Nursing Elites

1. 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.

2. A new parent, when asked by a nurse, explains that the 4-month-old infant has been nursing regularly every 3 to 4 hours and seems satisfied. However, the parent recently introduced solid food in the form of unbuttered popcorn to the infant as a supplement. What should be the primary nursing concern in this situation?

• A. Imbalanced nutrition, more than body requirements, related to introduction of a high-calorie food
• B. Risk for aspiration related to feeding the infant an inappropriate food
• C. Imbalanced nutrition, less than body requirements, related to introduction of a low-nutritive food
• D. Readiness for enhanced nutrition, related to the age of the infant

Correct answer: B

Rationale: The primary nursing concern in this situation is the risk for aspiration. Popcorn is a choking hazard for infants, as their airway is not fully developed to handle solid foods like popcorn. Choices A, C, and D are incorrect because the main focus should be on the immediate risk of aspiration due to the inappropriate solid food given to the infant, rather than on nutritional imbalances or readiness for enhanced nutrition.

3. Which characteristic best describes the fine motor skills of an infant at age 5 months?

• A. Neat pincer grasp
• B. Strong grasp reflex
• C. Builds a tower of two cubes
• D. Able to grasp object voluntarily

Correct answer: D

Rationale: By 5 months, infants develop the ability to grasp objects voluntarily, showing improved motor control. The neat pincer grasp and building towers are skills that develop later.

4. Which are included in the evaluation step of the nursing process? (Select all that apply.)

• A. All below
• B. Ascertaining if the plan requires modification
• C. Determination if the outcome has been met
• D. Selecting alternative interventions if the outcome has not been met

Correct answer: A

Rationale: The evaluation step involves determining if outcomes are met, modifying the plan if needed, and selecting alternative interventions if goals are not achieved.

5. 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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