EAQ NU272-02 Assignment 1

The nurse is discussing the neurological reflexes seen in an infant with the parents. Which reflex would the nurse state as being present indefinitely? 1 Landau 2 Parachute 3 Body righting 4 Neck righting

2. Parachute The parachute reflex appears at 7 to 9 months and persists indefinitely. The Landau reflex appears at 6 to 8 months and lasts until 12 to 24 months. Body righting appears at 6 months and lasts until 24 to 36 months. Neck righting appears at 3 months and lasts until 24 to 36 months.

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? Record your answer using a whole number. ______________ months

3 months If a health care provider detects hearing loss before the child is 3 months old and an intervention is initiated within 6 months, the child can achieve normal language development.

Which is a complication that may develop in the child with hypospadias with chordee? A. Renal failure B. Testicular cancer C. Testicular torsion D. Sexual difficulties

D. Sexual difficulties Chordee can affect the child's future reproductive capabilities, which are related to the inability to inseminate directly. Kidney function is not affected by hypospadias with chordee. The incidence of testicular cancer is not increased; nor is the risk for testicular torsion.

How much additional daily protein intake is required by the lactating client? 1 10 g 2 25 g 3 30 g 4 45 g

2. 25 g is the necessary amount of increased daily protein intake recommended for lactating women. 10 g of added protein will not meet the needs of the lactating client. 30 and 45 g are all more than the additional recommended amount, although most women in developed countries exceed this requirement.

Which is the expected color and consistency of amniotic fluid at 36 weeks' gestation? 1 Clear, dark amber colored, and containing shreds of mucus 2 Straw colored, clear, and containing little white specks 3 Milky, greenish yellow, and containing shreds of mucus 4 Greenish yellow, cloudy, and containing little white specks

2. By 36 weeks' gestation, amniotic fluid should be pale yellow or straw-colored with small particles of vernix caseosa present. Dark amber-colored fluid suggests the presence of bilirubin, an ominous sign. Greenish-yellow fluid may indicate the presence of meconium and suggests fetal compromise. Cloudy fluid suggests the presence of purulent material.

Which organization assists in establishing policies related to Medicare and Medicaid payment for meaningful use of electronic health records (EHRs)? 1 National Institutes of Health (NIH) 2 American Medical Informatics Association (AMIA) 3 Center for Medicare and Medicaid Services (CMS) 4 Health Information Management Systems Society (HIMSS)

3. Center for Medicare and Medicaid Services (CMS) CMS rules specify how health care facilities and providers make meaningful use of the EHRs and technologies to receive payment from Medicare and Medicaid. The NIH uses translational bioinformatics for medical research. The AMIA and the HIMSS have been involved in identifying nursing informatics competencies.

The nurse tells a client undergoing diuretic therapy to avoid working in the garden on hot summer days. Which condition is the nurse trying to prevent in this client? 1. Frostbite 2. Heatstroke 3. Hypothermia 4. Hyperthermia

2. Heatstroke Clients undergoing diuretic therapy are at risk of heatstroke when exposed to temperatures higher than 104°F (40°C). Frostbite occurs when the body is exposed to ice-cold temperatures. Hypothermia is a condition in which the skin temperature drops below 96.8°F (36°C). Hyperthermia occurs when the body is exposed to temperatures higher than 101.3°F (38.5°C).

Which statement indicates that the nurse is in the advanced beginner stage of Benner? 1 Learns about the profession through a specific set of rules and procedures 2 Identifies the basic principles of nursing care through careful observation 3 Understands the organization and specific care required by certain clients 4 Assesses the entire situation and transfers knowledge gained from multiple previous experiences

2. Identifies the basic principles of nursing care through careful observation According to the levels of proficiency set forth by Benner, the nurse in the advanced beginner stage is able to identify basic principles of nursing care through careful observation. The nurse in the novice stage learns about the profession through a specific set of rules and procedures. After reaching the competent stage, the nurse will be able to understand the organization and specific care required by certain clients. The nurse who has reached the proficient stage is able to assess an entire situation and transfer knowledge gained from multiple previous experiences.

