Nokea
The nurse is discussing issues that are important with parents considering a cross-racial adoption. Which statement made by the parents indicates further teaching is needed?
- A. "We will try to preserve the adopted child's racial heritage."
- B. "We are glad we will be getting full medical information when we adopt our child."
- C. "We will make sure to have everyone realize this is our child and a member of the family."
- D. "We understand strangers may make thoughtless comments about our child being different from us."
Correct Answer: C
Rationale: The statement about making sure others realize the child is part of the family may indicate a focus on external validation rather than on the child's needs and identity, suggesting a need for further teaching.
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The school nurse is assessing children for risk factors related to childhood injuries. Which child has the most risk factors related to childhood injury?
- A. Female, multiple siblings, stable home life
- B. Male, high activity level, stressful home life
- C. Male, even-tempered, history of previous injuries
- D. Female, reacts negatively to new situations, no serious previous injuries
Correct Answer: B
Rationale: A male child with a high activity level and a stressful home life has multiple risk factors for childhood injuries, requiring closer supervision and preventive measures.
At what age is the first dose of the hepatitis A vaccine recommended to be started?
- A. 1 year
- B. 1 month
- C. 12 years
- D. It is not recommended at any age
Correct Answer: A
Rationale: The correct answer is A: 1 year. The hepatitis A vaccine is now recommended for all children starting at age 1 year (i.e., 12 to 23 months). This is due to the recognition of hepatitis A as a significant child health problem, especially in areas with high infection rates. The virus is primarily spread through fecal-oral transmission, person-to-person contact, ingestion of contaminated food or water, and rarely through blood transfusion. Administering the first dose at 1 year helps protect children from this infection. Choices B and C are incorrect as the vaccine is not recommended at 1 month or 12 years. Choice D is also incorrect as the hepatitis A vaccine is recommended at a specific age to prevent the infection.
Which actions by the nurse demonstrate clinical reasoning? (Select all that apply.)
- A. All below
- B. Considering alternative actions
- C. Using formal and informal thinking to gather data
- D. Giving deliberate thought to a patient's problem
Correct Answer: A
Rationale: Clinical reasoning involves deliberate and thoughtful decision-making, considering alternatives, and using both formal and informal data gathering methods to provide optimum care.
Which type of family should the nurse recognize when the paternal grandmother, the parents, and two minor children live together?
- A. Blended
- B. Nuclear
- C. Extended
- D. Binuclear
Correct Answer: C
Rationale: An extended family includes relatives such as grandparents, aunts, uncles, and other extended family members living together, beyond just the nuclear family unit.
What tool would be most useful to assess maternal and newborn attachment behaviors?
- A. Apgar
- B. Ballard scale
- C. NCAST (Nursing Child Assessment Satellite Training) Feeding Scale
- D. Brazelton Neonatal Behavioral Assessment Scale
Correct Answer: C
Rationale: The NCAST Feeding Scale is the most suitable tool to evaluate maternal and newborn attachment behaviors during feedings. It focuses on observing the interaction between the parent and infant, providing insights into their bonding. The Apgar score is used to assess a neonate's immediate transition to life outside the womb, not specifically maternal and newborn attachment behaviors. The Ballard scale is used to estimate gestational age, not to assess attachment behaviors. The Brazelton Neonatal Behavioral Assessment Scale is designed to evaluate a newborn's responses to various stimuli, not specifically maternal and newborn attachment behaviors.