Fundamentals

After surgery a 5-year-old child experiences intense pain and an analgesic is prescribed. What should the nurse consider when administering the analgesic?

Even though children do not like medicines, analgesics will make them more comfortable

A nurse knows that children with attention deficit-hyperactivity disorder (ADHD) may be learning disabled. This means that these children:

Experience perceptual difficulties that interfere with learning

When caring for clients who are at risk for suicide, the nurse should consider that:

Formal suicide plans increase the likelihood that a client will attempt suicide.

Which theory explains psychosexual development through infancy to adolescence?

Freud's theory

A nurse is caring for a client admitted with cardiovascular disease. During the assessment of the client's lower extremities, the nurse notes that the client has thin, shiny skin, decreased hair growth, and thickened toenails. The nurse understands that this may indicate:

Arterial Insufficiency

The parent of an 11-month-old infant asks the nurse in the pediatric clinic when to start toilet training. The nurse tells the parent to wait until the infant has achieved more voluntary control and coordination. According to Erik Erikson, in what stage should toilet-training be achieved?

Autonomy versus shame and doubt

A 3-year-old child is found to have autism. Which behaviors should the nurse expect when observing this child?

Avoids eye contact and perform repetitive activities

A client at 11 weeks' gestation reports having to urinate more often. The nurse explains that urinary frequency often occurs because bladder capacity during pregnancy is diminished by:

Compression by the enlarging uterus

In an attempt to remain objective and support a client during a crisis, the nurse uses imagination and determination to project the self into the client's emotions. This technique is known as:

Empathy

Which condition does the nurse suspect in the newborn who has a fluid-filled sac, probably due to herniation of the brain and meninges through a defect in the skull?

Encephalocele

A group of clients from a psychiatric unit, accompanied by staff members, are going to a professional baseball game. The purpose of visits into the community under the supervision of staff members is:

Observing the clients' abilities to cope with a more complex society

A client who is scheduled for a modified radical mastectomy decides to have family members donate blood in the event it is needed. The client has type A negative blood. Blood can be used from relatives whose blood is:

Type A or O negative

Which skill, if it cannot be performed by a 3-year-old child, should alert the nurse that the child may be developmentally delayed?

Using a spoon effectively

Penicillin

for bacterial infections

A client has a permanent sigmoid colostomy, and colostomy irrigations are prescribed. The client asks the nurse why they are needed. How should the nurse respond?

"They help establish an elimination schedule."

A nurse is providing preoperative teaching to the parents of a toddler who is to undergo myringotomy. The nurse explains that the type of infection most common in children that are prone to otitis media is:

Bacterial

A nurse is reviewing the laboratory report of a newborn whose hematocrit level is 45%. What value denotes a healthy infant?

Between 45% and 65%

A client in active labor becomes very uncomfortable and asks a nurse for pain medication. Nalbuphine (Nubain) is prescribed. How does this medication relieve pain?

By acting on opioid receptors to reduce pain

A client's leg is placed in Buck's extension to immobilize a fracture until surgery can be performed. When caring for this client, the nurse understands that Buck's extension is a type of:

Cutaneous traction

What should the nurse do to enhance a neonate's behavioral development?

Help the parents stimulate their awake baby through touch, sound, and sight

Because of the high discomfort level during the transition phase of labor, nursing care should be directed toward

Helping the client maintain control

Which suicide method is the least lethal?

Ingesting pills

Ranitidine (Zantac) has been prescribed to help treat a client's gastric ulcer. The nurse expects this drug to act specifically by:

Inhibiting the histamine H 2 receptors

A client with a history of hypertension develops dyspnea on exertion. What does the nurse conclude is the most likely cause of the client's dyspnea?

Left heart failure

What is the outcome of an authoritative parenting style?

The child may become self-reliant.

A nurse is caring for a client at 42 weeks' gestation who is having a contraction stress test (CST). What does a positive result indicate?

The function of the placenta has diminished.

Megadoses of vitamin A are taken by a client. Why should the nurse question this practice?

The liver has a great storage capacity for vitamin A, even to toxic amounts.

Trichomonal Infection

A very common, protozoan parasite, STD

What type of respirations does the nurse expect to identify in a healthy newborn?

Abdominal and irregular

Which stage is observed in a 2-year-old child according to Freud's theory?

Anal stage

In which type of play do children play together, share toys, and communicate with each other?

Associative play

During prenatal classes the nurse teaches the difference between true labor and false labor. How does the nurse explain the difference?

