a nurse is teaching the mother of an 11 month old infant how to clean the infants teeth the nurse tells the mother to take which action

NCLEX-PN

Nclex Practice Questions 2024

1. A nurse is teaching the mother of an 11-month-old infant how to clean the infant's teeth. The nurse tells the mother to take which action?

A. Use a small amount of toothpaste and a soft-bristle toothbrush
B. Use water and a cotton swab and rub the teeth
C. Use diluted fluoride and rub the teeth with a soft washcloth
D. Dip the infant's pacifier in maple syrup so that the infant will suck

Correct answer: C

Rationale: The correct action when cleaning an infant's teeth is to use water and a cotton swab to gently rub the teeth. This method helps in removing any food particles or plaque buildup without the risks associated with toothpaste ingestion. Using a small amount of toothpaste and a soft-bristle toothbrush is not recommended for infants as they may swallow the toothpaste, leading to potential fluoride ingestion issues. Using diluted fluoride and rubbing the teeth with a soft washcloth is unnecessary at this age since infants typically receive fluoride through other sources like formula. Dipping the infant's pacifier in maple syrup is highly inappropriate and poses a significant risk of tooth decay due to the high sugar content, which can harm the infant's teeth.

2. A 12-year-old male is brought to his primary care provider to determine whether sexual abuse has occurred. The mother states, 'Because there is no permanent physical damage, he does not need any more treatment.' The nurse's response should be based on which of the following pieces of information?

A. Male victims of sexual abuse can have long-term psychological problems.
B. Survivors of male sexual abuse might become confused about their sexual identity.
C. Not all male sex abuse survivors grow up to abuse other children.
D. The needs of sexually abused children can vary based on gender and individual circumstances.

Correct answer: B

Rationale: Male children are sexually abused nearly as often as female children. Perpetrators are usually men but can be women. Needs of male children who have been sexually abused might be different from the needs of female survivors. Male survivors might respond in anger, question their sexuality, use alcohol and other drugs, and might try to prove their masculinity by performing daring acts. Choice A is incorrect because male victims of sexual abuse can indeed have long-term psychological problems. Choice C is incorrect as not all male sex abuse survivors grow up to abuse other children. Choice D is incorrect as the needs of sexually abused children can vary based on gender and individual circumstances.

3. Which information should be reported to the state Board of Nursing?

A. The facility fails to provide literature in both Spanish and English.
B. The narcotic count has been incorrect on the unit for the past 3 days.
C. The client fails to receive an itemized account of his bills and services received during his hospital stay.
D. The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath.

Correct answer: B

Rationale: The correct answer is 'The narcotic count has been incorrect on the unit for the past 3 days.' This information should be reported to the state Board of Nursing as it involves medication errors and potential drug diversion, which are serious issues that fall under the jurisdiction of the Board. Reporting medication discrepancies and errors in narcotic counts is crucial for patient safety and regulatory compliance. Choices A, C, and D involve different types of issues that are not within the direct purview of the Board of Nursing. Providing literature in multiple languages (Choice A), addressing billing practices (Choice C), and resolving staff performance issues (Choice D) should be handled internally or reported to the appropriate departments or authorities, such as the Joint Commission or the charge nurse.

4. Who may legally give informed consent?

A. an 86-year-old male with advanced Alzheimer's disease
B. a 14-year-old girl needing an appendectomy who is not an emancipated minor
C. a 14-year-old girl needing an appendectomy who is not an emancipated minor
D. a 6-month-old baby needing bowel surgery

Correct answer: C

Rationale: The correct answer is a 14-year-old girl needing an appendectomy who is not an emancipated minor. Informed consent can be given by individuals who are competent and not minors. Minors are generally unable to provide informed consent unless they are emancipated. Choice A is incorrect because an 86-year-old male with advanced Alzheimer's disease is considered incompetent to make decisions. Choice D is incorrect because a 6-month-old baby is unable to provide consent. Emancipated minors are an exception to the minor rule, as they can provide consent for their own treatment.

5. A home health nurse is planning for her daily visits. Which client should the home health nurse visit first?

A. A client with AIDS being treated with Foscarnet
B. A client with a fractured femur in a long leg cast
C. A client with laryngeal cancer with a laryngectomy
D. A client with diabetic ulcers on the left foot

Correct answer: C

Rationale: The correct answer is the client with laryngeal cancer who had a laryngectomy. This client is at risk for airway obstruction due to the surgical procedure, making it a priority visit. Clients with AIDS (choice A), a fractured femur (choice B), and diabetic ulcers (choice D) do not have immediate life-threatening conditions that require urgent attention compared to a client with a recent laryngectomy.