The nurse is testing an infant's visual acuity. By what age should the infant be able to fix on and follow a target?
a. 1 month
b. 1 to 2 months
c. 3 to 4 months
d. 6 months
ANS: C
Visual fixation and following a target should be present by ages 3 to 4 months. One to 2 months is too young for this developmental milestone. If the infant is not able to fix and follow by 6 months, further ophthalmologic evaluation is needed.
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The night nurse reported that the client had requested pain medication every 4 hours during the night. The nurse considers the most probable explanation for this to be: 1. The night nurse had more time to spend with the client. 2. The client must be afraid or lonely at night and is trying to get attention. 3. The client may not report pain in the presence of his parents based on their influence or cultural beliefs. 4. The client was asking for medication at night to help him sleep.
A 26-year-old patient sustained a head injury at the age of 19 . The patient has been on antiepileptic drugs and seizure free since 8 months after the accident and wants to discontinue the medications. What is the nurse's best response?
a. "Stop the medications now, and keep an accurate seizure chart to determine if medications need to be reinstituted." b. "Wait a full 10 years after the last seizure; then it is probably safe to stop the medication." c. "Antiepileptic drugs will be needed for life." d. "The dose must be gradually reduced so as not to precipitate status epilepticus."
Identify what the act of making a decision on the basis of an analysis of the available information is called
a. Bias b. Prejudice c. Stereotyping d. Judgment
Despite experiencing a loss of 35% of body weight, the client reports feeling "fat and overweight.". What is the most appropriate nursing diagnosis for this client?
A) Ineffective coping B) Body image disturbance C) Chronic low self-esteem D) Nutritional deficit