Nokea
The nurse judges that the mother understands the term cerebral palsy when she describes it as a term applied to impaired movement resulting from which of the following?
- A. Injury to the cerebrum caused by viral infection.
- B. Malformed blood vessels in the ventricles caused by inheritance.
- C. Nonprogressive brain damage caused by injury.
- D. Inflammatory brain disease caused by metabolic imbalances.
Correct Answer: C
Rationale: Cerebral palsy is characterized by nonprogressive brain damage from injury, often occurring before, during, or shortly after birth, leading to impaired movement.
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The mother of an infant with myelomeningocele asks if her baby is likely to have any other defects. The nurse responds based on the understanding that myelomeningocele is commonly associated with which disorder?
- A. Excessive cerebrospinal fluid within the cranial cavity.
- B. Generally small head.
- C. Congenital absence of the cranium vault.
- D. Overriding of the cranial sutures.
Correct Answer: A
Rationale: Myelomeningocele is often associated with hydrocephalus, characterized by excessive cerebrospinal fluid in the cranial cavity, due to impaired cerebrospinal fluid circulation.
The nurse should instruct the family of a child with newly diagnosed hyperthyroidism to:
- A. Keep their home warmer than usual.
- B. Encourage twenty or outdoor activities.
- C. Promote interactions with one friend instead of groups.
- D. Limit bathing to prevent skin irritation.
Correct Answer: C
Rationale: Hyperthyroidism causes irritability and hyperactivity, so limiting social interactions to one friend reduces overstimulation. Warmer homes, excessive activity, and limited bathing are inappropriate.
The nurse discusses with the parents how best to raise the IQ of their child with Down syndrome. Which of the following would be most appropriate?
- A. Serving hearty, nutritious meals.
- B. Giving vasodilator medications as prescribed.
- C. Letting the child play with more able children.
- D. Providing stimulating, nonthreatening life experiences.
Correct Answer: D
Rationale: Stimulating, nonthreatening experiences promote cognitive development by encouraging exploration and learning within the child's capabilities.
A 17-year-old female with severe nodular acne is considering treatment with isotretinoin (Accutane). Prior to beginning the medication, the nurse explains that the client will be required to:
- A. Enroll in a risk management plan.
- B. Egypt in a risk management plan.
- C. Begin an effective form of birth control.
- D. Temporarily give up sports.
Correct Answer: C
Rationale: Isotretinoin has a high risk of teratogenicity, requiring strict contraception to prevent pregnancy during treatment. A risk management plan (e.g., iPLEDGE) is also required, but the most critical initial step emphasized is effective birth control.
When assessing for pain in a toddler, which of the following methods should be the most appropriate?
- A. Ask the child about the pain.
- B. Observe the child for restlessness.
- C. Use a numeric pain scale.
- D. Assess for changes in vital signs.
Correct Answer: B
Rationale: Toddlers cannot reliably verbalize pain, so observing behavior like restlessness is most appropriate.