The nurse assessing a 17-month-old infant determines that the anterior fontanel is sunken, and further assesses the child for:
1. Craniosynostosis.
2. Dehydration.
3. Developmental delays.
4. Neglect.
2
Rationale: Sunken anterior fontanel is symptomatic of dehydration, and the nurse would assess the child's skin turgor, weight, urine output, and intake for further evidence of abnormalities. Craniosynostosis is premature closure of the fontanels, and sunken fontanels do not indicate increased risk for developmental delays or neglect.
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A 17-year-old student is a swimmer on her high school's swim team. She has had three bouts of otitis externa this season and wants to know what to do to prevent it. The nurse instructs her to:
a. Use a cotton-tipped swab to dry the ear canals thoroughly after each swim. b. Use rubbing alcohol or 2% acetic acid eardrops after every swim. c. Irrigate the ears with warm water and a bulb syringe after each swim. d. Rinse the ears with a warmed solution of mineral oil and hydrogen peroxide.
The nurse is preparing to administer a renal transplant recipient's first dose of mycophenolate mofetil (CellCept). Prior to administering the medication, the nurse appropriately reviews drug formulary information
What is the best understanding of this medication by the nurse? a. It is a calcineurin inhibitor used for induction therapy. b. It is an antimetabolite used for maintenance therapy. c. It is a polyclonal antibody used for maintenance therapy. d. It is an mTOR inhibitor used for maintenance therapy.
How should the nurse position the patient who is to have endotracheal suctioning?
a. supine c. high Fowler's b. Sims' d. side-lying
During a physical assessment of a 5-month-old child, the nurse observes the first tooth has just erupted and uses the opportunity to advise the mother to schedule a dental examination for her baby. When is the correct time for the dentist visit?
A) By the first birthday B) By the second birthday C) By entry into kindergarten D) By entry into first grade