Nokea
Which actions by the nurse demonstrate clinical reasoning? (Select all that apply.)
- A. All below
- B. Considering alternative actions
- C. Using formal and informal thinking to gather data
- D. Giving deliberate thought to a patient's problem
Correct Answer: A
Rationale: Clinical reasoning involves deliberate and thoughtful decision-making, considering alternatives, and using both formal and informal data gathering methods to provide optimum care.
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The nurse is teaching parents about the types of behaviors children exhibit when living with chronic violence. Which statement made by the parents indicates further teaching is needed?
- A. "We should watch for aggressive play."
- B. "Our child may show lasting symptoms of stress."
- C. "We know that our child will show caring behaviors."
- D. "Our child may have difficulty concentrating in school."
Correct Answer: C
Rationale: Children exposed to chronic violence may struggle with stress and concentration but are less likely to consistently exhibit caring behaviors without intervention and support.
At what stage can infants raise their heads and gain control of their trunks before walking due to which directional pattern of development?
- A. Cephalocaudal
- B. Anterior to posterior
- C. Proximodistal
- D. Normal growth curve charts
Correct Answer: A
Rationale: The correct answer is A: Cephalocaudal. The cephalocaudal pattern of development means that growth and motor control proceed from the head downward through the body. This explains why infants can raise their heads before they can sit and gain control of their trunks before walking. Choices B, C, and D are incorrect. Anterior to posterior refers to development from the front to the back, while proximodistal refers to development from the center of the body outward. Normal growth curve charts are used to track physical growth over time and are not directly related to the directional pattern of development in infants.
When assessing a family, the nurse determines that the parents exert little or no control over their children. This style of parenting is called which?
- A. Permissive
- B. Dictatorial
- C. Democratic
- D. Authoritarian
Correct Answer: A
Rationale: Permissive parenting is characterized by parents exerting little or no control over their children, leading to a lack of boundaries and structure.
The nurse is taking vital signs on a group of assigned preschool-aged children. Which assessment finding would indicate the need for further action?
- A. Respiratory rate of 20 breaths per minute
- B. Heart rate of 89 beats per minute
- C. Heart rate of 120 beats per minute
- D. Respiratory rate of 24 breaths per minute
Correct Answer: C
Rationale: A heart rate of 120 beats per minute is high for a preschool-aged child and may indicate an underlying issue that requires further assessment. A respiratory rate of 20 breaths per minute (choice A) is within the normal range for preschool children. Similarly, a heart rate of 89 beats per minute (choice B) falls within the expected range. A respiratory rate of 24 breaths per minute (choice D) is slightly elevated but may not be as concerning as a heart rate of 120 beats per minute.
The nurse is aware that which age group is at risk for childhood injury because of the cognitive characteristic of magical and egocentric thinking?
- A. Preschool
- B. Young school age
- C. Middle school age
- D. Adolescent
Correct Answer: A
Rationale: Preschool children are at higher risk for injury due to magical and egocentric thinking, which can lead to misjudgments about their abilities and dangers.