A nurse is assessing a 1-month-old infant at a pediatric office. Which of the following findings requires a referral for further care?

Limited hip abduction

Equal leg length

Symmetric gluteal and thigh skin folds

Femoral head remains in the acetabulum during the Barlow maneuver

Answer and Explanation

The Correct Answer is A

Rationale:

A. Limited hip abduction: Limited abduction of the hips in a 1-month-old can indicate developmental dysplasia of the hip (DDH). This finding warrants further evaluation, such as ultrasound imaging, to rule out structural abnormalities and initiate early treatment if needed.

B. Equal leg length: Equal leg length is a normal finding and does not require intervention. Leg length discrepancies are more concerning and often associated with hip dislocation or other musculoskeletal conditions.

C. Symmetric gluteal and thigh skin folds: Symmetry in the gluteal and thigh folds is a reassuring sign that typically rules out DDH. Asymmetry would be more suggestive of a hip abnormality requiring follow-up.

D. Femoral head remains in the acetabulum during the Barlow maneuver: This is a normal finding. The Barlow test assesses for hip instability, and if the femoral head remains stable within the socket, no further evaluation is needed.

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Free Nursing Study Resources

Correct Answer is ["A","C","E"]

Explanation

Rationale:

A. Keep objects in the client's room in the same place: Maintaining a consistent environment helps clients with vision loss navigate safely and confidently. Sudden changes in object placement can increase the risk of disorientation and injury.

B. Ensure there is high-wattage lighting in the client's room: While good lighting benefits clients with partial vision, high-wattage lighting can cause glare or discomfort. The focus should be on well-distributed, non-glare lighting suited to individual needs rather than universally high intensity.

C. Touch the client gently to announce presence: Gently touching a visually impaired client before speaking helps avoid startling them and fosters trust. It is a respectful way to make presence known when visual cues are unavailable.

D. Approach the client from the side: Approaching from the front is preferable so the client can better perceive the nurse's presence through remaining visual fields or auditory cues. Side approaches may lead to disorientation or surprise.

E. Allow extra time for the client to perform tasks: Clients with vision loss may require additional time to complete self-care or communication tasks. Rushing them can increase stress and compromise safety, so patience supports their independence.

A. "Opioids should not be given to older adults." B. "Pain perception is decreased in older adult clients." C. "Older adults report pain less frequently than younger clients." D. "Older adults require higher doses of pain medication."

Correct Answer is C

Explanation

Rationale:

A. "Opioids should not be given to older adults.": Opioids can be given to older adults when necessary, but with caution. The dose may need adjustment due to age-related changes in metabolism and increased sensitivity, not outright avoidance.

B. "Pain perception is decreased in older adult clients.": Pain perception does not decrease with age. Older adults may have conditions that affect communication or cognition, but their ability to feel pain remains intact, and they can still experience significant discomfort.

C. "Older adults report pain less frequently than younger clients.": Older adults often underreport pain due to beliefs that pain is a normal part of aging or fear of treatment consequences. This makes active assessment and trust-building essential in managing their pain effectively.

D. "Older adults require higher doses of pain medication.": Older adults typically require lower or more carefully titrated doses due to slower metabolism, decreased renal clearance, and heightened drug sensitivity, especially to central nervous system effects.

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A nurse is assessing a 1-month-old infant at a pediatric office. Which of the following findings requires a referral for further care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","C","E"]

Explanation

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Correct Answer is C

Explanation

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