Nokea
The parent of a 9-month-old infant is concerned that the infant's front soft spot is still open. The nurse should tell the parent:
- A. I will measure your baby's head to see if it is a normal size.
- B. Your infant will need to be referred for more testing.
- C. You should contact your physician immediately.
- D. It is normal because this soft spot usually closes between 12 and 18 months.
Correct Answer: D
Rationale: The anterior fontanelle typically closes between 12-18 months, so this is normal.
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Several high-school seniors are referred to the school nurse because of suspected alcohol misuse. When the nurse assesses the situation, what would be most important to determine?
- A. What they know about the legal implications of drinking.
- B. The type of alcohol they usually drink.
- C. The reasons they choose to use alcohol.
- D. When and with whom they use alcohol.
Correct Answer: C
Rationale: Understanding the reasons for alcohol use helps address underlying issues and tailor interventions.
During the initial assessment of a child admitted to the pediatric unit with osteomyelitis of the left tibia, when assessing the area over the tibia, which is a new needed finding?
- A. Diffuse tenderness.
- B. Decreased pain.
- C. Increased warmth.
- D. Localized edema.
Correct Answer: C
Rationale: Increased warmth is a key sign of osteomyelitis, indicating inflammation and possible infection in the affected bone.
A child with celiac disease is at risk for which complication if the diet is not followed?
- A. Renal failure.
- B. Intestinal lymphoma.
- C. Pulmonary fibrosis.
- D. Cardiomyopathy.
Correct Answer: B
Rationale: Untreated celiac disease increases the risk of intestinal lymphoma due to chronic inflammation. Renal, pulmonary, or cardiac complications are not directly associated.
When developing the plan of care for a child who is unconscious after a serious head injury, in which of the following positions should the nurse expect to place the child?
- A. Prone with hips and knees slightly elevated.
- B. Lying on the side, with the head of the bed elevated.
- C. Lying on the back, in the Trendelenburg position.
- D. In the semi-Fowler's position, with arms at the side.
Correct Answer: B
Rationale: Side-lying with the head elevated reduces intracranial pressure and maintains airway patency in an unconscious child.
A parent brings a 4-month-old to the clinic for a regular well visit and expresses concern that the infant is not developing appropriately. Which findings in the infant would indicate the need for further developmental screening?
- A. Has no interest in peek-a-boo games.
- B. Does not turn front to back.
- C. Does not babble.
- D. Continues to have head lag.
Correct Answer: D
Rationale: Head lag at 4 months suggests delayed motor development, requiring further evaluation.