Nokea
In terms of gross motor development, which should the nurse expect a 5-month-old infant to do? (Select all that apply.)
- A. Roll from abdomen to back.
- B. Put feet in mouth when supine.
- C. Roll from back to abdomen.
- D. Sit erect without support.
Correct Answer: A
Rationale: At 5 months old, an infant would typically be able to roll from abdomen to back (Choice A). This is an important gross motor skill that develops during this stage. Additionally, putting their feet in their mouth when lying on their back (Choice B) is also a common movement seen at this age. Both these actions demonstrate the increasing strength and coordination of the infant's muscles as they develop and explore their physical abilities. Rolling from back to abdomen (Choice C) and sitting erect without support (Choice D) typically develop later, around 6-7 months and 8-9 months, respectively. Moving from prone to sitting position (Choice E) and adjusting posture to reach an object (Choice F) are usually mastered around 8-9 months as well.
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20-year old Mr. Ang fell off from his horse, and sustained a lft hip fracture. Buck's extension traction is applied. The following statements are true about Buck's extension traction except:
- A. used as a temporary measure in adults to control muscle spasm and pain
- B. applied by orthopedic surgeon under aseptic conditions using wires and pins
- C. The pulling force is transmitted to the musculoskeletal structures
- D. used definitively to treat fractures in children
Correct Answer: D
Rationale: Buck's extension traction is typically used as a temporary measure in adults to control muscle spasm and pain while awaiting definitive treatment, such as surgery. It is applied by an orthopedic surgeon under aseptic conditions using wires and pins, through which the pulling force is transmitted to the musculoskeletal structures of the patient. However, Buck's extension traction is not used definitively to treat fractures in children; other treatment modalities are often preferred for pediatric fractures.
Before, during and after seizure. The nurse knows that the patient is ALWAYS placed in what position?
- A. Low fowler's
- B. Modified trendelenburg
- C. Side lying
- D. Supine
Correct Answer: C
Rationale: The correct position to place a patient before, during, and after a seizure is on their side, also known as the recovery position. Placing the patient in the side-lying position helps prevent aspiration if the patient vomits and ensures that the airway remains open. This position also helps to prevent choking and allows for drainage of fluids from the mouth. Additionally, it reduces the risk of airway obstruction and helps to maintain proper alignment of the head, neck, and spine. By placing the patient in the side-lying position, the nurse can ensure the patient's safety and well-being during and after a seizure episode.
A 3-month-old infant, born at 38 weeks of gestation, will hold a rattle if it is put in her hands, but she will not voluntarily grasp it. How should the nurse interpret this action?
- A. Normal development
- B. Significant developmental lag
- C. Slightly delayed development due to prematurity
- D. Suggestive of a neurologic disorder such as cerebral palsy
Correct Answer: C
Rationale: At 3 months of age, most infants should be able to voluntarily grasp objects placed in their hands. This infant, who was born at 38 weeks of gestation, is showing signs of slight delay in development. Premature infants often have developmental delays, especially in motor skills, compared to full-term infants. The fact that the infant can hold a rattle if it is put in her hands is a positive sign, indicating that she is on the right track developmentally but might be a little behind schedule. Continuing to monitor the infant's progress and providing appropriate developmental stimulation can help promote further motor skill development. There is no indication at this point to suspect a significant developmental lag or a neurologic disorder like cerebral palsy without further assessment and observation.
Which of the following patients should the nurse monitors because of increased risk for surgical complications?
- A. 25-year old with appendicitis
- B. patient 5'3" in height, weight 180 lbs
- C. 12-year old with fractured knee
- D. 17-year old with gallstone
Correct Answer: B
Rationale: The patient who is 5'3" in height and weighs 180 lbs is considered obese based on their body mass index (BMI). Obesity is a significant risk factor for surgical complications such as wound infections, blood clots, and respiratory issues. In obese patients, surgical procedures can be more challenging due to difficulties in accessing and visualizing surgical sites, longer surgery times, and increased stress on the body's organs. Therefore, this patient should be closely monitored for potential surgical complications.
The adrenal cortex is responsible for producing which substances?
- A. Glucocortocoids and androgens
- B. Mineralocortiroids and
- C. Catecholamines and epinephrine catecholamines
- D. Norepinephine and epinephrine
Correct Answer: A
Rationale: The adrenal cortex is the outer portion of the adrenal glands and is responsible for producing hormones known as corticosteroids. Within the corticosteroids, the adrenal cortex produces glucocorticoids (such as cortisol) which are involved in regulating metabolism and the immune response. Additionally, the adrenal cortex produces androgens which are male sex hormones, although they are present in both males and females. Therefore, the correct substances produced by the adrenal cortex are glucocorticoids and androgens (Choice A).