Nursing Elites

1. During a routine health assessment, the nurse notes that an 8-month-old infant has a significant head lag. Which is the most appropriate action?

• A. Recheck head control at the next visit
• B. Teach the parents appropriate exercises
• C. Schedule the child for further evaluation
• D. Refer the child for further evaluation if the anterior fontanel is still open

Correct answer: C

Rationale: Significant head lag at 8 months is concerning and warrants further evaluation, as it may indicate developmental delays or neurological issues.

2. What clinical manifestation(s) is associated with calcium depletion (hypocalcemia)?

• A. Nausea, vomiting
• B. Weakness, fatigue
• C. Muscle hypotonicity
• D. Neuromuscular irritability

Correct answer: D

Rationale: Hypocalcemia can lead to neuromuscular irritability, causing symptoms such as muscle cramps, tetany, or seizures. Other symptoms like nausea, vomiting, and weakness are less specific and can be related to various conditions.

3. The nurse is preparing to complete documentation on a patient's chart. Which should be included in documentation of nursing care? (Select all that apply.)

• A. Reassessments
• B. Nursing care provided
• C. Initial assessments
• D. All of the above

Correct answer: D

Rationale: Proper documentation includes reassessments, initial assessments, care provided, and the patient's response, but incident reports are typically documented separately.

4. The nurse is teaching parents about high-fiber foods that can prevent constipation. What foods should the nurse include in the teaching?

• A. Oranges
• B. All are correct
• C. Lima beans
• D. Baked beans

Correct answer: B

Rationale: The correct answer is B: All are correct. High-fiber foods like oranges, lima beans, baked beans, and raisin bran cereal are effective in preventing constipation. Oranges are a good source of fiber, lima beans and baked beans are high in fiber content, and raisin bran cereal is also rich in fiber. Bananas, which are not listed but could be considered by some as a high-fiber food, are actually low in fiber and may not be as effective in preventing constipation. Therefore, the nurse should include all the options provided in the teaching to help prevent constipation effectively.

5. Surgery is performed on a child to correct cryptorchidism. The parents understand the reason for the surgery if they tell the nurse this was done to do what?

• A. Prevent damage to the undescended testicle.
• B. Prevent urinary tract infections.
• C. Prevent prostate cancer.
• D. Prevent an inguinal hernia.

Correct answer: A

Rationale: The primary reason for correcting cryptorchidism through surgery is to prevent damage to the undescended testicle, which can lead to infertility and increase the risk of testicular cancer. Prevention of UTIs and prostate cancer are not the primary concerns in this context.

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