NCLEX-PN Exam Dumps | While performing a physical assessment on a 6-month-old infant, the nurse observes head lag. Which of

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Question 221/700

While performing a physical assessment on a 6-month-old infant, the nurse observes head lag. Which of the following nursing actions should the nurse perform first?

A. Ask the parents to allow the infant to lay on her stomach to promote muscle development.

B. Notify the physician because a developmental or neurological evaluation is indicated.

C. Document the findings as normal in the nurse's notes.

D. Explain to the parents that their child is likely to be mentally retarded.

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A nurse has b...; Question 462: During the health screening of an adolescent, which finding ...; Question 463: A couple from the Philippines living in the United States is...; Question 464: A 12-year-old male is brought to his primary care provider t...; Question 465: The method of splinting is always dictated by:...; Question 466: Which of the following foods is a complete protein?...; Question 467: The nurse provides a postoperative client with an analgesic ...; Question 468: Which is an appropriate outcome for the nursing diagnosis of...; Question 469: A client is taking the fluoroquinolone Ciprofloxin for acute...; Question 470: How does the ANA define the psychiatric nursing role?...; Question 471: When questioning an elder about suspected abuse, the nurse s...; Question 472: People who live in poverty are most likely to obtain health ...; Question 473: The nurse should utilize data about which of the following t...; Question 474: Some drugs are excreted into bile and delivered to the intes...; Question 475: A patient has just been prescribed Minipress to control hype...; Question 476: When a client with a major burn experiences body image distu...; Question 477: Metformin (Glucophage) is administered to clients with type ...; Question 478: Which of the following is not considered one of the five rig...; Question 479: Following a classic cholecystectomy resection for multiple s...; Question 480: Which of the following is one of the main goals for Healthy ...; Question 481: The nurse who was not promoted tells another friend, "I knew...; Question 482: A teenage client is admitted to the hospital because of acet...; Question 483: A patient has recently been prescribed Albuterol. Which of t...; Question 484: When suctioning a client, what is the usual amount of time t...; Question 485: The kind of man who beats a woman is:...; Question 486: Which of the following nursing diagnoses might be appropriat...; Question 487: Which statement best describes electrolytes in intracellular...; Question 488: Which of the following statements by an adult child of a cli...; Question 489: A corporate executive works 60-80 hours a week. The client i...; Question 490: A man expresses surprise that his wife has become very withd...; Question 491: An example of an extended care facility is a:...; Question 492: Which of the following procedures describes an opening betwe...; Question 493: A client describes her cervical mucus as clear, thin, and el...; Question 494: A nurse is returning phone calls in a pediatric clinic. Whic...; Question 495: The best definition of communication is:...; Question 496: After securing the client's safety from a faulty electric be...; Question 497: After breast reconstruction secondary to breast cancer, the ...; Question 498: Kleinman's Explanatory Model of Health and Illness is signif...; Question 499: Which type of exercises might be prescribed to strengthen th...; Question 500: A client with an ileus is placed on intestinal tube suction....; Question 501: Which of the following motions is identified with the corres...; Question 502: Which medication might the physician order if the client exp...; Question 503: A client is taking hydrocodone (Vicodin) for chronic back pa...; Question 504: An appropriate question when assessing a client's self-expec...; Question 505: A nurse observes a client sitting alone and talking. When as...; Question 506: In a disaster, triage situation, the nurse should be least c...; Question 507: The parents of a 2-year-old child ask the nurse how they can...; Question 508: A nurse is instructing a person who had a left CVA and right...; Question 509: One day postoperative, the client complains of dyspnea, and ...; Question 510: When making an occupied bed, it is important for the nurse t...; Question 511: Nursing care for a client undergoing chemotherapy includes a...; Question 512: A 4-year-old client is unable to go to sleep at night in the...; Question 513: A client with asthma develops respiratory acidosis. Based on...; Question 514: A nursing care plan for a client with sleep problems has