Nokea
The BEST implication of a 6-month-old baby's visuomotor coordination is
- A. voluntary release of objects
- B. comparison ability of small objects
- C. increasing ability to explore objects
- D. autonomy of actions
Correct Answer: A
Rationale: Voluntary release is a key milestone in visuomotor coordination at this age.
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which of the following must be present in order for an infant with complete transposition of the great vessels to survive at birth?
- A. coarctation of aorta
- B. pulmonary stenosis
- C. patent ductus arteriosus
- D. mitral stenosis
Correct Answer: C
Rationale: In an infant with complete transposition of the great vessels, the survival at birth depends on the presence of a patent ductus arteriosus (PDA) to allow mixing of oxygenated and deoxygenated blood. In this condition, the aorta arises from the right ventricle and the pulmonary artery arises from the left ventricle, leading to separate circulatory pathways for oxygenated and deoxygenated blood. The survival of the infant is dependent on the remaining fetal shunts, such as a PDA, to maintain an adequate mixing of blood until corrective surgery can be performed. Therefore, the presence of a PDA is essential for the survival of an infant with complete transposition of the great vessels at birth.
A patient who is suspected of having hypothyroidism should be expected which of these symptoms?
- A. tachycardia
- B. hyperthermia
- C. weight loss
- D. extreme fatigue
Correct Answer: D
Rationale: Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormone, leading to a slowing down of the body's metabolic processes. One of the hallmark symptoms of hypothyroidism is extreme fatigue or tiredness. This can be due to the overall decrease in metabolic rate affecting energy levels and causing a feeling of exhaustion. Other common symptoms of hypothyroidism include weight gain, cold intolerance, constipation, dry skin, and depression. Tachycardia (fast heart rate), hyperthermia (elevated body temperature), and weight loss are not typically associated with hypothyroidism, but rather with conditions such as hyperthyroidism where there is an excess of thyroid hormone production.
Which of these signs suggests that a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications?
- A. Tetanic contractions
- B. Weight loss
- C. Neck vein distention
- D. Polyuria
Correct Answer: C
Rationale: In the context of syndrome of inappropriate antidiuretic hormone (SIADH), complications such as hyponatremia and fluid overload can lead to increased volume in the venous system, including the neck veins. Neck vein distention is a sign associated with fluid overload and can be indicative of worsening complications in a client with SIADH. Tetanic contractions are not typical manifestations of complications in SIADH. Weight loss and polyuria are not commonly associated with SIADH due to the increased water retention caused by the syndrome.
The nurse is preparing a parent of a newborn for home phototherapy. Which statement made by the parent would indicate a need for further teaching?
- A. "I should change the baby's position many times during the day."
- B. "I can dress the baby in lightweight clothing while under phototherapy."
- C. "I should be sure that the baby's eyelids are closed before applying patches."
- D. "I can take the patches off the baby during feedings and other caregiving activities."
Correct Answer: D
Rationale: The correct statement should be that the patches need to remain on the baby's eyes at all times during phototherapy. Removing the eye patches can potentially allow harmful light exposure to the eyes, which can lead to complications such as eye damage. It is essential for the parent to understand the importance of keeping the eye patches on to protect the baby's eyes during phototherapy. Therefore, further teaching is needed to emphasize the importance of leaving the eye patches on at all times, even during feedings and caregiving activities.
If a client with increased pressure (ICP) demonstrates decorticate posturing, the nurse will observe:
- A. Flexion of both upper and lower extremities
- B. Extension of elbows and knees, plantar flexion of feet, and flexion of the wnsts
- C. Flexion of elbows, extension of the knees, and plantar flexion of the feet
- D. Extension of upper extremities, flexion of lower extremities
Correct Answer: B
Rationale: Decorticate posturing is characterized by flexion of elbows, wrists, and fingers; extension of elbows and knees; plantar flexion of the feet. This type of posturing typically indicates severe damage to the cerebral hemispheres or impairment of the corticospinal tract. When a client with increased intracranial pressure (ICP) displays decorticate posturing, it suggests significant brain injury and dysfunction. This abnormal posturing is a classic sign that requires immediate medical attention and intervention.