The nurse is providing anticipatory guidance to the parent of a 9-month-old infant during a well-baby visit. Which topic would be most appropriate?
- A. Cautioning about putting the infant in a walker
- B. Advising how to create a toddler-safe home
- C. Instructing on safety procedures during baths
- D. Warning about leaving small objects on the floor
Correct Answer: D
Rationale: The correct answer is D because at 9 months, infants become more mobile, increasing the risk of choking hazards from small objects left on the floor. Cautioning about putting the infant in a walker (Choice A) is not as crucial at this age as warning about choking hazards. While advising how to create a toddler-safe home (Choice B) is essential, the most critical concern at 9 months is small objects. Instructing on safety procedures during baths (Choice C) is important but does not address the immediate risk of choking hazards associated with small objects.
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A 10-month-old infant is diagnosed with gastroesophageal reflux. An esophageal (pH) probe monitor is ordered. What explanation for the purpose of the esophageal probe should the nurse provide to the parents?
- A. Assist in the passage of formula through the esophagus
- B. Identify the number of reflux episodes that are occurring
- C. Determine the time it takes for the stomach to empty its contents
- D. Monitor the pH within the stomach
Correct Answer: B
Rationale: The correct answer is B. The esophageal pH probe is used to identify the frequency and severity of reflux episodes by measuring the pH in the esophagus. Choice A is incorrect because the probe does not assist in the passage of formula through the esophagus. Choice C is incorrect as determining the time it takes for the stomach to empty its contents would require a different procedure. Choice D is incorrect as the esophageal pH probe monitors the pH in the esophagus, not the stomach.
The mother of a 6-year-old boy who has recently had surgery for the removal of his tonsils and adenoids complains that he has begun sucking his thumb again. Which defense mechanism should the nurse include when responding to the mother?
- A. Repression
- B. Regression
- C. Rationalization
- D. Fantasy
Correct Answer: B
Rationale: The correct answer is B: Regression. Regression is a common defense mechanism where a child reverts to an earlier stage of development, such as thumb-sucking, to cope with stress. In this scenario, the 6-year-old boy is using thumb-sucking (a behavior typical of earlier developmental stages) as a way to deal with the stress of surgery. Repression (choice A) involves unconsciously blocking out thoughts or feelings, which is not applicable in this case. Rationalization (choice C) is a defense mechanism where illogical or unreasonable explanations are provided to justify behavior, which is not relevant here. Fantasy (choice D) refers to the use of imagination to escape from reality, which is also not the appropriate defense mechanism for the situation described.
The nurse is interviewing the father of a 10-month-old girl. The child is playing on the floor when she notices an electrical outlet and reaches up to touch it. Her father says no firmly and moves her away from the outlet. The nurse should use this opportunity to teach the father what?
- A. That the child should be given a time-out
- B. That the child is old enough to understand the word no
- C. That the child will learn safety issues better if she is spanked
- D. That the child should already know that electrical outlets are dangerous
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is assessing a child suspected of having pinworms. Which is the most common symptom the nurse expects to assess?
- A. Restlessness
- B. Distractibility
- C. Rectal discharge
- D. Intense perianal itching
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is administering the first hepatitis A vaccine to an 18-month-old child. When should the child return to the clinic for the second dose of hepatitis A vaccination?
- A. After 2 months
- B. After 3 months
- C. After 4 months
- D. After 6 months
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.