Which statement is true regarding the importance of play for children? 1 Pretend play hampers the cognitive development of children. 2 Playing is important because it helps children to release frustration. 3 Children should be introduced to reality if they have imaginary playmates. 4 Children should completely avoid television, electronic games, and computer programs.

2. Playing serves as a medium for children to release frustration. Pretend play allows children to learn to understand others' points of view, develop skills in solving social problems, and become more creative. Some children have imaginary playmates. Imaginary playmates are a sign of health and help children distinguish between reality and fantasy. Television, videos, electronic games, and computer programs support development and the learning of basic skills. There should be limited use of these for preschoolers, but these need not be completely avoided. On the other hand, television, electronic games, and computer programs have lasting negative effects on a toddler's language development, reading skills, and short-term memory.

Which is the best way for the nurse to promote adherence to the restrictions after colorectal surgery? 1 Limit restrictions to nonessential foods. 2 Handle dietary changes in a matter-of-fact way. 3 Have the dietitian explain the restrictions to the parents. 4 Arrange to have an adult other than a parent stay at mealtime.

2. Toddlers are ritualistic and do not tolerate change well; therefore any change in diet should be done in a matter-of-fact way. Limited restrictions on nonessential foods are not always possible. Although the parents could consult with the dietitian, this action will not change the toddler's response to the dietary restrictions. The toddler is still dependent on the parents and therefore will respond better to them than to a stranger.

Which point listed by the nursing student is accurate regarding the loss of a client's medication records? 1 "Loss of medical records may lead to libel charges." 2 "The registered nurse would maintain accurate nursing records." 3 "There is an assumption that the care provided to the client was negligent." 4 "The health care facility needs to demonstrate why the medical records were lost."

3. "There is an assumption that the care provided to the client was negligent." In case a client's medical record is lost, there is an assumption that the care provided to the client was negligent. Loss of medical records may lead to a malpractice claim. The entire institution is responsible for maintaining medical records. Primary health care providers need to demonstrate why the medical records were lost.

The nurse working in a cardiac center is preparing to enter client data using health information technology. The nurse needs to refer to these data during subsequent follow-up client visits. Which type of record would the nurse use to enter the client's data? 1 Personal health record (PHR) 2 Electronic health record (EHR) 3 Electronic medical record (EMR) 4 Regional Health Information Organization (RHIO) health record

3. EMR The EMR is a client's health record within a health care provider's facility. These records are not intended to be shared between multiple facilities and agencies. The PHR is self-recorded and maintained by the client. An EHR is an individual's official, digital health record; it is shared among multiple facilities and agencies. RHIO health records are client records that can be exchanged among providers and across geographic areas.

While inspecting the external eye structure of a client, the nurse finds bulging of the eyes. Which condition would be suspected in the client? 1. Eye tumors 2. Hypothyroidism 3. Hyperthyroidism 4. Neuromuscular injury

3. Hyperthyroidism Bulging eyes may indicate hyperthyroidism. Tumors are characterized by abnormal eye protrusions. Hypothyroidism can be revealed by the coarseness of the hair of the eyebrows and the failure of the eyebrows to extend beyond the temporal canthus. Crossed eyes or strabismus may result from neuromuscular injury or inherited abnormalities.

The nurse is teaching crutch-walking to an adolescent. Which action indicates the need for more teaching? 1. Takes short steps of equal length 2. Looks forward to maintain balance 3. Looks down when placing the crutches 4. Assumes an erect posture when walking

3. Looks down when placing the crutches The child should maintain an erect walking posture, without looking down, to ensure equilibrium and prevent loss of balance. Taking short steps is the correct technique for safe ambulation while crutch-walking. Looking forward is the correct technique for safe ambulation while crutch-walking; it keeps the body's center of gravity over the hips. Maintaining an erect posture is the correct technique for safe ambulation during crutch-walking; it keeps the body's center of gravity over the hips.

Which scenario is a perfect example of primary prevention? 1 An infant receives the rotavirus vaccination in the hospital setting. 2 An adult in the early stages of Parkinson disease is advised to perform adequate exercise. 3 An older adult permanently paralyzed due to brain hemorrhage is transferred to a long-term care facility. 4 An older adult with Parkinson disease is administered carbidopa-levodopa to slow the progression of the disease.

