Nokea
Which of the following physical findings indicates that an 11-12-month-old child is at risk for developmental dysplasia of the hip?
- A. refusal to walk
- B. not pulling to a standing position
- C. negative Trendelenburg sign
- D. negative Ortolani sign
Correct Answer: B
Rationale: The nurse might be concerned about developmental dysplasia of the hip if an 11-12-month-old child doesn't pull to a standing position. An infant who does not walk by 15 months of age should be evaluated. Children should start walking between 11-15 months of age. Trendelenberg sign is related to weakness of the gluteus medius muscle, not hip dysplasia. Ortolani sign is used to identify congenital subluxation or dislocation of the hip in infants.
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Carrying a donor card for organ donation means that:
- A. medical care is altered in the event of serious injuries to get organs for donation.
- B. the family or legally responsible party of a client has no decision-making authority in the event that the client is considered for organ donation.
- C. a client is allowed to revoke his decision for organ donation at any time.
- D. a client is considered an organ donor for only one organ or tissue.
Correct Answer: C
Rationale: Revocation of the decision for organ donation may occur at any time, by either the client or his responsible party. When organ donation is considered, as many organs as the donor wished to donate are considered and accepted for donation if found appropriate. Medical care for an individual during immediate care and/or resuscitation is not altered to declare a client dead and ready for organ donation.
While walking in the hallway of an acute care unit of the hospital, the nurse overhears the change of shift report. The nurse should:
- A. make the charge nurse on the unit aware of the situation so that he or she can take the necessary steps to maintain the confidentiality of the information being reported.
- B. disregard the information because it changes quickly on the acute care unit and is outdated within 2-3 hours anyway.
- C. return to his or her own unit and not disclose that confidential information has been overheard.
- D. ignore the situation.
Correct Answer: A
Rationale: To protect the confidentiality of the information being reported, the nurse should make the charge nurse on the unit aware of the situation so that the information can be communicated in an appropriate way in privacy.
An example of a process standard on a med-surg unit is:
- A. a procedure for changing IV tubing.
- B. a policy for staffing.
- C. the job description of the CEO (chief executive officer).
- D. a procedure for checking waveforms on a client being treated on an intra-aortic balloon pump.
Correct Answer: A
Rationale: Process standards define the actions and behaviors required by staff to provide care.
Delegation of tasks to appropriate personnel allows the nurse to:
- A. take a break.
- B. keep other members of the team productive.
- C. maintain tight control of all aspects of the workflow.
- D. realize the importance of her role by making all decisions.
Correct Answer: B
Rationale: Maintaining the productivity of all team members by delegating tasks appropriate to the job descriptions of the personnel increases work effectiveness and efficiency.
A preschooler has successfully completed the test item 'counts 5 blocks' on the Denver II test. This pass is evidence of which of the following developmental concepts?
- A. centration
- B. causality
- C. nonreversibility
- D. conservation
Correct Answer: D
Rationale: Counting five blocks demonstrates conservation, the understanding that quantity remains constant despite changes in arrangement or appearance.