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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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.
These facts are true regarding the developmental stage of preschool children EXCEPT
- A. handedness is achieved by 3 years of age
- B. boys are usually later than girls in achieving bladder control
- C. knowing gender by 4 years
- D. egocentric thinking
Correct Answer: D
Rationale: Egocentric thinking is characteristic of preschool-age children.
Mr Santos is placed on seizure precaution. Which of the following would be contraindicated?
- A. Obtain his oral temperature g. Allow him to wear his own clothing f. Encourage to perform his own personal h. Encourage him to be out of bed hygiene
Correct Answer: A
Rationale: When a patient is placed on seizure precautions, obtaining oral temperature would be contraindicated. This is because sticking a thermometer in the mouth may pose a risk during a seizure episode, as the patient might bite down on it and cause injury. It is important to prioritize safety measures to minimize the risk of harm to the patient. Other methods of monitoring temperature, such as using a tympanic thermometer or a forehead thermometer, would be more appropriate in this situation.
The nurse observes flaring of nares in a newborn. This should be interpreted as:
- A. nasal occlusion.
- B. sign of respiratory distress.
- C. common response to sneezing.
- D. snuffles of congenital syphilis.
Correct Answer: B
Rationale: Flaring of nares in a newborn is typically interpreted as a sign of respiratory distress. When a baby is having trouble breathing or is not getting enough oxygen, the body compensates by increasing the size of the nasal passages to allow for easier airflow. This response helps the baby to breathe more effectively during times of respiratory distress. It is important for healthcare providers to recognize this sign as it may indicate the need for prompt intervention and support to help the baby breathe more comfortably.
A febrile patient's fluid output is in excess of normal because of diaphoresis. The nurse should plan fluid replacement based on the knowledge that insensible losses in an afebrile person are normally not greater than:
- A. 300ml/24hr
- B. 900ml/24hr
- C. 600ml/24hr
- D. 1200ml/24hr
Correct Answer: C
Rationale: Insensible losses are the fluid losses that occur without the individual being aware of it, such as through breathing, sweating, and through the skin. In an afebrile person, insensible losses are normally around 600ml per 24 hours. This amount can vary depending on factors such as temperature, humidity, and individual metabolism. When a patient is febrile and experiencing diaphoresis (excessive sweating), the fluid output can increase significantly due to the body's attempts to cool itself down. It is important for the nurse to consider these increased fluid losses when planning fluid replacement for a febrile patient to prevent dehydration.