EAQ 5
What is the acceptable respiratory rate in normal adolescent?
16
Which is the average annual increase in the height of preschoolers?
2.5 - 3 inches
What would the student nurse claim is an acceptable respiratory rate range in a 2 year old toddler?
25-32 breaths/min; acceptable range in child is 20 to 30 breaths/min, 6month old infant is 30-50 breaths/min, in newborns 35-40 breaths/min
What is the average height of a 4- year- old child?
3 feet, 4.5inches (103cm)
Which degree of edema will result in a 6mm deep indentation upon pressure application?
3+; 2mm= 1+, 4mm= 2+, 8mm= 4+
A client receiving fluphenazine decanoate develops dystonia early in therapy. Which medication would the nurse anticipate administering to reverse this side effect?
Benztropine- dystonia is extrapyramidal side effect (EPS) and this med reverses these;
Which theory states that a child'd growth pattern is related to gene activity?
Gesell's theory; Piaget's theory of cognitive development comprises four periods related to age, Erikson's theory of psychosocial development states that an individual need to accomplish a particular task before mastering the stage and progressing to another one, Havinghurst's theory of stage crisis is based on the developmental tasks
Which team member is most accountable when delegating a task to the health care team?
RN
At which stage of Kohlberg's theory would a child exhibit fear of punishment?
Stage 1; stage 2,-the child recognizes that there is more than one correct viewpoint, stage 3- an individual seeks the approval of and maintains the expectations of one's immediate group, stage 4- an individual expands focus from a relationship with others to societal concerns
Which action would the nurse take to prevent venous thrombus formation after abdominal surgery?
encourage the client to ambulate multiple times daily
Which condition is an example of a bacterial infection?
impetigo
Which statement is true about the diet plan for toddlers?
milk should be supplemented with solid food items such as vegetables and fruits
Which primary task is achieved by a delegator when delegating a task to a delegatee for an effective outcome?
motivating- inspiring the delegatee by motivation is the primary task; managing helps in assisting the staff with planning, priority setting, and decision-making, renewing provides self care to enhance the ability to care for staff, explaining helps in teaching and interpreting information to promote client well being
Which assessment finding is a late sign of heat failure?
peripheral edema
The parents of a preschooler tell the nurse that they try to inculcate good eating habits by asking the child to be at the table until the "plate is clean." Which condition is the child at risk for?
poor eating habits
Which hormone has both inhibiting and releasing action?
prolactin- secreted by the hypothalamus
Which stage of Kohlberg's theory explains the influence of moral values on an individual's thought?
society-maintaining orientation stage- individual expands focus from a relationship with others to societal concerns, influenced by moral values; good boy-nice girl= individual wants to win the approval of and maintain the expectations of one's immediate group, instrumental relativists= child wants to be on time to dinner, universal ethical principle orientation stage= defines "right" in accordance with self chosen ethical principles
Which statement is true for toddlers?
the incidence of poisoning is very common in toddlers
Which feature is associated with the "maturation phase" of normal wound healing?
the scar is firm and inelastic on palpation; proliferative phase= the fibrin strands form a scaffold or framework, inflammatory phase= white blood cells migrate into the wound, proliferative phase= epithelial cells are grown over the granulation tissue bed
Which stage of Kohlberg's development theory of moral development defines "right" by the decision of the conscience?
universal ethical principle orientation
A client recovering from deep partial-thickness burns develops chills, flank pain, and malaise. The primary health care providers makes a tentative diagnosis or urinary tract infection. Which diagnostic tests would the nurse expect the PCP to prescribe to confirm the diagnosis?
urinalysis with a urine culture and sensitivity- culture will identify the microorganism and sensitivity will identify the most appropriate antibiotic; altered bilirubin results indicate liver or biliary problems, creatine clearance reflects renal function
Which is the average optimal blood pressure of an adolescent?
110/65; infant = 85/45; toddler = 95/65; children between the ages of 6-13 years old = 105/65
A client has a prescription for 125mg of phenytoin by mouth three times a day. Phenytoin is supplied as an oral suspension of 25mg/5mL. How many milliliters of solution will the nurse administer for each dose?
25mL
If hearing loss is detected early, proper intervention can help a child achieve normal language development. Which should be the latest age that hearing loss should be detected to ensure that a child achieves normal language development?
3 months
The nurse is assessing a client's degree of eden and finds 8mm of depth. Which would be correct to document this condition?