Cervix effaces and dilates during true labor.

Electroconvulsive therapy (ECT) is a mode of treatment that is used primarily to treat:

Clinical depression

A client has recently started taking a new neuroleptic drug, and the nurse notes extrapyramidal effects. Which drug does the nurse anticipate will be prescribed to limit these side effects?

Cogentin

A 20-year-old developmentally disabled woman is a resident in a group home. She has had four abortions in the past 2 years, and the agency supervisor recommends that she be sterilized. It is obvious that the client is unable to exercise informed consent for sterilization. The nurse understands that the procedure cannot be performed without legal consent from the:

Court appointed individual or group

The nurse auscultates fine crackles in a client who has been in respiratory distress. When the nurse is providing information to the client about crackles, which would be appropriate to include?

Crackles are located in the smaller air passages.

According to Erikson, a young adult must accomplish the tasks associated with the stage known as:

Intimacy vs. Isolation

A client asks the nurse at the family planning clinic whether contraception is needed while she is breastfeeding. How should the nurse reply?

"You should use contraceptives, because ovulation may occur without a period."

Which characteristics are observed in the embryonic stage of prenatal development?

-Appearance of arm and leg buds -Rapid development of the nervous system -Beginning of development of fingers and toes

Which clinical manifestations should the nurse look for in a newborn with suspected spina bifida cystica?

-Rectal prolapse -Overflow incontinence -Flaccid partial paralysis of the lower extremities

A nurse is preparing to give a client a tepid bath and uses a bath thermometer to test the water temperature. What is the acceptable temperature range for a tepid bath?

98° to 100° F

Nystatin (Mycostatin)

Anti-fungal for C. albican infections

Gentian violet

Anti-infective for Candida albicans

A nurse is teaching a group of parents about child abuse. What definition of assault should the nurse include in the teaching plan?

Assault is a threat to do bodily harm to another person

A nurse is interviewing a client newly admitted to an outpatient program after withdrawal from alcohol. What behavior best indicates that the client has accepted that drinking is a problem?

Attends Alcoholics Anonymous meetings daily

A nurse is teaching a pregnant client with sickle cell anemia about the importance of taking supplemental folic acid. Folic acid is important for this client because it:

Compensates for a rapid turnover of red blood cells

A client is using ritualistic behaviors. Why should a nurse give the client ample time in which to perform the ritual?

Denial of this activity may precipitate a panic level of anxiety.

A nurse is caring for a client with vascular dementia. What does the nurse expect of this client's mental status?

Difficulty recalling recent events related to cerebral hypoxia

A client with advanced bone cancer is experiencing cachexia. The nurse discusses the nutritional aspect of palliative care with the family. Why is it important to explain these nutritional interventions to the family?

Enhance the quality of the client's life

A nurse in the fertility clinic is instructing a client who will be using progesterone gel vaginally in the treatment of luteal phase infertility. When discussing the side effects of progesterone, what should the nurse tell the client to expect?

Enlarged, tender breasts

A client is admitted with a conversion disorder. What is the primary nursing intervention?

Exploring ways to verbalize feelings

The nurse is caring for a school-aged child with cystic fibrosis. Which pathophysiological factor has the greatest impact on the child's health status and is of priority in the care plan?

Extremely thick mucus causes obstructed airways.

A nurse is caring for a preschooler who is being prepared for surgery. What does the nurse expect to have the most influence on the child's response to hospitalization?

Fear of bodily harm

Relatives of the victims of a home invasion in which several family members were killed receive crisis intervention services. Which therapy is most beneficial after the immediate event has passed?

Grief

A school-age child with a fracture of the femur near the epiphyseal plate is admitted to the hospital. The parents ask if there will be any aftereffects when the bone heals. Before responding, what should the nurse consider?

Growth of that leg may be affected.

A nurse is caring for several clients with the diagnosis of bulimia nervosa. What primary feeling does the nurse anticipate that these clients experience after an episode of bingeing?

Guilt

A client suffered an injury to the leg as a result of a fall. X-ray films indicate an intertrochanteric fracture of the femur. The client will be placed in Buck's traction until surgery is performed. When considering the client's plan of care, the nurse recalls that the primary purpose of Buck's traction is to:

Immobilize the fracture

A 65-year-old man is admitted to the hospital with a history of depression. The client, who speaks little English and has had few outside interests since retiring, says, "I feel useless and unneeded." The nurse concludes that the client is in Erikson's developmental stage of:

Integrity vs. Despair

A nurse administers several vitamins as part of a client's medical regimen. Which prescribed vitamin is essential for the synthesis of prothrombin by the liver?

