Nokea
The age by which the child can pull to stand, starting to pincer grasp, and plays pat-a-cake is
- A. 6 mo
- B. 7 mo
- C. 8 mo
- D. 9 mo
Correct Answer: D
Rationale: These milestones are typically achieved around 9 months of age.
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A mother is upset because her newborn has erythema toxicum neonatorum. What information should the nurse base the response to the mother?
- A. Easily treated
- B. Benign and transient
- C. Usually not contagious
- D. Usually not disfiguring
Correct Answer: B
Rationale: Erythema toxicum neonatorum is a common benign and transient rash that affects newborns. It typically appears in the first days of life and presents as red or pink blotches with small white or yellow papules in the center. The rash is not harmful, usually resolves on its own within a few days, and does not require treatment. Educating the mother that erythema toxicum neonatorum is a benign and transient condition can help alleviate her concerns and reassure her that it is a normal occurrence in newborns.
The patient is dangling at the bedside and states, "Oh, my stomach is tearing open." Which of the following actions should the nurse immediately take when dehiscence occurs?
- A. Have patient sit upright in a chair.
- B. Have patient lie down.
- C. Slow IV fluids.
- D. Obtain a sterile suture set.
Correct Answer: B
Rationale: When dehiscence, which is the separation of the layers of a surgical incision, occurs in a patient, it is important to have the patient lie down. This position will help decrease intra-abdominal pressure and reduce the risk of further complications. Having the patient sit upright in a chair can increase intra-abdominal pressure, worsening the dehiscence. Slowing IV fluids may be necessary to prevent fluid overload in certain situations, but it is not the immediate action required when dehiscence occurs. Obtain a sterile suture set may eventually be needed, but the priority in this situation is to stabilize the patient by having them lie down.
A 5-year-old girl is having a checkup before starting kindergarten. The nurse asks her to do the "finger-to-nose" test. What is the nurse testing for?
- A. Deep tendon reflexes
- B. Cerebellar function
- C. Sensory discrimination
- D. Ability to follow directions
Correct Answer: B
Rationale: The nurse is testing the girl's cerebellar function by asking her to do the "finger-to-nose" test. The cerebellum is the part of the brain that plays a crucial role in coordinating movement, balance, and posture. In the finger-to-nose test, the child is asked to touch her own nose and then the nurse's finger repeatedly. A properly functioning cerebellum helps control and coordinate these precise movements. If there are issues with the cerebellar function, the child might have difficulty performing this task accurately, indicating a potential problem with motor coordination and balance.
Following the American Cancer Society guidelines, the nurse should recommend that the women:
- A. Perform breast self-examination annually
- B. Have a physician conduct a clinical
- C. Have a mammogram annually examination every 2 years
- D. Have a normal receptor assay annually
Correct Answer: C
Rationale: The American Cancer Society recommends that women have a mammogram annually, starting at age 45, and then have the option to switch to every two years starting at age 55. This is based on evidence showing that regular mammograms can help detect breast cancer early when it is most treatable. Breast self-examinations are no longer recommended as a routine screening method due to studies showing they do not reduce mortality from breast cancer. Clinical breast exams conducted by a physician are also not recommended for routine screening in average-risk women, as they have not been shown to be effective in reducing breast cancer mortality. Normal receptor assay testing is not a screening test for breast cancer and is used to help determine the best treatment options for diagnosed breast cancer cases.
Which of the following communication methods is not an option for a patient following laryngectomy surgery?
- A. Placing a finger over the stoma
- B. Using a picture board
- C. Using a special valve that diverts air into
- D. Learning esophageal speech the oesophagus
Correct Answer: B
Rationale: Following laryngectomy surgery, the larynx (voice box) is removed, making it impossible for the patient to produce sound for speech. The options listed are alternative communication methods for patients post-surgery, except for using a picture board. Placing a finger over the stoma can help redirect air for speech, using a special valve can help divert air for speech as well, and learning esophageal speech involves speaking by swallowing air into the esophagus and then releasing it to create sound. Picture boards are not a common method of communication for patients following laryngectomy surgery.