Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a 10-month-old infant who is in a cast for developmental dysplasia of the hip (DDH).
Which of the following strategies should the nurse implement to promote the infant's growth and development?
A. Allow the infant to stand in the crib.
Encouraging the infant to stand in the crib while in a cast for developmental dysplasia of the hip (DDH) supports gross motor development and maintains neuromuscular stimulation. Standing promotes proprioceptive input, strengthens postural muscles, and supports bone mineralization through weight-bearing. Infants in hip spica casts or orthotic devices can safely stand with supervision, preserving developmental milestones. Normal serum calcium ranges from 8.5 to 10.5 mg/dL, and mechanical loading enhances osteoblastic activity and skeletal growth.
B. Provide a small electronic toy.
While electronic toys offer sensory stimulation, they do not adequately support gross motor development in infants with DDH. At 10 months, infants require opportunities for vertical positioning and weight-bearing to stimulate vestibular and musculoskeletal systems. Passive play with electronic toys may delay motor milestones such as cruising and standing. Developmental progress depends on integrated sensory-motor experiences, and reliance on sedentary toys may limit engagement of core and lower limb musculature.
C. Tie colorful latex balloons to the side of the crib.
Latex balloons pose a significant safety hazard due to the risk of aspiration and suffocation. When burst, latex fragments can occlude the airway, especially in infants with underdeveloped protective reflexes. The tracheal diameter in infants averages 4 to 5 mm, making obstruction by balloon fragments potentially fatal. Additionally, latex exposure may trigger allergic reactions, particularly in atopic individuals. The American Academy of Pediatrics strongly advises against latex balloon use in children under 8 years.
D. Change the infant's diaper as soon as soiling occurs.
Prompt diaper changes are essential for skin integrity, especially under a cast where moisture retention can lead to maceration and infection. However, this action does not directly promote growth and development. It is a hygiene measure that prevents irritant contact dermatitis and secondary infections such as Candida albicans. Normal skin pH ranges from 4.5 to 5.5, and prolonged exposure to urine and feces elevates pH, disrupting the acid mantle. While necessary, it lacks developmental stimulation.
E. None
None
F. None
None
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom SP23 N23 N240 Proctored Exam 3 Ch 11 24 32 43 44. Take the full exam now
Full Explanation
The correct answer is Choice A.
Choice A rationale: Encouraging the infant to stand in the crib while in a cast for developmental dysplasia of the hip (DDH) supports gross motor development and maintains neuromuscular stimulation. Standing promotes proprioceptive input, strengthens postural muscles, and supports bone mineralization through weight-bearing. Infants in hip spica casts or orthotic devices can safely stand with supervision, preserving developmental milestones. Normal serum calcium ranges from 8.5 to 10.5 mg/dL, and mechanical loading enhances osteoblastic activity and skeletal growth.
Choice B rationale: While electronic toys offer sensory stimulation, they do not adequately support gross motor development in infants with DDH. At 10 months, infants require opportunities for vertical positioning and weight-bearing to stimulate vestibular and musculoskeletal systems. Passive play with electronic toys may delay motor milestones such as cruising and standing. Developmental progress depends on integrated sensory-motor experiences, and reliance on sedentary toys may limit engagement of core and lower limb musculature.
Choice C rationale: Latex balloons pose a significant safety hazard due to the risk of aspiration and suffocation. When burst, latex fragments can occlude the airway, especially in infants with underdeveloped protective reflexes. The tracheal diameter in infants averages 4 to 5 mm, making obstruction by balloon fragments potentially fatal. Additionally, latex exposure may trigger allergic reactions, particularly in atopic individuals. The American Academy of Pediatrics strongly advises against latex balloon use in children under 8 years.
Choice D rationale: Prompt diaper changes are essential for skin integrity, especially under a cast where moisture retention can lead to maceration and infection. However, this action does not directly promote growth and development. It is a hygiene measure that prevents irritant contact dermatitis and secondary infections such as Candida albicans. Normal skin pH ranges from 4.5 to 5.5, and prolonged exposure to urine and feces elevates pH, disrupting the acid mantle. While necessary, it lacks developmental stimulation.
Similar Questions
A school nurse is performing a routine health assessment for a school-age child.
Which of the following findings indicates the nurse should investigate further for pediculosis capitis?
A. Dry patches on the scalp.
Choice A is not correct because dry patches on the scalp are not a common symptom of pediculosis capitis 123.
B. Pruritus of the scalp.
Pruritus, or itching, of the scalp, is a common symptom of pediculosis capitis, also known as head lice infestation 123.
C. Bald patches on the scalp.
Choice C is not correct because bald patches on the scalp are not a common symptom of pediculosis capitis 123.
D. Blisters on the scalp.
Choice D is not correct because blisters on the scalp are not a common symptom of pediculosis capitis 123.
