Nokea
Which of the following malignancies is least likely to occur in a 10-month-old infant?
- A. neuroblastoma
- B. nephroblastoma
- C. retinoblastoma
- D. hepatoblastoma
Correct Answer: D
Rationale: Hepatoblastoma is rare in infants under 1 year old, being more common in toddlers.
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Will is being assessed by Nurse Lucas for possible intussusception; which of the following would be least likely to provide valuable information?
- A. Abdominal palpation
- B. Family history
- C. Pain pattern
- D. Stool inspection
Correct Answer: B
Rationale: When assessing a patient like Will for possible intussusception, the least likely to provide valuable information would be the family history. While family history can help identify potential genetic predispositions or conditions that may contribute to a patient's current health concerns, in this case, the focus is on Will's immediate symptoms and diagnostic indicators related to possible intussusception. Abdominal palpation, pain pattern assessment, and stool inspection are more directly relevant to evaluating Will's current condition and determining the likelihood of intussusception. Family history, while important in a broader health context, would be least likely to provide immediate insights into Will's specific situation with intussusception.
By the age of 7 months, the infant is able to do all the following EXCEPT
- A. transfer object from hand to hand
- B. actively bounces
- C. uses radial palm grasp
- D. roll over
Correct Answer: D
Rationale: Rolling over is usually achieved earlier, by 4-6 months, while other skills are typical for 7 months.
A client has undergone a nephrectomy and is placed under observation after a urethral catheter insertion. As part of the nursing care plan, the nurse records the color of drainage from each tube and catheter. Which of the ff is the reason for this?
- A. To restore and maintain intravascular volume
- B. To provide a means for further comparison and evaluation
- C. To avoid interference with wound drainage
- D. To prevent pain related to obstruction
Correct Answer: B
Rationale: Recording the color of drainage from each tube and catheter is crucial in the nursing care plan as it provides a means for further comparison and evaluation. Changes in the color of drainage can indicate potential issues such as infection, bleeding, or other complications post-surgery. By monitoring the color of drainage, the nurse can identify any abnormal changes early on and take appropriate actions to address them promptly. This practice helps in assessing the patient's condition and ensuring optimal recovery and healing after the surgery.
Which nursing intervention is most appropriate for a client with multiple myeloma?
- A. Monitoring respiratory status
- B. Restricting fluid intake
- C. Balancing rest and activity
- D. Preventing bone injury
Correct Answer: D
Rationale: One of the primary concerns in clients with multiple myeloma is bone damage and fractures due to weakened bones caused by the disease. Preventing bone injury is a crucial nursing intervention to focus on for these clients. Measures to prevent bone injury include implementing fall precautions, encouraging safe mobility, providing supportive devices such as walkers or canes, and educating the client on strategies to prevent falls and fractures. Additionally, pain management and regular assessment for signs of bone damage are essential in caring for clients with multiple myeloma. Other interventions such as monitoring respiratory status, balancing rest and activity, and restricting fluid intake may be important in certain situations for these clients but preventing bone injury takes precedence due to the increased risk of skeletal complications associated with multiple myeloma.
Which is the most common cause of anemia in preterm newborns?
- A. Frequent blood sampling
- B. Respiratory distress syndrome
- C. Meconium aspiration syndrome
- D. Persistent pulmonary hypertension
Correct Answer: A
Rationale: The most common cause of anemia in preterm newborns is frequent blood sampling. Preterm infants are often subject to numerous blood tests for various reasons such as monitoring oxygen and blood gas levels, assessing bilirubin levels, infection screening, and more. These repeated blood withdrawals lead to a loss of red blood cells and can contribute to the development of anemia in preterm infants. Anemia in preterm newborns can have significant consequences, including impaired growth and development, delayed hospital discharge, and the potential need for blood transfusions. Therefore, minimizing unnecessary blood sampling and utilizing non-invasive monitoring methods whenever possible are key strategies in preventing and managing anemia in preterm newborns.