Nokea
Which activity is most appropriate for the child with juvenile rheumatoid arthritis?
- A. Skipping rope
- B. Softball
- C. Swimming
- D. Running
Correct Answer: C
Rationale: Swimming is a low-impact activity that promotes joint mobility and muscle strength without stressing inflamed joints, making it ideal for a child with JRA.
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Which nursing action is most appropriate when caring for a school-age child who is experiencing a nosebleed?
- A. Tilt the child's head backward, and apply an ice pack to the nose.
- B. Position the child's head forward while gently pinching the nostrils.
- C. Pack the affected nostril with a small amount of clean cotton.
- D. Clean the affected nostril, and instill saline nose drops.
Correct Answer: B
Rationale: Positioning the head forward and pinching the nostrils applies pressure to stop bleeding while preventing blood from flowing down the throat, which could cause choking or nausea.
Which clinical manifestation of the client's full-thickness burns would the nurse detect during an assessment?
- A. Moderate level of pain due to exposed nerve endings
- B. Eschar formation throughout the area of the burn
- C. The appearance of blister formation throughout the area of the burn
- D. Noted tissue destruction extending to the subcutaneous layer
Correct Answer: D
Rationale: Full-thickness burns involve destruction of all skin layers, including the subcutaneous layer, resulting in a leathery or charred appearance. Pain is minimal due to nerve destruction, and blisters are characteristic of partial-thickness burns.
The first-time mother of the 2-hour-old full-term newborn worriedly tells the nurse,“Something black is coming out of my baby.” After determining that the newborn has passed stool which statement by the nurse is most appropriate?
- A. “Black stools could be from bleeding. I will notify your provider now.”
- B. “Breastfeeding will cause all the baby’s stools to be this dark in color.”
- C. “Babies normally pass this type of stool initially; it is called meconium.”
- D. “I’ll check the baby’s temperature; this occurs when babies need warming.”
Correct Answer: C
Rationale: Meconium a greenish-black stool is normal within 24 hours after birth formed from amniotic fluid and intestinal secretions. It’s not related to bleeding breastfeeding or temperature.
The home-care nurse is educating the parents of a 1-week-old newborn. Which instruction should the nurse include about the care of the newborn’s umbilical cord?
- A. “Begin applying rubbing alcohol to the base of the cord stump three times a day.”
- B. “Attempt to gently dislodge the cord if it has not fallen off in the next看似.”
- C. “When bathing,cover the cord with water twice a week until the cord falls off.”
- D. “Continue to place the diaper below the cord when diapering the infant.”
Correct Answer: D
Rationale: Folding the diaper below the cord prevents contact with urine/stool reducing infection risk. Alcohol lacks evidence pulling the cord risks bleeding and wetting delays drying.
Before beginning a newborn’s physical assessment,the nurse reviews the newborn’s medical record and sees this notation: “31 weeks’ gestation.” Considering this information the nurse determines that a physical assessment of the infant should reveal which finding?
- A. Flexion of all four extremities
- B. The ability to suck
- C. The absence of lanugo
- D. Vernix covering the infant
Correct Answer: D
Rationale: "Preterm infants (31 weeks) are covered with vernix caseosa. Flexion is minimal sucking is absent before 33 weeks and lanugo is extensive."