A mother brings her 2-month-old daughter in for an examination and says, "My daughter rolled over against the wall, and now I have noticed that she has this spot that is soft on the top of her head. Is something terribly wrong?" How should the nurse respond?
"Perhaps that could be a result of your dietary intake during pregnancy."
"That 'soft spot' may be an indication of cretinism or congenital hypothyroidism."
"That 'soft spot is normal, and actually allows for growth of the brain during the first year of your baby's life."
"Your baby may have craniosynostosis, a disease of the sutures of the skull."
The Correct Answer is C
A. "Perhaps that could be a result of your dietary intake during pregnancy": This statement does not address the mother's concerns about the soft spot and shifts the focus away from the immediate issue. The soft spot, or fontanelle, is a normal anatomical feature and is not related to maternal dietary intake during pregnancy.
B. "That 'soft spot' may be an indication of cretinism or congenital hypothyroidism": This statement is misleading. While developmental delays can be associated with congenital hypothyroidism, the presence of a soft spot on a 2-month-old’s head is a normal finding, not a direct indication of a metabolic disorder.
C. "That 'soft spot' is normal, and actually allows for growth of the brain during the first year of your baby's life": This response provides accurate information about the anterior fontanelle, which is a normal feature in infants. The fontanelle allows for skull growth as the brain expands during the early months of life. It typically closes by 12-18 months of age.
D. "Your baby may have craniosynostosis, a disease of the sutures of the skull": This statement could cause unnecessary alarm for the mother. Craniosynostosis is a condition where one or more of the sutures in a baby’s skull fuse prematurely, but it would typically present with other signs such as an abnormal head shape. A soft spot on its own does not indicate this condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Behind with the nurse's hands placed firmly around his neck: This approach may be perceived as threatening or invasive, potentially increasing the patient's apprehension and discomfort. It is important to maintain a respectful and gentle approach, especially when working with a patient who may already feel uneasy.
B. Behind with hands placed on throat: Similar to option A, examining from behind and placing hands on the throat may cause anxiety and discomfort for the patient, particularly if they are not familiar with the procedure. This method does not provide a clear line of sight or reassurance for the patient.
C. The front with the nurse's thumbs placed on either side of his trachea and his head tilted forward: This technique is the most appropriate approach for examining the thyroid gland. Positioning the patient in front allows for better communication and visibility. Placing the thumbs on either side of the trachea is a standard method for palpating the thyroid, and having the patient tilt their head forward can help relax the neck muscles, making the examination more comfortable. Additionally, this approach allows the nurse to explain the procedure more easily, even with language barriers.
D. Have the patient perform the exam: While patient involvement in their care can be empowering, asking the patient to perform the exam may not be appropriate for a thyroid examination, as the nurse must assess the gland's size, consistency, and any potential nodules. This approach may also lead to further anxiety for the patient, who may not know how to perform the exam correctly.
Correct Answer is B
Explanation
A. To facilitate the movement of air through the nares: While the ciliated mucous membrane does help in the overall functioning of the nasal passages, its primary role is not to facilitate air movement but to filter and trap particles.
B. To filter coarse particles from inhaled air: The primary purpose of the ciliated mucous membrane in the nose is to trap and filter out coarse particles, such as dust, pollen, and microbes, from inhaled air. The cilia beat in a coordinated manner to move mucus and trapped particles towards the throat, where they can be swallowed or expelled, helping to keep the airways clear and protect the respiratory system.
C. To filter out odors: While the nasal cavity does play a role in detecting odors through the olfactory receptors located in the upper part of the nasal cavity, the ciliated mucous membrane itself is not primarily responsible for filtering odors.
D. To warm the inhaled air: The nasal passages do help warm inhaled air as it passes through, but this is more a function of the rich blood supply and the large surface area of the nasal cavity rather than the role of the ciliated mucous membrane specifically. The primary action of the ciliated mucous membrane is focused on filtering particles from the air.
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