Nokea
The nurse assesses a 7-month-old infant's growth and development. Which behavior should the nurse consider unusual?
- A. Drinking from a cup and spilling little of the liquid.
- B. Raising the chest and upper abdomen off the bed with the hands.
- C. Imitating sounds that the nurse makes.
- D. Crying loudly in protest when the mother leaves the room.
Correct Answer: A
Rationale: Drinking from a cup with minimal spilling is advanced for a 7-month-old, who typically lacks such fine motor control.
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The nurse is providing instructions to the parent of a child who had a myringotomy with insertion of tympanostomy tubes. Which instructions should the nurse provide the parent in case the tubes fall out?
- A. Bring the child to the emergency department immediately.
- B. It is not an emergency, but it is best to call the health care clinic.
- C. It is important to replace them immediately so that the surgical opening does not close.
- D. Clean the tubes with half-strength hydrogen peroxide for 30 minutes and then replace them into the child's ears.
Correct Answer: B
Rationale: The parent should be assured that if the tympanostomy tubes fall out, it is not an emergency, but it is best if the primary health care provider or health care clinic is notified. The size and appearance of the tympanostomy tubes should be described to the parent after surgery so that he or she will be familiar with their appearance. The remaining options are incorrect.
The nurse caring for a client after shoulder arthroplasty for rheumatoid arthritis monitors the client for brachial plexus compromise. To assess the status of the median nerve, which action would the nurse perform?
- A. Have the client spread all of the fingers wide and resist pressure.
- B. Monitor for flexion of the biceps by having the client raise the forearm.
- C. Have the client move the thumb toward the palm and back to the neutral position.
- D. While grasping the nurse's hand, note the strength of the client's first and second fingers.
Correct Answer: D
Rationale: To assess the median nerve status, the client should be instructed to grasp the nurse's hand. The nurse should note the strength of the client's first and second fingers. A weak grip may indicate compromise of the median nerve. Asking the client to spread all fingers wide and resist pressure assesses the ulnar nerve status. Monitoring for flexion of the biceps by raising the forearm assesses the cutaneous nerve status. Asking the client to move the thumb toward the palm and back to neutral position assesses the radial nerve status.
The nurse is admitting a client with a diagnosis of Guillain-Barre syndrome. During the history taking, the nurse should ask if the client has recently experienced which physical problem?
- A. Meningitis
- B. Seizures or head trauma
- C. A back injury or spinal cord trauma
- D. A respiratory or gastrointestinal (GI) infection
Correct Answer: D
Rationale: Guillain-Barre syndrome is a clinical condition of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or GI infection in the 1 to 4 weeks before the onset of neurological deficits. Occasionally it has been triggered by vaccination or surgery. The other options are not associated with an incidence of this syndrome.
A client with a history of chronic obstructive pulmonary disease (COPD) is prescribed prednisone. The nurse should monitor the client for which of the following adverse effects?
- A. Hyperglycemia.
- B. Hypotension.
- C. Weight loss.
- D. Bradycardia.
Correct Answer: A
Rationale: Prednisone can cause hyperglycemia, requiring blood glucose monitoring.
A 70-year-old, previously well client asks the nurse, 'I notice I have tremors. Is this just normal for my age?' The best response for the nurse to make is which of the following?
- A. I wouldn't be worried because this is common with aging
- B. You should report this to the physician because it may indicate a problem
- C. You should drink orange juice when this occurs
- D. You should have your blood pressure checked when this occurs
Correct Answer: B
Rationale: Tremors in a 70-year-old are not necessarily normal and may indicate conditions like Parkinson's or medication side effects, requiring physician evaluation. Orange juice or blood pressure checks are not directly relevant.