MCN 2

The nurse exemplifies awareness of the rights of a client whose anger is escalating by: A. Taking a directive role in verbalizing feelings B. Using an authoritarian, confrontational approach C. Putting the client in a seclusion room D. Applying mechanical restraints

A. Taking a directive role in verbalizing feelings

Which of the following tests provides a precise quantitative measure of hearing? A. Tuning fork tests B. Romberg test C. Audiometer test D. Tonometry

C. Audiometer test

The nurse is teaching about autism spectrum disorder to a group of community members. Which risk factor should the nurse include? A. Maternal age over 40 B. Female gender C. Paternal age less than 20 D. Parents who are close in age

A. Maternal age over 40

Which therapeutic agent is called the universal antidote? A. Glucose B. Activated Charcoal C. Protamine Sulfate D. Pysostigmine

B. Activated Charcoal

Which of the following is a possible cause of enuresis? A. Urinary tract infection B. Diaper rash C. Skin infection D. Too many Kegel exercises

A. Urinary tract infection

TRUE OR FALSE: Enuresis happens only at night. A. True B. False

B. False

Which diagnosis is related to the development of Reye's syndrome in conjunction with aspirin administration in the pediatric patient? A. Varicella B. Meningitis C. Encephalitis D. Strep throat

A. Varicella

4. Which of the following medications will likely be ordered for the client? A. Prozac B. Valium C. Risperdal D. Lithium

B. Valium (Diazepam) - anxiolytic

A urethral defect in which the urethral opening is not at the end of the penis but on the ventral (lower) aspect of the penis: A. Patent Urachus B. Hydronephrosis C. Hypospadias D. Epispadias

C. Hypospadias

When assessing a 17-year-old male client with depression for suicide risk, which of the following questions is best? A. "What movies about death have you watched lately?" B. "Can you tell me what you think about suicide?" C. "Has anyone in your family ever committed suicide?" D. "Are you thinking about killing yourself?"

D. "Are you thinking about killing yourself?"

People with celiac disease often have which other disease? A. Autoimmune thyroid disease B. Type 1 diabetes C. Rheumatoid arthritis D. All of the above

D. All of the above

A nursing action that promotes ideal nutrition in an infant with congestive heart failure (CHF) is: A. Feeding formula that is supplemented with additional calories. B. Allowing the infant to nurse at each breast for 20 minutes. C. Providing large feedings every 5 hours. D. Using firm nipples with small openings to slow feedings.

A. Feeding formula that is supplemented with additional calories.

Which nursing diagnosis is highest-priority for a child undergoing chemotherapy and experiencing nausea and vomiting? A. Fluid and Electrolyte Imbalance B. Alterations in Nutrition C. Alterations in Skin Integrity D. Body Image Disturbances

A. Fluid and Electrolyte Imbalance

It would be most helpful for the nurse to deal with a client with severe anxiety by: A. Give specific instructions using speak in concise statements. B. Ask the client to identify the cause of her anxiety. C. Explain in detail the plan of care developed D. Urge the client to focus on what the nurse is saying

A. Give specific instructions using speak in concise statements.

The drug Deferoxamine is administered in which drug overdose? A. Iron B. Beta blockers C. Calcium gluconate D. Digoxin

A. Iron

A complication of Acute Lymphocytic Leukemia wherein blindness, hydrocephalus, recurrent seizures, nuchal rigidity, headache, irritability: A. CNS involvement B. Renal Involvement C. Testicular Invasion D. Wilm's Tumor

A. CNS involvement

A surgery to straighten the penis. It is done for a condition of the penis: A. Chordee Procedure B. Meatotomy C. Bladder Neck Reconstruction D. Vagotomy

A. Chordee Procedure

A child born with Down syndrome should be evaluated for which associated cardiac manifestation? A. Congenital heart defect (CHD). B. Systemic hypertension. C. Hyperlipidemia. D. Cardiomyopathy.

A. Congenital heart defect (CHD).

The nurse is caring for a child with an autism spectrum disorder (ASD). For which condition should the nurse screen the patient? A. Depression B. Schizophrenia C. Diabetes mellitus D. Gout

A. Depression

All of the following are true about Tourette syndrome, EXCEPT: A. Drug treatment completely eliminates symptoms B. It is involuntary and may be a chronic condition C. Symptoms are generally most severe during adolescence D. Symptoms are generally detected in children

A. Drug treatment completely eliminates symptoms

What is the most common cause of encopresis? A. Emotional problems B. Bad conduct C. Chronic constipation D. Attention seeking behavior

A. Emotional problems

When counseling an obese adolescent, the nurse should advise the client that which complication is the most common? A. Lifelong obesity. B. Gastrointestinal problems. C. Orthopedic problems. D. Psychosocial problems.

A. Lifelong obesity.

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

Situation: Knowledge and skills in the care of violent clients with Oppositional Defiant Disorder is vital in the psychiatric unit. A nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway and making aggressive remarks. Which of the following statements is most appropriate to make to this patient? A. What is causing you to become agitated? B. You need to stop that behavior now. C. You will need to be restrained if you do not change your behavior. D. You will need to be placed in seclusion.

A. What is causing you to become agitated?

The external structure of the ear is identified as the: A. auricle. B. atrium. C. aureole. D. auriga.

A. auricle.

Who is more likely to have the habit of bedwetting? A. Girls B. Boys C. Both D. Neither

B. Boys

Which of the following statement is true regarding the visual changes associated with cataracts? A. Both eyes typically cataracts at the same time B. The loss of vision is experienced as a painless, gradual blurring C. The patient is suddenly blind D. The patient is typically experiences a painful, sudden blurring of vision.

B. The loss of vision is experienced as a painless, gradual blurring

What is the minimum age at which a child can be considered to be suffering from enuresis? A. 2 years B. 3 years C. 4 years D. 5 years

D. 5 years

The nurse is providing dietary instructions to the mother of an 8-year-old child diagnosed with celiac disease. Which of the following foods, if selected by the mother, would indicate her understanding of the dietary instructions? A. Ham sandwich on whole-wheat toast B. Spaghetti and meatballs C. Hamburger with ketchup D. Cheese omelet

D. Cheese omelet

For the past 18 months, an eight-year-old child has exhibited involuntary, purposeless, rapid recurrent movements of the arms and face as well as spontaneous unintelligible vocalizations. When receiving verbal cues, the child can decrease and sometimes extinguish the erratic movements for several minutes. The diagnosis is: A. atypical tic disorder. B. chronic motor tic disorder. C. stereotypic movement disorder. D. Tourette disorder.

D. Tourette disorder.

A 7-year-old child has been diagnosed with rheumatic fever. Which of the following physical findings would the nurse expect to assess? A. Vesicular rash over the face and chest B. Yellow pigmentation of the sclerae of the eyes C. Palpable mass in the upper right quadrant of the abdomen D. Warm and swollen knees and elbows

D. Warm and swollen knees and elbows

Which drug is used in acetaminophen overdose? A. Acetylcysteine B. Physostigmine C. Flumazenil D. Acetylsalicylic Acid

A. Acetylcysteine

For an 18-year-old with newly diagnosed cancer, the nurse formulates a nursing diagnosis of Anxiety related to the threat of death secondary to cancer diagnosis. Which expected outcome would be appropriate for this client? A. "Client verbalizes feelings of anxiety." B. "Client doesn't guess at prognosis." C. "Client uses any effective method to reduce tension." D. "Client stops seeking information."

