Nokea
Which is an appropriate play activity for a 7-month-old infant to encourage visual stimulation?
- A. Playing peek-a-boo
- B. Playing pat-a-cake
- C. Imitating animal sounds
- D. Showing how to clap hands
Correct Answer: A
Rationale: Playing peek-a-boo is an appropriate play activity for a 7-month-old infant to encourage visual stimulation. By engaging in peek-a-boo, infants can improve their visual tracking skills, focus, and attention. The sudden appearance and disappearance of faces during the game can captivate the baby's attention and help develop their visual processing abilities. Additionally, playing peek-a-boo can foster social interaction, bonding, and trust between the infant and caregiver, contributing to the baby's overall development and well-being.
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One nursing diagnosis for JRA is impaired physical mobility. Select all nursing interventions that apply.
- A. Give pain medication prior to ambulation.
- B. Assist with range-of-motion activities.
- C. Encourage the child to eat a high-fat diet.
- D. Provide oxygen as necessary.
Correct Answer: A
Rationale: Giving pain medication prior to ambulation can help alleviate discomfort and improve the child's ability to perform physical activities, thus promoting mobility.
A male client age 78, complaints of dizziness, especially when he stands up after sleeping or sitting. The client also informs the nurse that he periodically experiences nosebleeds and blurred vision. Which of the ff conditions should the nurse assess for the client?
- A. Postural hypotension
- B. Postural Hypertension
- C. White coat hypertension
- D. White coat hypotension
Correct Answer: A
Rationale: The client's symptoms of dizziness upon standing up, along with nosebleeds and blurred vision, are suggestive of postural hypotension. Postural hypotension, also known as orthostatic hypotension, is a drop in blood pressure that occurs when a person stands up from a sitting or lying position. This drop in blood pressure can lead to symptoms such as dizziness, lightheadedness, blurred vision, and in some cases, nosebleeds. It is more common in older adults, like the 78-year-old male client in this scenario. Therefore, the nurse should assess for postural hypotension in this client to manage his symptoms and prevent complications.
Stroking the newborn's cheek along the side of the mouth causes the newborn to turn the head toward that side and begin to suck. This is which reflex?
- A. Perez
- B. Sucking
- C. Rooting
- D. Extrusion
Correct Answer: C
Rationale: The described reflex involving stroking the newborn's cheek along the side of the mouth causing the newborn to turn the head toward that side and begin to suck is known as the rooting reflex. This reflex is essential for newborns to find the nipple and start breastfeeding. Stroking the cheek triggers the baby to turn towards the stimulus, helping them locate the source of food for feeding.
When evaluating a client's response to fluid replacement therapy, the observation that indicates adequate tissue perfusion to vital organ is;
- A. Urinary output of 30 ml in an hour
- B. Central venous pressure reading of 2 cm H20
- C. Pulse rates of 120 and 110 in a 15- minute period
- D. Blood pressure readings of 50/30 and 70/40 mm Hg within 30 minutes
Correct Answer: A
Rationale: The observation that indicates adequate tissue perfusion to vital organs is a urinary output of 30 ml in an hour. Adequate tissue perfusion is essential to ensure that vital organs receive enough blood and oxygen. Monitoring urinary output is a crucial indicator of perfusion status, as it reflects the perfusion of the kidneys. A urinary output of at least 30 ml/hour or more indicates that the kidneys are receiving sufficient blood flow and are able to produce urine, which helps in removing waste products from the body. In this case, a urinary output of 30 ml in an hour suggests adequate tissue perfusion to vital organs. The other options do not directly reflect tissue perfusion to vital organs and may indicate inadequate perfusion or compromised hemodynamic status.
Which of the following signs indicates to the nurse that digoxin (Lanoxin) has been effective for a patient?
- A. Urine output decreases
- B. Heart rate higher than 95
- C. Urine output increases
- D. Heart rate lower than 50
Correct Answer: C
Rationale: Digoxin is a medication commonly used to treat heart failure and certain types of irregular heart rhythms. One of the therapeutic effects of digoxin is an improvement in cardiac output, leading to better tissue perfusion. As the heart's pumping ability improves, blood flow to the kidneys also increases, resulting in an increase in urine output. Therefore, an increase in urine output is a positive indication that digoxin is effective for the patient. Monitoring urine output can be a valuable way for nurses to assess the response to digoxin therapy and the overall cardiac function of the patient.