Integrated Exam 3

When teaching parents about fifth disease (erythema infectiosum) and its transmission, the nurse should provide which information? 1. Fifth disease is transmitted by respiratory secretions. 2. Fifth disease has an unknown transmission mode. 3. Fifth disease is transmitted by respiratory secretions, stool, and urine. 4. Fifth disease is transmitted by stool.

1. Fifth disease is transmitted by respiratory secretions. RATIONALE: Fifth disease is transmitted by respiratory secretions. The transmission mode for roseola is unknown. Rubella is transmitted by respiratory secretions, stool, and urine. Intestinal parasitic conditions, such as giardiasis and pinworm infection, are transmitted by stool.

A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing? A. Coughing B. Sneezing C. Talking D. Valsalva maneuver E. Vomiting F. Keeping the head of the bed between 30- 35 degrees

A, B, D, E

At what age does a child starting receiving a yearly flu vaccine? A. 12 months B. 6 months C. 2 months D. 24 months

B. 6 months

A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and determines that which of the following results would verify the diagnosis? A. Cloudy CSF, decreased protein, and decreased glucose B. Cloudy CSF, elevated protein, and decreased glucose C. Clear CSF, elevated protein, and decreased glucose D. Clear CSF, decreased pressure, and elevated protein

B. Cloudy CSF, elevated protein, and decreased glucose Rationale: A diagnosis of meningitis is made by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure, turbid or cloudy CSF, elevated leukocytes, elevated protein, and decreased glucose levels.

Which patient below with ICP is experiencing Cushing's Triad? A patient with the following: A. BP 150/112, HR 110, RR 8 B. BP 90/60, HR 80, RR 22 C. BP 200/60, HR 50, RR 8 D. BP 80/40, HR 49, RR 12

C. BP 200/60, HR 50, RR 8 These vital signs represent Cushing's triad. There is an increase in the systolic pressure, widening pulse pressure of 140 (200-60=140), and bradycardia.

Claire, a 33 y.o. is on your floor with a possible bowel obstruction. Which intervention is priority for her? A. Obtain daily weights B. Measure abdominal girth C. Keep strict intake and output D. Encourage her to increase fluids

B. Measure abdominal girth Rationale: Measuring abdominal girth provides quantitative information about increases or decreases in the amount of distention

Which of the following is contraindicated in a patient with increased ICP? A. Lumbar puncture B. Midline position of the head C. Hyperosmotic diuretics D. Barbiturates medications

A. Lumbar puncture Lumbar punctures are avoided in patients with ICP because they can lead to possible brain herniation.

A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower extremities. Which of the following conditions would most likely be suspected? A. Sepsis B. Neurogenic shock C. Autonomic dysreflexia D. Hypervolemia

B. Neurogenic shock

The nurse must place a wrist restraint on a client. The client tells the nurse that he does not want to wear the restraint. Which is the best nursing action to implement at this time? A. Sedate the client first. B. Apply the wrist restraint. C. Contact the client's family. D. Reconsider alternative measures.

D. Reconsider alternative measures. Rationale: Before applying restraints, the nurse must exhaust alternative measures to restraints such as a bed alarm, distraction, and a sitter. If the nurse determines that a restraint is necessary, its use is discussed with the client and family and a prescription is obtained from the health care provider. The nurse should explain carefully to the client and family the indications for the restraint, the type of restraint selected, and the anticipated duration for its use. Sedation can be considered as a chemical restraint. The nurse avoids applying the restraint on a client who refused it to prevent client coercion and future charges of battery.

A nurse is caring for a client who has a left intracranial hemorrhage. Which of the following assessment findings is the nurse likely to document? A. Spasticity of the left foot B. Negative Babinski sign C. Ocular hypertension D. Right-sided hemiparesis

D. Right-sided hemiparesis

What are some patient priorities during the emergent phase of burn management? (select all that apply) A. Fluid volume B. Respiratory status C. Psychosocial D. Wound closure E. Nutrition

A and B

The nurse manager is providing an educational session to the nursing staff in a skilled nursing facility on the guidelines for the safe use of physical restraints. Which are safe guidelines? Select all that apply. A. A health care provider's prescription is required. B. Restraints should be secured with a quick-release tie. C. Restraints are secured to side rails so that they can be easily removed as necessary. D. Restraints are used when other measures have failed to prevent self-injury or injury to others. E. Restraints can be used as a usual part of treatment plans, as indicated by the client's condition or symptoms. F. The use of restraints can be prescribed PRN (as needed) as long as the nurse performs a thorough assessment before applying them.

