Nokea
The nurse meets the frantic father at an ED door. He says he just delivered his wife’s full-term newborn in the car when the temperature outside is only 10°F (—12.2°C). In response to the cold environment,the nurse knows that the infant’s body will immediately begin to produce heat by which mechanism?
- A. Shivering
- B. Metabolizing body fat
- C. Dilating surface blood vessels
- D. Decreasing flexion of the extremities
Correct Answer: B
Rationale: When skin receptors of full-term newborns perceive a drop in environmental temperature the sympathetic nervous system is stimulated. This in turn stimulates metabolism of brown fat thus producing heat that is transferred to the peripheral circulation. Shivering is rarely seen in newborns and it does little to produce heat. Newborns conserve heat by constricting not dilating blood vessels. Decreasing flexion promotes heat loss by exposing more skin surface.
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Which intervention is most appropriate for a child with a musculoskeletal disability using a wheelchair?
- A. Encourage competitive sports to build strength.
- B. Provide a firm mattress to prevent bedsores.
- C. Teach the child to avoid all physical activity.
- D. Limit the child's interaction with peers.
Correct Answer: B
Rationale: A firm mattress helps distribute weight evenly, reducing the risk of pressure ulcers in a child with limited mobility due to a musculoskeletal disability.
When a 10-year-old child falls from a bicycle and loses a permanent incisor tooth, which advice can the nurse provide to the parents before they take the child to see a dentist?
- A. Submerge the tooth in water in a cup.
- B. Place the tooth under the child's tongue.
- C. Wrap the tooth in a clean cloth.
- D. Clean the tooth with alcohol.
Correct Answer: C
Rationale: Wrapping the tooth in a clean cloth preserves it for potential reimplantation by keeping it clean and protected without compromising its viability.
The nurse is caring for the full-term newborn male who is 24 hours old and was circumcised with a Gomco clamp 30 minutes ago. Which interventions should the nurse plan for care of the newborn’s circumcision? Select all that apply.
- A. Monitor the newborn’s penis hourly for 4 to 6 hours.
- B. Observe for and document the first voiding after circumcision.
- C. Use prepackaged commercial diaper wipes for perineal cleansing.
- D. Apply petroleum ointment around the penis after each diaper change.
- E. Apply tightly a size-smaller diaper to provide hemostasis.
Correct Answer: A,B,D
Rationale: Monitor the penis for swelling/bleeding document first void to rule out obstruction and apply petroleum ointment to prevent bleeding. Commercial wipes may irritate and tight diapers cause pain.
Which diversional activity is best for meeting the burned child's developmental needs?
- A. Reading the newspaper
- B. Coloring simple designs
- C. Playing with an action figure
- D. Playing a solitary card game
Correct Answer: B
Rationale: Coloring simple designs is a developmentally appropriate activity for a school-age child, promoting fine motor skills and creativity while being feasible for a bedridden patient with burns.
Which information about methamphetamine use is most accurate and important for the parents to know?
- A. Methamphetamines are tried by most adolescents and cause no harm.
- B. Methamphetamines are known to lead to addiction.
- C. Methamphetamines are a central nervous system depressant.
- D. Methamphetamines are harmful only if taken intravenously.
Correct Answer: B
Rationale: Methamphetamines are highly addictive stimulants, and informing parents about the risk of addiction is critical to understanding the severity of the adolescent's behavior.