bee...; Question 515: One of the major functions of the kidneys in maintaining nor...; Question 516: When the nurse is determining the appropriate size of an oro...; Question 517: American families are having difficulty adequately performin...; Question 518: Signs of impaired breathing in infants and children include ...; Question 519: A nurse suspects a patient is developing Bell's Palsy. The n...; Question 520: A legal right to confidentiality of client information is wa...; Question 521: An Rh-negative woman with previous sensitization has deliver...; Question 522: The nurse is teaching a client about communicable diseases a...; Question 523: A hospitalized adult client who routinely works from midnigh...; Question 524: When choosing a needle gauge for an intramuscular injection ...; Question 525: A client has experienced a CVA with right hemiparesis and is...; Question 526: A client with massive chest and head injuries is admitted to...; Question 527: When giving an intramuscular injection to an infant. Which o...; Question 528: To remove a client's gown when she has an intravenous line, ...; Question 529: A 20-year-old male client had a diving accident with subsequ...; Question 530: A client is having problems with her ankles. To assess her a...; Question 531: A patient that has TB can be taken off restrictions after wh...; Question 532: A client has been diagnosed with Disseminated Intravascular ...; Question 533: A health care worker is concerned about a new mother being o...; Question 534: A nurse is teaching a group of clients with a diagnosis of S...; Question 535: A client is told that his test is positive, but in fact, the...; Question 536: An advance directive is written and notarized according to l...; Question 537: A client is diagnosed with HIV. Which of the following are a...; Question 538: A fifty-five year-old man suffered a left frontal lobe CVA. ...; Question 539: A 2-year-old child diagnosed with HIV comes to a clinic for ...; Question 540: When working with multicultural populations, the nurse shoul...; Question 541: For a client requiring total oral care, it is important for ...; Question 542: To manage time most effectively, the nurse responds to which...; Question 543: Safety measures for using crutches must be taught to clients...; Question 544: A 10-month-old child is brought to the Emergency Department ...; Question 545: A client receiving drug therapy with furosemide and digitali...; Question 546: A client who is experiencing infertility says to the nurse, ...; Question 547: In managing nausea related to Morphine epidural analgesia, t...; Question 548: A female having her first child is experiencing which type o...; Question 549: Quality is defined as a combination of all of the following ...; Question 550: A client turns her ankle. She is diagnosed as having a Pulle...; Question 551: Which of the following microorganisms are considered normal ...; Question 552: The highest incident of child abuse occurs in children in wh...; Question 553: Padding on a restraint helps:; Question 554: The tendency of a drug to combine with its receptor is calle...; Question 555: The nurse is caring for a dying client who has persistently ...; Question 556: Which of the following is responsible for laws mandating the...; Question 557: A client with a diagnosis of Schizophrenia has been released...; Question 558: If a client is suffering from thyroid storm, the PN can expe...; Question 559: The PN is caring for a client with diabetes insipidus. The n...; Question 560: Which of the following syndromes associated with incomplete ...; Question 561: Referral for client education in the community can be accomp...; Question 562: Which of the following developmental milestones for a 6-mont...; Question 563: Using clichés in therapeutic communication leads the client ...; Question 564: The physician wants to know if a client is tolerating his to...; Question 565: A nurse working in a pediatric clinic and observes the follo...; Question 566: The nurse has completed client teaching about introducing so...; Question 567: When a client who is having trouble conceiving says to the n...; Question 568: A case management clinical pathway for congestive heart fail...; Question 569: Which of the following represents a normal serum potassium l...; Question 570: A 32 year-old male with a complaint of dizziness has an orde...; Question 571: A nurse is instructing a patient about the warning signs of ...; Question 572: Clients who take iron preparations should be warned of the p...; Question 573: Which of the following vaccines are not part of the regular ...; Question 574: The primary organ for drug elimination is the:...; Question 575: When a client has a chest drainage system in place, where sh...; Question 576: For which of the following conditions might blood be drawn