A. "Client verbalizes feelings of anxiety."

The nurse is presenting to a group of parents whose children are suspected of having autism spectrum disorder (ASD). Which statement by the nurse should be included? A. "The features of autism are typically apparent by the time a child is 3 years of age." B. "You should notice deficits in your child by the age of 5." C. "A feature of ASD is the ability to understand nonverbal behavior." D. "A child with ASD should be able to successfully engage in imaginative play."

A. "The features of autism are typically apparent by the time a child is 3 years of age."

Which of the following nursing diagnoses would be most appropriate for a child with pneumonia during the acute phase of illness? A. Activity intolerance related to poor oxygen-carbon dioxide exchange B. Altered urinary elimination related to hypervolemic state C. Pain related to swelling of abdominal lymph nodes D. Excess fluid volume related to excessive mucus production

A. Activity intolerance related to poor oxygen-carbon dioxide exchange

It involves the over proliferation of granulocytes and more frequent in late adolescence. A. Acute Myeloid Leukemia B. Nephroblastoma C. Acute Lymphocytic Leukemia D. Asthma

A. Acute Myeloid Leukemia

The client is arrogant and manipulative. In ensuring a therapeutic milieu, the nurse does one of the following: A. Agree on a consistent approach among the staff assigned to the client. B. Suggest that the client take a leading role in the social activities C. Provide the client with extra time for one-on-one sessions D. Allow the client to negotiate the plan of care

A. Agree on a consistent approach among the staff assigned to the client.

A 4-year-old girl has been admitted to the hospital with a diagnosis of pneumococcal pneumonia. Her parents are extremely distraught over her condition and the fact she has not wanted to eat anything for the past 2 days. Which nursing approach would be most important to take to help alleviate the high anxiety level of these parents? A. Allow the parents to remain with the child as much as possible. B. Encourage the parents to return home and get some rest. C. Tell the parents that their child is receiving the best care possible. D. Avoid telling the parents unnecessary facts regarding her prognosis.

A. Allow the parents to remain with the child as much as possible.

What is one of the most common types of tics? A. Blinking B. Shoulder Shrugging C. All of these answers are correct D. Barking or yelping

A. Blinking

The primary problem in cataract is: A. Blurring of vision B. Loss of peripheral vision C. Presence of floaters D. Halos around light

A. Blurring of vision

6. You are conducting a lecture about chemotherapy. Which of the following statements is correct about the rate of cell growth in relation to chemotherapy? A. Faster growing cells are more susceptible to chemotherapy B. Faster growing cells are less susceptible to chemotherapy C. Slower growing cells are more susceptible to chemotherapy D. Non-dividing cells are more susceptible to chemotherapy

A. Faster growing cells are more susceptible to chemotherapy

5. The parents of a child diagnosed with autism spectrum disorder (ASD) are trying to determine why their child has the disorder. In response, the nurse should include which etiology? A. Genetic factors B. Chemical factors C. Psychological factors D. Toxins

A. Genetic factors

A child with cancer has the following lab result: WBC 10,000, RBC 5, and platelet of 20,000. When planning this child's care, which risk should the nurse consider most significant? A. Hemorrhage B. Anemia C. Infection D. Pain

A. Hemorrhage

What measure at home could help a child with an upper respiratory infection breathe more easily? A. Increasing room humidity B. Limiting fluid intake C. Enforcing strict bed rest D. Playing "rapid breathing" games

A. Increasing room humidity

Which of the following best describes encopresis? A. Leaking of stool in an inappropriate place B. Leaking of urine in an inappropriate place C. Inability to pass stool D. Inability to pass urine

A. Leaking of stool in an inappropriate place

A patient is admitted to the oncology unit for diagnosis of suspected Hodgkin's disease. Which of the following symptoms is typical of Hodgkin's disease? A. Night sweats and fatigue B. Weight gain C. Nausea and vomiting D. Painful cervical lymph nodes

A. Night sweats and fatigue

The nurse is administering medications to a child with cystic fibrosis. Which of the following methods would the nurse most likely use to give medications to treat the pancreatic involvement seen in this disease? A. Open capsule and sprinkle on food B. Pour in medication cup and have child drink C. Shake inhaler and hold close to mouth D. Draw up in syringe and administer subcutaneously

A. Open capsule and sprinkle on food

A narrow tube that connects bladder and umbilicus fails to close during embryonic development. A. Patent Urachus B. Hydronephrosis C. Hypospadias D. Epispadias

A. Patent Urachus

A newborn is diagnosed with a congenital heart defect (CHD). The test results reveal that the lumen of the duct between the aorta and pulmonary artery remains open. This defect is known as _____________________. A. Patent ductus arteriosus (PDA). B. Ventricular septal defect (VSD). C. Hypoplastic left heart syndrome. D. Pulmonic stenosis (PS).

A. Patent ductus arteriosus (PDA).

A child has been diagnosed with Kawasaki disease. Which of the following signs and symptoms would the nurse expect to see? A. Reddened and crusty eyes B. Vertigo C. Purpural rash over torso D. Diarrhea

A. Reddened and crusty eyes

10. The clinic nurse is reviewing the health care provider's prescription for a child who has been diagnosed with scabies. Lindane has been prescribed for the child. The nurse questions the prescription if which is noted in the child's record? A. The child is 18 months old. B. The child is being bottle-fed. C. A sibling is using lindane for the treatment of scabies. D. The child has a history of frequent respiratory infections.

A. The child is 18 months old.

A nurse is working with a client who has schizophrenia, paranoid type. Which of the following outcomes related to the client's delusional perceptions would the nurse establish? A. The client will demonstrate realistic interpretation of daily events in the unit. B. The client will perform daily hygiene and grooming without assistance. C. The client will take prescribed medications without difficulty. D. The client will participate in unit activities.

A. The client will demonstrate realistic interpretation of daily events in the unit.

A nurse is evaluating therapy with the family of a client with anorexia nervosa. Which of the following would indicate that the therapy was successful? A. The parents reinforce increased decision making by the client. B. The parents clearly verbalize their expectations for the client. C. The client verbalizes that family meals are now enjoyable. D. The client tells her parents about feelings of low-self-esteem.

A. The parents reinforce increased decision making by the client.

A patient with asthma is prescribed to take inhaled Salmeterol and Fluticasone for long-term management of asthma. You observe the patient taking these medications. Which option below best describes the correct order in how to take these medications? A. The patient inhales the Salmeterol first and then waits 5 minutes before inhaling the Fluticasone. B. The patient inhales the Fluticasone first and then waits 5 minutes before inhaling the Salmeterol. C. The patient inhales the Salmeterol first and then waits 1 minute before inhaling the Fluticasone. D. The patient inhales the Fluticasone and immediately inhales the Salmeterol.