1 An infant receives the rotavirus vaccination in the hospital setting. Primary prevention consists of all health promotion efforts and wellness education activities. An infant receiving the rotavirus vaccination is an example of primary prevention. An adult in the early stages of Parkinson disease is advised to perform adequate exercises; this is an example of secondary prevention. An older adult permanently paralyzed due to brain hemorrhage is transferred to a long-term care facility. This is an example of tertiary prevention. An older adult with Parkinson disease is administered carbidopa-levodopa to slow the progression of the disease. This is an example of secondary prevention.

The parents of an adolescent treated for allergies privately tell the nurse that they suspect that their child is a hypochondriac. Which therapeutic response would the nurse provide? 1 Discussing developmental behaviors of adolescents 2 Explaining potentially serious complications of allergies 3 Discussing some of the underlying causes of hypochondriasis 4 Explaining that the parents may be transferring their fears to their adolescent

1. Adolescents are very aware of their changing bodies and become especially concerned with any alteration resulting from illness or injury. Explaining the complications of allergies does not address concepts related to growth and development of the adolescent and may cause unnecessary concern about the child's physical condition. A discussion about hypochondriasis may reinforce the parents' concern. Indicating that the parents may be engaging in transference is accusatory and is not supported by adequate data; this response may precipitate such feelings as anger and guilt.

A new mother is concerned that her 1-month-old infant is nursing every 2 hours. Which response by the nurse is most appropriate? 1. "It's common for newborns to nurse this often. Let's talk about how you're adjusting with the new baby." 2. "Breast milk is easily digested; giving your infant a little rice cereal will keep him full longer." 3. "It sounds as though your baby is a little spoiled; try to resist feeding more often than every 4 hours." 4. "You may not be producing enough milk; it'll be important for you to supplement feedings with formula."

1. "It's common for newborns to nurse this often. Let's talk about how you're adjusting with the new baby." Newborns typically nurse every 2 to 3 hours. Although breast milk is easily digested, feeding solids to an infant is not recommended at this age. Feeding satisfies a fundamental need; one does not spoil an infant by nursing as needed. Adequate intake is evidenced in infant weight gain and adequate urinary and bowel elimination. Supplementing feedings with formula may lead to decreased milk production.

A client is being initiated on bisphosphonates. Which advice will the nurse provide? 1. "Take it on an empty stomach." 2. "This medication should be taken at night before bed." 3. "These medications should be taken with food or milk." 4. "Lie down for a bit after taking the medication."

1. "Take it on an empty stomach." Bisphosphonates should be taken on an empty stomach in the morning because food and some minerals reduce absorption. The client should remain upright for 30 minutes after taking the medication.

Which refers to the professional obligation of the nurse to assume responsibility for actions? 1 Accountability 2 Individuality 3 Responsibility 4 Bioethics

1. Accountability Nurses have an obligation to uphold the highest standards of practice, assume full responsibility for actions, and maintain quality in the knowledge base and skill of the profession; this is referred to as accountability. Individuality and responsibility are positive characteristics of the nurse but are not necessarily professional obligations. Bioethics is a field of study concerned with the ethics and philosophical implications of certain biological and medical procedures and treatments.

Which phrase would the nurse use to document a fetal heart rate (FHR) increase of 15 beats over the baseline rate of 135 beats per minute that lasts 15 seconds? 1. An acceleration 2. An early increase 3. A sonographic motion 4. A tachycardic heart rate

1. An acceleration An acceleration is an abrupt increase in FHR above the baseline of 15 beats/min for 15 seconds; if the acceleration persists for more than 10 minutes, it is considered a change in baseline rate. Early decelerations, not increases, occur. An early deceleration starts before the peak of the uterine contraction and returns to baseline when the uterine contraction ends. A sonographic motion is not a term used in fetal monitoring. A tachycardic FHR is one faster than 160 beats per minute.

