Nokea
while gently abducting the hips, the nurse feels the femoral head slip into the acetabulum. the nurse documents this finding as a positive:
- A. barlow's test
- B. jackson's sign
- C. ortolani's sign
- D. trendelenburg's sign glomerulonephritis?
Correct Answer: C
Rationale: Ortolani's sign is a physical exam maneuver used to detect congenital hip dislocation in infants. When performing Ortolani's sign, the nurse gently abducts the hips and feels the femoral head slipping back into the acetabulum. This is considered a positive finding and suggests the presence of hip dysplasia. Barlow's test, on the other hand, involves gently adducting the hip to feel for instability and potential dislocation. Jackson's sign is a maneuver for detecting hip dislocation by observing leg length discrepancy. Trendelenburg's sign is a test for hip abductor weakness. Hematuria is the presence of blood in urine and is not related to hip exams or signs.
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A nurse is conducting a teaching session for parents of infants. The nurse explains that which behavior indicates that an infant has developed object permanence?
- A. Recognizes familiar face, such as mother
- B. Recognizes familiar object, such as bottle
- C. Actively searches for a hidden object
- D. Secures objects by pulling on a string
Correct Answer: C
Rationale: Object permanence is the understanding that objects continue to exist even when they can't be seen, heard, or touched. When an infant actively searches for a hidden object, it demonstrates that the infant has developed object permanence. This behavior implies that the infant understands that the object still exists even though it is temporarily out of sight. This usually emerges around 8-12 months of age, according to Piaget's theory of cognitive development. The other choices do not specifically relate to the concept of object permanence as directly as actively searching for a hidden object does.
The child who helps to undress, puts 3 words together (subject, verb, object), and handles a spoon well has an age around
- A. 15 mo
- B. 18 mo
- C. 24 mo
- D. 30 mo
Correct Answer: C
Rationale: These milestones are typically achieved around 24 months.
The nurse is meeting a 5-year-old child for the first time and would like the child to cooperate during a dressing change. The nurse decides to do a simple magic trick using gauze. How should this action be interpreted?
- A. Inappropriate, because of child's age
- B. A way to establish rapport
- C. Too distracting, when cooperation is important
- D. Acceptable, if there is adequate time
Correct Answer: B
Rationale: Using a simple magic trick with gauze to engage a 5-year-old child during a dressing change is a way to establish rapport. This approach can help build trust and reduce anxiety by making the procedure more engaging and less intimidating for the child. By creating a positive interaction through a fun activity, the nurse can promote cooperation and make the dressing change a smoother experience for the child. Overall, the use of a magic trick in this context is appropriate and beneficial for enhancing the child's cooperation and comfort.
Which of the ff. nursing actions is most appropriate when doing perineal care on an uncircumcised male patient?
- A. Leave the foreskin retracted so air can keep the area dry
- B. Do not retract the foreskin during washing
- C. Replace the foreskin over the head of the penis after washing
- D. Use alcohol and a cotton swab to clean under the foreskin
Correct Answer: C
Rationale: When performing perineal care on an uncircumcised male patient, it is important to replace the foreskin over the head of the penis after washing. The foreskin should not be left retracted or pulled back forcibly as it can cause irritation and discomfort to the patient. Leaving the foreskin retracted can also lead to potential complications such as paraphimosis, where the foreskin becomes trapped behind the head of the penis. Proper hygiene involves gently retracting the foreskin to clean underneath it and then returning it to its natural position to protect the sensitive glans penis. Using gentle, warm water with mild soap is typically sufficient for cleaning, and alcohol should be avoided as it can cause irritation and dryness to the sensitive genital area.
For a client in addisonian crisis, it would be very risky for a nurse to administer:
- A. potassium chloride.
- B. hydrocortisone.
- C. normal saline solution
- D. fludrocortisone.
Correct Answer: A
Rationale: Addisonian crisis, also known as acute adrenal crisis, is a life-threatening condition that occurs when there is a severe deficiency in cortisol and aldosterone hormones, usually resulting from adrenal gland insufficiency. In this situation, it is crucial to administer hydrocortisone (a synthetic form of cortisol) promptly to replace the lacking hormone. Potassium levels in individuals experiencing an Addisonian crisis can be elevated due to the lack of aldosterone, which normally helps regulate electrolyte levels such as potassium. Therefore, administering potassium chloride in this scenario can lead to further complications and exacerbate the existing electrolyte imbalance. In contrast, normal saline solution can help with fluid and electrolyte balance, and fludrocortisone can be administered to replace the deficient aldosterone.