Nokea
The nurse is preparing to perform a physical assessment on a 10-year-old girl. The nurse gives her the option of her mother staying in the room or leaving. This action should be considered which?
- A. Appropriate because of the child's age
- B. Appropriate, but the mother may be uncomfortable
- C. Inappropriate because of the child's age
- D. Inappropriate because the child is the same sex as the mother
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A newborn is admitted to the nursery with a complete bilateral cleft lip and palate. The mother refuses to see or hold her infant. What should the nurse do first?
- A. Restate what the physician has told her about plastic surgery
- B. Suggest holding her baby without making eye contact
- C. Encourage and allow the mother to express her feelings
- D. Recognize and allow the mother to express her feelings
Correct Answer: D
Rationale: In this situation, the priority is to acknowledge and validate the mother's feelings, creating a supportive environment for her. Option D is correct as it focuses on recognizing and allowing the mother to express her emotions. This approach can help build trust and facilitate communication. Options A and B are incorrect as they do not address the mother's emotional needs and may come across as dismissive. Option C is less appropriate as it only encourages expression without explicitly recognizing the mother's current emotional state.
A major reason for the development of respiratory distress syndrome in the preterm infant is:
- A. Excessive surfactant
- B. Lack of surfactant
- C. Immature immune system
- D. Lack of body fat
Correct Answer: B
Rationale: The correct answer is B: Lack of surfactant. Respiratory distress syndrome (RDS) in preterm infants is primarily due to a lack of surfactant, which is crucial for keeping the lungs inflated. Without adequate surfactant, the alveoli collapse, leading to breathing difficulties. Choice A, Excessive surfactant, is incorrect as RDS is caused by an insufficient amount of surfactant. Choice C, Immature immune system, and Choice D, Lack of body fat, are not directly related to the development of respiratory distress syndrome in preterm infants.
Pretending a sheet is a cape to mimic a superhero is characteristic of which childhood phenomenon?
- A. Artificialism
- B. Symbolic functioning
- C. Critical thinking
- D. Dramatic play
Correct Answer: B
Rationale: The correct answer is B, symbolic functioning. Symbolic functioning refers to children using objects, actions, or ideas to represent other objects, actions, or ideas. In this scenario, pretending a sheet is a cape to mimic a superhero demonstrates the child's ability to engage in symbolic play. Choice A, artificialism, is incorrect as it refers to the belief that inanimate objects have lifelike qualities. Choice C, critical thinking, does not directly relate to the imaginative play described in the question. Choice D, dramatic play, is close but not as precise as symbolic functioning, which specifically highlights the use of objects to represent something else.
A child is admitted with suspected pyloric stenosis. Which of the following should be included in the plan of care?
- A. Monitor for signs of metabolic acidosis
- B. Observe for projectile vomiting
- C. Provide large, infrequent feedings to allow for rest
- D. Place the infant in a supine position after feeding
Correct Answer: B
Rationale: The correct answer is B: 'Observe for projectile vomiting.' Projectile vomiting is a classic sign of pyloric stenosis, caused by obstruction at the pylorus. Choice A is incorrect as metabolic alkalosis, not acidosis, often occurs due to the loss of hydrochloric acid from persistent vomiting. Choice C is incorrect as frequent, small feedings are preferred to prevent overloading the stomach. Choice D is incorrect as placing the infant in an upright position after feeding can help reduce reflux.
A sixteen-year-old boy is diagnosed with osteosarcoma. What information should the nurse know regarding the treatment plan?
- A. Amputation of the affected extremity is rarely necessary.
- B. Intensive radiation is the primary treatment modality.
- C. Treatment usually consists of surgery and chemotherapy.
- D. Bone marrow transplantation is the preferred option for long-term survival.
Correct Answer: C
Rationale: Osteosarcoma is typically treated with a combination of surgery and chemotherapy. This approach aims to remove the tumor and reduce the risk of metastasis. Amputation of the affected extremity may be necessary in some cases to ensure complete removal of the tumor. Intensive radiation is not the primary treatment for osteosarcoma, and bone marrow transplantation is not the standard treatment for this type of cancer.