Nokea
Which of the following statements best describes the gross motor development of a 2-year old?
- A. She skips without falling.
- B. She walks up and down stairs.
- C. She rides a tricycle.
- D. She is able to broad jump.
Correct Answer: B
Rationale: A 2-year-old can typically walk up and down stairs with support, a key gross motor milestone. Skipping , riding a tricycle , and broad jumping are skills developed later, around 3-5 years.
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A patient with effective pain relief.
Which of the following nursing actions is MOST important to provide a patient with effective pain relief?
- A. Teach the patient about his pain.
- B. Establish a trusting relationship with the patient.
- C. Determine how various relaxation techniques affect the pain.
- D. Provide alternative measures to relieve pain.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not most important (2) correct-necessary to work with patient to identify interventions to relieve pain (3) part of intervention and evaluation phase (4) only a portion of interventions used to relieve pain
The nurse is preparing a five-year-old child for surgery.
- A. What is the best action for the nurse when the informed consent for a five-year-old’s surgery is signed by the mother, and the parents are divorced with joint legal custody?
- B. Notify the physician.
- C. Inform surgery.
- D. Contact the father to obtain consent.
- E. Continue the child’s preoperative preparation.
Correct Answer: D
Rationale: In cases of joint legal custody, consent from either parent is sufficient for surgical procedures. Since the mother has signed the informed consent, no further action is needed, and the nurse should continue preoperative preparation. Notifying the physician, informing surgery, or contacting the father is unnecessary.
The nurse is caring for a four-year-old child with a closed head injury. The nurse would be reassured by which of the following observations?
- A. The child is able to state his name when asked who he is.
- B. The child reaches for a stuffed animal brought from home.
- C. The child maintains himself in opisthotonos.
- D. The child withdraws from mildly painful stimuli.
Correct Answer: A
Rationale: Stating his name indicates orientation, a positive sign post-head injury. Options B, C, and D are less reassuring: reaching for a toy is nonspecific, opisthotonos suggests meningeal irritation, and withdrawal may occur in unconscious states.
A mother brings her 17-month-old son to the well-baby clinic for a routine check-up. She confides to the nurse that she is concerned because her son sucks his thumb, especially at night when he is put to bed.
Which of the suggestions by the nurse would be BEST?
- A. If you want the behavior to stop put a negative reinforcer, such as red pepper, on this thumb.'
- B. Don't intervene at this time. This behavior usually subsides after 24 months of age.'
- C. What you are seeing is a common form of self-stimulation. You should discourage this behavior.'
- D. This behavior will cause malformation of his teeth. You should wrap his thumb at bedtime.'
Correct Answer: B
Rationale: Strategy: 'BEST' indicates there may be more than one correct response. Remember growth and development concepts. (1) controversial treatment for an older child (2) correct-normal behavior, peaks at 18-20 months, most prevalent when child is hungry or tired (3) normal behavior in child this age, should not be discouraged (4) malocclusion occurs if thumb sucking persists past 4 years old or when permanent teeth erupt
The nurse is caring for a client with a history of bipolar disorder who is receiving valproic acid (Depakote) 500 mg PO bid. Which of the following laboratory results should the nurse report immediately?
- A. Liver enzymes elevated to twice normal.
- B. Sodium 140 mEq/L.
- C. Potassium 4.0 mEq/L.
- D. Hemoglobin 13 g/dL.
Correct Answer: A
Rationale: Elevated liver enzymes suggest hepatotoxicity, a serious valproic acid side effect. Options B, C, and D are normal.