A, B, D Rationale: A physical restraint is a mechanical or physical device that is used to immobilize a client or extremity. It restricts the freedom of movement or normal access to a client's body. A health care provider's prescription is required for the use of restraints. Restraints should be secured with a quick-release tie so that they can be easily removed in an emergency. Restraints are considered for use only when other measures have failed to prevent self-injury or injury to others. Restraints are secured to the bed frame, not the side rails, because the client may be injured if the side rail is lowered. Restraints are not a usual part of treatment plans, indicated by the person's condition or symptoms, and are not prescribed on a PRN basis.

During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following would be most appropriate to institute? A. Limiting conversation with the child B. Keeping extraneous noise to a minimum C. Allowing the child to play in the bathtub D. Performing treatments quickly

B. Keeping extraneous noise to a minimum Rationale: A child in the acute stage of meningitis is irritable and hypersensitive to loud noise and light. Therefore, extraneous noise should be minimized and bright lights avoided as much as possible. There is no need to limit conversations with the child. However, the nurse should speak in a calm, gentle, reassuring voice. The child needs gentle and calm bathing. Because of the acuteness of the infection, sponge baths would be more appropriate than tub baths. Although treatments need to be completed as quickly as possible to prevent over stressing the child, any treatments should be performed carefully and at a pace that avoids sudden movements to prevent startling the child and subsequently increasing intracranial pressure.

A registered nurse (RN) on the night shift assists a staff member in completing an incident report for a client who was found sitting on the floor. Following completion of the report, the RN intervenes if the staff member prepares to take which action? A. Notify the nursing supervisor. B. Ask the unit secretary to telephone the health care provider. C. Document in the nurses' notes that an incident report was filed. D. Forward the incident report to the Continuous Quality Improvement Department.

C. Document in the nurses' notes that an incident report was filed. Rationale: Nurses are advised not to document the filing of an incident report in the nurses' notes for legal reasons. Incident reports inform the facility's administration of the incident so that risk management personnel can consider changes that might prevent similar occurrences in the future. Incident reports also alert the facility's insurance company to a potential claim and the need for further investigation. Options 1, 2, and 4 are accurate interventions.

A mother brings her 15-month-old child to the health care provider's office with complaints that the child has suddenly developed a bright red rash on her cheeks. She has no other symptoms and has been playing and eating as usual. Based on the appearance of the child, what might the nurse suspect the child's diagnosis to be? A. Rubella B. Roseola C. Fifth disease D. Chicken pox

C. Fifth disease Rationale: Fifth disease has the general appearance of "slapped cheeks." Many children do not have any symptoms prior to the appearance of the reddened cheeks. This characteristic is not associated with the communicable diseases identified in options 1, 2, or 4.

The nurse is developing a plan of care for a newborn diagnosed with bilateral club feet. Which instruction should the nurse plan to include in the parents education? A.The regimen of manipulation and casting is effective in all cases of bilateral club feet. B. Genetic testing is wise for future pregnancies because other children born to this couple may also be affected. C. If casting is needed, it will begin at birth and continue for 12 weeks, at which time the condition will be reevaluated. D. Surgery performed immediately after birth has been found to be the most effective for achieving a complete recovery

C. If casting is needed, it will begin at birth and continue for 12 weeks, at which time the condition will be reevaluated. Rationale: For the infant with clubfoot, casting should begin at birth and continue for at least 12 weeks or until maximum correction is achieved. At this time, corrective shoes may provide support to maintain alignment, or surgery can be performed. Surgery is usually delayed until the child is 4 to 12 months old. Options 1 and 4 are inaccurate. Option 2 does not specifically address the subject of the question.

The nurse performs an admission assessment on a child and suspects physical abuse. Based on this suspicion, what is the primary legal nursing responsibility? A. Refer the family to the appropriate support groups. B. Assist the family in identifying resources and support systems. C. Report the case in which the abuse is suspected to the local authorities. D. Document the child's physical assessment findings accurately and thoroughly.

C. Report the case in which the abuse is suspected to the local authorities. Abuse is the nonaccidental physical injury or the nonaccidental act of omission of care by a parent or person responsible for a child. It includes neglect and physical, sexual, and emotional maltreatment. The primary legal nursing responsibility when child abuse is suspected is to report the case. Suspected child abuse should be reported to the local authorities. Although documentation of assessment findings, assisting the family, and referring the family to appropriate resources and support groups are important, the primary legal responsibility is to report the suspected case.

