Nokea
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.
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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.
The nurse is measuring both the chest and head circumference during the full-term newborn’s initial assessment. The newborn’s father observes this and asks the nurse why both measurements are necessary. Which explanation is most accurate?
- A. “Comparing the measurements helps determine if there are head or chest size abnormalities.”
- B. “Measuring the head circumference provides information about future intellectual ability.”
- C. “Measuring the newborn’s chest provides needed information when assessing cardiac health.”
- D. “Comparing the head and chest measurements helps to determine future adult body size.”
Correct Answer: A
Rationale: The circumference of the normal newborn’s head is approximately 2 centimeters greater than the chest at birth. Extreme differences may indicate abnormalities like microcephalus or hydrocephalus. Head size doesn’t predict intelligence chest size doesn’t assess cardiac health and measurements don’t predict adult size.
Breech extraction is only indicated in:
- A. Retained second twin.
- B. Footling breech.
- C. Extended breech.
- D. Flexed breech.
- E. Breech in first twin.
Correct Answer: A
Rationale: Breech extraction is indicated for a retained second twin to expedite delivery and prevent complications. Other breech presentations typically require cesarean section or external cephalic version.
When assessing the infant undergoing phototherapy for hyperbilirubinemia,the nurse notes a maculopapular rash over the infant’s buttocks and back. What action should the nurse take next?
- A. Document the results in the newborn’s medical record.
- B. Call the HCP immediately to report this finding.
- C. Discontinue the phototherapy immediately.
- D. Assess the infant’s axillary temperature.
Correct Answer: A
Rationale: A transient maculopapular rash is a common benign side effect of phototherapy requiring only documentation. No further action is needed.
Which statement by the parents indicates they understand the home care instructions given by the nurse?
- A. We've made arrangements for a homebound teacher.
- B. We'll use ice packs on our child's joints during episodes of inflammation.
- C. We'll serve meals that prevent excess weight gain.
- D. We'll keep our child in bed most of the time.
Correct Answer: C
Rationale: Maintaining a healthy weight reduces stress on inflamed joints in JRA. Serving meals that prevent excess weight gain shows understanding of home care instructions to support joint health.