An infant born at 25 weeks gestation was treated with prolonged oxygen therapy. Prolonged oxygen therapy places the infant at risk for:
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Solution
Answer D is correct. Retinopathy of prematurity is caused by damage to immature blood vessels in the retina, which can be the result of high levels of oxygen. Answers A, B, and C are not associated with prolonged oxygen therapy; therefore, they are incorrect.
The nurse is palpating the fontanels of a 2-month-old. The fontanels should feel:
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Solution
Answer C is correct. The fontanels of a 2-month-old should feel flat and firm to the touch. Tense, bulging fontanels indicate increased intracranial pressure; therefore, answers A and D are incorrect. Soft, sunken fontanels indicate dehydration; therefore, answer B is incorrect.
The primary nursing consideration when working with a newly admitted adolescent with anorexia nervosa is:
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Solution
Answer D is correct. The primary nursing consideration is restoring the client’s nutritional status. Answers A, B, and C are an important part of the client’s care but are not the primary nursing considerations of the newly admitted client with anorexia nervosa; therefore, they are incorrect.
Which client is most likely to be affected with Cooley’s anemia?
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Solution
Answer A is correct. Cooley’s anemia, also known as thalassemia major, is a genetic disease primarily affecting those of Mediterranean descent. Answers B, C, and D are incorrect because they are not likely to be affected with Cooley’s anemia.
The nurse is assessing an infant with coarctation of the aorta. The nurse can expect to find:
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Solution
Answer D is correct. Coarctation of the aorta is an acyanotic heart defect characterized by the presence of diminished femoral pulses and bounding radial and brachial pulses. Answers A, B, and C are incorrect because they describe the child with a cyanotic heart defect.
Stranger anxiety is defined as the distress that occurs when the infant is separated from the parents or caregivers. Stranger anxiety first peaks at:
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Solution
Answer C is correct. Stranger anxiety first peaks when the infant is 7–9 months of age. Stranger anxiety does not peak before age 7 months; therefore, answers A and B are incorrect. Answer D is incorrect because stranger anxiety first peaks before 12 months of age.
The nurse is caring for a 6-year-old following revision of a ventriculoperitoneal shunt. An expected nursing intervention is:
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Solution
Answer B is correct. The nurse should measure the child’s head circumference daily to determine the effectiveness of the shunt. Answer A is incorrect because it is a medical intervention. Answer C is incorrect because the fontanels would be closed. Answer D is incorrect because it is not necessary to maintain the child in a prone position.
The American Cancer Society’s current recommendation is that women should have a baseline mammogram done between the ages of:
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Solution
Answer C is correct. According to the American Cancer Society, women should have a baseline mammogram done between the ages of 35 and 40. After age 40, women should have an annual mammogram. Answers A, B, and D are incorrect because they do not follow the recommendations of the American Cancer Society.
An 8-month-old infant has been diagnosed with iron deficiency anemia. What food should be added to the infant’s diet?
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Solution
Answer B is correct. Fortified rice cereal will provide the infant with an additional source of iron. Orange juice and whole milk are poor sources of iron and should not be added to the diet until the infant is older; therefore, answers A and C are incorrect. Answer D is incorrect because strained meat should not be added until the infant is older.
Which of the following describes a nosocomial infection?
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Solution
Answer A is correct. Nosocomial infections are infections acquired in the healthcare facility. Answer B is incorrect because the infection was not acquired in the healthcare facility. Answers C and D refer to community acquired infections; therefore, they are incorrect.