Nokea
Which reflex, present at birth, is elicited by stroking the sole of the infant's foot, resulting in the fanning of the toes?
- A. Babinski
- B. Moro
- C. Sucking
- D. Rooting
Correct Answer: A
Rationale: The Babinski reflex is the correct answer. This reflex is characterized by the fanning out of the toes when the sole of the foot is stroked. It is a normal reflex in infants and is typically present at birth, disappearing by around 12 months of age. The Moro reflex, which involves the infant's response to a sudden loss of support or a loud noise, is not related to the fanning of toes. Sucking and rooting reflexes are related to feeding behaviors and are not elicited by stroking the sole of the foot.
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The nurse is conducting a teaching session for parents on nutrition. Which characteristics of families should the nurse consider that can cause families to struggle in providing adequate nutrition? (Select all that apply.)
- A. Homelessness
- B. Lower income
- C. Migrant status
- D. All of the above
Correct Answer: D
Rationale: Factors like homelessness, lower income, and migrant status can create barriers to providing adequate nutrition for children.
The nurse manager is compiling a report for a hospital committee on the quality of nursing-sensitive indicators for a nursing unit. Which does the nurse manager include in the report?
- A. The average age of the nurses on the unit
- B. The salary ranges for the nurses on the unit
- C. The education and certification of the nurses on the unit
- D. The number of nurses who have applied but were not hired for the unit
Correct Answer: C
Rationale: The education and certification of nurses are key nursing-sensitive indicators that reflect the quality of care provided on the unit.
When assessing an infant with intussusception, what type of stool would the nurse expect to find?
- A. Soft, seedy stool
- B. Currant-jelly stool
- C. Ribbon-like stool
- D. Soft and pasty stool
Correct Answer: B
Rationale: The correct answer is B: Currant-jelly stool. This type of stool, which is red and mucous-like, is a classic sign of intussusception in infants. Choice A (Soft, seedy stool) is incorrect as it does not specifically describe the characteristic stool associated with intussusception. Choice C (Ribbon-like stool) is incorrect; ribbon-like stool may be seen in conditions like colon cancer, not intussusception. Choice D (Soft and pasty stool) is also incorrect as it does not match the typical stool finding in intussusception.
Which dietary information should the nurse include in the teaching plan for a school-age child with chronic renal failure?
- A. High in sodium
- B. Low in Vitamin D
- C. Low in phosphorus
- D. Supplementation of vitamins C, E, K
Correct Answer: C
Rationale: A low-phosphorus diet is recommended for children with chronic renal failure to prevent hyperphosphatemia, which can lead to bone disease and other complications. Phosphorus is found in many processed foods and should be limited. Choices A, B, and D are incorrect because high sodium intake can lead to fluid retention and hypertension, while Vitamin D supplementation and vitamins C, E, K are not specifically indicated for dietary recommendations in chronic renal failure.
What is one focus of current health care?
- A. Increased provision of nursing services
- B. Disease prevention
- C. Symptom management
- D. Identification of disease processes
Correct Answer: B
Rationale: The correct answer is 'Disease prevention.' Modern healthcare places emphasis on preventing diseases to enhance overall health and well-being. While nursing services, symptom management, and disease identification are crucial components of healthcare, disease prevention plays a key role in reducing the burden of illness on individuals and communities.