Nokea
The nurse is assessing the dental status of an 18-month-old child. How many teeth should the nurse expect to examine?
- A. 6
- B. 8
- C. 12
- D. 16
Correct Answer: C
Rationale: An 18-month-old child should have approximately 12 teeth. In general, children begin dentition around 6 months of age. During the first 2 years of life, a quick guide to the number of teeth a child should have is as follows: Subtract the number 6 from the number of months in the age of the child. In this example, the child is 18 months old, so the formula is 18 - 6 = 12. The correct answer is 12. Choice A (6) is incorrect as it does not consider the child's age. Choices B (8) and D (16) are incorrect as they do not align with the dental development timeline and the specific age of the child in question.
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When evaluating a kinetic family drawing, which of the following nursing actions is most effective?
- A. instructing the child to draw their family doing something
- B. suggesting specific elements to include in the drawing
- C. discouraging the child from discussing the drawing
- D. noting the omission of any family members
Correct Answer: D
Rationale: When evaluating a kinetic family drawing, the most effective nursing action is noting the omission of any family members. This approach helps healthcare providers gather crucial information about family dynamics. It is important to pay attention to what the child includes and omits in the drawing, as it can provide insights into underlying emotions and concerns. Choices A, B, and C are not recommended actions for evaluating the drawing. Instructing the child to draw their family doing something or suggesting specific elements to include may bias the drawing, leading to misinterpretations. Discouraging the child from discussing the drawing can impede communication and the understanding of the child's perspective.
Which of the following methods of contraception is able to reduce the transmission of HIV and other STDs?
- A. intrauterine device (IUD)
- B. Norplant
- C. oral contraceptives
- D. vaginal sponge
Correct Answer: D
Rationale: The correct answer is the vaginal sponge. The vaginal sponge is a barrier method of contraception that, when used with foam or jelly contraception, reduces the transmission of HIV and other STDs, as well as reducing the risk of pregnancy. Intrauterine devices (IUDs), Norplant, and oral contraceptives can prevent pregnancy but not the transmission of HIV and STDs. Clients using the contraceptive methods in Choices A, B, and C should be counseled to use a chemical or barrier contraceptive to decrease the transmission of HIV or STDs.
An assessment of the skull of a normal 10-month-old baby should identify which of the following?
- A. closure of the posterior fontanel.
- B. closure of the anterior fontanel.
- C. overlap of cranial bones.
- D. ossification of the sutures
Correct Answer: A
Rationale: The correct answer is the closure of the posterior fontanel. By 10 months of age, the posterior fontanel should be closed. The anterior fontanel typically closes around 12-18 months of age. Overlapping of cranial bones is not a normal finding and may indicate craniosynostosis, a condition where the sutures close too early. Ossification of the sutures is also not a normal finding in a 10-month-old baby as the sutures should remain open to allow for the growth of the skull.
When a woman is receiving postpartum epidural morphine, the nurse should plan to observe for which of the following side effects to occur within the first 3 hours?
- A. nausea and vomiting
- B. itching
- C. urinary retention
- D. somnolence
Correct Answer: B
Rationale: A side effect of postpartum epidural morphine is the onset of itching within 3 hours of injection and lasting up to 10 hours. Nausea and vomiting might occur 4-7 hours after injection. While urinary retention is a side effect of postpartum epidural morphine, it is not typically assessed within the first 3 hours. Somnolence is a rare side effect and not commonly observed within the first 3 hours. Therefore, itching is the most likely side effect to be observed within the initial 3 hours after administering postpartum epidural morphine.
When removing hard contact lenses from an unresponsive client, what should the nurse do?
- A. Gently irrigate the eye with an irrigating solution from the inner canthus outward.
- B. Grasp the lens with a gentle pinching motion.
- C. Don sterile gloves before attempting the procedure.
- D. Ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens.
Correct Answer: D
Rationale: When removing hard contact lenses, it is crucial to ensure that the lens is correctly positioned on the cornea before removal. Directly grasping the lens can potentially scratch the cornea, so it is essential to gently manipulate the lids to release the lens safely. Gently irrigating the eye is unnecessary and could be harmful, especially without the client's cooperation. Wearing sterile gloves is also unnecessary for this specific procedure. Therefore, the correct approach is to ensure the proper positioning of the lens and then gently manipulate the lids to release it. Options A and C are incorrect because irrigating the eye and wearing sterile gloves are not necessary for contact lens removal. Option B is incorrect as directly grasping the lens can be harmful to the cornea.