Nokea
Rectal temperatures are indicated in which situation?
- A. In the newborn period
- B. Whenever accuracy is essential
- C. Rectal temperatures are never indicated
- D. When rapid temperature changes are occurring
Correct Answer: B
Rationale: Rectal temperatures are recommended when definitive measurements are necessary in infants older than age 1 month. Rectal temperatures are not done in the newborn period to avoid trauma to the rectal mucosa. Rectal temperature is an intrusive procedure that should be avoided whenever possible.
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The nurse is preparing to assess a 10-month-old infant. He is sitting on his fathers lap and appears to be afraid of the nurse and of what might happen next. Which initial actions by the nurse should be most appropriate?
- A. Initiate a game of peek-a-boo.
- B. Ask the infants father to place the infant on the examination table.
- C. Talk softly to the infant while taking him from his father.
- D. Undress the infant while he is still sitting on his fathers lap.
Correct Answer: A
Rationale: Peek-a-boo is an excellent means of initiating communication with infants while maintaining a safe, nonthreatening distance. The child will most likely become upset if separated from his father. As much of the assessment as possible should be done with the child on the fathers lap. The nurse should have the father undress the child as needed during the examination.
Which is the single most important factor to consider when communicating with children?
- A. Presence of the childs parent
- B. Childs physical condition
- C. Childs developmental level
- D. Childs nonverbal behaviors
Correct Answer: C
Rationale: The nurse must be aware of the childs developmental stage to engage in effective communication. The use of both verbal and nonverbal communication should be appropriate to the developmental level. Nonverbal behaviors vary in importance based on the childs developmental level and physical condition. Although the childs physical condition is a consideration, developmental level is much more important. The presence of parents is important when communicating with young children but may be detrimental when speaking with adolescents.
What is the earliest age at which a satisfactory radial pulse can be taken in children?
- A. 1 year
- B. 2 years
- C. 3 years
- D. 6 years
Correct Answer: B
Rationale: Satisfactory radial pulses can be taken in children older than 2 years. In infants and young children, the apical pulse is more reliable.
Which parameter correlates best with measurements of total muscle mass?
- A. Height
- B. Weight
- C. Skinfold thickness
- D. Upper arm circumference
Correct Answer: D
Rationale: Upper arm circumference is correlated with measurements of total muscle mass. Muscle serves as the bodys major protein reserve and is considered an index of the bodys protein stores. Height is reflective of past nutritional status. Weight is indicative of current nutritional status. Skinfold thickness is a measurement of the bodys fat content.
The nurse is taking a sexual history on an adolescent girl. Which is the best way to determine whether she is sexually active?
- A. Ask her, Are you sexually active?
- B. Ask her, Are you having sex with anyone?
- C. Ask her, Are you having sex with a boyfriend?
- D. Ask both the girl and her parent if she is sexually active.
Correct Answer: B
Rationale: Asking the adolescent girl if she is having sex with anyone is a direct question that is well understood. The phrase sexually active is broadly defined and may not provide specific information for the nurse to provide necessary care. The word anyone is preferred to using gender-specific terms such as boyfriend or girlfriend. Using gender-neutral terms is inclusive and conveys acceptance to the adolescent. Questioning about sexual activity should occur when the adolescent is alone.