A nurse is collecting data from a 4-month-old infant at a well-child visit. For which of the following findings should the nurse notify the provider?

Anterior fontanel closed

Plays with toes

Posterior fontanel closed

Moves objects to mouth

Answer and Explanation

The Correct Answer is A

The correct answer is A. Anterior fontanel closed. The anterior fontanel is one of two soft spots on an infant's skull that allow for brain growth and development. The anterior fontanel normally closes between 9 and 18 months of age. If it closes earlier than expected, it may indicate a condition called craniosynostosis, which is when the skull bones fuse prematurely and restrict brain growth. This can lead to increased intracranial pressure, developmental delays, and abnormal head shape. Therefore, if a nurse observes that a 4-month-old infant has a closed anterior fontanel, they should notify the provider for further evaluation. The other options are normal developmental milestones for a 4-month-old

infant and do not require notification of the provider.

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Correct Answer is C

Explanation

The correct answer is C. The nurse should document factual and objective information about the incident, such as what the client said and what actions were taken by the nurse and other staff members. The nurse should not document opinions or assumptions about the cause of the fall, such as blaming the assistive personnel or stating that the client has no injuries without performing a thorough assessment. The nurse should also not document that an incident report was completed and sent to risk management, as this is confidential information that should not be part of the medical record.

A. “I will wait 15 minutes before taking a second tablet." B. "I will swallow the tablet for faster absorption." C. "I should stop taking the medication if I get a headache." D. "I should expect pain relief in 1 to 3 minutes."

Correct Answer is D

Explanation

The correct answer is D. I should expect pain relief in 1 to 3 minutes. Sublingual nitroglycerin tablets are placed under the tongue and dissolve quickly to relieve chest pain caused by angina. The medication works by dilating blood vessels and improving blood flow to the heart. The onset of action is usually within 1 to 3 minutes.

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A nurse is collecting data from a 4-month-old infant at a well-child visit. For which of the following findings should the nurse notify the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?

Correct Answer is C

Explanation

A nurse is reinforcing discharge teaching with a client who has angina and a prescription for sublingual nitroglycerin tablets. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is caring for a client who has schizophrenia and is taking an antipsychotic medication. Which of the following screening tools should the nurse use to identify tardive dyskinesia?

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A nurse is reinforcing teaching with a client who has GERD and a prescription for pantoprazole. Which of the following statements indicates an understanding of the teaching?

A nurse is preparing to administer eye drops to a child. Which of the following actions should the nurse take?

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