Nokea
While examining a 2-year-old child, Nurse Galina sees that the anterior fontanel is open. She should:
- A. Notify the doctor
- B. Look for other signs of abuse
- C. Recognize this as a normal finding
- D. Ask about a family history of Tay-Sachs disease
Correct Answer: C
Rationale: Nurse Galina should recognize an open anterior fontanel as a normal finding in a 2-year-old child. The anterior fontanel is a soft spot on a baby's skull where the skull bones have not yet fused together. It usually closes by the time a child is 18 to 24 months old. The open fontanel at 2 years of age is within the normal range of closure, and it is not a cause for concern in this case. No need to notify the doctor, look for other signs of abuse, or ask about a family history of Tay-Sachs disease based on this finding.
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Latasha, age 8 years, is being admitted to the hospital from the emergency department with an injury from falling off her bicycle. Which will help her most in her adjustment to the hospital?
- A. Explain hospital schedules to her, such as mealtimes.
- B. Use terms such as "honey" and "dear" to show a caring attitude.
- C. Explain when parents can visit and why siblings cannot come to see her.
- D. Orient her parents, because she is young, to her room and hospital facility.
Correct Answer: A
Rationale: Explaining hospital schedules to Latasha, such as mealtimes, will help her most in adjusting to the hospital environment. Providing her with a sense of routine and structure can help reduce her anxiety and uncertainty during her stay. By knowing when things like meals will happen, Latasha can feel more in control of her surroundings and what to expect, which can be comforting for a child in a new and potentially scary situation like being in the hospital.
During a routine checkup, the nurse assesses a client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the common AIDS-related cancer?
- A. Squamous cell carcinoma
- B. Leukemia
- C. Multiple myeloma
- D. Kaposi's sarcoma
Correct Answer: D
Rationale: Kaposi's sarcoma is the most common AIDS-related cancer. It is a type of cancer that usually appears as lesions on the skin, mouth, or internal organs. Kaposi's sarcoma is caused by human herpesvirus 8 (HHV-8) and is more likely to develop in individuals with weakened immune systems, such as those with AIDS. The risk of developing Kaposi's sarcoma is higher in people with HIV/AIDS due to the weakened immune system's inability to fight off infections and certain cancers. Regular assessment for signs and symptoms of Kaposi's sarcoma is important in people living with AIDS in order to detect and treat it early.
The LPN is caring for a patient in the preoperative period who, even after verbalizing concerns and having questions answered, states, "I know I am not going to wake up after surgery." Which of the following actions should the nurse take?
- A. Reassure patient everything will be all right
- B. Explain national surgery death rate
- C. Inform the registered nurse
- D. Ask family to comfort the patient
Correct Answer: C
Rationale: The correct action for the LPN to take in this situation is to inform the registered nurse. The patient's statement indicates a high level of fear and anxiety about the surgery and their potential outcome. It is important to involve the registered nurse, who can provide further assessment, support, and interventions to address the patient's concerns appropriately. Simply reassuring the patient or providing statistics about national surgery death rates may not address the underlying fear and may require additional support and intervention. Asking the family to comfort the patient may not be the most appropriate immediate action as the patient's concerns are specific and may require professional support. Bringing the registered nurse into the situation allows for a comprehensive approach to addressing the patient's emotional needs before the surgery.
The Andrews family has been taking good care of their youngest, Archie, who was diagnosed with asthma. Which of the following statements indicate a need for further home care teaching?
- A. "He should increase his fluid intake regularly to thin secretions."
- B. "We'll make sure that he avoids exercise to prevent attacks."
- C. "He is to use his bronchodilator inhaler before the steroid inhaler."
- D. "We need to identify what things trigger his attacks." 50
Correct Answer: B
Rationale: It is important to note that exercise should not be completely avoided for a child with asthma. Regular physical activity is beneficial for overall health and can help improve lung function in asthmatic individuals. Supervised and controlled exercise under the guidance of healthcare providers can be safe for children with asthma. Avoiding exercise altogether can lead to deconditioning and other health issues. It is important to educate the family on the proper management of asthma during exercise, such as using a rescue inhaler before engaging in physical activity. Therefore, this statement indicates a need for further home care teaching.
All the following are true about infant sleep between 2-6 months EXCEPT
- A. total sleep hours are about 14-16 hr/24 hr
- B. sleeps about 9-10 hr concentrated at night
- C. sleeps 2 naps/day
- D. the sleep cycle time is similar to that of adults
Correct Answer: D
Rationale: Infant sleep cycles differ significantly from adult patterns.