4+ edema; 2mm = 1+; 4mm = 2+; 6mm = 3+
At which age would the nurse expect permanent detention to erupt?
5 years
Which percentage of his or her adult weight does an individual gain during the adolescent years?
50%
Which is the minimum heart rate of a 14 year old?
60
What is the maximum acceptable heart rate of a 16 year old?
90bpm
The nurse is measuring the blood pressure of toddlers. Which blood pressure finding is the nurse most often to find in the toddlers?
95/65; infants = 85/54, children above 6 = 105/65, between 10-13 = 110/65
which ethnic group has a greater incidence of osteoporosis due to musculoskeletal differences?
Chinese Americans- have increased incidence of osteoporosis because they have shorter and smaller bones with lower bone density; irish americams have taller and broader bones, african americans have decreased incidence of osteoporosis, egyptian american are shorter in stature
Which professionals in a health care organization can be delegators?
RNs
Which term is used to indicate and absence of menstruation?
amenorrhea; dysmenorrhea is painful menstruation
which diagnostic test is used for direct visualization of ligaments, menisci, and articular surface of joints?
arthroscopy; muscle biopsy conducted to diagnose atrophy and inflammation, ultrasound is used to view soft tissue disorders/traumatic joint injuries/osteomyelitis, electromyography evaluates diffuse or localized muscle weakness
Which electrical activity of the cardiac conduction system is reflected in the P wave?
atrial depolarization
Which physical assessment technique involves listening to the sounds of the body?
auscultation
In which stage of Erikson's theory does the child initiate self care activities?
autonomy vs. sense of shame and doubt; initiative vs. guilt stage is the third stage- children like to pretend and try out new roles; integrity vs. despair is the eighth stage- many older adults view their lives with a sense of satisfaction; middle-age adults achieve success at the stage of generativity vs. self absorption and stagnation- contribute to furture generation through parenthood, teaching, and community
Which noninvasive assessment and management skills certification would the nurse be required to use for airway maintenance and cardiopulmonary resuscitation (CPR)?
basic life support
Which catecholamine receptor is responsible for increased heart rate?
beta-1 receptor
According to the disaster triage system, which dolor tag would the nurse feel is more suitable for a client who died in the earthquake?
black
Which activity demonstrates fine motor skills in infants aged 2 to 4 months?
bringing objects from hand to mouth; turning from side to back, sitting erect using support, and showing good head control are gross motor skills
Determine how an adolescent can establish group identity during psychosocial development?
by building close peer relationships to achieve acceptance in society
How do adolescents establish group identity during psychosocial development?
by building close peer relationships to achieve acceptance in the society
How do adolescents establish health identity during psychosocial development?
by evaluating their own health with a feeling of well being, by having the ability to function normally in the absence of any disease of infirmity
After a surgical thyroidectomy a client exhibits carpopedal spasms and tremors. The client reports tingling in the fingers and around the mouth. The nurse suspects a deficiency in which mineral?
calcium- hypocalcemia occurs with accidental removal of the parathyroid glands, administer calcium gluconate to treat
The nurse applies a cold pack to relieve musculoskeletal pain. Which rationale explained the analgesic properties of cold therapy?
causing local vasoconstriction, preventing edema and muscle spasms
Which part of the brain primarily regulates muscle function and coordinates movement?
cerebellum- regulates motor movements resulting in smooth and balanced muscular activity; cerebrum is associated with higher brain functions, such as though and action; epithalamus acts as a connection between the motor pathways and regulates emotions; hypothalamus regulates body temp and secretions of the endocrine gland
Which of these skills should be present in a 6 to 8 month old child?
child can sit alone without support; a child after 8 months of age should be able to pick up small objects, place objects in containers, and pull themselves up to stand or sit
Which interview technique is the nurse using when asking a client to score his or her pain on a scale from 0 to 10?
close ended question; asking whether anything else is bothering the client is an example of probing, when nurse responds with "go on" it is back channeling
Which sexually transmitted infection is caused by human papillomavirus?
condylomata acuminata - genital warts; neisseria gonorrhoeae causes gonorrhea; herpes simplex virus causes herpes; chlamydia trachomatis causes chlamydia
which side effect would the nurse monitor for in a severely depressed client who received electroconvulsive therapy?
confusion immediately after treatment- the electrical energy passing through the cerebral cortex during ECT results in a temporary state of confusion
Which developmental milestone would the nurse expect when assessing a preschooler?