Full Explanation
Pruritus, or itching, of the scalp, is a common symptom of pediculosis capitis, also known as head lice infestation 123.
Choice A is not correct because dry patches on the scalp are not a common symptom of pediculosis capitis 123.
Choice C is not correct because bald patches on the scalp are not a common symptom of pediculosis capitis 123.
Choice D is not correct because blisters on the scalp are not a common symptom of pediculosis capitis 123.
A nurse is bathing a toddler and notices that she has several bruises.
Which of the following actions should the nurse take first?
A. Ask the parents what caused the bruises.
The initial step in assessing unexplained bruising in a toddler is to gather information directly from the caregivers. This establishes a clinical baseline and allows the nurse to evaluate consistency, plausibility, and emotional responses. Bruising in toddlers can be developmental due to increased mobility, but patterns, location, and frequency matter. Normal platelet count ranges from 150,000 to 450,000/mm³; abnormal bruising may suggest thrombocytopenia, coagulopathy, or trauma. Early dialogue supports accurate documentation and escalation if needed.
B. Ask the toddler what caused the bruises.
Choice B is not correct because while it may be important to gather information from the toddler, the nurse’s first action should be to notify the provider.
C. Notify social services.
Choice C is not correct because while notifying social services may be necessary in some cases, the nurse’s first action should be to notify the provider.
D. Notify the provider.
Notifying the provider is essential for collaborative care but should follow initial data collection. The provider relies on the nurse’s observations and caregiver input to determine next steps, including diagnostic testing or referral. Immediate escalation without context may delay appropriate triage or misdirect resources. The nurse’s role includes thorough documentation, pattern recognition, and initiating dialogue with caregivers to inform the provider’s clinical judgment. This ensures a coordinated, evidence-based response.
Full Explanation
The correct answer is Choice A.
Choice A rationale: The initial step in assessing unexplained bruising in a toddler is to gather information directly from the caregivers. This establishes a clinical baseline and allows the nurse to evaluate consistency, plausibility, and emotional responses. Bruising in toddlers can be developmental due to increased mobility, but patterns, location, and frequency matter. Normal platelet count ranges from 150,000 to 450,000/mm³; abnormal bruising may suggest thrombocytopenia, coagulopathy, or trauma. Early dialogue supports accurate documentation and escalation if needed.
Choice B rationale: While engaging the toddler may seem appropriate, their developmental stage limits reliable verbal communication. Toddlers typically lack the cognitive and linguistic capacity to describe events accurately, especially those involving trauma or abuse. Their responses may be influenced by fear, confusion, or limited vocabulary. Relying on their account prematurely risks misinterpretation and emotional distress. Assessment should prioritize adult sources first, followed by observational and clinical data to guide further action.
Choice C rationale: Notifying social services is a critical step in suspected abuse but must follow preliminary assessment and documentation. Premature reporting without context may lead to unnecessary distress for the family and compromise the integrity of the investigation. The nurse must first gather objective findings, caregiver explanations, and clinical indicators. Social services involvement is warranted when findings suggest non-accidental trauma, inconsistent histories, or high-risk environments. The decision must be evidence-informed and procedurally sound.
Choice D rationale: Notifying the provider is essential for collaborative care but should follow initial data collection. The provider relies on the nurse’s observations and caregiver input to determine next steps, including diagnostic testing or referral. Immediate escalation without context may delay appropriate triage or misdirect resources. The nurse’s role includes thorough documentation, pattern recognition, and initiating dialogue with caregivers to inform the provider’s clinical judgment. This ensures a coordinated, evidence-based response.
A nurse is collecting data from an adolescent.
Which of the following should the nurse identify as the greatest risk for suicide?
A. Family conflict.
Choice A is not correct because while family conflict can be a contributing factor to suicide risk, it is not the greatest risk factor.
B. Homosexuality.
Choice B is not correct because homosexuality itself is not a risk factor for suicide; however, discrimination and bullying related to one’s sexual orientation can increase suicide risk.
C. Availability of firearms.
Choice C is not correct because while the availability of firearms can increase the likelihood of a completed suicide attempt, it is not the greatest risk factor for suicide.
D. Active psychiatric disorder.
Having a psychiatric disorder, such as depression, anxiety disorder, or bipolar disorder, is a significant risk factor for suicide in adolescents.
Full Explanation
Having a psychiatric disorder, such as depression, anxiety disorder, or bipolar disorder, is a significant risk factor for suicide in adolescents.
Choice A is not correct because while family conflict can be a contributing factor to suicide risk, it is not the greatest risk factor.
Choice B is not correct because homosexuality itself is not a risk factor for suicide; however, discrimination and bullying related to one’s sexual orientation can increase suicide risk.
Choice C is not correct because while the availability of firearms can increase the likelihood of a completed suicide attempt, it is not the greatest risk factor for suicide.