When examining an infant, which area should the nurse examine first?

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Question 1 of 5

When examining an infant, which area should the nurse examine first?

Correct Answer: A

Rationale: The correct answer is A: Ear. Examining the ear first is crucial in infants as it allows the nurse to assess for any signs of infection or abnormalities that could impact the infant's overall health. Ear infections are common in infants and can lead to serious complications if not detected early. By examining the ear first, the nurse can promptly address any issues and provide appropriate treatment. Summary of why other choices are incorrect: - B: Nose - While examining the nose is important, it is not the priority in infants as ear issues are more common and can have immediate implications on health. - C: Throat - Throat examination is important but typically follows ear examination in infants, as ear infections are more prevalent. - D: Abdomen - Abdominal examination is important for overall health assessment but is not the initial area to examine in infants as ear issues take precedence due to their frequency and potential impact.

Question 2 of 5

The nurse is assessing a patient's skin during an office visit. What is the best technique to use to best assess skin temperature?

Correct Answer: A

Rationale: The correct answer is A: Palpation. Palpation involves using the hands to touch and feel the skin to assess its temperature accurately. This technique allows the nurse to detect variations in temperature more effectively compared to visual inspection (Choice C) or listening with a stethoscope (Choice B). Using a thermometer (Choice D) may also provide a precise measurement, but palpation allows for a more comprehensive assessment of skin temperature by considering factors such as localized warmth or coolness.

Question 3 of 5

The nurse has just started an assessment of the newborn child of a woman of Vietnamese origin. Considering the mother's cultural background, which of the following statements about this examination is true? The mother:

Correct Answer: A

Rationale: The correct answer is A because in Vietnamese culture, touching or examining the fontanelles (soft spots on a baby's head) is considered disrespectful and potentially harmful. This is due to the belief that the fontanelles are fragile and touching them can impact the baby's health. It is crucial for the nurse to respect and be sensitive to the cultural beliefs and practices of the mother to establish trust and provide culturally competent care. Choice B is incorrect because there is no specific cultural taboo in Vietnamese culture about touching the infant's diaper area during examination. Choice C is incorrect as assuming that the husband should be the primary communicator of medical information goes against the principle of patient autonomy. Choice D is incorrect as there is no indication that Vietnamese mothers prefer written reports over verbal communication regarding their child's growth and development.

Question 4 of 5

The nurse is assessing mental health in children. Which of the following statements is true?

Correct Answer: A

Rationale: The correct answer is A because all aspects of mental health in children are indeed interrelated. Mental health encompasses various components such as emotional, social, and psychological well-being, which are interconnected and influence each other. Understanding and assessing mental health in children require considering the holistic picture. Choice B is incorrect because children are not inherently labile and unstable until the age of 2 years. Choice C is incorrect as children's mental health is influenced by various factors beyond just their parents' mental health. Choice D is incorrect because mental health assessment in children can be done using age-appropriate methods even before they develop the ability to concentrate.

Question 5 of 5

A 45-year-old woman is at the clinic for a mental health assessment. When giving her the Four Unrelated Words Test, the nurse would be concerned if the patient:

Correct Answer: C

Rationale: The correct answer is C because the inability to recall four unrelated words after a 30-minute delay indicates potential issues with short-term memory retention, which is concerning for cognitive impairment or memory disorders. This delay allows for the consolidation of memory, so failure at this point suggests a more significant problem compared to immediate recall. A: Not being able to give four unrelated words within 5 minutes may indicate some difficulty, but it does not necessarily indicate a severe issue as more time is typically allowed for this task. B: Inability to give four unrelated words within 30 seconds could be due to various factors such as anxiety or processing speed, but it does not necessarily indicate a memory issue. D: Not being able to recall four unrelated words after a 60-minute delay is expected to be more challenging than a 30-minute delay, so this alone does not raise as much concern as failing the 30-minute delay test.

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