Nokea
The mother of a one-month-old calls the clinic to report that the back of her infant's head is flat. How should the nurse respond?
- A. Turn the infant on the left side braced against the crib when sleeping.
- B. Prop the infant in a sitting position with a cushion when not sleeping.
- C. Place a small pillow under the infant's head while lying on the back.
- D. Position the infant on the stomach occasionally when awake and active.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A 14-year-old adolescent with a history of substance abuse is brought to the emergency department by the parents, who suspect that the adolescent has relapsed. What is the nurse's priority action?
- A. Obtain a urine sample for toxicology screening
- B. Discuss treatment options with the parents
- C. Establish a therapeutic relationship with the adolescent
- D. Administer a medication to reverse the effects of the substance
Correct Answer: A
Rationale: In this scenario, the nurse's priority action should be to obtain a urine sample for toxicology screening. This step is crucial in identifying the substances involved in the relapse, which will guide appropriate treatment strategies. Establishing a therapeutic relationship and discussing treatment options come after obtaining necessary diagnostic information to ensure a comprehensive care plan.
A 4-year-old child is brought to the clinic with complaints of ear pain and fever. The practical nurse suspects otitis media. Which symptom supports this suspicion?
- A. Clear nasal discharge.
- B. Dry, hacking cough.
- C. Tugging at the ear.
- D. Sore throat.
Correct Answer: C
Rationale: Tugging at the ear is a common symptom in children with otitis media. It often indicates discomfort or pain in the ear, suggesting inflammation or infection in the middle ear. This behavior is frequently observed in young children who are unable to express their discomfort verbally, making it a significant clinical indicator for otitis media in this age group.
A 10-year-old girl who has had type 1 diabetes mellitus (DM) for the past two years tells the nurse that she would like to use a pump instead of insulin injections to manage her diabetes. Which assessment of the girl is most important for the nurse to obtain?
- A. Understanding of the quality control process used to troubleshoot the pump
- B. Interpretation of fingerstick glucose levels that influence diet selections
- C. Knowledge of her glycosylated hemoglobin A1c levels for the past year
- D. Ability to perform the pump for basal insulin with mealtime boluses
Correct Answer: A
Rationale: In a patient transitioning to an insulin pump, understanding the quality control process to troubleshoot the pump is essential for ensuring proper and safe management of diabetes. This knowledge enables the individual to identify and address any issues that may arise with the pump, helping maintain optimal glycemic control and prevent complications.
During a well-baby check of a 7-month-old infant, the practical nurse notes an absence of babbling. Which focused assessment should the PN implement?
- A. Visual function.
- B. Auditory function.
- C. Cognitive function.
- D. Social development.
Correct Answer: B
Rationale: The absence of babbling in a 7-month-old infant is a concerning auditory development milestone. Babbling is an early stage of language development which involves making various sounds. A lack of babbling could indicate a hearing impairment or other auditory issues. Therefore, the practical nurse should focus on assessing the infant's auditory function to determine if further evaluation or intervention is necessary.
A 7-year-old child with cystic fibrosis is admitted to the hospital with a respiratory infection. The nurse is teaching the child's parents about the importance of chest physiotherapy (CPT). Which statement by the parents indicates they need further teaching?
- A. We should perform CPT before meals.
- B. CPT will help loosen mucus in the lungs.
- C. We should perform CPT right after the child eats.
- D. CPT is an important part of our child's treatment.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.