A. The patient inhales the Salmeterol first and then waits 5 minutes before inhaling the Fluticasone.

Which of the following is a part of the main structures that play a role with altering intracranial pressure: A. Neurons B. Cerebrospinal fluid C. Periosteum D. Dura mater

B. Cerebrospinal fluid

What nursing diagnosis is seen with acute lymphocytic leukemia and thrombocytopenia? A. potential for injury B. self-care deficit C. potential for self-harm D. alteration in comfort

A. potential for injury

Situation: A 17-year-old writer is admitted for the second time accompanied by his wife. He is demanding, arrogant talked fast and hyperactive. Initially the nurse should plan this for a manic client: A. set realistic limits to the client's behavior B. repeat verbal instructions as often as needed C. allow the client to get out feelings to relieve tension D. assign a staff to be with the client at all times to help maintain control

A. set realistic limits to the client's behavior

You care for a 3-year-old with hypospadias. After a surgical repair, he has a urethral urinary catheter inserted. You would want to teach his parents that: A. the catheter insertion site will leave only a minimal scar. B. back pressure from such drainage may result in nephrotic syndrome. C. He must be reevaluated at puberty for testicular function. D. He will always have tenderness on penile erection.

A. the catheter insertion site will leave only a minimal scar.

What is the most common symptom of Tourette's Syndrome? A. tics B. heart attacks C. seizures D. broken bones

A. tics

A nurse is assigned to care for a patient with nephrotic syndrome. The nurse assesses which important parameter on a daily basis? A. weight B. albumin levels C. activity tolerance D. blood urea nitrogen (BUN) level

A. weight

What is the name for a condition where the unequal (variable) curvature of the cornea or lens cannot properly focus light onto the retina, resulting in incoming light rays focusing at different points? A. Ametropia B. Astigmatism C. Emmetropia D. Hyperopia E. Myopia

B. Astigmatism

Which of the following methods should the nurse use to provide the most accurate assessment of an adolescent's status regarding obesity? A. A food intake diary for 1 week. B. Body mass index. C. A 4-hour dietary history. D. Skinfold thickness measurements.

B. Body mass index.

The part of the ear that contains the receptors for hearing is the: A. Utricle B. Cochlea C. Middle ear D. Tympanic cavity

B. Cochlea

The nursing care plan for a toddler diagnosed with Kawasaki Disease (mucocutaneous lymph node syndrome) should be based on the high risk for development of? A. Pulmonary embolism B. Coronary artery aneurysms C. Vesicular rash D. Chronic arthritis

B. Coronary artery aneurysms

A child with cerebral palsy has been fitted for braces and is beginning physical therapy to assist with ambulation. The parents ask why he needs the braces when he was crawling without any assistive devices. Select the nurse's best response. A. "The cerebral palsy has progressed, and he now needs more assistance to ambulate." B. "As your child grows, different muscle groups may need more assistance." C. "Most children need braces to help with ambulation." D. "We have found that when children with use braces, they are less likely to fall."

B. "As your child grows, different muscle groups may need more assistance."

.A nursing instructor is teaching about the prevalence of bipolar disorder. Which student statement indicates that learning has occurred? A. "This disorder is more prevalent in the lower socioeconomic groups." B. "This disorder is more prevalent in the higher socioeconomic groups." C. "This disorder is equally prevalent in all socioeconomic groups." D. "This disorder's prevalence cannot be evaluated on the basis of socioeconomic groups."

B. "This disorder is more prevalent in the higher socioeconomic groups."

You are the nurse taking care of a patient who is receiving ibuprofen for back pain, and the patient complains of burning epigastric pain after swallowing his ibuprofen pills for the last few days. You suggest which of the following to the patient? A. "Try taking the pills without any water." B. "Try taking the pills with a full glass of water." C. "Take the pills right before lie down you go to sleep." D. "Request the pills more frequently." E. "Try taking the pills while lying down."

B. "Try taking the pills with a full glass of water."

In the management of bulimic patients, the following nursing interventions will promote a therapeutic relationship EXCEPT: A. Establish an atmosphere of trust B. Discuss their eating behavior. C. Help patients identify feelings associated with binge-purge behavior D. Teach patient about bulimia nervosa

B. Discuss their eating behavior.

Identify one method of preventing encopresis. A. Discipline the child B. Eat a diet high in fat C. Drink plenty of fluids D. Eat a diet high in salt

B. Eat a diet high in fat

An inflammation of brain tissue and, possibly, the meninges that can arise from protozoan, bacterial, fungal, or viral invasions: A. Reye Syndrome B. Encephalitis C. Sturge-Weber Syndrome D. Cerebral Palsy

B. Encephalitis

An 18-year-old female client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment findings would the nurse expect to note specifically in the client? A. Weakness B. Enlarged lymph nodes C. Fatigue D. Weight gain

B. Enlarged lymph nodes

The parents of a young man with schizophrenia express feelings of responsibility and guilt for their son's problems. How can the nurse best educate the family? A. Acknowledge the parent's responsibility. B. Explain the biological nature of schizophrenia. C. Refer the family to a support group. D. Teach the parents various ways they must change.

B. Explain the biological nature of schizophrenia.

Which of the following behaviors demonstrated by an individual may be indicative of hearing loss? A. Not looking at the examiner when being questioned B. Frequently asking for the question to be repeated C. Talking in a high-pitched voice D. Speaking slowly with well-articulated consonants

B. Frequently asking for the question to be repeated

Mario is admitted to the emergency room with drug-included anxiety related to over ingestion of prescribed antipsychotic medication. The most important piece of information the nurse in charge should obtain initially is the: A. Length of time on the med. B. Name of the ingested medication & the amount ingested C. Reason for the suicide attempt D. Name of the nearest relative & their phone number

B. Name of the ingested medication & the amount ingested

Malignant cancer of the kidney; usually unilateral; encapsulated at the time of diagnosis: A. Acute Myeloid Leukemia B. Nephroblastoma C. Acute Lymphocytic Leukemia D. Asthma

B. Nephroblastoma

The nurse should administer an as-needed dose of magnesium hydroxide after noting what information while reviewing a patient's medical record? A. Abdominal pain and bloating B. No bowel movement for 3 days C. A decrease in appetite by 50% over 24 hours D. Muscle tremors and other signs of hypomagnesemia

B. No bowel movement for 3 days

To help meet the nutritional needs of a child with pneumonia, you would: A. Encourage reducing fluid intake B. Offer small, frequent feedings C. Encourage intake of three large meals daily D. Suggest feeding by enteral tube feedings.

B. Offer small, frequent feedings

A complication of Acute Lymphocytic Leukemia wherein from invasion of leukemia cells the kidneys enlarge and function impaired A. CNS involvement B. Renal Involvement C. Testicular Invasion D. Wilm's Tumor

B. Renal Involvement

Which of the following best describes enuresis? A. The inability to control stool in a person that is already toilet trained B. The inability to control urine in a person that is already toilet trained C. Frequent urination D. Painful urination

B. The inability to control urine in a person that is already toilet trained

Which of the following statement is true regarding the visual changes associated with cataracts? A. Both eyes typically cataracts at the same time B. The loss of vision is experienced as a painless, gradual blurring C. The patient is suddenly blind D. The patient is typically experiences a painful, sudden blurring of vision

B. The loss of vision is experienced as a painless, gradual blurring

The client with anorexia nervosa is improving if: A. She eats meals in the dining room. B. Weight gain C. She attends ward activities. D. She has a more realistic self-concept.

