate the child's previous reactions to punishment
- C. Provide the child with positive feedback
- D. Encourage other children on the unit to describe the token system
Correct Answer: A
Rationale: The first step in developing a behavior modification program for an aggressive child is to determine what activities, foods, and toys the child enjoys. By understanding the child's preferences, the nurse can tailor the program to be more engaging and effective, increasing the likelihood of success in modifying the aggressive behavior.
During a routine physical exam, a male adolescent client tells the nurse, 'sometimes, my mother gets angry because I want to be with my own friends.' What is the best initial response by the nurse?
- A. Offer reassurance that his mother's concern is normal
- B. Determine if his friends are engaged in unsafe behaviors
- C. Ask about the client's response to his mother's anger
- D. Offer to discuss his concerns with his mother
Correct Answer: C
Rationale: When a client expresses concerns about family dynamics, it is important to explore their feelings and reactions to the situation. By asking about the client's response to his mother's anger, the nurse can gain insight into the client's emotions, thoughts, and coping mechanisms. Understanding these aspects is crucial in providing appropriate support and guidance.
The parents of a 3-year-old boy who has Duchenne muscular dystrophy ask, 'How can our son have this disease? We are wondering if we should have any more children.' What information should the nurse provide to parents?
- A. This is an inherited X-linked recessive disorder, which primarily affects male children in the family
- B. The striated muscle groups of males can be impacted by a lack of the protein dystrophin in their mothers
- C. The male infant had a viral infection that went unnoticed and untreated so muscle damage was incurred
- D. Birth trauma with a breech vaginal birth causes damage to the spinal cord, thus weakening the muscles
Correct Answer: A
Rationale: The correct answer is A. Duchenne muscular dystrophy is an X-linked recessive disorder that primarily affects males. It is crucial for the nurse to explain to the parents that this condition follows an inheritance pattern where the gene mutation responsible for the disorder is located on the X chromosome. Males have only one X chromosome, so if they inherit the mutated gene, they will develop the disease. Females, on the other hand, have two X chromosomes, providing a backup copy that can compensate for the mutation. Understanding this inheritance pattern is essential for family planning decisions, as the risk of passing on the disorder to future children can be explained based on this genetic inheritance.
When assessing a 10-year-old newly diagnosed with osteomyelitis, which information is most important for the nurse to obtain?
- A. Recent history of infection recurrences.
- B. Cultural heritage and beliefs.
- C. Family history of bone disorders.
- D. Increased fluid intake occurrences.
Correct Answer: A
Rationale: In a 10-year-old with newly diagnosed osteomyelitis, the most important information for the nurse to obtain is the recent history of infection recurrences. This is crucial because osteomyelitis is an infection of the bone, and assessing for any recent recurrence of infections can help in determining the possible source of the osteomyelitis and guide the treatment plan accordingly.