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Nurse talking with parents of 6 mo infant about gross motor development. Which gross motor skills are expected in next 3 mo? (Select all that apply.)
- A. Rolls from back to front
- B. Bears weight on legs
- C. Walks holding onto furniture
- D. Sits unsupported
- E. Sits down from standing position
Correct Answer: A,B,D
Rationale: The correct answer is A, B, and D. By 9 months, infants typically develop the ability to roll from back to front (choice A), bear weight on legs (choice B), and sit unsupported (choice D). Rolling from back to front demonstrates improved core strength and coordination. Bearing weight on legs indicates developing leg muscles and balance. Sitting unsupported signifies improved trunk control and balance. Choices C and E involve more advanced skills typically seen around 9-12 months. Choice C, walking holding onto furniture, is usually seen around 10-12 months, and choice E, sitting down from a standing position, typically emerges around 9-12 months.
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Home health nurse is discussing dangers of food poisoning with client. Which info should nurse include in counseling? (Select all that apply.)
- A. Most food poisoning is caused by virus
- B. Immunocompromised individuals are at risk for complications from food poisoning
- C. Clients who are especially at risk are instructed to eat/drink only pasteurized milk, yogurt, cheese, and other dairy products
- D. Healthy people usually recover from illness in few weeks
- E. Handling raw & fresh food separately to avoid cross-contamination may prevent food poisoning
Correct Answer: B,C,E
Rationale: The correct answers are B, C, and E.
B: Immunocompromised individuals have weakened immune systems, making them more susceptible to severe complications from food poisoning.
C: Clients at risk should consume only pasteurized dairy products to avoid harmful bacteria. Unpasteurized dairy can contain pathogens.
E: Separating raw and fresh foods prevents cross-contamination, reducing the risk of foodborne illnesses.
Incorrect:
A: Most food poisoning is caused by bacteria, not viruses.
D: Healthy individuals may recover faster, typically within a few days, not weeks.
Nurse manager is reviewing care of client with seizures with nurses on unit. Which statements by nurse requires more instruction?
- A. I will place the client on his side
- B. I will go to the nurses' station for assistance
- C. I will administer meds as prescribed
- D. I will be prepared to insert an airway
Correct Answer: B
Rationale: The correct answer is B because leaving the client during a seizure to go to the nurses' station for assistance is unsafe. The nurse should stay with the client to ensure safety. A: Placing the client on their side helps prevent aspiration. C: Administering prescribed meds is appropriate. D: Being prepared to insert an airway is essential in case of respiratory compromise.
Nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crusting. Which should the nurse suspect?
- A. Allergic reaction
- B. Ringworm
- C. Systemic lupus erythematosus
- D. Herpes zoster
Correct Answer: D
Rationale: The correct answer is D: Herpes zoster. The presentation of linear clusters of fluid-containing vesicles with crusting is characteristic of herpes zoster, also known as shingles. This is caused by the reactivation of the varicella-zoster virus, which initially causes chickenpox. The linear distribution along a dermatome is a key feature distinguishing it from other conditions. Allergic reaction (A) typically presents with hives or erythema, not vesicles. Ringworm (B) presents with a circular, scaly rash. Systemic lupus erythematosus (C) is an autoimmune disease with a different presentation.
Nurse is reviewing hand hygiene techniques with a group of APs. Which instructions should the nurse include when discussing handwashing? (Select all that apply.)
- A. Apply 3-5 mL of liquid soap to dry hands
- B. Wash hands with soap & water for at least 15 seconds
- C. Rinse hands with hot water
- D. Use a clean paper towel to turn off hand faucets
- E. Allow hands to air dry after washing
Correct Answer: B,D
Rationale: Correct Answer: B, D
Rationale:
B: Washing hands with soap & water for at least 15 seconds is crucial to ensure thorough cleaning and removal of germs.
D: Using a clean paper towel to turn off hand faucets helps prevent recontamination of clean hands.
Incorrect Choices:
A: Applying 3-5 mL of liquid soap to dry hands is not specified in handwashing guidelines.
C: Rinsing hands with hot water can strip the skin of natural oils and may not be necessary for effective hand hygiene.
E: Allowing hands to air dry after washing may not be sufficient to eliminate germs and is not a recommended step in hand hygiene protocols.
Nurse manager is reviewing guidelines to prevent injury with staff nurses. Which of the following should nurse manager include in teaching? (Select all that apply.)
- A. Request assistance when repositioning a client
- B. Avoid twisting spine or bending at waist
- C. Keep knees slightly lower than hips when sitting for long periods of time
- D. Use smooth movements when lifting & moving clients
- E. Take break from repetitive movements every 2-3h to flex & stretch joints & muscles
Correct Answer: A,B,D
Rationale: Correct Answer: A, B, D
Rationale:
A: Requesting assistance when repositioning a client is crucial to prevent injury as it reduces the risk of strain on the nurse's body.
B: Avoiding twisting the spine or bending at the waist helps in maintaining proper body mechanics and prevents back injuries.
D: Using smooth movements when lifting and moving clients reduces the risk of musculoskeletal injuries.
Summary of Incorrect Choices:
C: Keeping knees slightly lower than hips when sitting for long periods is related to ergonomics but not directly to preventing injury with client handling.
E: Taking breaks from repetitive movements every 2-3 hours is important for overall health but not specific to preventing injury with client handling.