A client with diabetes mellitus experiences a sudden fall in blood glucose levels while traveling by air. The client is not carrying any medications or a copy of a personal medical record. Which type of health information technology would be beneficial for this client? 1 Personal health record (PHR) 2 Clinical health care informatics 3 Electronic medical record (EMR) 4 Regional health information organization (RHIO)

1. Personal health record (PHR) The PHR is an electronic health record that consists of health data and the treatment provided for the client. The client can enter the data and maintain these health records. It is easy to carry and helps health care providers provide treatment in emergency conditions. Health care facilities maintain an EMR for each client. The client does not have access to these records in the air. Clinical health care informatics seeks to transform client health by educating and training health care professionals. It does not help provide emergency treatment to the client while traveling. RHIO oversees the exchange of the client's information among the client's health care providers and across geographic areas.

How are profits used in a for-profit health care organization? 1 Profits are paid out to shareholders. 2 Profits are used to buy new equipment. 3 Profits are used to build additional facilities. 4 Profits are invested in improving health care services.

1. Profits are paid out to shareholders. Health care organizations can be classified as for-profit and not-for-profit based on how the profits are distributed. In a for-profit organization, the profits are generated for the shareholders. In a not-for-profit organization, the profits are used to buy new equipment, build additional facilities, and improve health care services.

In clients with human immunodeficiency virus (HIV), which potential complication is most important for the nurse to teach prevention strategies? 1 Infection 2 Depression 3 Social isolation 4 Kaposi sarcoma

1. The client has a weakened immune response. Instructions regarding rest, nutrition, and avoidance of unnecessary exposure to people with infections help reduce the risk for infection. Clients can be taught cognitive strategies to cope with depression, but the strategies will not prevent depression. The client may experience social isolation as a result of society's fears and misconceptions; these are beyond the client's control. Although Kaposi sarcoma is related to HIV infection, there are no specific measures to prevent its occurrence.

The nurse is obtaining consent from an unemancipated minor to perform an abortion. When would the nurse consider the consent-giving process to be appropriately completed? Select all that apply. One, some, or all responses may be correct. 1 Consent has been obtained from the spouse. 2 Consent has been given specifically by a court. 3 Self-consent has been granted by a court order. 4 Consent has been given by a grandparent. 5 Consent has been obtained from at least one parent of the minor.

2, 3, 5 An unemancipated minor is allowed to consent to an abortion if one of three conditions is fulfilled. The minor may give consent if consent has been obtained from at least one parent. The minor may also give consent if consent has been given specifically by a court or self-consent has been granted by a court order. The spouse or grandparents of unemancipated minors are not allowed to give consent for abortions.

Which qualities would an effective leader exhibit? Select all that apply. One, some, or all responses may be correct. 1. Born with the right stuff 2. Elicit a vision from people 3. Bring out the best in people 4. Engender discipline and obedience 5. Inspire people to bring the vision into reality

2, 3, 5 Leadership is the ability to elicit a vision from people and to inspire and empower those people to do what it takes to bring the vision into reality. A leadership quality is to bring out the best in people. Leaders are not born with the right stuff; rather they develop these qualities gradually over time when they perform with the right kind of attitude and determination. Leaders must possess the ability to inspire the commitment of followers and allow them to achieve goals autonomously rather than simply engendering discipline and obedience.

The nurse is gathering a client's health history. Which information would the nurse classify as biographical information? Select all that apply. One, some, or all responses may be correct. 1 Symptoms 2 Client's age 3 Family structure 4 Type of insurance 5 Occupation status

2, 4, 5 Biographical information is factual demographic data about the client usually obtained by the admitting office staff. The client's age, types of insurance, and occupation status are considered biographical information. If the client presents with an illness, the nurse gathers details about the symptoms of the illness, which is descriptive information, not biographical information. The nurse obtains information about family structure while assessing the family history of the client. It is not biographical information.

Which psychophysiological factors influence communication between the nurse and a client? Select all that apply. One, some, or all responses may be correct. 1. Privacy level 2. Emotional status 3. Information exchange 4. Level of caring expressed 5. Growth and development

2, 5 Growth and development and emotional status are two psychophysiological factors that influence communication between the nurse and a client. Privacy level is an environmental factor. Information exchange is a situational factor. Level of caring expressed is a relational factor.

After surgery, an adolescent has a patient-controlled analgesia (PCA) pump that is set to allow morphine delivery every 6 minutes. Which statement indicates to the nurse that the family understand instructions about the PCA pump? 1. "I'll make sure that she pushes the PCA button every 6 minutes." 2. "She needs to push the PCA button whenever she needs pain medication." 3. "I'll have to wake her up on a regular basis so she can push the PCA button." 4. "I'll press the PCA button every 6 minutes so she gets enough pain medication while she's sleeping."

