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: 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. An 18-month-old child should have approximately 12 teeth.
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Which of the following is true of advanced directives?
- A. They should be appropriately documented in the client's chart.
- B. They are only applicable if the client has a terminal illness.
- C. They are required if the client is unconscious.
- D. They are non-legal requests.
Correct Answer: A
Rationale: Advanced directives are legal requests regarding a client's health care regardless of the severity of their illness or level of consciousness. They should be verified on admission and documented in the client's chart.
The physician's role in case management includes all of the following except:
- A. participating in interdisciplinary planning for clients.
- B. serving as the expert for resource utilization.
- C. consulting with the case management team to facilitate timely orders as needed.
- D. contributing to the documentation of a client's needs for services.
Correct Answer: B
Rationale: The physician is an integral part of the case-management process in terms of assisting with defining the client's needs and the time frames for movement through the health care system; however, the physician is the expert for medical diagnosis and treatment rather than resource utilization.
A nurse is giving shift report off to the oncoming LPN. Which of these is an inappropriate shift report?
- A. The nurse gives report to the oncoming LPN, checking a wound vac and dressing together.
- B. The nurse reports in SBAR format, noting that the client was noncompliant with their diet during the shift.
- C. The nurse reports in the hallway, SBAR format, and alerts the oncoming LPN about how rude the client was throughout the shift.
- D. The nurse reports at bedside with the oncoming LPN and discusses the client's concerns after the chart has been reviewed.
Correct Answer: C
Rationale: Report should be at the bedside, in SBAR format, and given in an objective way.
Which of the following nursing measures is most appropriate to meet the expected outcome of positive body image?
- A. administering immune globulin intravenously
- B. assessing the extremities for edema, redness and desquamation every 8 hours
- C. explaining progression of the disease to the client and his or her family
- D. assessing heart sounds and rhythm
Correct Answer: C
Rationale: Teaching the client and family about progression of the disease includes explaining when symptoms can be expected to improve and resolve. Knowledge of the course of the disease can help them understand that no permanent disruption in physical appearance will occur that could negatively affect body image. Clients with Kawasaki disease might receive immune globulin intravenously to reduce the incidence of coronary artery lesions and aneurysms. Cardiac effects could be linked to body image, but Choice 3 is the most direct link to body image. The nurse assesses symptoms to assist in evaluation of treatment and progression of the disease.
During an emergency procedure, is the surgical timeout a requirement?
- A. As long as the surgical timeout would not cause a delay leading to injury or death, the time-out should be performed by the surgical team.
- B. No, in an emergency procedure, the timeout does not need to be performed.
- C. No, the surgical timeout is optional depending on the surgeon's preferences.
- D. Yes, the surgical timeout should be performed in all cases.
Correct Answer: A
Rationale: The surgical timeout should be performed as long as the delay in performing the timeout would not have negative consequences.