Nokea
The child begins to understand right and left by age of
- A. 3 yr
- B. 4 yr
- C. 5 yr
- D. 6 yr
Correct Answer: C
Rationale: Understanding right and left typically develops around age 5.
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Regarding physical growth of preschool children (3-5 years), all are true EXCEPT
- A. 7-8 kg weight increment/yr
- B. 20 primary teeth erupted by 3 years
- C. brain stops myelinization by 8 years
- D. height increment/yr average is 5-6 cm up to 18 years
Correct Answer: A
Rationale: Weight increment varies and is generally less than 7-8 kg/yr.
A school-age child, admitted for intravenous antibiotic therapy for osteomyelitis, reports difficulty in going to sleep at night. Which intervention should the nurse implement to assist the child in going to sleep at bedtime?
- A. Request a prescription for a sleeping pill.
- B. Allow the child to stay up late and sleep late in the morning.
- C. Create a schedule similar to the one the child follows at home.
- D. Plan passive activities in the morning and interactive activities right before bedtime.
Correct Answer: C
Rationale: Creating a schedule similar to the one the child follows at home will provide familiarity and routine, which can help in establishing a bedtime routine and promoting better sleep. Consistency in sleep schedules is important for children, as it helps regulate their circadian rhythm and promotes quality sleep. By mirroring the child's home schedule, the nurse can create a sense of normalcy and comfort for the child, making it easier for them to fall asleep at bedtime. This approach is non-pharmacological and focuses on promoting healthy sleep habits, which is beneficial for the child's overall well-being and recovery process.
Several hours after returning from surgery, the nurse tells the patient that she is ordered to be ambulated. The patient asks, "Why?" Which of the following complications would the nurse correctly explain can be prevented by early postoperative ambulation?
- A. Increased peristalsis
- B. Coughing
- C. Pneumonia
- D. Wound healing  A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET K
Correct Answer: C
Rationale: Early postoperative ambulation is important for preventing complications such as pneumonia. When a patient remains immobile for an extended period after surgery, they are at an increased risk of developing pneumonia due to decreased lung expansion and secretions pooling in the lungs. Ambulation helps improve lung function, promote better oxygenation, and prevent respiratory complications like pneumonia. In contrast, increased peristalsis helps prevent constipation, coughing helps prevent respiratory complications as well, and wound healing is not directly related to the need for early postoperative ambulation.
An adult is receiving total parenteral nutrition. The nurse knows which of the following assessments is essential?
- A. Evaluation of the peripheral venous site
- B. Confirmation that the tube is in the stomach
- C. Assessment of the GI tract, including bowel sounds
- D. Fluid and electrolyte monitoring
Correct Answer: D
Rationale: For an adult receiving total parenteral nutrition (TPN), it is essential for the nurse to monitor fluid and electrolyte levels closely. TPN provides all essential nutrients, including fluids and electrolytes, directly into the bloodstream. Monitoring these levels is crucial to prevent potential complications such as fluid overload, electrolyte imbalances, and hyperglycemia. Assessing and maintaining appropriate fluid and electrolyte balance are essential components of managing a patient receiving TPN to ensure optimal patient outcomes.
The Glasgow coma scale is used to .evaluate the level of consciousness in the neurological and neurological patients. The three assessment factors included in this scale are:
- A. pupil size, response to pain, motor responses
- B. Pupil size, verbal response, motor response
- C. Eye opening, verbal response, motor response
- D. Eye opening, response to pain, motor response J.E, is an 18-year old freshman admitted to the ICU following a motor vehicle accident in which he sustained multiple trauma including a ruptured spleen, myocardial contusion, fractured pelvis, and fractured right femur. He had a mild contusion, but is alert and oriented. His vital signs BP 120/80, pulse 84, respirations 12, and temperature 99 F orally.
Correct Answer: C
Rationale: The Glasgow Coma Scale (GCS) is a neurological scale that is used to assess the level of consciousness in patients. It is based on three factors: eye opening, verbal response, and motor response. Each factor is scored on a scale of 1 to 4 or 6, with a lower total score indicating a lower level of consciousness.