B. Weight gain

A child develops carditis from rheumatic fever. The nurse knows that the areas of the heart affected by carditis are the: A. coronary arteries. B. heart muscle and the mitral valve. C. aortic and pulmonic valves. D. contractility of the ventricles.

B. heart muscle and the mitral valve.

The caregivers of a 2-year-old who has had a common cold for 4 days calls the nurse in the Emergency Department at 2 AM on a cold winter night to say that the child has awakened with a barking cough and an elevated temperature; she seems blue around her mouth. The nurse would most appropriately recommend which of the following to the caregiver? A. "Turn on all of the hot water taps in the bathroom and close the door. Take the child into the steam filled room for 15 minutes. If there is no relief, bring the child to the emergency room." B. "Bundle the child up and take her out into the cold for a few minutes. Call back if the exposure to the cold air does not provide relief." C. "Bring the child to the emergency room immediately." D. "Put a cool mist humidifier or vaporizer in the room to see if that relieves the cough. Call back if there's no relief in an hour."

C. "Bring the child to the emergency room immediately."

The school nurse has provided an instructional session about impetigo to parents of the children attending the school. Which statement, if made by a parent, indicates a need for further instruction? A. "It is extremely contagious." B. "It is most common in humid weather." C. "Lesions most often are located on the arms and chest." D. "It might show up in an area of broken skin, such as an insect bite."

C. "Lesions most often are located on the arms and chest."

A child in the PICU with a head injury is comatose and unresponsive. The parent asks if he needs pain medication. Select the nurse's best response. A. "Pain medication is not necessary as he is unresponsive and cannot feel pain." B. "Pain medication may interfere with his ability to respond and may mask any signs of improvement." C. "Pain medication is necessary to make him comfortable." D. "Pain medication is necessary for comfort, but we use it cautiously as it increases the demand for oxygen."

C. "Pain medication is necessary to make him comfortable."

The nurse is caring for a 2-month-old infant who is at risk for cerebral palsy due to extreme low birth weight and prematurity. His parents ask why a speech therapist is involved in his care. Select the nurse's best response. A. "Your child is likely to have speech problems because of his early birth. Involving the speech therapist now will ensure vocalization at a developmentally appropriate age." B. "The speech therapist will help with tongue and jaw movements to assist with babbling." C. "The speech therapist will help with tongue and jaw movements to assist with feeding." D. "Many members of the health-care team are involved in your child's care so that we will know if there are any unmet needs."

C. "The speech therapist will help with tongue and jaw movements to assist with feeding."

Nurses should begin screening for lead poisoning when a child reaches which age? A. 12 months B. 6 months C. 18 months D. 24 months

C. 18 months

An alternate continence procedure that reconstruct bladder capacity, pelvic floor function, and bladder contractility: A. Chordee Procedure B. Meatotomy C. Bladder Neck Reconstruction D. Vagotomy

C. Bladder Neck Reconstruction

A 7-year-old child has been scheduled for a tonsillectomy. Which of the following would be most important to assess prior to surgery? A. Specific gravity of urine B. Pulse and respiratory rate C. Bleeding and clotting time D. Blood pressure both lying down and sitting up

C. Bleeding and clotting time

You have developed the nursing diagnosis Risk for Impaired Tissue Integrity related to effects of radiation for a client with Hodgkin's lymphoma who is receiving radiation to the groin area. Which nursing activity is best delegated to a nursing assistant caring for the client? A. Apply alcohol-free lotion to the area after cleaning. B. Explain good skin care to the client and family. C. Clean the skin over daily with a mild soap. D. Check the skin for signs of redness or peeling.

C. Clean the skin over daily with a mild soap.

The nurse is assessing a 3-year-old child for symptoms of autism spectrum disorder (ASD). Which assessment finding should lead the nurse to question the diagnosis? A. Inability to react accordingly to social clues B. Engages in repetitive behaviors C. Comprehends language well beyond the complexity of age D. Displays self-destructive behavior

C. Comprehends language well beyond the complexity of age

In which poisoning the Digibind is used as an effective antidote? A. Cholinergics B. Benzodiazepine C. Digoxin D. Atropine

C. Digoxin

A heart transplant may be indicated for a child with severe heart failure and: A. Patent ductus arteriosus (PDA). B. Ventricular septal defect (VSD). C. Hypoplastic left heart syndrome. D. Pulmonic stenosis (PS).

C. Hypoplastic left heart syndrome.

The ear bones that transmit vibrations to the oval window of the cochlea are found in the: A. Inner ear B. Outer ear C. Middle ear D. Eustachian tube

C. Middle ear

When planning the discharge of a client with chronic anxiety, Nurse Chris evaluates achievement of the discharge maintenance goals. Which goal would be most appropriately having been included in the plan of care requiring evaluation? A. The client eliminates all anxiety from daily situations B. The client ignores feelings of anxiety C. The client identifies anxiety producing situations D. The client maintains contact with a crisis counselor

C. The client identifies anxiety producing situations

A client taking Dilantin (phenytoin) for grand mal seizures is preparing for discharge. Which information should be included in the client's discharge care plan? A. The medication can cause dental staining. B. The client will need to avoid a high-carbohydrate diet. C. The client will need a regularly scheduled CBC. D. The medication can cause problems with drowsiness.

C. The client will need a regularly scheduled CBC.

While working in the ICU, you are assigned to care for a patient with a seizure disorder. Which of these nursing actions will you implement first if the patient has a seizure? A. Place the patient on a non-rebreather mask will the oxygen at 15 L/minute. B. Administer lorazepam (Ativan) 1 mg IV. C. Turn the patient to the side and protect airway. D. Assess level of consciousness during and immediately after the seizure.

C. Turn the patient to the side and protect airway.

Which of the following would the nurse expect to assess in a child with celiac disease having a celiac crisis secondary to an upper respiratory infection? A. Respiratory distress B. Lethargy C. Watery diarrhea D. Weight gain

C. Watery diarrhea

Discharge teaching for a child with celiac disease would include instructions about avoiding which of the following? A. Rice B. Milk C. Wheat D. Chicken

C. Wheat

A 6-year-old child is diagnosed as having streptococcal pharyngitis. When planning care, you should be aware that the chief danger of such an infection is that: A. lymph nodes will swell and obstruct the airway. B. the infection may spread and cause a tooth abscess. C. a small proportion of children develop rheumatic fever. D. four out of five children develop nephrosis afterward.

C. a small proportion of children develop rheumatic fever.

You are assessing a child for wheezes. You know that wheezing in children is best heard: A. as the child cries. B. without a stethoscope. C. as the child exhales. D. with the child supine.

C. as the child exhales.

After climbing on the trees that surround a six-year-old female child's home, the child reports that the "angry trees" made her fall. This animistic thinking is: A. a coping mechanism to allay the child's guilt feelings. B. an abnormal thought process for a child of this age. C. characteristic of preoperational thought. D. indicative of childhood schizophrenia.