f...; Question 577: All of the following are causes of vaginal bleeding in late ...; Question 578: Which of the following is likely to increase the risk of sex...; Question 579: Which of the following statements by a client indicates adeq...; Question 580: Light therapy can be effective for:...; Question 581: A client and his family facing the end stage of a terminal i...; Question 582: Which of the following conditions is mammography used to det...; Question 583: Which of the following blood pressure parameters indicates P...; Question 584: Which of the following values should the nurse monitor close...; Question 585: A female client complains to the nurse at the health departm...; Question 586: Which of the following medications should be held 24-48 hour...; Question 587: The nurse teaching an obese client about nutritional needs a...; Question 588: The ICU nurse caring for a client who has just been declared...; Question 589: A 13 year old girl is admitted to the ER with lower right ab...; Question 590: A nurse teaching a patient with COPD pulmonary exercises sho...; Question 591: A client taking isotretinoin (Accutane) tells the nurse that...; Question 592: A nurse runs into the significant other of a patient with en...; Question 593: The major electrolytes in the extracellular fluid are:...; Question 594: The Token Economy is a type of therapy that focuses on:...; Question 595: Which of the following arterial blood gas values indicates a...; Question 596: When discussing the patterns of use of alcohol and other dru...; Question 597: A person using over-the-counter nasal decongestant drops who...; Question 598: A client who has a known history of cardiac problems and is ...; Question 599: A nurse is assessing a patient in the rehab unit at shift ch...; Question 600: In teaching clients with Buck's Traction, the major areas of...; Question 601: The greatest time savers when planning client care include a...; Question 602: A client with a nasogastric (NG) tube begins vomiting. What ...; Question 603: The nurse supporting a family who has just experienced a sud...; Question 604: An appraisal of self-care practices involves an assessment o...; Question 605: Two staff nurses were considered for promotion to head nurse...; Question 606: A serious complication of a total hip replacement is displac...; Question 607: Which of the following coping mechanisms protects an individ...; Question 608: Which of the following vaccines is a live virus?...; Question 609: While admitting a client to an acute-care psychiatric unit, ...; Question 610: The nurse observes bilateral bruises on the arms of an elder...; Question 611: Which of the following actions should a nurse take first for...; Question 612: Mr. H is upset regarding being in the hospital for another d...; Question 613: Nurses caring for clients who have cancer and are taking opi...; Question 614: If Ms. Barrett's distance vision is 20/30, which of the foll...; Question 615: The nurse is assessing an elder who the nurse suspects is be...; Question 616: When medications have an additive, synergistic, or antagonis...; Question 617: Which of the following terms refers to soft-tissue injury ca...; Question 618: The nurse teaching a client about hepatitis and its transmis...; Question 619: If a client has chronic renal failure, which of the followin...; Question 620: Support systems during the grieving process include all of t...; Question 621: Which direction given to the nursing assistant is most likel...; Question 622: Ten-year-old Jackie is admitted to the hospital with a medic...; Question 623: Which of the following tests is commonly performed on newbor...; Question 624: The nurse should teach a client in the Emergency Department,...; Question 625: Which of the following observations is most important when a...; Question 626: A client diagnosed with Borderline Personality Disorder freq...; Question 627: A client recently lost a child due to poisoning. The client ...; Question 628: Acyclovir (Zovirax) is the agent of choice for which of the ...; Question 629: A client begins a regimen of chemotherapy. Her platelet coun...; Question 630: A nurse at outpatient clinic is returning phone calls that h...; Question 631: The goals of palliative care include all of the following ex...; Question 632: A client was involved in a motor vehicle accident in which t...; Question 633: Distraction therapy is:; Question 634: Rehabilitation services begin:; Question 635: A nurse has been ordered to administer Morphine to a patient...; Question 636: A concern regarding maternal and infant mortality and morbid...; Question 637: In a disaster situation, the nurse assessing a diabetic clie...; Question 638: A nurse has been ordered to set-up Buck's traction on a pati...; Question 639: A client with stress incontinence should be