Nokea
The nurse observes a child's position is supine with his arms and legs rigidly extended and the hands pronated. How does the nurse identify this posture?
- A. Correct anatomical position
- B. Decorticate
- C. Decerebrate
- D. Opisthotonos
Correct Answer: C
Rationale: In decerebrate posturing, arms are extended along the side of the body and hands are pronated. This posture indicates brainstem function only.
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A parent comments that her infant has had several ear infections in the past few months. Why are infants more susceptible to otitis media?
- A. Infants are in a supine or prone position most of the time.
- B. Sucking on a nipple creates middle ear pressure.
- C. They have increased susceptibility to upper respiratory tract infections.
- D. The Eustachian tube is short, straight, and wide.
Correct Answer: D
Rationale: An infant's Eustachian tubes are short, wide, and straight, allowing microorganisms easy access to the middle ear.
What will the nurse include when documenting a grand mal seizure? (Select all that apply.)
- A. Presence of incontinence
- B. Current dose of antispasmodic medication
- C. Activity level prior to and following seizure
- D. Level of consciousness following seizure
- E. Length of seizure
Correct Answer: A,C,D,E
Rationale: Documentation on a seizure should include LOC following episode, activity prior to and following seizure, change in color, respiration, muscle tone, and length of seizure.
A child is diagnosed with nonparalytic strabismus. How will this disorder most likely be corrected?
- A. Patching the unaffected eye
- B. Corrective lenses
- C. Laser treatment
- D. Surgery
Correct Answer: B
Rationale: In nonparalytic strabismus, the refractory error is usually corrected with eyeglasses.
A child is brought to the emergency department after he fell and hit his head on the ground. Which nursing assessment suggests the child has a concussion?
- A. Sleepy but easily arousable
- B. Complaining of a stiff neck
- C. Cannot remember what happened to him
- D. Pupils react sluggishly to light
Correct Answer: C
Rationale: A concussion is a temporary disturbance of the brain that is immediately followed by a period of unconsciousness, often accompanied by a loss of memory of the events.
Which aspect(s) of a child's development does the nurse caution parents that hearing impairment can affect? (Select all that apply.)
- A. Speech clarity
- B. Language development
- C. Immunity to disease
- D. Personality development
- E. Academic achievement
Correct Answer: A,B,D,E
Rationale: All the options, except immunity to disease, are areas in which a hearing impairment could interfere with normal development.