NURSING 410- Com Health Guided Learning_Practice C- Detailed Answer Key

1. A nurse is speaking with the mother of a 6-year-old child. Which of the following statements by the mother should concern the nurse? A. "The teacher says my child has to squint to see the board." Rationale: Squintin ...

1. A nurse is speaking with the mother of a 6-year-old child. Which of the following statements by the mother should concern the nurse? A. "The teacher says my child has to squint to see the board." Rationale: Squinting to see the board may indicate a vision problem. It is essential to assess children for hearing and vision problems. If not caught early, they lead to frustration and decreased ability to learn. B. "My child has recently lost both front top teeth." Rationale: This is the age when children begin to lose their deciduous teeth and replace them with their permanent teeth. This is an expected response. C. "My child often cheats when we play board games." Rationale: Children of 5 to 7 years of age often cheat to win at games because they feel winning is most important. This is an expected response. D. "Sometimes my child acts bossy with his friends." Rationale: Children of this age are often bossy and are learning how to interact with peers. They have to learn to appreciate how others feel, but this is a gradual process, as they are still somewhat egocentric. This is an expected response. 2. A nurse is assessing a toddler in the well-child clinic. At what point in the physical examination should the nurse examine the tympanic membrane? A. At the end Rationale: When examining the toddler, the nurse should follow a modified head-to-toe approach, starting at the head but deferring anything that the toddler is likely to view as invasive and traumatic to the very end. The toddler is likely to resist not only having the ears examined, but also anything that follows. B. At the beginning Rationale: The nurse should not examine the tympanic membranes first because the toddler is likely to view examination of the ear canal as invasive and traumatic. The toddler is likely to resist not only having the ears examined, but also anything that follows. C. Before the head and neck are examined Rationale: The nurse should not examine the tympanic membrane before the head and neck. D. Before the chest and abdomen are auscultated Rationale: The nurse should not examine the tympanic membrane before the chest and abdomen are auscultated. 3. A nurse is completing an admission assessment on an adolescent client who is a vegetarian. He eats milk products but does not like beans. Which of the following items should the nurse suggest the client order for lunch to provide the nutrients most likely to be lacking in his diet? A. Peanut butter and jelly sandwich Rationale: A vegetarian diet may be low in protein, especially if the client does not substitute protein-rich beans for meat protein. Peanut butter is an excellent source of protein. A peanut butter and jelly sandwich, especially if prepared on protein-enriched bread, can provide almost 20 grams of protein. B. Baked potato topped with sour cream Rationale: A vegetarian diet may be low in protein, especially if the client does not substitute protein-rich beans for meat protein. Potatoes have a minimal amount of protein and, although sour cream does have some protein, it is a more significant source of fat. C. Bagel with cream cheese Rationale: A vegetarian diet may be low in protein, especially if the client does not substitute protein-rich beans for meat protein. Bagels, if made with enriched flour, may have a minimal amount of protein, and although cream cheese also has some protein, it is a more significant source of fat. D. Fruit salad Rationale: A vegetarian diet may be low in protein, especially if the client does not substitute protein-rich beans for meat protein. Fruit salad is a healthy side dish for this client. However, it is not a source of protein. CONTINUED........