Nokea
The nurse understands that blocks to therapeutic communication include what? (Select all that apply.)
- A. Socializing
- B. All are applicable
- C. Using clich©s
- D. Defending a situation
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A 3-year-old child, previously potty-trained, becomes a bed-wetter again during a hospital stay. Which explanation should the nurse provide to the parents?
- A. "Your child is no longer potty-trained and will need to be retrained when she goes home."
- B. "The child may have developed a bladder infection in the hospital. I will notify the doctor."
- C. "Preschool children may regress in their behaviors when they are ill in the hospital but should return to normal when they go back home."
- D. "Don't worry about it, she is fine."
Correct Answer: C
Rationale: During a hospital stay, preschool children may exhibit regression in behaviors such as bed-wetting due to stress. It is important for parents to understand that this behavior is a common response to the hospital environment and should resolve once the child is back home. Therefore, the correct explanation for the nurse to provide to the parents is choice C. Choice A is incorrect because it inaccurately states that the child is no longer potty-trained. Choice B is incorrect as it assumes a medical issue without evidence. Choice D is incorrect as it dismisses the parents' concerns without addressing the underlying cause of the behavior.
What findings would the nurse consider normal in assessing the anterior fontanel of a neonate?
- A. Closed anterior fontanel
- B. Sunken anterior fontanel
- C. Bulging anterior fontanel
- D. Pulsating anterior fontanel
Correct Answer: D
Rationale: The correct answer is D: Pulsating anterior fontanel. The fontanel should feel flat, firm, and well demarcated. Pulsations are frequently visible at the anterior fontanel, which is a normal finding in a neonate. A closed anterior fontanel, as mentioned, is a potential sign of a major abnormality. A sunken or bulging fontanel (when the infant is quiet) may be indicative of distress or a major abnormality. Therefore, options A, B, and C are considered abnormal findings when assessing the anterior fontanel of a neonate.
What interventions should be implemented to maintain the skin integrity of a preterm infant born at 30 weeks?
- A. Avoid cleaning the skin
- B. Bathe the infant with sterile water
- C. Cleanse the skin with a gentle alkaline-based soap and water
- D. Thoroughly rinse the skin with plain water after bathing
Correct Answer: B
Rationale: The correct intervention to maintain the skin integrity of a preterm infant born at 30 weeks is to bathe the infant with sterile water. Bathing with sterile water or a neutral pH solution is recommended to protect the delicate skin of preterm infants, which is more permeable and prone to damage. Choices A, C, and D are incorrect as avoiding cleaning the skin may lead to hygiene issues, cleansing with alkaline-based soap can be harsh on the delicate skin, and thoroughly rinsing with plain water after bathing may not be as gentle and protective for preterm infants.
During an otoscopic examination on an infant, in which direction is the pinna pulled?
- A. Up and back
- B. Up and forward
- C. Down and back
- D. Down and forward
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
An infant is born with anencephaly. Based on the knowledge of this diagnosis, what information does the nurse consider when interacting with the family?
- A. Many treatment options exist.
- B. Immediate surgery is necessary.
- C. The condition is incompatible with life.
- D. The child will have permanent disabilities.
Correct Answer: C
Rationale: The correct answer is C: 'The condition is incompatible with life.' Anencephaly is the most serious neural tube defect where both hemispheres of the brain are absent. It is incompatible with life, as there are no medical or surgical treatment options available. While some infants with mature brain stem function can maintain vital functions for a short period, anencephaly is ultimately not survivable. Choice A is incorrect as there are no treatment options for anencephaly. Choice B is incorrect as immediate surgery is not necessary for this condition. Choice D is incorrect as an infant with anencephaly will not have permanent disabilities since the condition is not compatible with life.