copying squares; also run well and walk up and down steps with ease, learn to jump and hope rather jumping and hopping with ease
The nurse cares for a client with an abnormal cortisol level. The nurse recalls which information about cortisol?
cortisol stimulates gluconeogenesis
Which is the action of an antidiuretic hormone (ADH)?
decreases water loss in urine- released by the pituitary gland in response to either a decrease in blood volume or an increased concentration of sodium or other substances in the plasma, acts to decrease the production of urine by increasing the reabsorption of water by renal tubules
which infection is caused due to fungus?
dermatophytosis- single or multiple patches appear on the skin
Which disorder is caused by the deficiency of antidiuretic hormone?
diabetes insipidus; excessive production of growth hormone results in acromegaly and excessive production of andrenocorticotropic hormone causes Cushing syndrome; syndromes of innapropriate antidiuretic hormone occurs as a results of the increased production of antidiuretic hormone
Which hormone may cause vaginal carcinomas in a female child after birth?
diethylstilbestrol - has a teratogenic effect; progesterone and androgens may cause masculinization of a female fetus; estrogen may cause congenital defects in the female reproductive system
Which diagnostic procedure is used to detect muscle weakness?
electromyography (EMG)
How many days is the neonatal period?
first 28 days of life
Which characteristic does the nurse associate with a punch biopsy?
it is performed using a circular cutting instrument 2 to 6mm in diameter; shave biopsies are usually recommended for superficial or raised lesion, excisional biopsies are comparatively more uncomfortable, shave biopsies remove the skin portion that rises above surrounding tissues
which description describes a coalesced type of skin lesion configuration?
lesions merge together and appear confluent; circumscribed skin lesions are well defined with sharp borders, annular skin lesions are ringlike with raised borders around flat centers of the normal skin, lesions with wavy borders that resemble a snake are described as serpiginous
Which finding in a urinalysis indicated a urinary tract infection?
leukoesterases- released by WBC in response to an infection or inflammation; presence of crystals in urine indicates that specimen has been allowed to stand, bilirubin indicates anorexia nervosa, diabetic ketoacidosis, and prolonged fasting, ketones indicated diabetic ketoacidosis
Which term would the nurse document in the client's medical record after reduced urinary output?
oliguria- urinary output of less than 400mL in a 24 hour interval
Which sleep pattern would the nurse recognize as normal in preschoolers?
on average, a preschooler sleeps about 12 hours a night; by age 5 children rarely take daytime naps except in cultures in which siesta is custom, partial awakening followed by a normal return to sleep is normal in preschoolers, about 30% of infant's sleep time is in the REM cycle
which organism is a common opportunistic infection in a client infected with HIV?
oropharyngeal candidiasis- most common infection associated with HIV because immune system can no longer control Candida fungal growth; Pneumocystis jiroveci pneumonia (PCP) more common in AIDS, cryptosporidiosis intestinal infection in AIDS, taxoplasma gondii through contact with cat feces common in AIDS
The nurse understands that haloperidol is most effective for clients who exhibit which type of behavior?
overactive- reduces emotional tension, excessive psychomotor activity, panic, and fear; can worsen depression, increases feelings of lassitude and fatigue
Which hormone is released from the posterior pituitary gland?
oxytoxcin- acts on the uterus and mammary glands; prolactin, growth hormone, and luteinizing hormone are produced by the anterior pituitary gland
Which emergency medical service (EMS) health care professional provides advanced life support to the clients who survived large-scale disaster?
paramedics
Which assessing technique involves tapping a client's skin with the fingertips to cause vibrations in the underlying tissues?
percussion
Which conditions pose the greatest risk for injury for an adolescent?
substance abuse, motor vehicle accidents
Which cardiovascular adverse effect would the nurse associate with use of clomiphene?
tachycardia; chest pain is a rare side effect
Which finding could be described as visibly dilated, superficial, and cutaneous small blood vessels found on the face and thighs?
telangiectasia- permanent condition; tenting is the failure of the skin to immediately return to the normal position after a gently pitch, angioma is a tumor that consists of blood and lymph vessels, varicosity is the increased prominence of superficial veins
at which age does the anterior fontanel of the skull close?
12-18 months
Which is the maximum volume of an intramuscular injection recommended for a preschool-aged child?
