Nokea
The nurse prepares to teach an adolescent scheduled for an appendectomy about what to expect. The adolescent says, "I would rather look this up on the Internet." The nurse should:
- A. Explain that completing a teaching checklist is required by the hospital.
- B. Help the client find information on the Internet.
- C. Provide the client with written information instead.
- D. Explain that information found on the Internet cannot be trusted.
Correct Answer: B
Rationale: Assisting with finding reliable online information respects the adolescent's autonomy.
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The nurse is assessing the infant shown in the figure. On observing the infant from this angle, the nurse should document that this infant has which of the following?
- A. Ortolani's 'click.'
- B. Limited abduction.
- C. Galeazzi's sign.
- D. Asymmetric gluteal folds.
Correct Answer: D
Rationale: Asymmetric gluteal folds are a clinical sign of developmental dysplasia of the hip, indicating possible hip dislocation or asymmetry.
Which of the following, if described by the parents of a child with cystic fibrosis (CF), indicates that the parents understand the underlying problem of the disease?
- A. An abnormality in the body's mucus-secreting glands.
- B. Formation of fibrous cysts in various body organs.
- C. Failure of the pancreatic ducts to develop properly.
- D. Addition to the formation of antibodies against streptococcus.
Correct Answer: A
Rationale: Cystic fibrosis is caused by an abnormality in mucus-secreting glands, leading to thick mucus that affects multiple organs, particularly the lungs and pancreas.
Which of the following would be the best activity for the nurse to include in the plan of care for an infant experiencing severe diarrhea?
- A. Monitoring the total 8-hour formula intake.
- B. Weighing the infant each day.
- C. Checking the anterior fontanel every shift.
- D. Monitoring abdominal skin turgor every shift.
Correct Answer: B
Rationale: Daily weights provide an accurate measure of fluid loss in diarrhea.
A 10-month-old looks for objects that have been removed from his view. The nurse should instruct the parents that:
- A. Neuromuscular development enables the child to reach out and grasp objects.
- B. The child's curiosity has increased.
- C. The child understands the permanence of objects even though the child cannot see them.
- D. The child is now able to transfer objects from hand to hand.
Correct Answer: C
Rationale: This behavior indicates object permanence, a cognitive milestone typically achieved around 9-12 months.
A male adolescent who underwent repair of an inguinal hernia earlier today and is getting ready to go home receives instructions about resuming physical activities. Which of the following statements would indicate that he has understood the instructions?
- A. I can start riding my bike next week.
- B. I have to skip physical education classes for 2 weeks.
- C. I can start wrestling again in 3 weeks.
- D. I can return to my weight-lifting class in 2 weeks.
Correct Answer: B
Rationale: Avoiding strenuous activities like PE for 2 weeks prevents strain on the surgical site.