C. characteristic of preoperational thought.

You are administering a Snellen chart test to a patient. What results would you expect to get if your patient was legally blind? A. 20/20 vision B. 20/40 vision C. 20/60 vision D. 20/200 vision

D. 20/200 vision

Which of the following children is at risk of recurrent otitis media? A. An 18-month-old infant who lives with a smoker B. A 2-year-old child who has had two ear infections in the past 6 months C. A 6-month-old infant who has a sibling who had tubes inserted at 3 years of age D. An 18-month-old infant who has had three episodes of ear infections in a 5-month period

D. An 18-month-old infant who has had three episodes of ear infections in a 5-month period

A 5-year-old girl Hannah is recently diagnosed with Kawasaki disease. Apart from the identified symptoms of the disease. she may also likely develop which of the following? A. Sepsis B. Meningitis C. Mitral Valve Disease D. Aneurysm Formation

D. Aneurysm Formation

The nurse reviews the laboratory results for a child with a suspected diagnosis of rheumatic fever, knowing that which laboratory study would assist in confirming the diagnosis? A. Immunoglobulin B. Red blood cell count C. White blood cell count D. Anti-streptolysin O titer

D. Anti-streptolysin O titer

Which of the following is/are Type(s) of Refractive Errors? A. myopia B. hyperopia C. Astigmatism D. Presbyopia E. All of the above

E. All of the above

You see a 3-year-old boy in an ambulatory setting for localized wheezing on auscultation. Which statement by his mother would be most important to report? A. She gives the child hard candy as an afternoon treat. B. The child has two cousins who have allergies. C. She likes the child to play by himself for 15 minutes every afternoon. D. The child was eating peanuts yesterday.

D. The child was eating peanuts yesterday.

The client's vision is tested with a Snellen's chart. The results of the tests are documented as 20/60. The nurse interprets this as: A. The client can read at a distance of 60 feet what a client with normal vision can read at 20 feet. B. The client is legally blind. C. The client's vision is normal D. The client can read only at a distance of 20 feet what a client with normal vision can read at 60 feet.

D. The client can read only at a distance of 20 feet what a client with normal vision can read at 60 feet.

Which information is most essential in the initial teaching session for the family of a young adult recently diagnosed with schizophrenia? A. Symptoms of this disease imbalance in the brain. B. Genetic history is an important factor related to the development of schizophrenia. C. Schizophrenia is a serious disease affecting every aspect of a person's functioning. D. The distressing symptoms of this disorder can respond to treatment with medications.

D. The distressing symptoms of this disorder can respond to treatment with medications.

The following are management for Encopresis, EXCEPT: A. The treatment of encopresis begins with a therapeutic regimen to empty the bowels of impacted stool, most often with laxatives, enemas, or a combination of both B. Behavior interventions are centered on habit re-learning. C. Reserving time in a busy household for children to evacuate their bowels about two times daily D. Child is able to evacuate their bowels before they leave for school in the morning because then they are less likely to experience encopresis and embarrassment in school. E. None of the above

E. None of the above

While assessing a 4-month-old infant, the nurse notices hyperpigmented nevi on the lower back. Which of the following is false regarding hyperpigmented nevi? A. Hyperpigmented nevi may be scattered B. Hyperpigmented nevi are frequently mistaken as bruises C. Hyperpigmented nevi fade over time D. Hyperpigmented nevi may be associated with Sturge-Weber syndrome E. Hyperpigmented nevi are most commonly found on dark skinned children

Hyperpigmented nevi may be associated with Sturge-Weber syndrome

It occurs when children fail to respond to medications during an attack with an extreme emergency because a child may die of heart failure due to a combination of exhaustion, atelectasis and acidosis from bronchial plugging: A. Status Asthmaticus B. Urinary Tract Infection C. Asthma D. Acute Allergic Reaction

A. Status Asthmaticus

The nurse is examining a 4-year-old who is injured and crying. What might the nurse document about the child's breathing? A. Tachypnea B. Tachycardia C. Respirations are slow and shallow D. Respirations are regular

A. Tachypnea

Which of the following assessments would make the nurse suspect that a child has strabismus? A. Tilts head to see B. Turns head to see C. Does not respond when spoken to D. Has difficulty hearing

A. Tilts head to see

The primary reason for performing iridectomy after cataract extraction is: A. To prevent secondary glaucoma B. To improve the vision of the client C. To prevent postop hemorrhage D. To reduce eye discomfort

A. To prevent secondary glaucoma

Which of the following instructions would Nurse Courtney include in a teaching plan that focuses on initial prevention for Sheri who is diagnosed with rheumatic fever? A. Treating streptococcal throat infections with an antibiotic B. Giving penicillin to patients with rheumatic fever C. Using corticosteroid to reduce inflammation D. Providing an antibiotic before dental work

A. Treating streptococcal throat infections with an antibiotic

What tissue of the gastrointestinal tract is affected in Celiac disease? A. Stomach, causing gastritis B. Small intestine, causing villous atrophy C. Large intestine, causing ulceration D. Rectum, causing fistulation

B. Small intestine, causing villous atrophy

A nursing diagnosis for bulimia nervosa is powerlessness related to feeling not in control of eating habits. The goal for this problem is: A. Patient will learn problem solving skills B. Patient will have decreased symptoms of anxiety. C. Patient will perform self-care activities daily. D. Patient will verbalize how to set limits on others.

A. Patient will learn problem solving skills

It is an acute encephalopathy with accompanying fatty infiltration of the liver, heart, lungs, pancreas, and skeletal muscle that occurs in children from 1 to 18 years of age regardless of gender: A. Reye Syndrome B. Encephalitis C. Sturge-Weber Syndrome D. Cerebral Palsy

A. Reye Syndrome

A 6 year old male is diagnosed with nephrotic syndrome. In your nursing care plan you will include which of the following as a nursing diagnosis for this patient? A. Risk for infection B. Deficient fluid volume C. Constipation D. Overflow urinary incontinence

A. Risk for infection

The mother of a child diagnosed with a potentially life-threatening form of cancer says to the nurse, "I don't understand how this could happen to us. We have been so careful to make sure our child is healthy." Which response by the nurse is most appropriate? A. "This must be a difficult time for you and your family. Would you like to talk about how you are feeling?" B. "Why do you say that? Do you think that you could have prevented this?" C. "You shouldn't feel that you could have prevented the cancer. It is not your fault." D. "Many children are diagnosed with cancer. It is not always life-threatening."

A. "This must be a difficult time for you and your family. Would you like to talk about how you are feeling?"

To determine if ascites is increasing in amount in a child with nephrotic syndrome, which measurements would be most appropriate? A. Abdominal Circumference B. Urine for protein C. Blood pressure D. Bowel sounds

A. Abdominal Circumference

A child diagnosed with congestive heart failure (CHF) is receiving maintenance doses of digoxin and furosemide. She is rubbing her eyes when she is looking at the lights in the room, and her HR is 70 beats per minute. The nurse expects which laboratory finding? A. Hypokalemia. B. Hypomagnesemia. C. Hypocalcemia. D. Hypophosphatemia.

A. Hypokalemia.

An eight-year-old female child is referred to the child/adolescent psychiatric and mental health clinical nurse specialist for verbalizing fears that her immigrant grandmother will die. The widowed grandmother wears heavy black clothes, prays throughout the day, and secludes herself from everyone except the child. Although the grandmother is physically healthy, she discusses her impending death with the child. The clinical nurse specialist recognizes that: A. cultural factors may negate the significance of seemingly obvious symptoms. B. religious fixations are common in delusional systems. C. the grandmother and the child communicate only in the grandmother's native language. D. the grandmother is exhibiting classic signs of endogenous depression.