The nurse notes that a postoperative client has not been obtaining relief from pain with the prescribed opioid analgesics when a particular licensed coworker is assigned to the client. Which action is most appropriate for the nurse to take? A. Reassign the coworker to the care of clients not receiving opioids. B. Notify the health care provider that the client needs an increase in opioid dosage. C. Review the client's medication administration record immediately and discuss the observations with the nursing supervisor. D. Confront the coworker with the information about the client having pain control problems and ask if the coworker is using the opioids personally.

C. Review the client's medication administration record immediately and discuss the observations with the nursing supervisor. In this situation, the nurse has noted an unusual occurrence, but before deciding what action to take next, the nurse needs more data than just suspicion. This can be obtained by reviewing the client's record. State and federal labor and opioid regulations, as well as institutional policies and procedures, must be followed. It is therefore most appropriate that the nurse discuss the situation with the nursing supervisor before taking further action. To reassign the coworker to clients not receiving opioids ignores the issue. The client does not need an increase in opioids. A confrontation is not the most advisable action because it could result in an argumentative situation.

Which finding is characteristic during the emergent period after a deep full thickness burn injury? A. Blood pressure of 170/100 mm Hg B. Foul-smelling discharge from wound C. Pain at site of injury D. Urine output of 10 mL/hr

D. Urine output of 10 mL/hr During the fluid shift of the emergent period, blood flow to the kidney may not be adequate for glomerular filtration. As a result, urine output is greatly decreaseD. Foul-smelling discharge does not occur during the emergent phase and blood pressure is usually low. Pain does not occur with deep full-thickness burns.

A nurse is caring for a client who was admitted with a bleeding duodenal ulcer. Which of the following assessment findings of the client's emesis should the nurse expect? A. Coffee-ground appearance B. Bright red in color C. Containing fat D. Bright green in color

A. Coffee-ground appearance

A client is referred to a surgeon by the general practitioner. After meeting the surgeon, the client decides to find a different surgeon to continue treatment. The nurse supports the client's action, utilizing which ethical principle? 1. beneficence 2. veracity 3. autonomy 4. privacy

3. autonomy Autonomy is the right of individuals to take action for themselves. Beneficence is an ethical principle to do good and applies when the nurse has a duty to help others by doing what is best for them. Veracity refers to truthfullness. Privacy is the nondisclosure of information by the health care team.

Which diagnostic test would be used first to evaluate a client with upper GI bleeding? A. Upper GI series B. Endoscopy C. Hemoglobin (Hb) levels and hematocrit (HCT) D. Colonoscopy

B. Endoscopy

The newly admitted client has a large burned area on the right arm. The burned area appears red, has blisters, and is very painful. How should this injury be categorized? A. Superficial B. Partial-thickness superficial C. Partial-thickness deep D. Full thickness

B. Partial-thickness superficial Option B: The characteristics of the wound meet the criteria for a superficial partial-thickness injury (color that is pink or red; blisters; pain present and high).

A nurse is caring for a client diagnosed with increased ICP who is given mannitol IV. Which of the following is the appropriate nursing action with the administration of this medication? A. Assess for hyperglycemia B. Maintain an open airway C. Monitor intake and output D. Measure temperature frequently

C. Monitor intake and output

The parent of a 12-month-old child who has received the MMR, Varivax, and hepatitis A vaccines calls the clinic to report redness and swelling at the vaccine injection sites and a temperature of 100.3° F. The nurse will perform which action? a. Recommend aspirin or an NSAID for pain and fever. b. Recommend acetaminophen and cold compresses. c. Report these adverse effects to the Vaccine Adverse Event Reporting System (VAERS). d. Schedule an appointment in clinic so the provider can evaluate the child.

b. Recommend acetaminophen and cold compresses These are common, minor side effects of vaccines and can be treated with acetaminophen and cold compresses. Aspirin is contraindicated in children because of its association with Reye's syndrome. Since these are not serious adverse effects, they do not need to be reported to VAERS. It is not necessary to schedule a clinic visit.

A nurse is caring for a preschooler who sustained deep partial-thickness burns on his hands as a result of touching a hot pot on the stove. When performing discharge teaching, the nurse should: 1. include the child in the teaching process. 2. go into the hallway with the parent to do the teaching. 3. be sure that the child has learned a lesson and won't repeat the action. 4. delay the teaching until both parents are present.

1. include the child in the teaching process.

