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The nurse is doing a routine assessment on a 14-month-old infant and notes that the anterior fontanel is closed. How should the nurse interpret this finding?
- A. Normal finding
- B. Finding requiring a referral
- C. Abnormal finding
- D. Normal finding, but requires rechecking in 1 month
Correct Answer: A
Rationale: The closure of the anterior fontanel in a 14-month-old infant is a normal finding. The anterior fontanel typically closes by around 18 months of age. The closure of the fontanel is a sign of normal growth and development as the bones of the skull fuse together. It is not a cause for concern at this age, and the nurse should document this as a normal finding.
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Fred is a 12-year-old boy diagnosed with pneumococcal pneumonia. Which of the following would Nurse Nica expect to assess?
- A. Mild cough
- B. Slight fever
- C. Chest pain
- D. Bulging fontanel
Correct Answer: C
Rationale: Pneumococcal pneumonia often presents with symptoms such as chest pain due to inflammation of the lung tissue. In children, chest pain may be a common symptom alongside other signs like fever, cough, and difficulty breathing. Since Fred has been diagnosed with pneumococcal pneumonia, Nurse Nica would expect to assess him for chest pain as part of the typical presentation of this condition in children.
The school nurse is conducting a class for school-age children on Lyme disease. Which is characteristic of Lyme disease?
- A. Difficult to prevent
- B. Treated with oral antibiotics in stages 1, 2, and 3
- C. Caused by a spirochete that enters the skin through a tick bite
- D. Common in geographic areas where the soil contains the mycotic spores that cause the disease
Correct Answer: C
Rationale: Lyme disease is caused by a spirochete bacterium called Borrelia burgdorferi, which enters the skin through the bite of an infected deer tick. It is primarily transmitted to humans through the bite of infected black-legged ticks, commonly known as deer ticks. These ticks carry the bacterium in their gut and can transmit it to humans when they feed on blood. Therefore, Lyme disease is characterized by being caused by a spirochete that enters the skin through a tick bite. Option C is the correct answer in this case, as options A, B, and D do not accurately describe the characteristics of Lyme disease.
The nurse is preparing to perform a physical assessment on a 10-year-old girl. The nurse gives her the option of her mother either staying in the room or leaving. How should this action be interpreted?
- A. Appropriate because of child's age
- B. Appropriate because mother would be uncomfortable making decisions for child
- C. Inappropriate because of child's age
- D. Inappropriate because child is same sex as mother
Correct Answer: A
Rationale: It is appropriate for the nurse to offer the 10-year-old girl the option of having her mother stay in the room during the physical assessment because of the child's age. At this age, children may start to seek more independence and privacy, and allowing the child to make the decision can help promote a sense of autonomy and respect for her feelings. It is important to consider the child's preferences and comfort during medical procedures, which can help build trust and improve the overall experience for the child.
What term describes irregular areas of deep blue pigmentation seen predominantly in newborns of African, Asian, Native American, or Hispanic descent?
- A. Acrocyanosis
- B. Erythema toxicum
- C. Mongolian spots
- D. Harlequin color changes
Correct Answer: C
Rationale: Mongolian spots are irregular areas of deep blue pigmentation commonly seen in newborns of African, Asian, Native American, or Hispanic descent. They are flat, benign, and usually appear on the lower back or buttocks, but can also occur on other parts of the body. Mongolian spots are caused by pigment that is trapped deep in the layers of the skin and tend to fade over time, usually by the age of 5 or 6, although they may persist into adulthood in some cases. It is important for healthcare providers to be aware of Mongolian spots to differentiate them from other skin conditions and provide reassurance to parents.
A nurse is working with a dying client and his family. Which communication technique is most important to use?
- A. Reflection
- B. Clarification
- C. Interpretation
- D. Active listening
Correct Answer: D
Rationale: Active listening is the most important communication technique to use when working with a dying client and their family. This technique involves the nurse fully concentrating, understanding, responding, and remembering what is being said. By actively listening, the nurse can provide empathy, support, and validation to the client and their family members during this emotionally challenging time. This technique helps in creating a safe and supportive environment for honest and open communication, allowing the nurse to assess and address the needs and concerns of both the client and their family effectively.