A. cultural factors may negate the significance of seemingly obvious symptoms.

A 14-year-old child sustains a fall at home. After an x-ray examination, the child is determined to have a fractured arm and a plaster cast is applied. The nurse provides instructions to the parents regarding care for the child's cast. Which statement by the parents indicates a need for further instruction? A. "The cast may feel warm as the cast dries." B. "I can use lotion or powder around the cast edges to relieve itching." C. "A small amount of white shoe polish can touch up a soiled white cast." D. "If the cast becomes wet, a blow drier set on the cool setting may be used to dry the cast."

B. "I can use lotion or powder around the cast edges to relieve itching."

Two child/adolescent psychiatric and mental health clinical nurse specialists are conducting a continuing education class for nurses, psychiatric technicians, and aides who have varying levels of experience and education. The clinical nurse specialists begin the class by introducing themselves and relating their backgrounds and experience. The class is then asked to do the same and tell why they are there. This method reflects which principle of adult learning theory? A. Assessment of group dynamics B. Assessment of knowledge and learning needs of participants C. Establishment of group cohesiveness and rapport with participants D. Establishment of the clinical nurse specialists' role as experts

B. Assessment of knowledge and learning needs of participants

A mother arrives at the emergency department with her 4-year-old child and states that the child fell off a bunk bed. A head injury is suspected, and a nurse is monitoring the child continuously for signs of increased intracranial pressure (ICP). Which of the following is a late sign of increased ICP in this child? A. Nausea B. Bradycardia C. Bulging fontanel D. Dilated scalp veins

B. Bradycardia

Which of the following is included in the health teachings among clients receiving Valium? A. Avoid foods rich in tyramine. B. Take the medication after meals. C. It is safe to stop it anytime after long term use. D. Double up the dose if the client forgets her medication.

B. Take the medication after meals.

Anxiety is caused by: A. an objective threat B. a subjectively perceived threat C. hostility turned to the self D. masked depression

B. a subjectively perceived threat

You assist your patient with using their inhaler. The inhaler contains the medication Budesonide. Before administering the inhaler, you will want to connect what device to the inhaler to help decrease the patient from developing ________? A. Peak flow meter; pneumonia B. Incentive spirometer; thrush C. Spacer; thrush D. Peak flow meter; mouth sores

C. Spacer; thrush

During play, a toddler with a history of tetralogy of Fallot (TOF) might assume which position? A. Sitting. B. Supine. C. Squatting. D. Standing.

C. Squatting.

A client is experiencing anxiety attack. The most appropriate nursing intervention should include? A. Turning on the television B. Leaving the client alone C. Staying with the client and speaking in short sentences D. Ask the client to play with other clients

C. Staying with the client and speaking in short sentences

A disorder is limited to the ophthalmic branch of the fifth nerve, the lesion is usually confined to the upper aspect of the face. A. Reye Syndrome B. Encephalitis C. Sturge-Weber Syndrome D. Cerebral Palsy

C. Sturge-Weber Syndrome

An activity appropriate for the client is: A. table tennis B. painting C. chess D. cleaning

D. cleaning

Situation: A 19-year-old client came to you with rapid speech headache and inability to focus with what the doctor was saying. The nurse assesses the level of anxiety as: A. Mild B. Moderate C. Severe D. Panic

C. Severe

After tonsillectomy surgery, the preferred position of a child until fully awake is on the: A. side with the head elevated. B. abdomen with a pillow under the chest. C. back with warm compresses applied to the throat. D. side with continuous oxygen by cannula at 30%.

B. abdomen with a pillow under the chest.

The type of seizure, also known as a petit mal seizure, that occurs more often in children between the ages of 4 and 12 years is the: A. generalized seizure. B. absence seizure. C. atonic seizure. D. jackknife seizure.

B. absence seizure.

Situation: A 17-year-old gymnast is admitted to the hospital due to weight loss and dehydration secondary to starvation. Which of the following nursing diagnoses will be given priority for the client? A. altered self-image B. fluid volume deficit C. altered nutrition less than body requirements D. altered family process

B. fluid volume deficit

You're providing education to a group of nursing students about nephrotic syndrome. A student describes the signs and symptoms of this condition. Which signs and symptoms verbalized by the student require you to re-educate the student about this topic? A. Slight proteinuria B. Hypoalbuminemia C. Edema D. Hyperlipidemia

A. Slight proteinuria

The characteristic manifestation that will differentiate bulimia nervosa from anorexia nervosa is that bulimic individuals A. have episodic binge eating and purging B. have repeated attempts to stabilize their weight C. have peculiar food handling patterns D. have threatened self-esteem

A. have episodic binge eating and purging

The nurse is discussing the need for early diagnosis and treatment of autism spectrum disorder (ASD) with parents of children suspected of having the condition. Which statement should the nurse include? A. "Early diagnosis and treatment provide the only means for a cure of ASD." B. "Early diagnosis and treatment give your child the best chance of becoming a fully functioning adult." C. "Early diagnosis and treatment provide the best way to ensure that your child can be admitted to an assisted living facility as an adult." D. "Early diagnosis and treatment prevent your child from developing any other mental condition."

B. "Early diagnosis and treatment give your child the best chance of becoming a fully functioning adult."

4. The nurse is addressing a group of parents whose children are suspected of having autism spectrum disorder (ASD). Which statement by the parents indicates that additional teaching is necessary? A. "The essential features of autism are typically noticed by 3 years of age." B. "We should notice deficits in our children by the age of 5." C. "A feature of ASD is the inability to understand nonverbal behavior." D. "A child with ASD should will not engage in imaginative play."

B. "We should notice deficits in our children by the age of 5."

The charge nurse of a psychiatric unit is planning the client assignment for the day. The most appropriate staff to be assigned to a client with a potential for violence is which of the following: A. A timid nurse B. A mature experienced nurse C. an inexperienced nurse D. a soft-spoken nurse

B. A mature experienced nurse

Mental health is defined as: A. The ability to distinguish what is real from what is not. B. A state of well-being where a person can realize his own abilities can cope with normal stresses of life and work productively. C. Is the promotion of mental health, prevention of mental disorders, nursing care of patients during illness and rehabilitation D. Absence of mental illness

B. A state of well-being where a person can realize his own abilities can cope with normal stresses of life and work productively.

Which of the following nursing diagnoses would be most appropriate for a child with pneumonia during the acute phase of illness? A. Excess fluid volume related to excessive mucus production. B. Activity intolerance related to poor oxygen-carbon dioxide exchange C. Altered urinary elimination related to hypovolemic state D. Pain related to swelling of abdominal lymph nodes

B. Activity intolerance related to poor oxygen-carbon dioxide exchange

A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate because he complains that it makes him feel sick. Which of the following medications might be alternatively prescribed for mood stabilization in bipolar disorders? A. Sertraline (Zoloft) B. Valproic acid (Depakote) C. Trazodone (Desyrel) D. Paroxetine (Paxil)

B. Valproic acid (Depakote)

A 3-month-old has been diagnosed with a ventricular septal defect (VSD). The flow of blood through the heart is _____________________. A. Patent ductus arteriosus (PDA). B. Ventricular septal defect (VSD). C. Hypoplastic left heart syndrome. D. Pulmonic stenosis (PS).

