Question

1. A nurse is assessing the fontanels of an 8-month-old infant. Which of the following findings should the nurse recognize as an expected finding?

1. The anterior fontanel is open.
2. The posterior fontanel is open.
3. Both fontanels are the same size.
4. Both fontanels show molding.

2. A nurse is caring for a client who has acute diverticulitis. Which of the following diets should the nurse recommend to the client?

1. High residue
2. Lactose-free
3. Gluten-free
4. Low-fiber

3. A nurse is caring for a client who is 48 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse include in the plan of care?

1. Administer low-dose heparin.
2. Place the client on a full liquid diet.
3. Use an incentive spirometer every 3 hr.
4. Maintain the client on bed rest.

4. A nurse is providing teaching to the parent of an infant who has a cleft lip palate. Which of the following feeding techniques should the nurse include in the teaching?

1. Burp the infant frequently during feedings.
2. Position the nipple at the front of the infant’s mouth.
3. Hold the infant in a supine position.
4. Use feeding devices without nipples.

5. A nurse is an acute mental health care facility is prioritizing care for multiple clients. Which of the following clients should the nurse see first?

1. A client who has depressive disorder and requires assistance with ADLs
2. A client who has obsessive-compulsive disorder and is upset about a change in daily routine
3. A client who is taking clozapine to treat schizophrenia and report a sore throat
4. A client who has narcissistic personality disorder and is mocking others during group therapy.

Answer 1

1. The correct option is a) , the anterior fontanel is open because it generally closes between 12-18 months .

2. The correct option is a) high residue diet . High residue diet means high fiber & low fat example whole wheat, fresh fruits & vegetables.

3. The correct option is c) use an incentive spirometry every 3hrs to avoid lung collapse by immobilisation .

4. The correct option is a) Burp the infant frequently during feeding . Babies with a cleft need to be burped more often because they take in more air while feeding.