1mL; 0.5mL for newborns and infants, school ages and older children may tolerate 2mL if they have sufficient muscle mass
A health care provider prescribes furosemide for a client with hypervolemia. The nurse recalls that furosemide exerts its effects in which part of the renal system?
Loop of Henle; thiazide act n the distal tubule in the kidney, potassium-sparing diuretics act in the collecting duct in the kidney, plasma expanders(not diuretics) act in the glomerulus of the nephron in the kidney
Which period of Piaget's theory explains self consciousness in adolescents?
Period IV; Period I-an infant develops a schema or actions pattern dealing with the environment, Period II- the child demonstrates animism in which he or she personifies objects, Period III- the child thinks about an action that earlier was performed physically
Which medication is available in an injectable form?
Pitocin
Which chemical would the nurse identify as being responsible for the occurrence of Braxton Hicks contradictions during the final weeks of pregnancy?
Prostaglandins
Which GI change may be found in the client with burn injuries?
abdominal distention- due to loss of peristalsis; GI mobility may be inhibited, blood flow may be reduced and mucosal damage might have occurred
Which is the most common cause of death among adolescents?
accidents- approximately 74% of all deaths; suicide is third leading cause, homicide is the second leading cause, death by substance abuse affects 30% of adolescents
Which component of delegation is retained while the delegator is delegating the client's care task to the nursing aide?
accountability
a client is scheduled for adrenalectomy. Which action would the nurse expect in the plan of care?
administer parenteral corticosteroids- steroid therapy usually is given intravenously or intramuscularly and continued intraoperatively to prepare for the acute adrenal insufficiency that follows surgery; diet must supply amply protein and potassium
which hormone aids in regulating intestinal calcium and phosphorus absorption?
adrenal glucocorticoids- regulate by increasing or decreasing protein metabolism; insulin acts together with growth hormone to build and maintain health bone tissue; thyroxine increases the rate of protein synthesis in all types of tissues; parathyroid hormone secretion increases in response to decreased serum calcium concentration and stimulates the bones to promote osteoclastic activity
Which statement is accurate regarding erythropoietin?
an erythropoietin deficiency is associated with renal failure; produced by the kidneys; deficiency occurs in renal failure; deficiency causes anemia; secreted in response to hypoxia, which results in decreased oxygenated blood flow to the tissues
A client with schizophrenia who is receiving an antipsychotic medication begins to exhibit a shuffling gait and tremors. The primary health care provider prescribes the anticholinergic medication benztropine, 2mg daily. The nurse should inquire about which symptoms when assessing the client?
constipation- the anticholinergic activity of each medication is magnified, and adverse effects such as paralytic ileus may occur; can cause dryness of the mouth and decreased respiration
Which hormone is formed from cholesterol?
cortisol- all lipid soluble hormones are synthesized from cholesterol; all water soluble hormones are formed from amino acids
Which autoantigens are responsible for the development of Chron disease?
crypt epithelial cells; thyroid cell surfaces are autoantigens responsible for Hashimoto thyroiditis, the pulmonary and glomerular basement membranes act as autoantigens responsible for Goodpasture syndrome
The nurse understands which medication may cause gynecological malignancies in females?
diethylstilbestrol; oxytocin used to start or strengthen labor contractions and to control bleeding after birth, raloxifene is used to prevent postmenopausal osteoporosis, use of thalidomide during pregnancy may cause birth defects in the newborn
which medication would the nurse identify as being used to manage nonmetastatic gestational trophoblastic disease?
dinoprostone- is a synthetic medication derived from naturally occurring prostaglandins, methylergonovine is used to treat postpartun hemorrhage. oxytocin is used for labor induction. mifepristone is used to induce an abortion.
Which statement is true about Piaget's theory of cognitive development?
during the sensorimotor stage, infants develop an action pattern for dealing with their environment; Piaget's theory includes four periods that are related to age, early preoperational stage= animism. concrete operations stage= children able to perform mental operations
During which period of pregnancy may medication exposure cause meromelia, cleft lip, and enamel hypoplasis?
embryonic period; teratogenic exposure during the fetal period may cause a disruptioin in the functional ability of the fetus, exposure during the presomite period or preimplantation period may result in fetal death
Which characteristic of clients with antisocial personality disorder would the nurse consider when planning care?
