While obtaining a health history of a 3-month-old infant from the mother, the nurse asks about the infant’s ability to suck and grasp the mother’s finger. What is the nurse assessing?
Intelligence
Cerebral cortex function
Reflexes
Cranial nerves
The Correct Answer is C
Choice A reason: Intelligence cannot be assessed in a 3-month-old, as cognitive abilities are not yet developed enough for evaluation. Sucking and grasping are innate behaviors driven by reflexes, not conscious thought, making this an incorrect assessment focus.
Choice B reason: Cerebral cortex function is immature in a 3-month-old, and sucking and grasping are primarily brainstem-mediated reflexes. These actions do not directly assess higher cortical functions like memory or reasoning, making this an incorrect choice.
Choice C reason: Sucking and grasping in a 3-month-old are primitive reflexes (sucking reflex and palmar grasp reflex), mediated by the brainstem. Assessing these evaluates normal neurological development, making this the correct focus of the nurse’s inquiry.
Choice D reason: While sucking involves Cranial Nerves V, VII, IX, and XII, and grasping involves spinal reflexes, the nurse is assessing the presence of these reflexes, not the cranial nerves directly. Reflex assessment is the primary focus, making this less precise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The dose is 25 mg/kg × 10 kg = 250 mg. With 500 mg tablets, 250 mg requires 250 ÷ 500 = 0.5 tablet. This precise calculation ensures the correct dose, minimizing the risk of under- or overdosing, making this the correct choice.
Choice B reason: A 0.75 tablet dose equals 375 mg (0.75 × 500 mg), exceeding the ordered 250 mg. This could lead to toxicity, as Amoxicillin overdosing may cause gastrointestinal or renal issues, making this an incorrect and potentially harmful choice.
Choice C reason: A 1.25 tablet dose equals 625 mg (1.25 × 500 mg), significantly more than the ordered 250 mg. This excessive dose risks severe side effects, including allergic reactions or organ stress, making this an unsafe and incorrect choice.
Choice D reason: A 0.25 tablet dose equals 125 mg (0.25 × 500 mg), less than the ordered 250 mg. This underdose could lead to ineffective treatment, increasing the risk of bacterial resistance, making this an incorrect choice for the prescribed dose.
Correct Answer is B
Explanation
Choice A reason: Writing a series of numbers tests attention or working memory, not recent memory recall. Recalling words after a delay specifically assesses short-term memory, which is more relevant for a 70-year-old, so this is not the best method.
Choice B reason: Asking a patient to recall four words after 10 minutes directly tests recent memory, a key cognitive function in older adults. This method is standard in assessments like the Mini-Mental State Exam, making it the best choice for evaluating memory.
Choice C reason: Verifying information like a mother’s maiden name tests long-term memory, not recent recall. Recent memory involves retaining new information, so recalling words after a delay is more appropriate, making this incorrect.
Choice D reason: Naming past presidents relies on long-term memory and general knowledge, not recent memory. Recalling newly learned words after 10 minutes better assesses short-term memory, so this is not the best approach for recent memory.
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