Nokea
The nurse is assisting low-income families to access health care. The nurse is aware that, in today's society, this most accurately defines the diversity of a modern family.
- A. A family consists of parents and their offspring living together.
- B. A family is whatever the child and family say it is.
- C. A family is two or more people related or unrelated who are living together.
- D. A family is two or more genetically related persons living together with separate roles.
Correct Answer: B
Rationale: In today's diverse society, the concept of family has evolved beyond traditional definitions. Choice B, 'A family is whatever the child and family say it is,' reflects the contemporary understanding that families can take various forms, based on self-identification and individual perspectives. Choice A is too restrictive, as modern families may not solely consist of parents and their offspring living together. Choice C is somewhat inclusive but lacks the recognition of self-identification and diversity within families. Choice D focuses on genetic relation and roles, which may not apply to all modern family structures. Therefore, choice B is the most suitable and inclusive definition of a modern family in today's society.
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A parent tells the nurse, "My 9-month-old baby no longer has the same strong grasp that was present at birth and no longer acts startled by loud noises." How should the nurse explain these changes in behavior?
- A. "I will check these responses before deciding how to proceed."
- B. "Failure of these responses may be related to a developmental delay."
- C. "Additional sensory stimulation is needed to aid in the return of these responses."
- D. "These responses are replaced by voluntary activity at about five months of age."
Correct Answer: D
Rationale: The correct answer is D: "These responses are replaced by voluntary activity at about five months of age." The grasp reflex and startle reflex (Moro reflex) are normal in newborns but typically disappear as the infant's nervous system matures and voluntary control develops. Choice A is incorrect because checking the responses before deciding a course of action does not address the developmental milestone related to the reflexes. Choice B is incorrect as it jumps to a conclusion of developmental delay without considering the normal developmental process. Choice C is incorrect as additional sensory stimulation is not necessary for the return of these reflexes, as they are expected to naturally diminish as part of normal development.
The nurse closely monitors the temperature of a child with minimal change nephrotic syndrome. The purpose of this assessment is to detect an early sign of which possible complication?
- A. infection
- B. hypertension
- C. encephalopathy
- D. edema
Correct Answer: A
Rationale: Monitoring the temperature of a child with minimal change nephrotic syndrome is crucial to detect early signs of infection. Infection is a common complication in nephrotic syndrome, and fever can be an early indicator. Hypertension (choice B) is not typically associated with nephrotic syndrome. Encephalopathy (choice C) is a neurological complication and would present with altered mental status rather than a change in temperature. Edema (choice D) is a common symptom of nephrotic syndrome but is not typically monitored through temperature assessment.
The nurse is caring for an infant with candidal diaper rash. Which topical agent would the nurse expect the healthcare provider to order?
- A. Corticosteroids.
- B. Antifungals.
- C. Antibiotics.
- D. Retinoids.
Correct Answer: B
Rationale: Antifungal agents are the appropriate treatment for candidal diaper rash as it is a fungal infection. Corticosteroids, antibiotics, and retinoids are not indicated for this condition. Corticosteroids may worsen fungal infections, antibiotics are used for bacterial infections, and retinoids are typically used for acne and skin conditions unrelated to candidal diaper rash.
A parent tells a nurse at the clinic, 'Each morning I offer my 24-month-old child juice, and all I hear is 'No.' What should I do because I know my child needs fluid?' What strategy should the nurse suggest?
- A. Offer the child a choice of two juices.
- B. Distract the child with a favorite food.
- C. Offer the child the glass in a firm manner.
- D. Allow the child to see the parent getting angry.
Correct Answer: A
Rationale: Offering a choice between two options allows the child to feel a sense of control while ensuring they get the necessary fluids. Providing a choice empowers the child and increases the likelihood of cooperation. Distracting the child with food or offering the glass in a firm manner may not address the underlying issue of refusal. Allowing the child to witness the parent's anger can create a negative environment and may not help in resolving the situation positively.
What information should be included in the preoperative plan of care for an infant with myelomeningocele?
- A. Positioning the infant supine with a pillow under the buttocks
- B. Covering the sac with saline-soaked nonadhesive gauze
- C. Wrapping the infant snugly in a blanket
- D. Applying a diaper to prevent fecal soiling of the sac
Correct Answer: B
Rationale: Covering the sac with saline-soaked nonadhesive gauze is essential in the preoperative care of an infant with myelomeningocele. This practice helps prevent infection and maintains moisture around the sac before surgery, promoting optimal healing outcomes. Positioning the infant supine with a pillow under the buttocks may be uncomfortable and unnecessary. Wrapping the infant snugly in a blanket does not address the specific care needs of the myelomeningocele. Applying a diaper over the sac can increase the risk of infection and should be avoided in this case.