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During a routine health assessment, the nurse notes that an 8-month-old infant has significant head lag. Which is the nurse's most appropriate action?
- A. Teach parents appropriate exercises.
- B. Recheck head control at next visit.
- C. Refer child for further evaluation.
- D. Refer child for further evaluation if anterior fontanel is still open. TestBankWorld.org
Correct Answer: C
Rationale: Significant head lag in an 8-month-old infant can be a concerning sign indicating potential developmental delays or muscle weakness. The most appropriate action for the nurse in this situation is to refer the child for further evaluation by a healthcare provider, such as a pediatrician or developmental specialist, to assess and address the underlying cause of the head lag. It is important to rule out any potential developmental issues early on to provide the necessary interventions and support for the infant's optimal growth and development.
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A nurse in the emergency department is assessing a 5-year-old child with symptoms of pneumonia and a fever of 102° F. Which intervention can the nurse implement to promote a sense of control for the child?
- A. None; this is an emergency and the child should not participate in care.
- B. Allow the child to hold the digital thermometer while taking the child's blood pressure.
- C. Ask the child if it is OK to take a temperature in the ear.
- D. Have parents wait in the waiting room.
Correct Answer: C
Rationale: Involving the child in decision-making and asking for their permission before performing a procedure promotes a sense of control and autonomy. By asking the child if it is OK to take the temperature in the ear, the nurse respects the child's preferences and helps them feel more empowered in the situation. This fosters a positive therapeutic relationship and can help reduce the child's anxiety during the medical assessment.
The nurse is assigned to a client with polymyositis. Which expected outcome in the plan of care relates to a potential problem associated with polymyositis?
- A. "Client will lose 2lb per week on a calorie-restricted diet."
- B. "Client will exhibit no signs or symptoms of aspiration."
- C. "Client will exhibit bowel and bladder continence."
- D. "Client will exhibit alertness and orientation to person, place, and time."
Correct Answer: B
Rationale: Polymyositis is a condition that involves inflammation of the muscles, including the muscles involved in swallowing (dysphagia) and breathing. This can lead to a higher risk of aspiration, where food or fluids go into the airway instead of the esophagus. Therefore, monitoring for signs and symptoms of aspiration and ensuring the client exhibits no signs of aspiration are crucial in the care of a client with polymyositis. The other options are not directly related to the potential problems associated with polymyositis and are more general aspects of nursing care.
A preterm newborn has been receiving orogastric feedings of breast milk. The nurse initiates nipple feedings, but the newborn tires easily and has weak sucking and swallowing reflexes. What is the most appropriate nursing intervention?
- A. Encourage mother to breastfeed.
- B. Try nipple-feeding preterm newborn formula.
- C. Resume orogastric feedings of breast milk.
- D. Resume orogastric feedings of formula.
Correct Answer: C
Rationale: The most appropriate nursing intervention in this situation is to resume orogastric feedings of breast milk. The newborn is showing signs of fatigue and weak sucking and swallowing reflexes during nipple feedings, indicating that they may not be ready to tolerate full oral feedings yet. By resuming orogastric feedings of breast milk, the newborn can continue to receive nutrition while building strength and coordination for oral feedings. It is important to progress gradually and monitor the newborn's tolerance for oral feedings before attempting nipple feedings again.
Mr. RR is admitted to the hospital with a diagnosis of brain tumor. Mr. RR's doctor is very much concerned about the possibility of increased intracranial pressure. The following is the most reliable index of cerebral state:
- A. Level of consciousness
- B. Unilateral papillary dilatation
- C. Increased systolic BP
- D. Decreased pulse pressure
Correct Answer: A
Rationale: The most reliable index of cerebral state in a patient diagnosed with a brain tumor and concerning increased intracranial pressure is the level of consciousness. Changes in consciousness, such as alterations in alertness, orientation, and responsiveness, are significant indicators of the brain's functioning and can provide valuable insights into the impact of increased intracranial pressure. Monitoring the level of consciousness helps healthcare providers assess neurological status and make critical decisions regarding the management of intracranial pressure. Unilateral papillary dilatation, increased systolic blood pressure, and decreased pulse pressure may also be important indicators but are not as reliable or direct as changes in the level of consciousness when evaluating cerebral status in this context.
The statement about sleep which is NOT true is
- A. melatonin is secreted in dark-light cycle
- B. slow-wave sleep is needed for brain injury protection
- C. rapid eye movement (REM) sleep is responsible for dreams
- D. both REM and non-REM cycles are sufficient for sleep
Correct Answer: B
Rationale: Slow-wave sleep is primarily restorative, not protective against brain injury.