A nurse is caring for a 3-year-old child with viral meningitis. Which signs and symptoms does the nurse expect to find during the initial assessment? Select all that apply. 1. Bulging anterior fontanel 2. Fever 3. Nuchal rigidity 4. Petechiae 5. Irritability 6. Photophobia

2, 3, 5, 6 RATIONALE: Common signs and symptoms of viral meningitis include fever, nuchal rigidity, irritability, and photophobia. A bulging anterior fontanel is a sign of hydrocephalus, which isn't likely to occur in a toddler because the anterior fontanel typically closes by age 24 months. A petechial, purpuric rash may be seen with bacterial meningitis.

Which of the following is the recommended immunization schedule for diphtheria, tetanus toxoids, and acellular pertussis (DTaP)? 1. Birth, 2 months, 6 months, 15 to 18 months, and 10 to 12 years 2. 1 month, 2 months, 6 months, 15 to 18 months, and 4 to 6 years 3. 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years 4. Birth, 3 months, 6 months, 12 months, and 4 to 6 years

3. 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years RATIONALE: According to the American Academy of Pediatrics and the Committee on Infectious Diseases, the DTaP vaccine should be administered at 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years (before the start of school).

A nurse is assessing an 8-month-old child for signs of neurologic deficit and increased intracranial pressure (ICP). These signs include: 1. a depressed fontanel. 2. slurred speech. 3. tachycardia. 4. an altered level of consciousness.

4. an altered level of consciousness. RATIONALE: One sign of neurologic deficit in an 8-month-old child includes a decreased or altered level of consciousness. The fontanel would bulge — not depress — if he had increased ICP. Slurred speech isn't a sign of increased ICP in an infant because the child isn't able to speak at this age. However, a change in cry may be noted. Bradycardia — not tachycardia — is a sign of increased ICP.

Select all the signs and symptoms that occur with increased ICP: A. Decorticate posturing B. Tachycardia C. Decrease in pulse pressure D. Cheyne-stokes E. Hemiplegia F. Decerebrate posturing

A, D, E, F Option B is wrong because bradycardia (not tachycardia) happens in the late stage along with an INCREASE (not decrease) in pulse pressure.

A patient has superficial partial thickness burns 63% of her body. The patient weighs 91 kg. Use the Parkland Burn Formula to calculate the total amount of Lactated Ringerss that will be given over the next 24 hours? A. 22,932 mL B. 26,208 mL C. 16,380 mL D. 12,238 mL

A. 22,932 mL

A female patient has deep partial thickness burns on 58.5% of her body. The patient weighs 63 kg. Use the Parkland Burn Formula: What is the flow rate during the FIRST 8 hours (mL/hr) based on the total you calculated? A. 921 mL/hr B. 938 mL/hr C. 158 mL/hr D. 789 mL/hr

A. 921 mL/hr

The nursing assistant is caring for a client who had a hip pinned after being fractured. The registered nurse intervenes and determines the nursing assistant needs further teaching if the nurse observes the nursing assistant taking which action? A. Leaving both side rails down on the bed B. Answering the client's call bell promptly C. Keeping the call bell within the client's reach D. Placing the client's personal articles and telephone within reach

A. Leaving both side rails down on the bed Rationale: Safe nursing actions intended to prevent injury to the client include keeping side rails up, the bed in low position, providing a call bell that is within the client's reach, and placing the client's personal articles and telephone within reach. Responding promptly to the client's use of the call light minimizes the chance that the client will try to get up alone, which could result in a fall.

The nurse is caring for a female client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission? A. Nothing by mouth B. Skim milk C. Regular diet D. Clear liquids

A. Nothing by mouth

Which of the following assessment data indicated nuchal rigidity? A. Positive Kernig's sign B. Negative Brudzinski's sign C. Positive homan's sign D. Negative Kernig's sign

A. Positive Kernig's sign Rationale: A positive Kernig's sign indicated nuchal rigidity, caused by an irritative lesion of the subarachnoid space. Brudzinski's sign is also indicative of the condition.

Which of the following measures should the nurse focus on for the client with esophageal varices? A. Recognizing hemorrhage B. Controlling blood pressure C. Encouraging nutritional intake D. Teaching the client about varices

A. Recognizing hemorrhage Rationale: Recognizing the rupture of esophageal varices, or hemorrhage, is the focus of nursing care because the client could succumb to this quickly. Controlling blood pressure is also important because it helps reduce the risk of variceal rupture. It is also important to teach the client what varices are and what foods he should avoid such as spicy foods.

