Nokea
What is the most consistent and commonly used indicator of pain in infants?
- A. Increased respirations
- B. Increased heart rate
- C. Thrashing of arms and legs
- D. Facial expression of discomfort
Correct Answer: D
Rationale: Facial expression has consistently been validated as an indicator of pain in infants. Behavioral pain measures are most reliable for sharp procedural pain in infants. Increased heart rate and respirations are indicative of a generalized and complex response to stress, not specific for pain in infants. Thrashing of arms and legs is a reliable indicator in young children, not specifically in infants.
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Where would nonpathologic cyanosis normally be present in the newborn shortly after birth?
- A. Feet and hands
- B. Bridge of nose
- C. Circumoral area
- D. Mucous membranes
Correct Answer: A
Rationale: Nonpathologic cyanosis in newborns shortly after birth is typically present in the feet and hands, known as acrocyanosis. This is a normal finding due to the immature peripheral circulation in newborns. Cyanosis of the bridge of the nose, circumoral area, and mucous membranes indicates generalized cyanosis, which suggests a potential underlying distress or major abnormality. Therefore, choice A is correct as it describes the expected location for nonpathologic cyanosis in newborns, while choices B, C, and D represent areas associated with abnormal cyanosis.
The nurse is administering activated charcoal to a preschool child with acetaminophen (Tylenol) poisoning. What potential complications from the use of activated charcoal should the nurse plan to assess for?
- A. Diarrhea
- B. Vomiting
- C. All are correct
- D. Intestinal obstruction
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is teaching parents about potential causes of colic in infancy. Which should the nurse include in the teaching session?
- A. Overeating
- B. All are applicable
- C. Frequent burping
- D. Parental smoking
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 13-year-old boy comes to the school nurse complaining of sudden and severe scrotal pain. He denies any trauma to the scrotum. What is the most appropriate nursing action?
- A. Refer him for immediate medical evaluation
- B. Administer analgesics and recommend scrotal support.
- C. Apply an ice bag and observe for increasing pain.
- D. Reassure the adolescent that occasional pain is common with the changes of puberty.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
By what age does birth weight usually triple?
- A. 1 year
- B. 1 month
- C. 2 years
- D. 6 months
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.