Nokea
Which information about methamphetamine use is most accurate and important for the parents to know?
- A. Methamphetamines are tried by most adolescents and cause no harm.
- B. Methamphetamines are known to lead to addiction.
- C. Methamphetamines are a central nervous system depressant.
- D. Methamphetamines are harmful only if taken intravenously.
Correct Answer: B
Rationale: Methamphetamines are highly addictive stimulants, and informing parents about the risk of addiction is critical to understanding the severity of the adolescent's behavior.
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Crowning is best defined as:
- A. When the greatest diameter of fetal head comes through vulva.
- B. When presenting part reaches the pelvic floor.
- C. When the perineum bulges in front of fetal head.
- D. When fetal head is visible at vulva.
- E. When head is delivered.
Correct Answer: C
Rationale: Crowning occurs when the perineum bulges due to the fetal head’s largest diameter stretching the vaginal opening just before delivery. Other definitions describe different stages.
Which intervention is most appropriate for a child with a musculoskeletal disability using a wheelchair?
- A. Encourage competitive sports to build strength.
- B. Provide a firm mattress to prevent bedsores.
- C. Teach the child to avoid all physical activity.
- D. Limit the child's interaction with peers.
Correct Answer: B
Rationale: A firm mattress helps distribute weight evenly, reducing the risk of pressure ulcers in a child with limited mobility due to a musculoskeletal disability.
Which nursing action should be avoided when giving care to a child diagnosed with Wilms' tumor?
- A. Palpating the child's abdomen
- B. Collecting a catheterized urine sample
- C. Assessing pupillary reflex with a penlight
- D. Eliciting a patellar reflex with a reflex hammer
Correct Answer: A
Rationale: Palpating the abdomen in a child with Wilms' tumor risks dislodging tumor cells, potentially causing metastasis, and should be avoided to ensure safety.
The nurse is caring for the full-term newborn male who is 24 hours old and was circumcised with a Gomco clamp 30 minutes ago. Which interventions should the nurse plan for care of the newborn’s circumcision? Select all that apply.
- A. Monitor the newborn’s penis hourly for 4 to 6 hours.
- B. Observe for and document the first voiding after circumcision.
- C. Use prepackaged commercial diaper wipes for perineal cleansing.
- D. Apply petroleum ointment around the penis after each diaper change.
- E. Apply tightly a size-smaller diaper to provide hemostasis.
Correct Answer: A,B,D
Rationale: Monitor the penis for swelling/bleeding document first void to rule out obstruction and apply petroleum ointment to prevent bleeding. Commercial wipes may irritate and tight diapers cause pain.
The nurse meets the frantic father at an ED door. He says he just delivered his wife’s full-term newborn in the car when the temperature outside is only 10°F (—12.2°C). In response to the cold environment,the nurse knows that the infant’s body will immediately begin to produce heat by which mechanism?
- A. Shivering
- B. Metabolizing body fat
- C. Dilating surface blood vessels
- D. Decreasing flexion of the extremities
Correct Answer: B
Rationale: When skin receptors of full-term newborns perceive a drop in environmental temperature the sympathetic nervous system is stimulated. This in turn stimulates metabolism of brown fat thus producing heat that is transferred to the peripheral circulation. Shivering is rarely seen in newborns and it does little to produce heat. Newborns conserve heat by constricting not dilating blood vessels. Decreasing flexion promotes heat loss by exposing more skin surface.