You're providing a free educational clinic to new moms about immunizations. You inform the attendees that the Measles, Mumps, and Rubella (MMR) vaccine is given? A. at 6 and 12 months B. 12 months and 4-6 years C. at 4 and 6 months D. at 2 and 12 months

B. 12 months and 4-6 years

Ralph has a history of alcohol abuse and has acute pancreatitis. Which lab value is most likely to be elevated? A. Calcium B. Glucose C. Magnesium D. Potassium

B. Glucose Rationale: Glucose level increases and diabetes mellitus may result due to the pancreatic damage to the islets of Langerhans

While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions? A. Hemorrhagic shock B. Autonomic dysreflexia C. Neurogenic shock D. Pulmonary embolism

C. Neurogenic shock

A patient with increased ICP has the following vital signs: blood pressure 99/60, HR 65, Temperature 101.6 'F, respirations 14, oxygen saturation of 95%. ICP reading is 21 mmHg. Based on these findings you would? A. Administered PRN dose of a vasopressor B. Administer 2 L of oxygen C. Remove extra blankets and give the patient a cool bath D. Perform suctioning

C. Remove extra blankets and give the patient a cool bath It is important to monitor the patient for hyperthermia (a fever). A fever increases ICP and cerebral blood volume, and metabolic needs of the patient. The nurse can administer antipyretics per MD order, remove extra blankets, decrease room temperature, give a cool bath or use a cooling system. Remember it is important to prevent shivering (this also increases metabolic needs and ICP).

A parent has a question about the Rotavirus vaccine and when it is administered. As the nurse you know that ________ doses are given, and the last dose is given at ________? A. 2; 6 months B. 3; 4 months C. 4; 4-6 years D. 3; 6 months

D. 3; 6 months

A 1-year-old child is seen in the pediatrician's office with complaints of an elevated temperature the preceding night. When gathering subjective assessment data from the mother, which statement would most likely indicate that the child has an acute otitis media infection? A. The child is crying and irritable. B. The child's temperature currently is 40° C (104° F). C. The child is pulling at her ear and rolling her head from side to side. D. The mother noted purulent discharge from the child's ear last night.

D. The mother noted purulent discharge from the child's ear last night. Rationale: Subjective data are what the mother tells the nurse during the initial assessment. This is apparent in option 4 because the mother is explaining the child's ear drainage that occurred last night. The other options are considered objective data, which are observations that the nurse makes.

The nurse is providing instructions to the mother of an infant who is seen in the clinic for recurrent episodes of otitis media. Which statement by the mother should indicate an understanding of the methods to decrease the risk of reoccurrence? A. "I will feed my infant in an upright position." B. "I will stop breast-feeding as soon as possible." C. "I will maintain bottle feeding as long as possible." D. "I will allow my infant to have a bottle during nap time."

A. "I will feed my infant in an upright position." Rationale: To decrease the risk of recurrent otitis media, the mother should be encouraged to breast-feed during infancy and to discontinue bottle-feeding as soon as possible. The infant also is fed in an upright position and should never be given a bottle while in bed. The mother also is instructed not to smoke in the child's presence, because passive smoke increases the risk of otitis media.

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits: A. A positive Brudzinski's sign B. A negative Kernig's sign C. Absence of nuchal rigidity D. A Glascow Coma Scale score of 15

A. A positive Brudzinski's sign Signs of meningeal irritation compatible with meningitis include nuchal rigidity, positive Brudzinski's sign, and positive Kernig's sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is fixed. Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the knee and thigh are extended from a flexed-right angle position. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glascow Coma Scale of 15 is a perfect score and indicates the client is awake and alert with no neurological deficits.

When should a child receive the first dose of the Hepatitis B vaccine? A. Birth B. 2 months C. 4 months D. 6 months

A. Birth

A client, age 22, is admitted with bacterial meningitis. Which hospital room would be the best choice for this client? A. A private room down the hall from the nurses' station B. An isolation room three doors from the nurses' station C. A semiprivate room with a 32-year-old client who has viral meningitis D. A two-bed room with a client who previously had bacterial meningitis

B. An isolation room three doors from the nurses' station Rationale: A client with bacterial meningitis should be kept in isolation for at least 24 hours after admission and, during the initial acute phase, should be as close to the nurses' station as possible to allow maximal observation. Placing the client in a room with a client who has viral meningitis may cause harm to both clients because the organisms causing viral and bacterial meningitis differ; either client may contract the other's disease. Immunity to bacterial meningitis can't be acquired; therefore, a client who previously had bacterial meningitis shouldn't be put at risk by rooming with a client who has just been diagnosed with this disease.

