Nokea
The nurse prepares for a Denver Screening of a 3 year-old child in the clinic. The mother asks the nurse to explain the purpose of the test. What is the nurse's best response about the purpose of the Denver?
- A. It measures a child's intelligence.
- B. It assesses a child's development.
- C. It evaluates psychological responses.
- D. It helps to determine problems.
Correct Answer: B
Rationale: It assesses a child's development. The Denver test screens for developmental milestones in young children.
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An elderly client is severely dehydrated. Which is the best way to assess the effectiveness of fluid restoration therapy?
- A. Assess the client's skin turgor every shift.
- B. Record weights daily.
- C. Ask the client if she is thirsty.
- D. Record all intake.
Correct Answer: B
Rationale: Daily weights provide an objective measure of fluid restoration, as 1 kg approximates 1 L of fluid. Skin turgor is less reliable in elders, thirst is subjective, and intake alone doesn't confirm absorption.
A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about her obstetric history, which includes 3 year-old twins at home and a miscarriage 10 years ago. She is 8 weeks pregnant. Which description of her obstetric history is written correctly?
- A. Gravida 4 para 2
- B. Gravida 2 para 1
- C. Gravida 3 para 1
- D. Gravida 3 para 2
Correct Answer: C
Rationale: Gravida 3 para 1. Gravida is the number of pregnancies and Parity is the number of pregnancies that reach viability (not the number of fetuses). Thus, for this woman, she is now pregnant, had 2 prior pregnancies, and 1 viable birth (twins).
The nurse is to administer a tube feeding to a client. Before administering the feeding, what is essential for the nurse to do?
- A. Ask the client if she feels full
- B. Aspirate the nasogastric tube and check for acid
- C. Change the tubing
- D. Feel over the end of the tube and do not administer if air is felt
Correct Answer: B
Rationale: Aspirating and checking for acidic pH confirms nasogastric tube placement in the stomach, preventing aspiration. Other actions are irrelevant or unsafe.
A nurse is reinforcing teaching to the parent of a 6 year-old with a urinary tract infection on how to avoid repeat infections. Which statements by the parent indicate that the teaching has been effective? Select all that apply.
- A. I just bought my child new nylon panties.
- B. I will make sure my child does not hold urine.
- C. I will not give my child any more bubble baths.
- D. I will teach my child to wipe from the front to the back.
- E. I will use antibacterial soap for bathing my child.
Correct Answer: B,C,D
Rationale: Nylon panties can trap moisture, increasing infection risk; cotton is preferred. Not holding urine prevents bacterial growth. Avoiding bubble baths reduces irritation. Wiping front to back prevents bacterial spread. Antibacterial soap may disrupt natural flora, increasing infection risk.
The school nurse suspects that a third grade child might have attention deficit hyperactivity disorder (ADHD). Prior to referring the child for further evaluation, the nurse should
- A. Observe the child's behavior on at least 2 occasions
- B. Consult with the teacher about how to control impulsivity
- C. Compile a history of behavior patterns and developmental accomplishments
- D. Compare the child's behavior with classic signs and symptoms
Correct Answer: C
Rationale: Compile a history of behavior patterns and developmental accomplishments. A comprehensive history is essential for accurate ADHD diagnosis.