Nokea
What is the priority assessment for a nurse when caring for an infant suspected of having necrotizing enterocolitis (NEC)?
- A. Hold feedings.
- B. Check gastric residuals before feedings.
- C. Take rectal temperature.
- D. Closely monitor abdominal distention.
Correct Answer: D
Rationale: The correct answer is D: Closely monitor abdominal distention. Monitoring the abdomen for signs of distention is crucial in the early detection of necrotizing enterocolitis (NEC). In NEC, the bowel wall is edematous and breaking down, leading to abdominal distention. Holding feedings is important in the management of NEC, as feedings may need to be stopped temporarily. Checking gastric residuals before feedings helps in assessing the infant's tolerance to feedings. Taking rectal temperatures is contraindicated in NEC as it can lead to the perforation of the bowel.
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A nurse is carrying on a conversation with a 7-year-old child during an office visit. Which is an example of the level of language development the nurse should expect in this child?
- A. Fascination with bathroom language
- B. Difficulty understanding the concept of 'half past' in reference to time
- C. Ability to carry on an adult conversation
- D. Inability to speak in full sentences
Correct Answer: B
Rationale: The correct answer is B. Understanding time concepts like 'half past' can be challenging for a 7-year-old, indicating the level of language development. Choice A is incorrect as fascination with bathroom language is common in this age group but not necessarily indicative of language development. Choice C is incorrect as a 7-year-old typically cannot carry on an adult conversation due to cognitive and experiential limitations. Choice D is incorrect as by the age of 7, children should be able to speak in full sentences.
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.
At what age is binocularity, the ability to fixate on one visual field with both eyes simultaneously, typically achieved?
- A. 1 month
- B. 3 to 4 months
- C. 6 to 8 months
- D. 12 months
Correct Answer: B
Rationale: Binocularity, the ability to fixate on one visual field with both eyes simultaneously, is typically achieved by the age of 3 to 4 months. Achieving binocularity at 1 month is too early for most infants as their visual system is still developing. Similarly, 6 to 8 months and 12 months are beyond the normal age range for achieving binocularity, and delayed achievement could indicate potential issues like strabismus, which may lead to visual impairment if not addressed.
The parents of a 5-year-old child ask the nurse how they can minimize misbehavior. Which responses should the nurse give? (Select all that apply.)
- A. Set clear and reasonable goals
- B. Teach desirable behavior through your own example
- C. Don't call attention to unacceptable behavior
- D. All of the above
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A major reason for the development of respiratory distress syndrome in the preterm infant is:
- A. Excessive surfactant
- B. Lack of surfactant
- C. Immature immune system
- D. Lack of body fat
Correct Answer: B
Rationale: The correct answer is B: Lack of surfactant. Respiratory distress syndrome (RDS) in preterm infants is primarily due to a lack of surfactant, which is crucial for keeping the lungs inflated. Without adequate surfactant, the alveoli collapse, leading to breathing difficulties. Choice A, Excessive surfactant, is incorrect as RDS is caused by an insufficient amount of surfactant. Choice C, Immature immune system, and Choice D, Lack of body fat, are not directly related to the development of respiratory distress syndrome in preterm infants.