During the acute phase of burn management, what is the best diet for a patient who has experienced severe burns? A. High fiber, low calories, and low protein B. High calorie, high protein and carbohydrate C. High potassium, high carbohydrate, and low protein D. Low sodium, high protein, and restrict fluids to 1 liter per day

B. High calorie, high protein and carbohydrate

A 12 month old receives a series of vaccinations which includes the Hepatitis A vaccine. When should the child receive the 2nd dose of this vaccine? A. in 3 months B. at the 18 month visit C. when the child is 4-6 years old D. in 2 months

B. at the 18 month visit Rationale: The first dose of HepA is given at 12 months and then the second dose is given 6 months from that dose, which would be at the 18 month visit.

The adolescent patient has nuchal rigidity, fever, vomiting, and lethargy. The nurse knows to prepare for the following test: A. blood culture. B. lumbar puncture. C. throat and ear culture. D. CAT scan

B. lumbar puncture. Meningitis is an infection of the meninges, the outer membrane of the brain. Since it is surrounded by cerebrospinal fluid, a lumbar puncture will help to identify the organism involved.

During a routine pediatric visit, a 2 month old patient will need which of the following vaccines?* A. MMR (Measles, Mumps, Rubella) B. Hepatitis A C. Hepatitis B D. DTaP (Diphtheria, Tetanus, Pertussis) E. Hib (Haemophilus Influenzae Type B) F. Varicella G. Polio H. RV (Rotavirus) I. PCV (Pneumococcal Conjugate Vaccine)

C, D, E, G, H, and I Rationale: At 2 months the patient should receive: DTaP, Hepatitis B, Hib, Polio, RV, and PCV.

The nurse assesses a client's burn injury and determines that the client sustained a full-thickness burn. Based on this determination, which finding did the nurse note? A. A dry wound surface B. Charring at the wound site C. Absence of wound sensation D. A wet, shiny, weeping wound surface

C. Absence of wound sensation Rationale: Decreased or absence of wound sensation would occur in full-thickness or deep full-thickness burns. A partial-thickness superficial burn appears wet, shiny, and weeping, or it may contain blisters. The wound blanches with pressure, is painful, and is very sensitive to touch or air currents. A dry wound surface occurs in a more serious injury. Charring would occur in a deep full-thickness burn

A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which of the following would be included in the plan of care? A. No precautions are required as long as antibiotics have been started B. Maintain airborne isolation precautions for at least 24 hours after the initiation of antibiotics C. Maintain droplet isolation precautions for at least 24 hours after the initiation of antibiotics D. Maintain neutropenic precautions

C. Maintain droplet isolation precautions for at least 24 hours after the initiation of antibiotics Rationale: A major priority of nursing care for a child suspected of having meningitis is to administer the prescribed antibiotic as soon as it is ordered. The child is also placed on droplet isolation for at least 24 hours while culture results are obtained and the antibiotic is having an effect.

Brenda, a 36 y.o. patient is on your floor with acute pancreatitis. Treatment for her includes: A. Continuous peritoneal lavage B. Regular diet with increased fat C. Nutritional support with enteral nutrition D. Insertion of a T tube to drain the pancreas

C. Nutritional support with enteral nutrition

What is the priority intervention for a child with a severe burn? A. Cool the burn with ice B. Offer oral rehydration C. Oxygen by NRB D. Remove jewelry

C. Oxygen by NRB

The most important pathophysiologic factor contributing to the formation of esophageal varices is: A. Decreased prothrombin formation B. Decreased albumin formation by the liver C. Portal hypertension D. Increased central venous pressure

C. Portal hypertension Rationale: As the liver cells become fatty and degenerate, they are no longer able to accommodate the large amount of blood necessary for homeostasis. The pressure in the liver increases and causes increased pressure in the venous system. As the portal pressure increases, fluid exudes into the abdominal cavity. This is called ascites.

You promote hemodynamic stability in a patient with upper GI bleeding by: A. Encouraging oral fluid intake B. Monitoring central venous pressure C. Monitoring laboratory test results and vital signs D. Giving blood, electrolyte and fluid replacement

D. Giving blood, electrolyte and fluid replacement Rationale: To stabilize a patient with acute bleeding, NS or LR solution is given I.V. until BP rises and urine output returns to 30ml/hr.

