Nokea
During a well-baby examination, the nurse measures the head circumference, and it is the same as the chest circumference. On the basis of this measurement, what action should the nurse take?
- A. Document these measurements in the infant's health care record.
- B. Tell the mother that the infant is growing faster than expected.
- C. Suggest to the health care provider that a skull x-ray be performed.
- D. Report the presence of hydrocephalus to the health care provider.
Correct Answer: A
Rationale: The head circumference growth rate during the first year is approximately 0.4 inches (1 cm) per month. By 10 to 12 months of age, the infant's head and chest circumferences are equal. In this case, where the head circumference matches the chest circumference, it is a normal finding in infants around 10-12 months. Therefore, the most appropriate action is to document these measurements in the infant's health care record. Suspecting hydrocephalus or suggesting a skull x-ray would be premature and not indicated based on this measurement. Similarly, telling the mother that the infant is growing faster than expected is not accurate and could cause unnecessary concern.
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Central venous access devices (CVADs) are frequently utilized to administer chemotherapy. What is an advantage of using CVADs for chemotherapeutic agent administration?
- A. CVADs are more expensive than a peripheral IV.
- B. Weekly administration is possible.
- C. Chemotherapeutic agents can be caustic to smaller veins.
- D. The client or family can administer the drug at home.
Correct Answer: C
Rationale: The correct advantage of using CVADs for chemotherapeutic agent administration is that chemotherapeutic agents can be caustic to smaller veins. Many chemotherapeutic drugs are vesicants, which can cause tissue damage even in low concentrations. Using a CVAD to administer these agents into a large vein is optimal as it reduces the risk of damage. Choice A is incorrect as CVADs are actually more expensive than a peripheral IV, making it a disadvantage. Choice B is incorrect because the frequency of administration depends on the specific drug being administered, not on the access device, so it does not represent a universal advantage. Choice D is incorrect because IV chemotherapeutic agents are typically not self-administered at home; they are usually given in a hospital, outpatient, or clinic setting, making it an invalid advantage of using CVADs.
To identify risk factors associated with the use of an oral contraceptive, which question should the nurse ask a client providing subjective data?
- A. Do you normally experience menstrual cramps with your periods?
- B. Do you smoke cigarettes?
- C. Are you currently dieting?
- D. Do you engage in strenuous exercise, such as jogging?
Correct Answer: B
Rationale: The correct question the nurse should ask to identify risk factors associated with the use of an oral contraceptive is whether the client smokes cigarettes. Oral contraceptives are associated with an increased risk of thromboembolic phenomena, particularly when combined with other risk factors like smoking and a history of thrombosis. Other risk factors include hypertension, cerebrovascular disease, coronary artery disease, and postoperative thrombosis risk. Choices A, C, and D are not directly related to the increased risks associated with oral contraceptive use. Menstrual cramps, dieting, and strenuous exercise are not significant risk factors for thromboembolic events.
A nurse is reviewing the medical record of an older client with presbycusis. Which finding would the nurse expect to note in the client's record?
- A. Difficulty hearing whispered words in the voice test
- B. Improved hearing ability during conversational speech
- C. Unilateral conductive hearing loss
- D. Difficulty hearing low-pitched tones
Correct Answer: A
Rationale: Presbycusis, a sensorineural hearing loss, is the most common form of hearing loss in older adults. Typically, the loss is bilateral, resulting in difficulty hearing high-pitched tones. The condition is revealed when the client has difficulty hearing whispered words in the voice test and consonants during conversational speech. Choice A is correct because it reflects the expected finding in presbycusis. Choices B, C, and D are incorrect because presbycusis does not result in improved hearing ability during conversational speech, unilateral conductive hearing loss, or difficulty hearing low-pitched tones.
A nurse helps a young adult conduct a personal lifestyle assessment. The nurse carefully reviews the assessment with the young adult for which reason?
- A. Young adults may ignore physical symptoms and postpone seeking health care
- B. Young adults are unable to afford health insurance
- C. Young adults are at risk for a serious illness
- D. Young adults are exposed to hazardous substances
Correct Answer: A
Rationale: The corrected answer is A: Young adults may ignore physical symptoms and postpone seeking health care. Young adults are usually quite active, experience severe illnesses less commonly than members of older age groups, tend to ignore physical symptoms, and often postpone seeking health care. Clients in this developmental stage may benefit from a personal lifestyle assessment to identify habits that increase the risk for various chronic diseases. Choice B is incorrect because the ability to afford health insurance is not the primary reason for conducting a personal lifestyle assessment. Choice C is incorrect because young adults are not inherently at higher risk for serious illness compared to other age groups. Choice D is incorrect because exposure to hazardous substances is not the main focus when conducting a personal lifestyle assessment.
What causes an older female client's hair to turn gray?
- A. A loss of melanin occurs in the normal aging process.''
- B. The number of sweat glands and blood vessels decreases in the normal aging process.''
- C. The skin on the scalp becomes thin, causing moisture to escape.''
- D. It is caused by hereditary factors.''
Correct Answer: A
Rationale: The correct answer is 'A loss of melanin occurs in the normal aging process.' Graying hair in older adults is primarily due to a decrease in the number of melanocytes responsible for providing pigment and hair color. This reduction in melanin production leads to gray hair. The other choices are incorrect. While it is true that the skin becomes thinner with aging and the number of sweat glands and blood vessels decreases, these changes are not directly related to graying hair. Additionally, hereditary factors can influence when graying starts, but they do not cause the graying of hair itself.