Nokea
In terms of fine motor development, what should the infant of 7 months be able to do?
- A. Transfer objects from one hand to the other and bang cubes on a table.
- B. Use thumb and index finger in crude pincer grasp and release an object at will.
- C. Hold a crayon between the fingers and make a mark on paper.
- D. Release cubes into a cup and build a tower of two blocks.
Correct Answer: A
Rationale: At 7 months old, infants are typically able to transfer objects from one hand to the other and bang cubes on a table. This demonstrates the development of their fine motor skills related to coordination, dexterity, and object manipulation. They are refining their hand-eye coordination and grasping abilities at this stage, preparing for more complex fine motor tasks in the future. The ability to purposefully transfer objects between hands and make intentional actions, like banging cubes on a table, shows the progression of their fine motor development at this age.
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A nurse prepares to administer the medication in which muscle site?
- A. Deltoid
- B. Triceps
- C. Vastus lateralis
- D. Biceps
Correct Answer: C
Rationale: The nurse prepares to administer the medication in the vastus lateralis muscle site. This site is located on the thigh and is commonly used for intramuscular injections in infants, toddlers, and smaller children. It is preferred for its large and easily accessible muscle mass, making it suitable for injections. This muscle site is also less painful and has fewer major blood vessels and nerves, reducing the risk of complications during injection.
Seventy-two hours after cardiac surgery, a young child has a temperature of 101° F. Which action should the nurse take?
- A. Keep child warm with blankets.
- B. Apply a hypothermia blanket.
- C. Record temperature on nurses' notes.
- D. Report findings to physician.
Correct Answer: D
Rationale: A temperature of 101°F after cardiac surgery in a young child, especially 72 hours post-surgery, is a concerning finding that should be reported to the physician. This elevated temperature could indicate infection or another complication following the surgery. It is important for the physician to evaluate the child's condition and determine the appropriate course of action. Simply recording the temperature on nurses' notes or keeping the child warm with blankets is not adequate management in this situation. Applying a hypothermia blanket would also not be appropriate as the child is already febrile. The priority in this scenario is to report the findings to the physician for further assessment and intervention.
What is the role of a nurse during scratch test to detect allergies?
- A. Applying the liquid test antigen
- B. Determining the type of allergy
- C. Measuring the length and width of the
- D. Documenting the findings raised wheal
Correct Answer: A
Rationale: During a scratch test to detect allergies, one of the key roles of a nurse is to apply the liquid test antigen onto the patient's skin. The liquid test antigen contains small amounts of common allergens that could trigger a reaction in individuals who are allergic to them. By applying the test antigen onto the skin and creating small scratches or pricks, the nurse can observe if the patient develops a raised, red, itchy bump called a wheal at the site of the allergen exposure. This helps in identifying specific allergies and determining the appropriate treatment plan for the patient.
The single parent of a 3-year-old child who has just been diagnosed with chickenpox tells the nurse that she cannot afford to stay home with the child and miss work. The parent asks the nurse if some medication will shorten the course of the illness. Which is the most appropriate nursing intervention?
- A. Reassure the parent that it is not necessary to stay home with the child.
- B. Explain that no medication will shorten the course of the illness.
- C. Explain the advantages of the medication acyclovir (Zovirax) to treat chickenpox.
- D. Explain the advantages of the medication VCZ immune globulin (VariZIG) to treat chickenpox.
Correct Answer: B
Rationale: The most appropriate nursing intervention in this scenario is to explain to the parent that no medication will shorten the course of chickenpox. Chickenpox is a viral illness caused by the varicella-zoster virus, and there is no specific treatment to shorten its duration. Antiviral medications like acyclovir are typically reserved for severe cases or for individuals with compromised immune systems. VCZ immune globulin (VariZIG) is used for post-exposure prophylaxis in susceptible individuals who have been exposed to chickenpox and are at high risk for severe disease.
A patient who has just had a TURP asks his nurse to explain why he has to have the bladder irrigation because it seems to increase his pain. Which of the following explanations by the nurse is best?
- A. "The bladder irrigation is needed to stop the bleeding in the bladder."
- B. "Antibiotics are being administered into the bladder to prevent infection."
- C. "The irrigation is needed to keep the catheter from becoming occluded by blood clots."
- D. "Normal production of urine is maintained with the irrigations until healing can occur."
Correct Answer: C
Rationale: The best explanation for the patient is option C, which states, "The irrigation is needed to keep the catheter from becoming occluded by blood clots." After a transurethral resection of the prostate (TURP), it is common for the patient to have some bleeding in the bladder. Bladder irrigation is done to prevent blood clots from forming and blocking the catheter. Keeping the catheter patent is important to ensure proper drainage of urine and prevent complications such as urinary retention. While the other options are related to potential reasons for bladder irrigation, option C directly addresses the immediate concern of preventing catheter occlusion by blood clots post-TURP surgery.