A nurse is caring for a client hospitalized with a complete intestinal obstruction. Which of the following findings should the nurse expect? A. Absence of bowel sounds in all 4 quadrants B. Normal bowel sounds with passage of blood-tinged stool C. Passing of flatus and high-pitched gurgling present in all 4 quadrants D. Hyperactive bowel sounds above the obstruction and absent below

D. Hyperactive bowel sounds above the obstruction and absent below

A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid: A. Is clear and tests negative for glucose B. Is grossly bloody in appearance and has a pH of 6 C. Clumps together on the dressing and has a pH of 7 D. Separates into yellow concentric rings and test positive of glucose

D. Separates into yellow concentric rings and test positive of glucose Rationale: Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.

A patient has an acute upper GI hemorrhage. Your interventions include: A. Treating hypovolemia B. Treating hypervolemia C. Controlling the bleeding source D. Treating shock and diagnosing the bleeding source

A. Treating hypovolemia Rationale: A patient with an acute upper GI hemorrhage must be treated for hypovolemia and hemorrhagic shock. You as a nurse can't diagnose the problem. Controlling the bleeding may require surgery or intensive medical treatment

A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? A. Urine output increases B. Pupils are 8 mm and nonreactive C. Systolic blood pressure remains at 150 mm Hg D. BUN and creatinine levels return to normal

A. Urine output increases Rationale: Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes. Fixed and dilated pupils are symptoms of increased ICP or cranial nerve damage. No information is given about abnormal BUN and creatinine levels or that mannitol is being given for renal dysfunction or blood pressure maintenance.

A nurse is reviewing the record of a child with increased ICP and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse would expect to note which of the following if this type of posturing was present? A. Abnormal flexion of the upper extremities and extension of the lower extremities B. Rigid extension and pronation of the arms and legs C. Rigid pronation of all extremities D. Flaccid paralysis of all extremities

B. Rigid extension and pronation of the arms and legs Rationale: Decerebrate posturing is characterized by the rigid extension and pronation of the arms and legs.

Which ethical principle is used when a client asks about her prognosis? A. Nonmaleficence B. Veracity C. Beneficence D. Fidelity

B. Veracity Veracity is the ethical principle that means to tell the truth. There can be no mistruth or deceit. Beneficence is the duty to do good and promote kindness. Fidelity is being faithful and keeping promises. Nonmaleficence is the duty not to harm, as well as prevent harm.

A child is sent to the school nurse by the teacher. On assessment, the school nurse notes that the child has a rash. The nurse suspects that the child has erythema infectiosum (fifth disease), because the skin assessment revealed a rash that has which characteristics? A. A discrete rose-pink maculopapular rash on the trunk B. A highly pruritic, profuse macule to papule rash on the trunk C. An erythema on the face that has a "slapped face" appearance D. A discrete pinkish red maculopapular rash that is spreading to the trunk

C. An erythema on the face that has a "slapped face" appearance Rationale: The classic rash of erythema infectiosum, or fifth disease, is the erythema on the face. The discrete rose-pink maculopapular rash is the rash of exanthema subitum (roseola). The highly pruritic, profuse macule to papule rash is the rash of varicella (chickenpox). The discrete pinkish red maculopapular rash is the rash of rubella (German measles).

The nurse is reviewing the laboratory analysis of cerebrospinal fluid (CSF) obtained during a lumbar puncture from a child who is suspected of having bacterial meningitis. Which result would most likely confirm this diagnosis? A. Clear CSF with low protein and low glucose B. Cloudy CSF with low protein and low glucose C. Cloudy CSF with high protein and low glucose D. Decreased pressure and cloudy CSF with high protein

C. Cloudy CSF with high protein and low glucose Rationale: A diagnosis of meningitis is made by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include increased pressure and cloudy CSF with high protein and low glucose. Therefore, options 1, 2, and 4 are incorrect.

Which of the following signs and symptoms of increased ICP after head trauma would appear first? A. Bradycardia B. Large amounts of very dilute urine C. Restlessness and confusion D. Widened pulse pressure

C. Restlessness and confusion Rationale: The earliest symptom of elevated ICP is a change in mental status. Bradycardia, widened pulse pressure, and bradypnea occur later. The client may void large amounts of very dilute urine if there's damage to the posterior pituitary.