advised:...; Question 640: A 60-year-old widower is hospitalized after complaining of d...; Question 641: Attaching a restraint to a side rail or other movable part o...; Question 642: A nurse is screening patients for immunizations. Which of fo...; Question 643: When a couple experiencing infertility presents for a fertil...; Question 644: A nurse is assigned to do pre-operative teaching on a blind ...; Question 645: Two staff nurses were considered for promotion to head nurse...; Question 646: Which type of dressing is recommended to place over a site w...; Question 647: When assessing a client in the Emergency Department whose me...; Question 648: Which of the following individuals may legally give informed...; Question 649: Which of the following home-care strategies is most likely t...; Question 650: A client is 36 hours post-op a TKR surgery. 270 cc's of sero...; Question 651: After 12 months of cessation of menses, which of the followi...; Question 652: While repositioning a comatose client, the nurse senses a ti...; Question 653: A 24 year-old man has been admitted to the hospital due to w...; Question 654: Which of the following foods present a problem for a client ...; Question 655: According to the ANA Code of Ethics for Nurses, professional...; Question 656: Broccoli, oranges, dark greens, and dark yellow vegetables c...; Question 657: A hospitalized client has just been informed that he has ter...; Question 658: A client with a pleural drainage system to suction has gentl...; Question 659: When caring for a Native-American family, the nurse needs to...; Question 660: Which of the following microorganisms is easily transmitted ...; Question 661: A client begins bleeding from the site of a previous arteria...; Question 662: A child comes to the clinic with a skin rash. The maculopapu...; Question 663: A 28 year-old male has a diagnosis of AIDS. The patient has ...; Question 664: A patient is scheduled for electro-convulsive therapy treatm...; Question 665: On first meeting, a new nurse manager makes eye contact, smi...; Question 666: The nurse notices that a family is waiting at the nursing st...; Question 667: Ethical and moral issues concerning restraints include all o...; Question 668: Which of the following strategies should the nurse include w...; Question 669: Erythropoietin used to treat anemia in clients with renal fa...; Question 670: Acute hyphema is associated with what type of injury?...; Question 671: A client with major head trauma is receiving bolus enteral f...; Question 672: A visitor accidentally knocks over a plastic pleural drainag...; Question 673: A patient that has delivered a 8.2 lb. baby boy 3 days ago v...; Question 674: Mr. Lee comes to the clinic with thick green drainage around...; Question 675: The 24-hour day-night cycle is known as:...; Question 676: A complication of total parenteral nutrition (TPN) is the de...; Question 677: In administering NSAID adjunctive therapy to an elderly clie...; Question 678: During the work phase of the nurse-client relationship, the ...; Question 679: A patient has experienced a severe third degree burn to the ...; Question 680: Why is it often necessary to draw a complete blood count and...; Question 681: When a client who is 25 years of age asks the nurse when she...; Question 682: Chemotherapeutic agents often produce a degree of myelosuppr...; Question 683: Which of the following solutions is routinely used to flush ...; Question 684: When a client informs the nurse that he is experiencing hypo...; Question 685: The nurse who was not promoted then went to the utility room...; Question 686: A nurse is assessing a 18 year-old female who has recently s...; Question 687: Teaching the client with gonorrhea how to prevent reinfectio...; Question 688: A client is admitted with a diagnosis of Multiple Drug Use. ...; Question 689: A nurse is setting up a vision-screening program for a new s...; Question 690: Which of the following medications is a serotonin antagonist...; Question 691: Which type of diet should the nurse provide to help a client...; Question 692: As part of the teaching plan for a client with type I diabet...; Question 693: A client has been taking a drug (Drug A) that is highly meta...; Question 694: A 20-year-old obese female client is preparing to have gastr...; Question 695: The acts enacted by states to provide immunity from liabilit...; Question 696: In an obstetrical emergency, which of the following actions ...; Question 697: Which of the following physical findings indicates that an 1...; Question 698: When a client needs oxygen therapy, what is the highest flow...; Question 699: A successful resolution of the nursing diagnosis Negative Se...; Question 700: A pregnant client has congenital heart disease. The nurse sh...

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