K

A senior high school student, whose immunization status is current, asks the school nurse which immunizations will be included in the precollege physical. Which vaccine should the nurse tell the student to expect to receive?

Measles, mumps, rubella (MMR)

A patient with trichomonal infection is most likely prescribed?

Metronidazole (Flagyl)

A nurse is caring for a client who is experiencing an underproduction of thyroxine (T 4). Which client response is associated with an underproduction of thyroxine?

Myxedema

At 32 weeks' gestation a client undergoes ultrasound, which reveals a low-lying placenta. What complication should the nurse anticipate as the client's pregnancy approaches term?

Painless vaginal bleeding

A 90-year-old female resident of a nursing home falls and fractures the proximal end of her right femur. The surgeon plans to reduce the fracture with an internal fixation device. The general fact about the older adult that the nurse should consider when caring for this client is that:

Physiological coping defenses are reduced

A mother tells her neighbor, a nurse, that her toddler has been found to have parasites (worms) and that the whole family will need to be treated. She asks the nurse what kind of worm it is. What is the most likely type of worm infestation?

Pinworm

A pregnant woman tells a nurse, "I think I can feel the baby move now. It feels like butterflies in my stomach. My friend calls it feeling life." What term should the nurse include when discussing fetal movement with the woman?

Quickening

A child has been admitted to the pediatric unit with a severe asthma attack. What type of acid-base imbalance should the nurse expect the child to develop?

Respiratory acidosis caused by impaired respirations and increased formation of carbonic acid

A nurse understands that the primary purpose for a client to undergo reconstructive surgery is to:

Restore function and/or appearance.

Doxepin (Sinequan) is prescribed for a 74-year-old man for treatment of a depressive episode that has not responded to several other medications. The nurse in the outpatient clinic reviews with the client the side effects of doxepin. The identification of which side effects by the client as needing to be reported to the health care provider allows the nurse to conclude that the teaching has been effective?

Retention of urine Thoughts of suicide

The parents of a boy with hypospadias with chordee ask a nurse why their child should undergo corrective surgery. What problem that may develop eventually should the nurse discuss with the parents?

Sexual difficulties

While caring for a newborn in a neonatal intensive care unit, the nurse notices that the neonate is not moving his legs simultaneously. Which condition might the nurse suspect to be the reason for this?

Spinal cord injury

If person is bleeding perfusely on IV with Heparin, what should you do?

Stop and use saline instead

A nurse is caring for a client who is cachectic. What information about the function of adipose tissue in fat metabolism is necessary to better address the needs of this client?

Stores triglycerides for energy reserves

A nurse places a newly admitted client with worsening preeclampsia in a private room. Why is it important for this client to be in a nonstimulating environment?

The probability of tonic-clonic seizures is reduced.

A client who has repeated episodes of cystitis is scheduled for a cystoscopy to determine the possibility of urinary tract abnormalities. The client asks the nurse to describe the procedure. The nurse's most appropriate response is, "This procedure is:

The visualization of the inside of the bladder with an instrument connected to a source of light."

A client who has had recurrent infections before and during pregnancy should be instructed to eat a nutrient-rich diet as a means of supporting the body's natural defense mechanisms. What should the nurse encourage the client to include in her diet?

Vitamins A, C, and E and selenium

A client is admitted to the emergency department after vomiting bright red blood. After the vomiting ceases and the vital signs are stabilized, the client is transferred to a medical-surgical unit. To assess for bleeding, the nurse on the medical-surgical unit should monitor the client for:

Tachycardia

A nurse places a school-aged child with bacterial meningitis in isolation with droplet precautions. What is the purpose of these precautions?

They keep the child away from uninfected people.

A nurse is caring for a client with acute kidney failure who is receiving a protein-restricted diet. The client asks why this diet is necessary. What information should the nurse include in a response to the client's questions?

This supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys.

A registered nurse advises parents to assist their child with stretching exercises. The child has impaired physical mobility due to neuromuscular impairment. What is the rationale for performing stretching exercises

To prevent contractures

A nurse notes that a client in the detoxification unit is exhibiting early signs of alcohol withdrawal. What clinical manifestations might the nurse have noticed?

Tremors and anorexia

A nurse who is caring for a client in labor uses nitrazine paper to test the pH of the client's leaking vaginal fluid. What color will the nitrazine paper turn if the leakage is amniotic fluid?