For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to: A. prevent respiratory alkalosis. B. lower arterial pH. C. promote carbon dioxide elimination. D. maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg

C. promote carbon dioxide elimination. Rationale: The goal of treatment is to prevent acidemia by eliminating carbon dioxide. That is because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP. Preventing respiratory alkalosis and lowering arterial pH may bring about acidosis, an undesirable condition in this case. It isn't necessary to maintain a PaO2 as high as 80 mm Hg; 60 mm Hg will adequately oxygenate most clients.

The client with a head injury has been urinating copious amounts of dilute urine through the Foley catheter. The client's urine output for the previous shift was 3000 ml. The nurse implements a new physician order to administer: A. Desmopressin (DDAVP, stimate) B. Mannitol (Osmitrol) C. Ethacrynic acid (Edecrin) D. Dexamethasone (Decadron)

A. Desmopressin (DDAVP, stimate)

The client has burns on both legs. These areas appear white and leather-like. No blisters or bleeding are present, and there is just a "small amount of pain." How will the nurse categorize this injury? A. Full-thickness B. Partial-thickness superficial C. Partial-thickness deep D. Superficial

A. Full-thickness The characteristics of the wounds meet the criteria for a full-thickness injury: color that is black, brown, yellow, white, or red; no blisters; pain minimal; outer layer firm and inelastiC. Partial-thickness superficial burns appear pink to red in color, with pain. Partial-thickness burn color is deep red to white in color with pain, and superficial burn color is pink to red, with pain.

A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which of the following symptoms would also be anticipated? A. Hypertension and bradycardia B. Decreased urine output or oliguria C. Respiratory depression D. Symptoms of shock

A. Hypertension and bradycardia

The client has been admitted with a diagnosis of acute pancreatitis. The nurse would assess this client for pain that is: A. Severe and unrelenting, located in the epigastric area and radiating to the back. B. Severe and unrelenting, located in the left lower quadrant and radiating to the groin. C. Burning and aching, located in the epigastric area and radiating to the umbilicus. D. Burning and aching, located in the left lower quadrant and radiating to the hip.

A. Severe and unrelenting, located in the epigastric area and radiating to the back. Rationale: The pain associated with acute pancreatitis is often severe and unrelenting, is located in the epigastric region, and radiates to the back.

A client recovering from a craniotomy complains of a "runny nose." Based on the analysis of the client's complaint, what is the best nursing action? A. Provide the client with tissues. B. Notify the health care provider. C. Tell the client not to blow the nose. D. Monitor the client for signs of a cold.

B. Notify the health care provider. Rationale: If the client has sustained a craniocerebral injury or is recovering from a craniotomy, careful observation of any drainage from the eyes, ears, nose, or traumatic area is critical. Cerebrospinal fluid is colorless and generally nonpurulent, and its presence is indicative of a serious breach of cranial integrity. The nurse would check the drainage for the presence of glucose, indicative of the presence of cerebrospinal fluid, and would also report the presence of any suspicious drainage to the health care provider.

Roxy is admitted to the hospital with a possible diagnosis of appendicitis. On physical examination, the nurse should be looking for tenderness on palpation at which location? A. left lower quadrant B. left upper quadrant C. right lower quadrant D. right upper quadrant

C. right lower quadrant Rationale: To be exact, the appendix is anatomically located at the Mc Burney's point at the right iliac area of the right lower quadrant.

The nurse evaluates the effectiveness of preventive teaching done with the parents of an infant with recurring acute otitis media. Which statement indicates that more teaching is needed? A. "My baby will continue to be breast-fed." B. "No one is permitted to smoke around the baby." C. "The baby received Haemophilus influenzae (Hib) vaccine." D. "We stopped giving the antibiotics to the baby when her fever subsided."

D. "We stopped giving the antibiotics to the baby when her fever subsided." Rationale: All antibiotics should be given for the prescribed time even if symptoms disappear, because the infection may not be completely eradicated, and then recurs. This basic principle of antibiotic therapy applies in this situation. Breast-feeding is done in a more upright position than is bottle-feeding. This reduces reflux, which is a predisposing factor in ear infections. Some infection protection and allergy protection comes from breast milk. Passive smoke can cause upper respiratory irritation. Hib is a common cause of acute otitis media, so the vaccine should reduce this source.

The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure? A. Side-lying, with legs pulled up and head bent down onto the chest B. Side-lying, with a pillow under the hip C. Prone, in a slight Trendelenburg's position D. Prone, with a pillow under the abdomen

A. Side-lying, with legs pulled up and head bent down onto the chest Rationale: The client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen, and with the head bent down onto the chest. This position helps to open the spaces between the vertebrae.