Nursing Elites

1. Baby M is 5 months old. You notice that she now has the ability to grasp objects between her fingers and opposing thumb. This is known as:

• A. Parachute reflex
• B. Grasp reflex
• C. Pincer grasp
• D. Prehension

Correct answer: C

Rationale: The correct answer is C: Pincer grasp. The pincer grasp is the ability to hold objects between the thumb and another finger, typically developed around 9-12 months. At 5 months, it is early for a pincer grasp to fully develop, but the beginning of this skill can be seen as early as 5 months. Choices A and B are incorrect as the parachute reflex is a protective response to falling and the grasp reflex is an automatic response to touch. Choice D, prehension, is a general term for the act of grasping or holding objects, but it does not specifically refer to holding objects between the thumb and fingers like the pincer grasp does.

2. The parents of a school-age child ask the nurse if she thinks that their child has attention deficit hyperactivity disorder (ADHD). Which statement regarding the child’s behavior at school is most indicative of ADHD?

• A. He finishes his work on time in order to go to recess.
• B. He occasionally gets into trouble for talking.
• C. He enjoys math but does not like reading.
• D. He cannot sit still in his seat and constantly moves his legs.

Correct answer: D

Rationale: The most indicative behavior of ADHD is the inability to sit still and constant movement, known as hyperactivity. This behavior is a hallmark symptom of ADHD, making option D the correct choice. Options A, B, and C do not specifically reflect the characteristic hyperactivity associated with ADHD, making them less indicative of the disorder. While option B suggests impulsivity, it is not as specific to ADHD as the hyperactivity described in option D.

3. The nurse is conducting a teaching session for parents on nutrition. Which characteristics of families should the nurse consider that can cause families to struggle in providing adequate nutrition? (Select all that apply.)

• A. Homelessness
• B. Lower income
• C. Migrant status
• D. All of the above

Correct answer: D

Rationale: Factors like homelessness, lower income, and migrant status can create barriers to providing adequate nutrition for children.

4. What physiologic state(s) produces the clinical manifestations of nervous system stimulation and excitement, such as overexcitability, nervousness, and tetany?

• A. Metabolic acidosis
• B. Respiratory alkalosis
• C. Metabolic and respiratory acidosis
• D. Metabolic and respiratory alkalosis

Correct answer: D

Rationale: Both metabolic and respiratory alkalosis can cause overexcitability and nervous system stimulation due to a decrease in ionized calcium levels, which can cause symptoms such as tetany and paresthesias. Acidosis typically has the opposite effect, leading to depression of the nervous system.

5. A 3-year-old child was adopted immediately after birth. The parents have just asked the nurse how they should tell the child that she is adopted. Which guideline concerning adoption should the nurse use in planning a response?

• A. It is best to wait until the child asks about it.
• B. The best time to tell the child is between the ages of 7 and 10 years.
• C. It is not necessary to tell a child who was adopted so young.
• D. Telling the child is an important aspect of their parental responsibilities.

Correct answer: D

Rationale: It is important to tell children about their adoption early, in an age-appropriate manner, as part of building trust and openness in the family relationship.

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