exhibits lack of empathy for others- self-satisfaction is of paramount concern to people with antisocial disorder, usually charming on the surface and can easily con people into doing what they want; OCD=engages in rituals and are perfectionists,
How will the nurse researcher categorize research in which subjects are given chlorhexidine and povidone-iodine as antiseptics?
experimental research
Which factor is the nurse assessing when checking the cardinal positions from the image?
extraocular muscle function- assessed using the corneal light reflex and the six cardinal positions of cranial nerves III, IV, and VI; Ishihara chart used to determine colorblindness, peripheral vision determined by performing a test called perimetry, intraocular pressure is determined by performing tonometry
What would the presence of ketones in the urine of a client indicate?
fat metabolism- happens when ingesting fewer calories than are needed for maintenance; increased red blood cells in the urine indicate cystitis, increased specific gravity of the urine indicated heart failure, presence of casts in the urine indicated urinary calculi
Which Korotkoff sound represents the diastolic blood pressure in an adolescent?
fifth; first sound is sharp represents systolic BP, third sound is crisper more intense tapping, fourth sound is muffled and low(corresponds to diastolic pressure in the toddler)
Which secondary skin lesion may include athlete's foot as an example?
fissure; surgical incisions and healed wounds are examples of scar type secondary lesion, a scale-type lesion would include flaking of the skin after a medication reaction or a sunburn, ulcer-type lesions may include pressure ulcers or chancres
A professor asks a student nurse to explain the stage when an adolescent has prevalence of egocentric thought. Which period of the Piaget's theory will the nurse explain?
formal operations
Which period of Piaget's theory marks the end of cognitive development?
formal operations
Identify the stage at which an adolescent develops abstract thinking?
formal operations period
Which period of Piaget's theory covers the prevalence of egocentrism in adolescents?
formal operations- prevalence of egocentric thought, leads to demonstrate feelings and behaviors characterized by self-consciousness; sensorimotor is first period- infants develop a schema or action pattern for dealing with the environment; preoperational is the second period - children learn to think with the use of symbols and mental images; concrete operations is the third period - children are able to coordinate two concrete perspectives in social and scientific thinking
Which form is a source of the dermal regeneration template artificial skin graft?
glycosaminoglycan bonded to silicone membrane; porcine skin is the source of a xenograft, cadaveric skin is the source of an allograft, porcine collagen bonded to silicone membrane is the source of biocomposite synthetic nylon mesh graft
Which of these stages is followed by the society- maintaining orientation, according to the Kohlberg's theory?
good boy-nice girl; Stage 1- punishment and obedience, Stage2- instrumental relativist orientation, Stage 3-good boy/nice girl, Stage 4-society maintaining
Which color tag would be given to "walking wounded" clients according to the disaster triage tag system?
green; red= life threatening conditions, black= expected to die or may be dead, yellow= major injuries that may require urgent treatment but can wait a short time
Which organ has only beta-1 receptors?
heart
Which would the nurse consider to be an example of a potential internal disaster?
hospital fire- any kind of event inside a health care facility or campus that could endanger the safety of clients or health care staff
Scald injuries could be caused by contact with which item?
hot liquids or steam; contact with grease and the alkali in oven cleaners may cause chemical injuries, an open flame in house fires may cause thermal injuries
A client is receiving haloperidol for agitation, and the nurse is monitoring the client for side effects. Which response identified by the nurse is unrelated to an extrapyramidal tract effect?
hypertensive crisis; akathisia= restlessness and twitching or crawling sensations in the muscles, opisthotonos= hyperextension and arching of the back, oculogyric crisis= uncontrolled upward movement of the eyes, all of these extrapyramidal side effects
A client is admitted to the hospital for an adrenalectomy. Before the client's replacement steroid therapy is regulated fully, the nurse will monitor the client for which complication?
hypotension- due to instability of the vascular system and the lability of circulating adrenal hormones
In which category of fluids would the nurse classify an intravenous solution of 0.45% sodium chloride?
hypotonic; hypotonic solutions are less concentrated (contains less than 0.85g of NaCl in each 100ml); isotonic colustions cause no change in the cellular volume or pressure because their concentration is equivalent to that of body fluid; hypertonic solutions contain more than 0.85g of solute in each 100mL
A mother diagnosed with AIDS states she has been caring for her baby even though she has not been feeling well. Which important information would the nurse determine regarding the care provided by the mother?
if the mother is breast feeding her baby- epidemiological evidence has identified breast milk as a source of HIV transmission
ranitidine has been prescribed to help treat a client's gastric ulcer. The nurse expects this medication to act specifically by which mechanism?
