Nokea
Which of the following findings should the nurse report to the provider?
- A. Unable to roll from back to abdomen
- B. Exhibits head lag when pulled to a sitting position
- C. Unable to hold a bottle
- D. Absent grasp reflex
Correct Answer: B
Rationale: The correct answer is B: Exhibits head lag when pulled to a sitting position. This finding indicates poor head control, a developmental milestone typically achieved around 4 months. Reporting this to the provider is crucial for further assessment and intervention. Choice A is incorrect as rolling from back to abdomen is typically achieved around 5-6 months. Choice C is incorrect as holding a bottle is a milestone around 6-10 months. Choice D is incorrect as the grasp reflex typically disappears around 3-4 months. The key is to identify the finding that deviates significantly from the expected developmental milestone, which is demonstrated by choice B.
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The nurse is planning care for the adolescent. Select the 5 interventions the nurse should include.
- A. Instruct the parent to ensure the pneumococcal vaccine is current.
- B. Administer folic acid as prescribed.
- C. Monitor oxygen saturation continuously.
- D. Place the client on strict bed rest.
- E. Apply cold compresses to the affected joints.
- F. Administer meperidine IV for pain.
Correct Answer: B,C,E,F,H
Rationale: The correct interventions for the adolescent are B, C, E, F, and H. Administering folic acid (B) is important for growth and development. Monitoring oxygen saturation (C) ensures respiratory function. Applying cold compresses (E) helps reduce inflammation in affected joints. Administering meperidine IV (F) addresses pain management. The rationale for excluding other choices: A is irrelevant for adolescent care, D may worsen joint symptoms, and G is incomplete.
Which of the following actions should the nurse take?
- A. Inform the client to contact the pharmacy regarding any questions related to the medication.
- B. Provide instructions to the client's parent with the client present.
- C. Instruct the client's parents to write down the information that is being provided.
- D. Ask how the client prefers to learn new information.
Correct Answer: D
Rationale: The correct answer is D: Ask how the client prefers to learn new information. This action is client-centered and promotes individualized care by understanding the client's preferred learning style. It helps tailor the teaching approach to best meet the client's needs, leading to improved understanding and compliance.
Choice A is incorrect because the nurse should provide medication information directly to the client instead of redirecting to the pharmacy.
Choice B is incorrect as it does not involve the client in the learning process, which is essential for effective education.
Choice C is incorrect as it focuses on the parents rather than the client, missing the opportunity to engage the client directly.
Overall, choice D stands out for its client-focused approach, making it the most appropriate action in this scenario.
Which of the following actions by the staff nurse indicates an understanding of infection control practices?
- A. Maintains droplet precautions while the child is coughing and sneezing.
- B. Applies a face mask after entering the child's room.
- C. Wears gloves when assisting the child to the bathroom.
- D. Follows airborne precautions by wearing an N95 respirator while caring for the child.
Correct Answer: A
Rationale: The correct answer is A because maintaining droplet precautions while the child is coughing and sneezing is essential for preventing the spread of infection through respiratory droplets. This action shows understanding of infection control practices by implementing specific measures to reduce transmission of pathogens. Choice B is incorrect as wearing a face mask after entering the room does not provide adequate protection during exposure to respiratory secretions. Choice C is incorrect as gloves are not sufficient for preventing transmission of respiratory infections. Choice D is incorrect as airborne precautions are not necessary for droplet precautions.
Which of the following reactions is an age-appropriate response to death?
- A. The child views the sibling's death as permanent.
- B. The child is curious about what happened to the sibling's body.
- C. The child can give a logical explanation for the sibling's death.
- D. The child feels responsible for the sibling's death.
Correct Answer: B
Rationale: The correct answer is B because it reflects a common and age-appropriate response to death in children. Curiosity about what happened to the body is natural as children try to make sense of the concept of death. It shows a child's attempt to understand the physical aspect of death without fully grasping its emotional implications. Choices A, C, and D are incorrect. A is incorrect because children often struggle with understanding death as permanent. C is incorrect because logical explanations for death usually come later in development. D is incorrect because children typically do not feel responsible for a sibling's death at a young age.
Which of the following actions should the nurse take first?
- A. Ask the client if he is considering harming himself.
- B. Encourage the client to attend a group therapy session.
- C. Administer an antidepressant to the client.
- D. Assist the client in completing his ADLs.
Correct Answer: A
Rationale: The correct answer is A. Asking the client if he is considering harming himself should be the first action because it assesses the client's immediate safety. This step is crucial in identifying any potential suicidal ideation and implementing appropriate interventions to ensure the client's well-being. Encouraging group therapy (B), administering medication (C), and assisting with ADLs (D) are important interventions but should come after addressing the client's safety concerns. It is essential to prioritize actions that address the most critical needs first to provide effective and timely care.