B. Ventricular septal defect (VSD).

It tends to occur in children with atopy or those hypersensitive to allergens of inflammation, bronchoconstriction and increased mucus production: A. Status Asthmaticus B. Urinary Tract Infection C. Asthma D. Acute Allergic Reaction

C. Asthma

The following are postoperative management of Exstrophy of the Bladder, EXCEPT: A. After surgical repair, a urethral urinary drainage catheter will be inserted to allow urine output without putting tension against the urethral sutures. B. After bladder closure, a suprapubic tube is placed for urine drainage and will typically remain in place for 4 to 6 weeks to allow the bladder to drain continuously and the surgical anastomoses to heal. C. The infant should be positioned on the back with the legs raised in traction at 90 degrees is maintained for 4 to 6 weeks after surgery and is essential to prevent failure of the closure D. A Bladder Neck Resection reconstructs the bladder neck and urethra and allows the child to void via the urethra and achieve continence.

B. After bladder closure, a suprapubic tube is placed for urine drainage and will typically remain in place for 4 to 6 weeks to allow the bladder to drain continuously and the surgical anastomoses to heal.

A client diagnosed with bipolar I disorder is distraught over insomnia experienced over the last 3 nights and a 12-pound weight loss over the past 2 weeks. Which should be this client's priority nursing diagnosis? A. Knowledge deficit related to bipolar disorder as evidenced by concern about symptoms B. Altered nutrition: less than body requirements related to hyperactivity as evidenced by weight loss C. Risk for suicide related to powerlessness as evidenced by insomnia and anorexia D. Altered sleep patterns related to mania as evidenced by insomnia for the past 3 nights

B. Altered nutrition: less than body requirements related to hyperactivity as evidenced by weight loss

A child has been seen by the school nurse for dizziness since the start of the school term. It happens when standing in line for recess and homeroom. The child now reports that she would rather sit and watch her friends play hopscotch because she cannot count out loud and jump at the same time. When the nurse asks her if her chest ever hurts, she says yes. Based on this history, the nurse suspects that she has: A. Ventricular septal defect (VSD). B. Aortic stenosis (AS). C. Mitral valve prolapse. D. Tricuspid atresia.

B. Aortic stenosis (AS).

A patient with glaucoma is ordered eye medication for the right eye in the form of an ointment and eye drop. The nurse will administer which type of medication first? A. Ointment and then the eye drops B. Eye drops and then the ointment C. Wipe the eyes before applying ointment the eyedrops D. Wipe the eyes before using the eyedrop and applying the ointment

B. Eye drops and then the ointment

A 2-year-old boy is seen for acute laryngotracheobronchitis. Which of the following observations would lead you to suspect that airway occlusion is occurring? A. He states he is tired and wants to sleep B. His respiratory rate is gradually increasing C. His cough is becoming harsher D. His nasal discharge is increasing

B. His respiratory rate is gradually increasing

Enlargement of the pelvis of the kidney with urine as a result of back-pressure is generally caused by obstruction, either of the ureter or of the point where the ureter joins the bladder, as with vesicoureteral reflux. A. Patent Urachus B. Hydronephrosis C. Hypospadias D. Epispadias

B. Hydronephrosis

Shortly after admission to an acute care facility, a male child with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium) 10 mg I.V. stat. How soon can the nurse administer a second dose of diazepam, if needed and prescribed? A. In 30 to 45 seconds B. In 10 to 15 minutes C. In 30 to 45 minutes D. In 1 to 2 hours

B. In 10 to 15 minutes

The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.

As the nurse, you know that it is important to implement a low sodium diet for a patient with nephrotic syndrome. However, it is important to implement what other type of diet due to another complication associated with this syndrome? A. Low-phosphate B. Low-fat C. High-carbohydrate D. Low-potassium

B. Low-fat

A procedure in which the urethra is extended to a usual position to establish better urinary function: A. Chordee Procedure B. Meatotomy C. Bladder Neck Reconstruction D. Vagotomy

B. Meatotomy

The nurse is planning care for an assigned client. The nurse should include information in the plan of care about prevention of human immunodeficiency virus (HIV) for which individuals specifically at risk? A. Lesbian persons B. Men-who-have-sex-with-men (MSM) C. Women-who-have-sex-with-women (WSW) D. Female-to-male (FTM) transgender persons

B. Men-who-have-sex-with-men (MSM)

Karen is pacing the floor and appears extremely anxious. The duty nurse approaches in an attempt to alleviate Karen's anxiety. The most therapeutic question by the nurse would be? A. Would you like to watch TV? B. Would you like me to talk with you? C. Are you feeling upset now? D. Ignore the client

B. Would you like me to talk with you?

You're providing care to a 6 year old male patient who is receiving treatment for nephrotic syndrome. Which assessment finding below requires you to notify the physician immediately? A. Frothy, dark urine B. Redden area on the patient's left leg that is swollen and warm C. Elevated lipid level on morning labs D. Urine test results that shows proteinuria

B. Redden area on the patient's left leg that is swollen and warm

Aspirin has been ordered for the child with rheumatic fever (RF) in order to: A. Keep the patent ductus arteriosus (PDA) open. B. Reduce joint inflammation. C. Decrease swelling of strawberry tongue. D. Treat ventricular hypertrophy of endocarditis.

B. Reduce joint inflammation.

The nurse is caring for a patient who requires compromised host precautions. Which action is most important for the nurse to take before delivering the patient's breakfast tray? A. Ask patient if she feels like eating at this time B. Remove fresh apple and orange from tray C. Call dietary department and ask for disposable utensils D. Declutter room before assisting patient to couch to eat

B. Remove fresh apple and orange from tray

The nurse is caring for a child who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated? A. Loosening restrictive clothing B. Restraining the client's limbs C. Removing the pillow and raising padded side rails D. Positioning the client to side, if possible, with the head flexed forward

B. Restraining the client's limbs

10. Nurse Maureen is developing a plan of care for a female client with anorexia nervosa. Which action should the nurse include in the plan? A. Provide privacy during meals B. Set-up a strict eating plan for the client C. Encourage client to exercise to reduce anxiety D. Restrict visits with the family

B. Set-up a strict eating plan for the client

An 18-year-old male with Hodgkin's Lymphoma and engaged. Which of the following diagnoses would be a priority for this client? A. Fatigue related to chemotherapy B. Sexual dysfunction related to radiation therapy C. Tissue integrity related to prolonged bed rest D. Anticipatory grieving related to terminal illness

B. Sexual dysfunction related to radiation therapy

A client who is complaining of tinnitus is describing a symptom that is: A. Objective B. Subjective C. Functional D. Prodromal

B. Subjective

When using a Snellen alphabet chart, the nurse records the client's vision as 20/40. Which of the following statements best describes 20/40 vision? A. The client has alterations in near vision and is legally blind. B. The client can see at 20 feet what the person with normal vision can see at 40 feet. C. The client can see at 40 feet what the person with normal vision sees at 20 feet. D. The client has a 20% decrease in acuity in one eye, and a 40% decrease in the other eye.

