The nurse is doing a routine assessment on a 19-month-old infant and notes that the anterior fontanel is closed. This should be interpreted as:
An abnormal finding-indicates the need for developmental assessment.
A normal finding.
An abnormal finding-indicates the need for immediate referral to a practitioner
A questionable finding-the infant should be rechecked in 1 month.
The Correct Answer is B
A. An abnormal finding-indicates the need for developmental assessment.
This is not accurate. The closure of the anterior fontanel within the expected age range does not indicate an abnormal finding or the need for additional developmental assessment.
B. A normal finding.
This is the correct interpretation. The anterior fontanel normally closes between 12 to 18 months, and closure by 19 months is within the expected developmental range.
C. An abnormal finding-indicates the need for immediate referral to a practitioner.
This is not necessary based on the information provided. The closure of the anterior fontanel within the expected timeframe is a normal finding.
D. A questionable finding-the infant should be rechecked in 1 month.
There's no need for rechecking in 1 month. The closure of the anterior fontanel at 19 months is considered normal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. FACES
The FACES scale, often depicted with a series of faces displaying different expressions, is commonly used for children who can understand and respond to a scale of faces indicating different levels of pain. It is suitable for older children who can articulate their feelings.
B. FLACC
The FLACC (Face, Legs, Activity, Cry, Consolability) scale is commonly used to assess pain in preverbal and non-verbal children, such as a 4-year-old. It evaluates the child's facial expression, leg movement, activity level, cry, and ease of consolability to determine the level of pain.
C. APPT
There is no widely recognized pain assessment tool referred to as "APPT." It may be a term specific to a certain context or institution.
D. Numeric
Numeric pain scales involve asking individuals to rate their pain on a numerical scale, usually ranging from 0 to 10. These scales are often used with older children and adults who can understand and communicate numerical values to describe their pain intensity.
Correct Answer is C
Explanation
A. Show them that the bleeding has stopped.
While showing that the bleeding has stopped is informative, it might not address the child's emotional response or desire for comfort. Applying a band-aid can provide a tangible and comforting solution.
B. Ask why they want a band-aid.
While understanding the child's reasons is important, in this situation, a direct question might not be necessary. The child's request for a band-aid is likely a common response to the perception of an injury or discomfort.
C. Apply a band-aid.
This is the most appropriate intervention in this situation. Applying a band-aid responds to the child's request, provides a tangible form of comfort, and can make the overall experience more positive.
D. Explain that a band-aid is not needed.
While it's true that a band-aid may not be medically necessary, providing one is a simple and kind gesture that can help ease the child's anxiety and contribute to a positive experience.
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