Blue

A client is scheduled for a pyloroplasty and vagotomy because of strictures caused by ulcers unresponsive to medical therapy. What information about the purpose of a vagotomy should the nurse include when reviewing the health care provider's discussion with the client?

Decreases acid in the stomach

A nurse has been assigned to care for a client with the diagnosis of obsessive-compulsive disorder (OCD). Before providing care for this client, the nurse should consider that clients with OCD:

Do not want to repeat the ritual but feel compelled to do so

A client who is suspected of having had a silent myocardial infarction has an electrocardiogram (ECG) prescribed by the health care provider. While the nurse prepares the client for this procedure, the client asks, "Why was this test prescribed?" The best reply by the nurse is, "This test will:

Reflect any heart damage

What should the nurse consider as the goal of therapy when administering allopurinol (Zyloprim) to a client with gout?

Decrease uric acid production

A nurse concludes that a 6-year-old child who has attained an acceptable level of psychosocial development has achieved Erikson's developmental conflicts related to trust, autonomy, and:

Initiative

When a client is experiencing hypovolemic shock with decreased tissue perfusion, the nurse expects that the body initially attempts to compensate by:

Maintaining peripheral vasoconstriction

An older adult client is talking to the nurse about his Vietnam experiences and shares that he still has flashbacks. While sitting with him the nurse notices that he is jumpy and exhibits startle reactions and poor concentration. The nurse identifies these as symptoms of:

Post-Traumatic Stress Disorder (PTSD)

A client who had a myocardial infarction receives a prescription for a beta-blocker and a nitroglycerin patch. The nurse determines that the purpose of the nitroglycerin patch is to decrease the:

Preload of the heart, thereby reducing the cardiac workload

On a visit to the well-baby clinic the parents are upset because their 9-month-old infant has severe diaper rash; one parent wants to know how to treat it and prevent it from recurring. What cause of diaper dermatitis should the nurse include when answering the parent's question?

Prolonged contact with an irritant

A client in her 30th week of gestation is in preterm labor, and the practitioner prescribes betamethasone (Celestone). The client asks the nurse why she is being given this drug. As a basis for the response the nurse takes into consideration that it:

Promotes neonatal pulmonary maturity

An older client with vascular dementia has difficulty following simple directions for selecting clothes to be worn for the day. The nurse identifies that these problems as the result of:

Receptive aphasia

A client with a conversion disorder is experiencing paralysis of a leg. The nurse can expect this client to:

Recover use of the affected leg but, under stress, to again experience these symptoms

A client with rheumatoid arthritis asks the nurse why it is necessary to inject hydrocortisone into the knee joint. What reason should the nurse include in a response to this question?

Reduces inflammation

A health care provider prescribes oxazepam (Serax) for a client who is beginning to experience withdrawal symptoms while undergoing detoxification. What are the primary reasons that oxazepam is given during detoxification?

Reduces the anxiety-tremor state and prevents more serious withdrawal symptoms

A 44-year-old client has been unable to function since her husband asked for a divorce 2 weeks ago. She is brought to the crisis intervention center by a friend. What type of crisis is this situation?

Situational

A client with heart failure is to receive digoxin (Lanoxin) and asks the nurse why the medication is necessary. The nurse explains that digoxin:

Slows and strengthens cardiac contractions

The transmission of which microorganism that causes maternal mastitis is minimized by frequent handwashing by nursing staff members?

Staphylococcus aureus

A preschool child is found to have chickenpox during the acute phase. The nurse tells the parents, "It's important not to expose your child to anyone undergoing certain types of prolonged medication therapy." What medication therapy puts a person at risk?

Systemic steroid

A client cannot understand how syphilis was contracted because there has been no sexual activity for several days. Which length of time associated with the incubation of syphilis should the nurse include in the teaching plan?

Two to six weeks

When a client develops steatorrhea, the nurse documents this stool as:

bulky and foul smelling

A young woman has been using oral contraceptives. When she misses her regular menstrual period, she visits the women's health clinic and tells the nurse that she may be pregnant because she missed taking her contraceptive pills for 1 week when she had the flu. How should the nurse respond?

"You may be right. One of the reasons that an exact schedule is prescribed for birth control pills is that they have to be taken regularly to be effective."

A woman with an active lifestyle is in her 30th week of pregnancy. Which activity will the nurse discourage?

