Nokea
When assessing the external ear, the nurse palpates a small protrusion of the helix called a Darwin tubercle. The nurse would document this finding as which of the following?
- A. A normal finding
- B. An abnormal finding
- C. A normal finding only in the older adult
- D. An abnormal finding only in the older adult
Correct Answer: A
Rationale: A Darwin tubercle is a small, painless, hereditary nodule located on the helix of the ear. It is a normal anatomical variation and is present in varying degrees in the general population, regardless of age. Therefore, it would be documented as a normal finding during the assessment of the external ear.
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The nurse is doing a routine assessment on a 14-month-old infant and notes that the anterior fontanel is closed. How should the nurse interpret this finding?
- A. Normal finding
- B. Finding requiring a referral
- C. Abnormal finding
- D. Normal finding, but requires rechecking in 1 month
Correct Answer: A
Rationale: The closure of the anterior fontanel in a 14-month-old infant is a normal finding. The anterior fontanel typically closes by around 18 months of age. The closure of the fontanel is a sign of normal growth and development as the bones of the skull fuse together. It is not a cause for concern at this age, and the nurse should document this as a normal finding.
The parents of a 12-month-old child ask the nurse whether the child can eat hot dogs. The nurse's reply should be based on which statement?
- A. Child is too young to digest hot dogs.
- B. Child is too young to eat hot dogs safely.
- C. Hot dogs must be sliced into sections to prevent aspiration.
- D. Hot dogs must be cut into small, irregular pieces to prevent aspiration.
Correct Answer: D
Rationale: The correct statement to guide the parents on feeding their 12-month-old child hot dogs is that the hot dogs must be cut into small, irregular pieces to prevent aspiration. Hot dogs are a high-risk choking hazard for young children due to their shape and texture. Cutting them into small, irregular pieces decreases the risk of choking as compared to slicing them into sections. It is essential to always supervise young children while they are eating to prevent choking incidents. So, the nurse should advise the parents to cut the hot dogs into small, irregular pieces to ensure the child's safety.
A 40 year old woman with aplastic anemia is prescribed estrogen with progesterone. The nurse can expect that these medications are given for which of the following reasons?
- A. To stimulate bone growth
- B. To enhance sodium and potassium
- C. To regulate fluid balance absorption
- D. To promote utilization and storage of fluids
Correct Answer: A
Rationale: Estrogen plays a crucial role in maintaining bone density and promoting bone growth in both men and women. Aplastic anemia is a condition where the bone marrow does not produce enough blood cells, leading to low blood cell counts. Estrogen therapy is often used in aplastic anemia to help stimulate bone growth and improve bone health. Additionally, estrogen can help protect against bone loss, which is important for overall bone health in individuals with this condition. Progesterone is commonly prescribed along with estrogen to provide a balanced hormonal therapy approach.
Which clinical manifestation should the nurse expect to see as shock progresses in a child and becomes decompensated shock?
- A. Thirst
- B. Irritability
- C. Apprehension
- D. Confusion and somnolence
Correct Answer: D
Rationale: As shock progresses and becomes decompensated in a child, profound perfusion abnormalities lead to inadequate oxygen and nutrient delivery to the brain. This can result in altered mental status such as confusion and somnolence. As the body struggles to maintain adequate perfusion to vital organs, the brain may be one of the first organs to demonstrate signs of inadequate perfusion. Thirst, irritability, and apprehension are more commonly seen in the early stages of shock. Confusion and somnolence indicate a more severe and critical state of shock where the child's body is struggling to maintain adequate blood flow to vital organs, including the brain.
What should be included in the plan of care for a preschool-age child who is admitted in a vasoocclusive sickle cell crisis (pain episode)?
- A. Pain management
- B. Administration of heparin
- C. Factor VIII replacement
- D. Electrolyte replacement
Correct Answer: A
Rationale: Pain management is a crucial component in the plan of care for a preschool-age child admitted with a vasoocclusive sickle cell crisis. Sickle cell disease causes blood vessels to become blocked, leading to ischemia and pain. Managing pain promptly and effectively is necessary to improve the child's comfort level and prevent complications. Pain management strategies typically involve the use of analgesic medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or opioids, tailored to the child's age and weight. Additionally, non-pharmacological interventions like distraction techniques and positioning can help in reducing pain and promoting relaxation in children during a sickle cell crisis.