Nokea
The parents of a school-age child ask the nurse if she thinks that their child has attention deficit hyperactivity disorder (ADHD). Which statement regarding the child's behavior at school is most indicative of ADHD?
- A. He finishes his work on time in order to go to recess.
- B. He occasionally gets into trouble for talking.
- C. He enjoys math but does not like reading.
- D. He cannot sit still in his seat and constantly moves his legs.
Correct Answer: D
Rationale: The most indicative behavior of ADHD is the inability to sit still and constant movement, known as hyperactivity. This behavior is a hallmark symptom of ADHD, making option D the correct choice. Options A, B, and C do not specifically reflect the characteristic hyperactivity associated with ADHD, making them less indicative of the disorder. While option B suggests impulsivity, it is not as specific to ADHD as the hyperactivity described in option D.
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Which is the most frequently used test for measuring visual acuity?
- A. Snellen letter chart
- B. Ishihara vision test
- C. Allen picture card test
- D. Denver eye screening test
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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 8-year-old girl asks the nurse how the blood pressure apparatus works. The most appropriate nursing action is which?
- A. Ask her why she wants to know.
- B. Determine why she is so anxious.
- C. Explain in simple terms how it works.
- D. Tell her she will see how it works as it is used.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What interventions would the nurse implement to maintain the skin integrity of a preterm infant born at 30 weeks?
- A. Avoid using alkaline-based soap.
- B. Bathe the infant with sterile water.
- C. Cleanse skin with a gentle alkaline-based soap and water.
- D. Thoroughly rinse skin with plain water after bathing in a mild hexachlorophene solution.
Correct Answer: B
Rationale: To maintain the skin integrity of a preterm infant born at 30 weeks, the nurse should bathe the infant with sterile water no more than two or three times per week. The eyes, oral and diaper areas, and pressure points should be cleansed daily. It is essential to avoid using alkaline-based soaps as they might destroy the 'acid mantle' of the skin. Additionally, cleansing with mild solutions and rinsing thoroughly with plain water is recommended to prevent skin irritation and maintain skin integrity. Therefore, options A, C, and D are incorrect as they do not align with the best practices for preterm infant skin care.
The parents of a child with sickle cell anemia ask why their child did not have a sickle cell crisis until he was approximately 6 months old. How should the nurse respond?
- A. Your child probably had a crisis, and you were unaware of the symptoms.
- B. Are you sure your child has sickle cell anemia and not sickle cell trait?
- C. Affected children can be asymptomatic in early infancy because of high levels of fetal hemoglobin that inhibit sickling.
- D. Have you asked your doctor about this yet?
Correct Answer: C
Rationale: The correct answer is C. Fetal hemoglobin (HbF) is present in high levels during early infancy, inhibiting sickling unlike adult hemoglobin (HbS). As the levels of HbF decrease and HbS increases, the risk of sickling and crises becomes more pronounced, typically after 6 months of age. Choice A is incorrect because it assumes the crisis went unnoticed, which is not supported by medical knowledge. Choice B is incorrect as it questions the child's diagnosis rather than explaining the phenomenon of delayed crises. Choice D is incorrect as it does not provide the parents with the necessary information regarding their query.