Nokea
A nurse is assessing the fontanels of 8-month-old infant.
which of the following findings should the nurse recognize as an expected finding?
- A. The anterior fontanel is open
- B. The posterior fontanel is open
- C. The anterior fontanel is sunken
- D. The anterior fontanel is bulging
Correct Answer: A
Rationale: The correct answer is A: The anterior fontanel is open. This is an expected finding in infants as the anterior fontanel typically remains open until around 18-24 months of age, allowing for the growth and expansion of the skull bones. It is a normal part of development and closure indicates maturation. The posterior fontanel closes earlier than the anterior fontanel, so option B is incorrect. Option C, sunken anterior fontanel, indicates dehydration, while option D, bulging anterior fontanel, is a sign of increased intracranial pressure, both of which are abnormal findings.
You may also like to solve these questions
A nurse is teaching a client about advanced directives. Which of the following statements by the client indicate an understanding of the teaching?
- A. A living will is a document that includes my wishes about health care decisions.
- B. My provider will make my health care decisions if I complete advanced directives.
- C. Advanced directives outline who inherits my material possessions in the event of my death.
- D. My partner needs to be present as a witness when I sign my living will
Correct Answer: A
Rationale: The correct answer is A: A living will is a document that includes my wishes about health care decisions. This statement demonstrates an understanding of advanced directives as a living will specifically pertains to healthcare decisions. It shows that the client comprehends that a living will outlines their preferences for medical treatment in case they are unable to communicate.
Choice B is incorrect because advanced directives are about the client's own wishes, not the provider making decisions. Choice C is incorrect as advanced directives do not pertain to material possessions but rather to healthcare decisions. Choice D is incorrect because a witness is typically required for legal purposes when signing a living will, but the presence of a partner is not mandatory.
A nurse is preparing to administer the first dose of cefazolin via intermittent IV infusion to a client.
Which of the following actions should the nurse take first?
- A. Review the client's allergy history.
- B. Monitor the client's temperature.
- C. Check the client's latest white blood cell(WBC) count.
- D. Explain the purpose of the medication to the client.
Correct Answer: A
Rationale: The correct answer is A: Review the client's allergy history. This should be done first to prevent potential harm to the client from allergic reactions. Knowing the client's allergy history helps the nurse identify any potential risks associated with administering medications. Monitoring temperature (B) and checking WBC count (C) are important but come after ensuring the safety of medication administration. Explaining the purpose of medication (D) is important but should be done after ensuring the client's safety.
A nurse is caring for a child who has cystic fibrosis and requires posterior drainage.
Which action should the nurse take?
- A. Perform the procedure prior to meals.
- B. Perform chest physiotherapy immediately after feeding.
- C. Place the child in a supine position for the procedure.
- D. Limit fluid intake before the procedure.
Correct Answer: A
Rationale: The correct answer is A: Perform the procedure prior to meals. This is because performing the procedure before meals helps prevent potential complications such as aspiration during feeding. By emptying the stomach before meals, the risk of regurgitation and aspiration is reduced. Choices B, C, and D are incorrect because chest physiotherapy immediately after feeding can increase the risk of aspiration, placing the child in a supine position can also increase the risk of aspiration, and limiting fluid intake before the procedure may lead to dehydration and is not necessary for this specific procedure.
A nurse is planning care for a group of clients and is working with one licensed practical nurse (LPN) and one assistive personnel (AP). Which of the following actions should the nurse take first to manage her time effectively?
- A. Delegate tasks to the AP
- B. Determine goals of the day
- C. Schedule daily activities.
- D. Develop an hourly time frame for tasks.
Correct Answer: B
Rationale: The correct answer is B: Determine goals of the day. This is the first step as it helps prioritize tasks and allocate time efficiently. By setting clear goals, the nurse can focus on essential activities and delegate tasks accordingly. Option A is incorrect because delegating tasks to the AP should come after determining goals to ensure tasks align with priorities. Options C and D are also incorrect as scheduling daily activities and developing an hourly time frame should be based on established goals.
The nurse is continuing to care for the client.
Provider Prescriptions
Day 1, 1100:
Lithium carbonate 600 mg PO BID
The nurse is assessing the client. Which of the following findings indicate an improvement in the client's condition? Select all that apply.
- A. The client engages in quiet activities in their room
- B. The client slept 5 hr. the previous night
- C. The client consumes 8 oz of high-calorie fluids each hour
- D. The client takes 2 short naps during the day
- E. The client appears to listen to unseen others.
Correct Answer: A,B,C,D
Rationale: Improved behaviors include engaging in quiet activities, sleeping adequately, consuming fluids, and napping appropriately. Listening to unseen others indicates ongoing psychosis.