2. "She needs to push the PCA button whenever she needs pain medication." Morphine, an opioid analgesic, relieves pain; when control of pain is given to the adolescent, anxiety and pain are usually diminished, resulting in a decreased need for the analgesic; only the adolescent should press the PCA button. Having the adolescent press the PCA button every 6 minutes is unnecessary. Although pain medication can be delivered as often as every 6 minutes, it should be used only if necessary. If the adolescent is sleeping, the pain is under control; waking the adolescent will interfere with rest. If the adolescent is sleeping, the pain is under control; also, this will result in an unnecessary and excessive dosage of the opioid.

Which disease is caused by the virus that causes chickenpox? 1 Athlete's foot 2 Herpes zoster 3 German measles 4 Infectious hepatitis Invasion of the post

2. Invasion of the posterior (dorsal) root ganglia by the same virus that causes chickenpox can result in herpes zoster, or shingles. This may be caused by reactivation of a previous chickenpox virus that has lain dormant in the body or by recent contact with an individual who has chickenpox. Athlete's foot is caused by a fungus. German measles is caused by a virus, but not the herpes virus. Hepatitis type A is caused by a virus, but not the herpes virus.

Which is the subset of clinical health care informatics? 1 Clinical informatics 2 Nursing informatics (NI) 3 Public health informatics 4 Clinical research informatics

2. Nursing informatics (NI) NI is the subset of clinical health care informatics. This is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice. Clinical health care informatics is a subdomain of clinical informatics. Public health informatics is one of the major domains of informatics that uses computer science and technology to improve public health. Clinical research informatics is a subdomain of clinical informatics.

During which week of pregnancy does placental development occur? 1 First 2 Third 3 Fifth 4 Seventh

2. Placental development begins during the third week of pregnancy. The other answer options, first, fifth, and seventh, are not when placental development occurs.

Which individual completes the developmental questionnaire for an infant using the Developmental (ASQ-3) screening? 1 Child 2 Parent 3 Nurse 4 Primary health care provider

2. The parent completes the questionnaire portion of the Development (ASQ-3) assessment. A health care professional, such as the nurse or primary health care provider, scores the assessment. The child's stage of development is assessed using this process.

The parents of a 2-year-old child are watching the nurse administer the Denver II Developmental Screening Test to their child. They ask, "Why did you make our child draw on paper? We don't let our child draw at home." Which is the best response by the nurse? 1. "I should have asked you about drawing first." 2. "These drawings help us determine your child's intelligence." 3. "It lets us test the child's ability to perform tasks requiring the hands." 4."I don't understand why drawing is forbidden in your home."

3. "It lets us test the child's ability to perform tasks requiring the hands." The Denver II Developmental Screening Test is one of the tests used to evaluate young children whose development appears to be behind the norm. It involves the use of a variety of methods to determine the level of development. The parents gave their consent to have the test done and were told that a variety of skills would be tested. A developmental screening test is designed not to test intelligence, but rather to test the child's ability to perform specific age-appropriate developmental tasks. It is inappropriate to question the parents' childrearing ability.

Which defines assessment? 1 Coordinating care delivery 2 Analyzing assessment data to determine diagnoses or issues 3 Collecting comprehensive data pertinent to the client's health and/or situation 4 Registered nurse provides consultation to influence an identified plan

3. Collecting comprehensive data pertinent to the client's health and/or situation Assessment is the process of collection of comprehensive data pertinent to the client's health and/or situation. Coordination of care refers to delivering care to the client. Diagnosis refers to analyzing the assessment data to determine the diagnoses or issues. Consultation is the process where a registered nurse discusses with other health care providers to influence the identified plan, enhance the abilities of other caregivers, and effect change.

Which preventive and primary care service provided by a community health center is most expensive? 1 Running errands 2 Health education 3 Disease management 4 Routine physical examinations

3. Disease management Disease management is the most expensive service provided by community health centers. Running errands is relatively inexpensive, because the cost is the merely the cost of transportation. Health education and routine physical examinations are inexpensive and can usually stop complications of diseases, which prevents from having to "manage" diseases, leading to costly and expensive treatment.

