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The nurse is discussing development and play activities with the parent of a 2-month-old. Recommendations should include giving a first rattle at about which age?
- A. 2 months
- B. 4 months
- C. 7 months
- D. 9 months
Correct Answer: A
Rationale: At 2 months old, infants start to demonstrate more control over their arm movements and are becoming more aware of objects around them. They may also start to grasp objects intentionally. Giving a first rattle at this age can help stimulate their senses, promote sensory exploration, and encourage their fine motor skills development. This early exposure to different textures, shapes, and sounds can also aid in their cognitive and sensory development, making it an appropriate choice for a parent looking to support their baby's early growth and learning.
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A client is admitted to an acute care facility with a tentative diagnosis of hypoparathyroidism. The nurse should monitor the client closely for the related problem of:
- A. Severe hypotension
- B. Profound neuromuscular irritability
- C. Excessive thirst
- D. Acute gastritis
Correct Answer: B
Rationale: Hypoparathyroidism is a condition characterized by decreased levels of parathyroid hormone, which can lead to low levels of calcium in the blood (hypocalcemia). Profound neuromuscular irritability is a significant complication of hypocalcemia and is a key concern for clients with hypoparathyroidism. Symptoms can include muscle cramps, tetany, seizures, and decreased cardiac contractility. Monitoring for neuromuscular irritability and promptly addressing low calcium levels are essential in the care of clients with hypoparathyroidism.
Cherry, the mother of an 11-month-old girl, Elizabeth, is in the clinic for her daughter's immunizations. She expresses concern to the nurse that Elizabeth cannot yet walk. The nurse correctly replies that, according to the Denver Developmental Screen, the median age for walking is:
- A. 12 months.
- B. 15 months.
- C. 10 months.
- D. 14 months.
Correct Answer: A
Rationale: The Denver Developmental Screening Test states that the median age for walking is around 12 months. This means that about half of all typically developing children will begin to walk by this age. It is important to note that there is a wide range of normal development, and not all children will hit these milestones at the same time. If Cherry's 11-month-old daughter, Elizabeth, is not yet walking, it does not necessarily indicate a developmental delay as long as she is meeting other milestones within a reasonable timeframe.
The American Academy of Pediatrics recommends the use of validated standardized developmental screening tools at three of the health maintenance visits, these are at
- A. 2 months, 6 months, and 12 months
- B. 6 months, 12 months, and 18 months
- C. 9 months, 18 months, and 30 months
- D. 12 months, 18 months, and 24 months
Correct Answer: C
Rationale: Developmental screenings are recommended at 9, 18, and 30 months.
Nurse Kara is giving instructions to an elderly client on diabetic foot care. Which teaching is not part of foot care?
- A. wear comfortable shoes that fit well and protect your feet
- B. trim your toenails straight across and file edges with emery board
- C. wash your feet in hot water to keep feet soft
- D. wear shoes at the beach or on hot pavement
Correct Answer: C
Rationale: Washing your feet in hot water is not recommended as it can actually worsen diabetic foot conditions. Hot water can lead to burns and damage the skin, especially for individuals with reduced sensation in their feet due to diabetes. It is advised to wash feet in warm water instead, avoiding hot temperatures to prevent injuries and complications. The other options provide important aspects of diabetic foot care such as wearing appropriate shoes, trimming toenails carefully, and being mindful of footwear choices to protect the feet.
The nurse is providing breast cancer education at a community facility. The American Cancer Society recommends that women get with mammograms:
- A. Yearly after age 40
- B. After the birth of the first child and every 2 years thereafter
- C. After the first menstrual period and annually thereafter
- D. Every 3 years between ages 20 and 40 and annually thereafter
Correct Answer: A
Rationale: The American Cancer Society recommends that women get yearly mammograms starting at age 40. This is because regular mammograms are the best way to detect breast cancer early when it's most treatable. Women at an average risk of breast cancer are advised to undergo yearly mammograms starting at age 40. Early detection through regular screening can help improve the chances of successful treatment and increase survival rates. It's important to follow these guidelines to ensure early detection and timely treatment of breast cancer.