Nokea
The nurse is assessing a 3-year-old child. Which assessment finding would the nurse identify as abnormal?
- A. Pedals tricycle without assistance
- B. Unscrews a bolt on a toy
- C. Falls when bending over to touch toes
- D. Builds a tower of 10 cubes
Correct Answer: C
Rationale: The correct answer is C. Falling when bending over to touch toes could indicate a developmental delay or a balance issue that may need further assessment. Choices A, B, and D are typical developmental milestones for a 3-year-old child. Pedaling a tricycle without assistance, unscrewing a bolt on a toy, and building a tower of 10 cubes are all age-appropriate activities for a child of this age.
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Rectal temperatures are indicated in which situation?
- A. In the newborn period
- B. Whenever accuracy is essential
- C. Rectal temperatures are never indicated
- D. When rapid temperature changes are occurring
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The parents of an 8-month-old infant voice concern to the nurse that their infant is not developing motor skills as the infant should. What question would be appropriate for the nurse to ask in determining if their fears are warranted?
- A. Does the infant move a toy back and forth from one hand to the other?
- B. Is the infant able to drink from a cup by oneself?
- C. Is the infant able to hold a pencil and scribble on paper?
- D. Does the infant place toys into a box or container and take them out?
Correct Answer: A
Rationale: The correct answer is A. By 8 months, an infant should be able to transfer objects between hands, which is an important motor skill milestone. This action shows coordination and developing fine motor skills. Choices B, C, and D involve more advanced motor skills that are typically not expected at 8 months of age. Drinking from a cup, holding a pencil to scribble, and engaging in purposeful play with toys are skills that develop later in infancy.
When transitioning from intravenous to oral morphine, what would the nurse anticipate regarding the oral dose in comparison to the intravenous dose to achieve equianalgesia?
- A. Same as the intravenous dose
- B. Greater than the intravenous dose
- C. One half of the intravenous dose
- D. One fourth of the intravenous dose
Correct Answer: B
Rationale: When switching from intravenous to oral morphine, a higher oral dose is required to achieve equianalgesia due to significant metabolism from the first-pass effect. Choosing the same oral dose as the intravenous dose would provide less pain relief. Opting for a dose greater than the intravenous dose is necessary to achieve the same analgesic effect. Therefore, options A, C, and D are incorrect.
What is an appropriate screening test for hearing that the nurse can administer to a 5-year-old child?
- A. Rinne test
- B. Weber test
- C. Pure tone audiometry
- D. Eliciting the startle reflex
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What interventions should be implemented to maintain the skin integrity of a preterm infant born at 30 weeks?
- A. Avoid cleaning the skin
- B. Bathe the infant with sterile water
- C. Cleanse the skin with a gentle alkaline-based soap and water
- D. Thoroughly rinse the skin with plain water after bathing
Correct Answer: B
Rationale: The correct intervention to maintain the skin integrity of a preterm infant born at 30 weeks is to bathe the infant with sterile water. Bathing with sterile water or a neutral pH solution is recommended to protect the delicate skin of preterm infants, which is more permeable and prone to damage. Choices A, C, and D are incorrect as avoiding cleaning the skin may lead to hygiene issues, cleansing with alkaline-based soap can be harsh on the delicate skin, and thoroughly rinsing with plain water after bathing may not be as gentle and protective for preterm infants.