Nokea
When assessing a child with a cleft palate, the nurse is aware that the child is at risk for more frequent episodes of otitis media due to which of the following?
- A. Lowered resistance from malnutrition
- B. Ineffective functioning of the Eustachian tubes
- C. Plugging of the Eustachian tubes with food particles
- D. Associated congenital defects of the middle ear.
Correct Answer: B
Rationale: Because of the structural defect, children with cleft palate may have ineffective functioning of their Eustachian tubes creating frequent bouts of otitis media.
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Mother Riza brings her normally developed 3-year old to the clinic for a check-up. The nurse would expect that the child would be at least skilled in...
- A. Riding a bicycle
- B. Tying shoelaces
- C. Stringing large beads
- D. Using blunt scissors
Correct Answer: C
Rationale: Stringing large beads is a fine motor skill expected of a 3-year-old.
What does the nurse explain can affect the survival of the X- and Y-bearing sperm after intercourse?
- A. Age
- B. Estrogen level
- C. Body temperature
- D. Level of feminine hygiene
Correct Answer: B
Rationale: Estrogen levels and the $\mathrm{pH}$ of the female reproductive tract can affect the survival of the X- and Y-bearing sperm as well as their motility.
Student practical nurses are discussing the North American Nursing Diagnosis Association International (NANDA-I) taxonomy in post conference on the acute care clinical setting. The students are aware that the role of the LPN with nursing diagnosis formulation is what?
- A. To initiate and identify nursing diagnosis specific to patient
- B. To update changes in nursing diagnosis as needed
- C. To have an understanding of nursing diagnosis terminology
- D. To accurately document nursing diagnosis on patient plan of care
Correct Answer: C
Rationale: The registered nurse is responsible to initiate, identify, update, and document nursing diagnoses. The licensed practical nurse is responsible to have an understanding of nursing diagnosis terminology.
You are assessing 7-year-old Mary's lymph nodes. Using the distal portion of your fingers, you press gently but firmly in a circular motion along the occipital and post auricular node areas. You record the findings as 'tender, enlarged, and warm lymph nodes.' Which of the following is TRUE?
- A. Your findings are within normal limits for Mary's age.
- B. Your assessment technique was incorrect and should be repeated.
- C. Your findings suggest infection or inflammation in the scalp area or external ear canal.
- D. Your recording of the information is complete because it includes temperature and tenderness.
Correct Answer: C
Rationale: Tender, enlarged, warm lymph nodes suggest infection/inflammation, likely in the scalp or ear canal, not normal for a healthy child.
Which of the following nursing diagnoses would be inappropriate for the infant with gastroesophageal reflux (GER)?
- A. Fluid volume deficit
- B. Risk for aspiration
- C. Altered nutrition: less than body requirements
- D. Altered oral mucous membranes
Correct Answer: D
Rationale: GER is the backflow of gastric contents into the esophagus resulting from relaxation or incompetence of the lower esophageal (cardiac) sphincter. No alteration in the oral mucous membranes occurs with this disorder.