Nokea
The twelve-year-old boy has fractured his arm because of a fall from his bike. After the injury has been casted, the nurse knows it is most important to perform all of the following assessments on the area distal to the injury except:
- A. capillary refill.
- B. radial and ulnar pulse.
- C. finger movement
- D. skin integrity
Correct Answer: B
Rationale: Assessing the radial and ulnar pulses is crucial in evaluating the circulation of blood to the hand. However, in this scenario of a fractured arm, the injury is distal to the hand (further away from the body). It is more critical to check capillary refill, finger movement, and skin integrity in the area distal to the injury to ensure there is no compromise to the blood flow, nerve function, or skin integrity following the injury. Checking the radial and ulnar pulse would be more relevant if the injury was closer to the wrist area, as it would directly impact these pulses.
You may also like to solve these questions
For a patient with gastroesophageal reflux symptoms, the purpose of esophageal pH monitoring is to evaluate for:
- A. esophagitis from the reflux.
- B. frequency of the reflux.
- C. gastric emptying delays.
- D. possible obstructions.
Correct Answer: B
Rationale: Esophageal pH monitoring measures the frequency and duration of acid exposure in the esophagus, helping diagnose GERD.
A college student goes to the college clinic and asks the best way to avoid contracting an STD. The nurse provides the clinic's standard STD teaching. Which statement by the student indicates the need for additional instruction?
- A. "There is no guarantee that I won't contract an STD if I choose to be sexually active."
- B. "Abstinence is the only sure way to avoid an STD."
- C. "If I use a condom with spermicide, I will be safer than if I don't use one."
- D. "If I question my partner about past sexual encounters, I can avoid STDs."
Correct Answer: D
Rationale: The statement "If I question my partner about past sexual encounters, I can avoid STDs" indicates a need for additional instruction. While communication with a partner about sexual history is important, relying solely on questioning a partner is not a foolproof method of avoiding STDs. Some individuals may not disclose their complete sexual history or may be unaware that they have an STD. It is crucial to emphasize the importance of using protection such as condoms consistently and correctly, getting tested regularly, and practicing safe sex in general.
A nurse is assessing for jaundice in a dark-skinned newborn. Where is the best place to assess for jaundice in this newborn?
- A. Buttocks
- B. Tip of nose and sclera
- C. Sclera, conjunctiva, and oral mucosa
- D. Palms of hands and soles of feet
Correct Answer: C
Rationale: The best place to assess for jaundice in a dark-skinned newborn is in the sclera, conjunctiva, and oral mucosa. Jaundice, which is caused by elevated levels of bilirubin in the blood, is more easily seen in these areas compared to the skin. While jaundice is commonly assessed on the skin in light-skinned individuals, it may not be as readily apparent in dark-skinned newborns. Therefore, examining the sclera, conjunctiva, and oral mucosa for a yellowish discoloration provides a more reliable indication of jaundice in dark-skinned infants. This approach ensures that healthcare providers can accurately detect and monitor jaundice in newborns of all skin tones.
A nurse makes the decision to apply a topical anesthetic to a child's skin before drawing blood. Which ethical principle is the nurse demonstrating?
- A. Autonomy
- B. Beneficence
- C. Justice
- D. Truthfulness
Correct Answer: B
Rationale: The nurse is demonstrating the ethical principle of beneficence by applying a topical anesthetic to the child's skin before drawing blood. Beneficence refers to the obligation to act in the best interest of the patient, promoting their well-being and preventing harm. In this case, the nurse is taking proactive steps to minimize the child's discomfort and potential pain during the blood draw procedure, thus upholding the principle of beneficence.
The nurse is testing an infant's visual acuity. By what age should the infant be able to fix on and follow a target?
- A. 1 month
- B. 1 to 2 months
- C. 3 to 4 months
- D. 6 months
Correct Answer: D
Rationale: By 6 months of age, infants should be able to fix on and follow a target with their eyes. This behavior is indicative of normal visual development in infants. It typically signifies that the infant's visual acuity is developing as expected. Therefore, by the age of 6 months, most infants should demonstrate the ability to focus on and track objects within their field of vision.