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Which action should the nurse implement when taking an axillary temperature?
- A. Take the temperature through one layer of clothing
- B. Add a degree to the result when recording
- C. Place the tip of the thermometer under the arm in the center of the axilla
- D. Hold the child's arm away from the body while taking the temperature
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The nurse is discussing growth and development with a group of parents. What should the nurse say about developmental milestones?
- A. Increase in body size.
- B. Age-specific tasks that most children can do at a certain time.
- C. The direction of growth.
- D. Refers to the age group of children.
Correct Answer: B
Rationale: The correct answer is B: "Age-specific tasks that most children can do at a certain time." Developmental milestones are specific tasks or abilities that most children can achieve at a certain age range. Choices A, C, and D are incorrect because developmental milestones are not just about increase in body size, the direction of growth, or the age group of children. They are more focused on the expected tasks and skills children can accomplish at particular ages.
When doing a nutritional assessment on a Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. The nurse should recognize that this diet is which?
- A. Lacking in protein
- B. Indicating they live in poverty
- C. Providing sufficient amino acids
- D. Needing enrichment with meat and milk
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When auscultating an infant's lungs, the nurse detects diminished breath sounds. What should the nurse interpret this as?
- A. Suggestive of chronic pulmonary disease
- B. Suggestive of impending respiratory failure
- C. An abnormal finding warranting investigation
- D. A normal finding in infants younger than 1 year of age
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When assessing a preschooler's chest, what should the nurse expect?
- A. Respiratory movements to be chiefly thoracic
- B. Anteroposterior diameter to be equal to the transverse diameter
- C. Retraction of the muscles between the ribs on respiratory movement
- D. Movement of the chest wall to be symmetric bilaterally and coordinated with breathing
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 6-year-old child has patient-controlled analgesia (PCA) for pain management after orthopedic surgery. The parents are worried that their child will be in pain. What should your explanation to the parents include?
- A. The child will continue to sleep and be pain-free
- B. Parents cannot administer additional medication with the button
- C. The pump can deliver baseline and bolus dosages
- D. There is a high risk of overdose, so monitoring is done every 15 minutes
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.