Leg lifts and sit ups

After being bitten by a rabid dog a 4-year-old child is to receive a series of antirabies inoculations. The nurse who is to administer the injections should recall that rabies is a:

Viral infection characterized by seizures and difficulty swallowing

A nurse evaluating a 1-year-old infant's hematocrit reading compares it with the expected hematocrit range for this age group. What is the hematocrit of a healthy 12-month-old infant?

29% to 41%

A nurse is caring for a newly admitted, extremely depressed client. The most appropriate initial goal for the client

Developing trust in others

The nurse instructs a pregnant client in the sources of protein that can be used to meet the increased daily requirement during pregnancy. How many grams of protein should the client eat each day?

60 g

A client being admitted for alcoholism reports having had alcoholic blackouts. The nurse knows that an alcoholic blackout is best described as:

Absence of memory in relation to drinking episodes

Building confidence in one's worth is important for a client who is scheduled for a below-the-knee amputation (BKA) because an amputation:

Affects an idealized self-image

What is the primary reason that the nurse encourages the family of an alcoholic to become involved in the treatment program

Alcoholism involves the entire family.

A nurse works with school-age children who have conduct disorder, childhood-onset type. The nurse knows that these children are at risk for progression to another disorder during adolescence. For signs of which disorder should the nurse evaluate their current behavior?

Antisocial personality

When completing a neurological assessment, the nurse determines that a client has a positive Romberg test. Which finding supports the nurse's conclusion?

Inability to stand with feet together when eyes are closed

A nurse determines that a newborn has a cephalhematoma. What did the nurse note?

Bleeding between the parietal bone and periosteum confined within the suture line

A nurse is caring for several clients with major thought disorders such as schizophrenia. They are all being treated with neuroleptic drugs. How do these drugs act in the body to promote mental health?

By blocking access to dopamine receptors at the postsynaptic receptor site

A client who is about to have a blood transfusion asks the nurse, "Which type of hepatitis is most frequently transmitted by transfusions?" The nurse should respond, "Although the risk is minimal, the type of hepatitis associated with blood transfusions is hepatitis:

C

The parent of a child who has received all of the primary immunizations asks the nurse which ones the child should receive before starting kindergarten. The nurse tells the parent that her child should receive:

DTaP, IPV, MMR

A client has a history of gastroesophageal reflux disease (GERD). Why should the nurse also monitor the client for clinical manifestations of heart disease?

Esophageal pain may imitate the symptoms of a heart attack.

Why should a patient with worsening preeclampsia be placed in a private room?

Even minimal sensory stimuli can trigger an exaggerated cerebral response such as seizures

Which of the following clinical manifestations does the nurse associate with rubeola?

Macular rash

What age-related fear should the nurse expect when preparing a 4-year-old child for surgery?

Intrusive procedures

The nurse providing postoperative care for a client who had kidney surgery reviews the client's urinalysis results. The nurse concludes that the presence of what substance in the urine needs to be reported to the health care provider?

Large Proteins

What criteria should the nurse consider when determining if an infection should be categorized as a health care-associated infection?

Occurred in conjunction with treatment for an illness.

When a disaster occurs, the nurse may have to first treat mass hysteria that is indicated by what response?

Panic

A nurse plans to talk to the parents of a toddler about toilet training. What should the nurse tell the parents is the most important factor in the process of toilet training?

Parents' attitude about it

When talking with a client who has alcoholism, the nurse notes that the client becomes irritable, makes excuses, and blames family and friends for the drinking problem. Which defense mechanisms does the nurse conclude that the client is using?

Projection and rationalization

In patients with pulmonic stenosis, which part of the heart should the nurse expect an increase in pressure?

Right ventricle

While assessing an infant, the nurse strokes the infant's cheek and the infant turns toward the nurse while making sucking sounds. What reflex did the nurse elicit?

Rooting reflex

A sexually active client presents with a sore throat and a generalized rash. The client states that a chancre that had been present healed approximately three months ago. The physical assessment and the serologic test findings indicate a diagnosis of syphilis. The nurse recognizes that the client is experiencing what stage of syphilis?

Secondary

How does the nurse perform tactile stimulation to initiate respiration in a newborn?

Stroke extremities and flick the soles of foot

According to Erikson, a child's increased vulnerability to anxiety in response to separation or pending separation from significant others results from failure to complete a developmental stage. What does the nurse call this stage?

Trust

What clinical manifestation of tetralogy of Fallot should the nurse expect when caring for an infant with this diagnosis?

clubbing of fingers