inhibiting the histamine at H2 receptors- limits gastric secretion; promoting the release of gastrin is undesirable; gastric hormones increase gastric acid
To prevent the development of ureteral colic from renal calculi in the future, which strategy would the nurse include in the client's plan of care?
instruct the client to drink at least 3L of fluid daily - this dilutes the urine and crystals are less likely to coalesce and form calculi
a 15 year old plans to go to a nightclub without informing his or her parents but is afraid of being caught. Which behavior would this indicate?
invulnerability- frequently leads to risk taking behaviors; seriation is the ability to mentally classify objects according to their quantitative dimension, personal fable is when an adolescent thinks that their thoughts and feeling and unique, adolescents have a belief that an imaginary audience constantly scrutinized their actions
Which description is associated with fissures?
linear cracks in the epidermis that extend into the dermis; ulcers= deep erosions extending beneath the epidermis, atrophy= thinning of the surface of the skin with a loss of skin marking, lichenifications= characterized by thick areas of epidermis with accentuated skin markings
Which is the etiological factor of nephrogenic diabetes insipidus (DI)?
lithium therapy; CNS infections such as meningitis are etiological factors of central DI, Goiter is commonly seen in Graves disease, sulfonamide is a goitrogen that can cause goiter
In which components of the nephron unit does furosemide decrease fluid reabsorption?
loop of Henle, distal tubules, proximal tubules- inhibits sodium and chloride reabsorption; glomerulus is the site of glomerular filtration; the BC is the site of the collection of glomerular filtrate and contains the glomerulus
which substance is released in response to low serum level of calcium?
parathyroid hormone- to maintain calcium homeostasis; renin released in response to decreased renal perfusion responsible for regulating BP, erythropoieten released by kidneys in response to poor blood flow to the kidneys to stimulate production of red blood cells. atrial natriuretic peptide produced in right atrium of heart in response to increased blood volume
When a client injuries the amphiarthrodial joint, which joint did the client injure?
pelvis- amphiarthroidal joints are those that permit slight movements; knee and elbow joints are examples of diarthroidal joints which are freely moveable; cranial joint is an example of an synarthroidal joint which is immovable
Which gland secretes melatonin?
pineal gland- secretes melatonin which regulates the circadian rhythm and reproductive system at the onset of puberty; thyroid gland secrete thyroid hormones; adrenal gland secretes androgens, corticosteroids, and catecholamines; parathyroid gland secretes the hormone calcitonin
Which is a secondary cause of adrenal insufficiency?
pituitary tumors (adrenocorticotropic hormone ACTH deficiency); primary causes include hemorrhage, tuberculosis, and metastatic cancer
which cation regulates intracellular osmolarity?
potassium- decrease in serum potassium causes a decrease in the cell wall pressure gradient and results in water moving out of the cell, also regulates metabolic activities, transmission and conduction of nerve impulses, cardiac conduction and smooth and skeletal muscle contraction
A client complains of pain in the ear. While examining the client, the nurse finds swelling in front of the left ear. Which lymph node would the nurse expect to be involved?
preauricular; mastoid or posterior auricular lymph node is present behind the ear, occipital lymph nodes are located in the back of the head, submental lymph nodes are located below the chin
Which age group would the nurse recommend that children be taught to swim under guided supervision?
preschoolers
Which statement about language development in preschoolers is correct?
preschoolers find words such as die and dye confusin
In which age group would the nurse anticipate observing associative play?
preschoolers- play with other child in cooperative manner in which they make something or play designated roles; parallel play is common among toddlers-each engages in an independent activity that is similar to but not influences or shared by others, adolescents- spend time with multiple friends at one time
Which key feature is associated with a stage 2 pressure ulcer?
presence of nonintact skin; sinus tracts may develop during stage 4 of pressure ulcers, subcutaneous tissue becomes damages or necrotic during stage 3 of pressure ulcers, a reddened area over a bony surface occurs in stage 1 of pressure ulcers
A client with a diagnosis of schizophrenia, paranoid type, has been receiving a phenothiazine medication. When the psychiatric daycare center plans a fishing trip, it will be important for the nurse to take which action?
provide the client with sunscreen- causes a photosensitivity
which causative organism colonization signified purulent exudates of the greenish-blue pus with fruity odor?
