Nokea
The age at which the infant achieves early head control with bobbing motion when pulled to sit is
- A. 2 mo
- B. 3 mo
- C. 4 mo
- D. 6 mo
Correct Answer: B
Rationale: Early head control with bobbing motion typically occurs around 3 months.
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A 10-mo-old boy has a left suprarenal mass. Surgery is accomplished with complete removal of the mass as well as the non-adherent lymph nodes; surgical biopsies are taken during surgery. The histology reveals poorly differentiated neuroblastoma with microscopic ipsilateral lymph nodes involvement. The contralateral lymph nodes are negative. Of the following, the BEST therapeutic approach for this infant is
- A. chemotherapy
- B. radiotherapy
- C. concomitant chemo-radiotherapy
- D. chemotherapy followed by radiotherapy
Correct Answer: A
Rationale: Complete resection with microscopic residual disease typically warrants adjuvant chemotherapy.
Which of the following signs indicates to the nurse that digoxin (Lanoxin) has been effective for a patient?
- A. Urine output decreases
- B. Heart rate higher than 95
- C. Urine output increases
- D. Heart rate lower than 50
Correct Answer: C
Rationale: Digoxin is a medication commonly used to treat heart failure and certain types of irregular heart rhythms. One of the therapeutic effects of digoxin is an improvement in cardiac output, leading to better tissue perfusion. As the heart's pumping ability improves, blood flow to the kidneys also increases, resulting in an increase in urine output. Therefore, an increase in urine output is a positive indication that digoxin is effective for the patient. Monitoring urine output can be a valuable way for nurses to assess the response to digoxin therapy and the overall cardiac function of the patient.
The nurse is caring for a client with bronchogenic carcinoma. Which nursing diagnosis takes highest priority?
- A. Disturbed body image related to changes in body functions
- B. Ineffective airway clearance related to obstruction by a tumor or secretions
- C. Anxiety related to actual threat to health status and changes in family dynamics
- D. Imbalanced nutrition: Less than body requirements related to anorexia and vomiting secondary to chemotherapy
Correct Answer: B
Rationale: In caring for a client with bronchogenic carcinoma, the highest priority nursing diagnosis would be Ineffective airway clearance related to obstruction by a tumor or secretions. This is crucial because any blockage in the airway can lead to serious respiratory complications, such as respiratory distress or respiratory failure. Ensuring effective airway clearance is essential to maintain adequate oxygenation and ventilation for the client. Addressing this priority nursing diagnosis promptly can help prevent potential life-threatening situations and promote optimal respiratory function for the client.
The MOST common behavioral sleep disorder in a 4-month-old baby who needs to be rocked to sleep is
- A. early signs of ADHD
- B. primary restless legs syndrome
- C. sleep terrors
- D. sleep-onset association disorder
Correct Answer: D
Rationale: Sleep-onset association disorder involves reliance on specific conditions to fall asleep.
The nurse teaches a patient how to live with a new tracheostomy. Which of the ff. instructions is appropriate?
- A. "Never suction your tracheostomy; you might damage your trachea."
- B. ""You should not feel bad about the tracheostomy – you should be feel lucky to be alive."
- C. "Be sure to protect your tracheostomy from pollutants such as powders, hair and chemicals."
- D. "Your tracheostomy will be cleaned each time you visit your doctor."
Correct Answer: C
Rationale: Option C, "Be sure to protect your tracheostomy from pollutants such as powders, hair and chemicals," is the most appropriate instruction for a patient with a new tracheostomy. It is important to keep the tracheostomy site clean and free from any potential irritants or contaminants that could cause infection or complications. Powders, hair, and chemicals can lead to irritation or clogging of the tracheostomy tube, so it is crucial for the patient to be mindful of avoiding such pollutants near the tracheostomy site.