Nokea
The nurse is assessing the growth and development of a 3-year-old child. Which speech and language skills should the nurse identify as normal developmental milestones for this child?
- A. Recognizes most letters and numbers.
- B. Uses 1-word sentences.
- C. Speaks in simple sentences with four or more words.
- D. Uses gestures with 1 to 2-word sentences.
Correct Answer: C
Rationale: Speaking in simple sentences with four or more words is a normal milestone for a 3-year-old.
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The nurse is assessing an infant with aortic stenosis and identifies bilateral fine crackles in both lung fields. What additional finding should the nurse expect to observe?
- A. Hypotension and tachycardia
- B. Vigorous feeding and satiation
- C. Fever
- D. Hemiplegia
Correct Answer: A
Rationale: Aortic stenosis can reduce cardiac output, leading to hypotension, with tachycardia as a compensatory response.
A six-year-old girl is being admitted to the hospital for repair of an umbilical hernia. Which information, collected by the admitting nurse, is particularly helpful in planning care for this child?
- A. List of achievement timeline for developmental milestones.
- B. Mother's use of alcohol, drugs, or cigarettes during pregnancy.
- C. Reactions to any previous hospitalizations.
- D. A history of rubella, rubeola, or chicken pox.
Correct Answer: C
Rationale: Previous hospitalization reactions inform emotional and developmental care planning.
A nurse is providing care for a toddler diagnosed with autism spectrum disorder and failure to thrive. What strategy should the nurse employ?
- A. Propose food even if the child shows no interest.
- B. Integrate play activities during meal times.
- C. Establish regular meal times.
- D. Permit a variety of food options.
Correct Answer: C
Rationale: Regular meal times provide structure, aiding nutrition in autism spectrum disorder.
A male adolescent comes to the clinic reporting severe testicular pain that started during a high school football practice. The nurse notes significant redness and swelling of the scrotum. What should the nurse do next?
- A. Provide the adolescent with a urinal for urinary hesitancy
- B. Immediately report the findings to the healthcare provider
- C. Collect a sterile urine sample for culture and sensitivity
- D. Obtain a swab of secretions from the penis and urethra
Correct Answer: B
Rationale: Severe testicular pain with redness and swelling suggests testicular torsion, a medical emergency requiring immediate reporting to the healthcare provider.
A child who weighs 30 kg is experiencing a grand mal seizure. The healthcare provider prescribes diazepam 0.3 mg/kg/dose intravenous (IV) STAT. The medication is available in 5 mg/mL vials. How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth).
- A. 1.8
Correct Answer: A
Rationale: The total dose is 9 mg (30 kg × 0.3 mg/kg). Dividing by the concentration (5 mg/mL) gives 1.8 mL (9 mg ÷ 5 mg/mL).