pseudomonas; proteus colonization causes pus with fishy odor, colonization of bacteroides causes brownish pus with a fecal odor, staphylococcus colonization results in purulent exudate of creamy yellow pus
Which dermatological problem is treated by using intralesional corticosteroids?
psoriasis; callulitis, erysipelas, and carbuncles are treated by using systemic antibiotics such as synthetic sulfur
Which psychotherapeutic theory uses hypnosis, dream interpretation, and free association as methods to release repressed feelings?
psychoanalytical model
which steps would the nurse undertake during the administration of eardrops in children ages 1 to 3 years?
pull the auricle down and back; cotton ball is placed in the outermost part of the ear canal, kept in side lying position for 2-3mins, dropper is held 1cm above the ear canal for the instillation of drops
Which action would the nurse take when administering eardrops to a 4 year old?
pull the auricle up and out; cotton ball is placed into the outermost part of the ear canal, kept on side-lying position for 2-3ming, hold dropper 1cm above the ear canal
Which procedure involves the examination of the ureters and renal pelvises?
pyelogram- a retrograde examination of the ureters and the pelvis of both kidneys; cystogram examines bladder, urethrogram exams urethra, a voiding cystourethrogram determines whether urine is flowing backward into the urethra
which estrogen antagonist would the health care provider prescribe a client for the prevention and treatment of osteoporosis in postmenopausal women?
raloxifene- increases bone mineral density, reducing bone desorption, and reducing incidences of osteoporotic vertebral fractures; denosumab is a monoclonal antibody used to treat osteoporosis when other meds are not effective, alendronate and zoledronic acid are commonly used for the prevention and treatment of osteoporosis
Which nursing practice is associated with a self-regulation skill?
reflecting on one's experience; evaluation involves reflecting on the nurse's own behavior, explanation involves supporting findings and conclusion, interpretation involves clarifying any data about which the nurse is uncertain
Which mechanism of action for wet-to-damp saline-moistened gauze for wound debridement is correct?
removing the necrotic tissue mechanically; dilution of viscous exudates is promoted through the continuous wet-gauze technique, topical enzyme preparations cause a breakdown of the denatured protein of the eschar, moisture-retentive dressings promote the spontaneous separation of necrotic tissue through autolysis
Which clinical manifestation is associated with hypernatremia in burns?
seizures; fatigue, parasathesias, and cardiac dysrhythmias are clinical manifestations of hyperkalemia
which characteristic of adolescence is exemplified by risk taking behavior without fear of consequences?
sense of invulnerability; toddler experiences animism in which objects come to life, personal fable= adolescent thinks of themselves as center of attention, imaginary audience= adolescents think they always have someone enthusiastically listening to or watching them
Which therapeutic communication technique is a coping strategy to help the nurse and client adjust to stress?
sharing humor
A client diagnosed with invasive cancer of the bladder has brachytherapy scheduled. Which successful therapy outcome would the nurse expect with this client?
shrinkage of the tumor when scanned- brachytherapy involves implanting isotope seeds in or next to the tumor and should control the growth and metastasis of cancerous tumor; urinary output will increase with successful therapy, may affect the client's bone marrow sites resulting in a reduction of WBCs
Which hormone is released from the pancreas?
somatostatin- inhibits the release of insulin and glucagon
According to the Centers for Disease Control and Prevention (CDC), which stage of the HIV disease is present in the client with a laboratory report revealing a CD4+ T-cell count of 520cells/mm3?
stage 1; greater than 500= stage 1, 200-499= stage 2, less than 200= 3rd stage, fourth stage of HIV disease indicates a confirmed HIV infection with no information regarding CD4+ T-cell counts
Which stage describes Oedipus complex, according to Freud's theory?
stage 3- the phallic stage
Which rational explains the purpose of administering diphenoxylate hydrochloride to clients with AIDS?
to manage diarrhea
Which of these age groups has the highest incidence of lead poisoning?
toddler
Which is the causative organism for syphilis?
treponema pallidum; campylobacter jejuni is the causative organism for proctitis; trichomonas vaginalis is the causative organism for vulvovaginitis; chlamydia trachomatis is the causative organism for salpinigits
Which step would the nurse follow when taking a toddler's blood pressure?
use a pediatric stethoscope bell to hear Korotkoff sounds
Which color of cerebrospinal fluid (CSF) may indicate subarachnoid hemorrhage in the client?
yellow