Which would the nurse teach the parents of a child who is being discharged from the hospital after a diagnosis of acute spasmodic laryngitis to help prevent another croup episode? 1. Perform postural drainage. 2. Discourage before-bedtime snacks. 3. Use a cool mist vaporizer in the child's room. 4. Demonstrate to the child how to expel air after inspiration.

3. Use a cool mist vaporizer in the child's room. Cool mist provides humidification. Postural drainage would likely increase the child's anxiety. There is no relationship between eating and the onset of spasmodic croup. It is useless to give instruction while the child is fighting to breathe.

Which conditions pose the greatest risk for injury for an adolescent? Select all that apply. One, some, or all responses may be correct. 1 Poisoning 2 Abduction 3 Home accidents 4 Substance abuse 5 Motor vehicle accidents

4, 5 Substance abuse and motor vehicle accidents pose the greatest risks of injury among adolescents. Poisoning and child abduction are more common among toddlers and preschoolers. Home accidents are common among toddlers as well.

Which order should parents introduce new foods to a 5-month-old who is now eating fortified cereal mixed with formula? 1 Meats and fish 2 Eggs and cheeses 3 Citrus fruits and bread 4 Vegetables and non-citrus fruits

4. Generally it is recommended that vegetables and non-citrus fruits be introduced after cereals because they are easily digested. The introduction of meats and fish, eggs and cheeses, and citrus fruit and bread should be delayed until after 6 months of age.

Client-Medication A-Isoniazid B-Rifampin C-Pyrazinamide D-Ethambutol Which tuberculosis client is at risk for developing optic neuritis? 1. Client A 2. Client B 3. Client C 4. Client D

4. Client D Ethambutol is an antitubercular medication that causes optic neuritis. Client D is at risk for optic neuritis. Client A is at risk for vitamin B deficiency. Client B is at risk for liver toxicity. Client C is at risk for sunburn.

Which definition does the World Health Organization (WHO) use to define "health"? 1 A condition when people are free of disease 2 A condition of life rather than pathological state 3 An actualization of inherent and acquired human potential 4 A state of complete physical, mental, and social well-being

4. The WHO defines health as a "state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity." Pender, Murdaugh, and Parsons (2011) explains that all people free of disease are not healthy. Pender, Murdaugh, and Parsons (2011) suggest that for many people, health is a condition of life rather than pathological state. Life conditions such as environment, diet, or lifestyle choices can have positive or negative effects on health long before an illness is evident. Pender, Murdaugh, and Parsons (2011) define health as the actualization of inherent and acquired human potential through goal-directed behavior, competent self-care, and satisfying relationships with others.

Which consistent approach would the nurse use for a client with an antisocial personality disorder? A. Warm and firm without being punitive B. Indifferent and detached but nonjudgmental C. Conditionally acquiescent to client demands D. Clearly communicative of personal disapproval

A. Warm and firm without being punitive The nurse would be warm and firm without being punitive. The client needs positive relationships with other adults, but clear, consistent limits must be presented to minimize attempts at manipulation. Acting indifferent and detached but nonjudgmental is not a therapeutic approach. Being indifferent and detached gives the impression that the nurse does not care. Being conditionally acquiescent to client demands is not a therapeutic approach because clear, consistent limits are necessary to prevent manipulation. Being clearly communicative of personal disapproval is a judgmental attitude that should be avoided.

A client tells the nursing assistant "I am so worried about the results of the biopsy they took today." The nurse overhears the nursing assistant reply, "Don't worry. I'm sure everything will come out all right." Which conclusion would the nurse make about the nursing assistant's answer? A. It shows empathy. B. It uses distraction. C. It gives false reassurance. D. It makes a value judgement

C. It gives false reassurance A person cannot know the results of the biopsy until it is examined under a microscope. The response does not allow the client to voice concerns, shuts off communication, and provides reassurance that may not be accurate. This answer does not empathize with the client; it minimizes the client's concerns. This response is not a form of distraction; it minimizes the client's concern and shuts off communication. This response does not contain any value statements.