B. The client can see at 20 feet what the person with normal vision can see at 40 feet.

Your patient is ordered to take Acetazolamide for treatment of glaucoma. What in the patient's history would require you to hold the medication and obtain an order clarification from the physician? A. The patient has open-angle glaucoma. B. The patient is allergic to sulfonamides. C. The patient reports tunnel vision. D. The patient's IOP is 25 mmHg.

B. The patient is allergic to sulfonamides.

The clinic nurse is preparing to test the visual acuity of a client using a Snellen chart. Which of the following identifies the accurate procedure for this visual acuity test? A. Both eyes are assessed together, followed by the assessment of the right and then the left eye. B. The right eye is tested followed by the left eye, and then both eyes are tested. C. The client is asked to stand at a distance of 40ft. from the chart and is asked to read the largest line on the chart. D. The client is asked to stand at a distance of 40ft from the chart and to read the line than can be read 200 ft away by an individual with unimpaired vision.

B. The right eye is tested followed by the left eye, and then both eyes are tested.

Assessment of suicidal risk in children and adolescents requires the nurse to know which of the following? A. Children rarely commit suicide unless one of their parents has already committed suicide, especially in the past year. B. The risk of suicide increases during adolescence, with those who have recently suffered a loss, abuse, or family discord being most at risk. C. Children do have a suicidal risk that coincides with some significant event such as a recent gun purchase in the family. D. Adolescents typically don't choose suicide unless they live in certain geographical regions.

B. The risk of suicide increases during adolescence, with those who have recently suffered a loss, abuse, or family discord being most at risk.

Which of these facts is UNTRUE? A. Estimated that 200,000 Americans have the most severe form of Tourette's B. Tic severity peaks in the late teen years. C. Early tic symptoms are noticed between the ages of 3-9 D. No one medication eliminates all symptoms

B. Tic severity peaks in the late teen years.

A patient asks you to explain how the intraocular pressure is measured to help detect glaucoma. You state that IOP (intraocular pressure) is measured by what instrument below? A. Goniscope B. Tonometry C. Ophthalmoscope D. Phoroptor

B. Tonometry

It occurs more often in females as an ascending infection from the perineum because the urethra is shorter in girls: A. Status Asthmaticus B. Urinary Tract Infection C. Asthma D. Acute Allergic Reaction

B. Urinary Tract Infection

The parents of a child with juvenile idiopathic arthritis call the clinic nurse because the child is experiencing a painful exacerbation of the disease. The parents ask the nurse if the child can perform range-of-motion exercises at this time. The nurse should make which response? A. "Avoid all exercise during painful periods." B. "Range-of-motion exercises must be performed every day." C. "Have the child perform simple isometric exercises during this time." D. "Administer additional pain medication before performing range-of-motion exercises."

C. "Have the child perform simple isometric exercises during this time."

Family discharge teaching has been effective when the parent of a toddler diagnosed with Kawasaki disease (KD) states: A. "The arthritis in her knees is permanent. She will need knee replacements." B. "I will give her diphenhydramine (Benadryl) for her peeling palms and soles of her feet." C. "I know she will be irritable for 2 months after her symptoms started." D. "I will continue with high doses of Tylenol for her inflammation."

C. "I know she will be irritable for 2 months after her symptoms started."

The nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by the parents indicates a need for further instruction? A. "I will encourage my child to perform prescribed exercises." B. "I will have my child wear soft fabric clothing under the brace." C. "I should apply lotion under the brace to prevent skin breakdown." D. "I should avoid the use of powder because it will cake under the brace."

C. "I should apply lotion under the brace to prevent skin breakdown."

7. After the nurse provides dietary restrictions to the parents of a child with celiac disease, which statement by the parents indicates effective teaching? A. "Well follow these instructions until our child's symptoms disappear." B. "Our child must maintain these dietary restrictions until adulthood." C. "Our child must maintain these dietary restrictions lifelong." D. "We'll follow these instructions until our child has completely grown and developed."

C. "Our child must maintain these dietary restrictions lifelong."

A client began taking lithium for the treatment of bipolar disorder approximately 1 month ago. The client asks if it is normal to have gained 12 pounds in this time frame. Which is the appropriate nursing reply? A. "That's strange. Weight loss is the typical pattern." B. "What have you been eating? Weight gain is not usually associated with lithium." C. "Weight gain is a common but troubling side effect." D. "Weight gain occurs only during the first month of treatment with this drug."

C. "Weight gain is a common but troubling side effect."

You care for a 6-year-old boy with acute glomerulonephritis. When planning care for him, you should be aware that glomerulonephritis usually follows an infection of what organism? A. Group B Streptococci B. Staphylococcus viridans C. A Beta-hemolytic Streptococcus D. One of the rhinoviruses

C. A Beta-hemolytic Streptococcus

Myopia and hyperopia can be classified as which of the following? A. A problem that causes blurry vision B. A refractive disorder C. A refractive error D. Ametropia

C. A refractive error

It involves lymphoblasts or immature WBC's with rapid proliferation of lymphoblasts, RBC and platelet production fall and invasion of body organs by the WBC's begins: A. Acute Myeloid Leukemia B. Nephroblastoma C. Acute Lymphocytic Leukemia D. Asthma

C. Acute Lymphocytic Leukemia

A child with minimal change nephrotic syndrome (MCNS) has generalized edema. The skin appears stretched, and areas of breakdown are noted over the bony prominences. The child has been receiving Lasix twice daily for several days. Which does the nurse expect to be included in the treatment plan to reduce edema? A. An increase in the amount and frequency of Lasix. B. Addition of a second diuretic, such as mannitol. C. Administration of intravenous albumin. D. Elimination of all fluids and sodium from the child's diet.

C. Administration of intravenous albumin.

You're assisting your patient who has asthma to bed. The patient is experiencing a frequent cough and chest tightness. You auscultate the patient's lung fields and note expiratory wheezes. The patient's peak flow rate is 78% less than their best peak flow reading. Which medication will provide the patient with the fastest relief from these signs and symptoms of an asthma attack? A. Theophylline B. Tiotropium C. Albuterol D. Cromolyn

C. Albuterol

Physiologically, the middle ear, containing the three ossicles, serves primarily to: A. Maintain balance B. Translate sound waves into nerve impulses C. Amplify the energy of sound waves entering the ear D. Communicate with the throat via the Eustachian tube.

C. Amplify the energy of sound waves entering the ear

What is the best intervention to teach the client when she feels the need to starve? A. Allow her to starve to relieve her anxiety B. Do a short term exercise until the urge passes C. Approach the nurse and talk out her feelings D. Call her mother on the phone and tell her how she feels

C. Approach the nurse and talk out her feelings

When caring for a client with a diagnosis of thrombocytopenia, the nurse should plan to: A. Discourage the use of stool softeners B. Assess temperature readings every six hours C. Avoid invasive procedures D. Encourage the use of a hard, brittle toothbrush

C. Avoid invasive procedures

2. The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action? A. Hold the next dose of insulin. B. Come to the clinic immediately. C. Encourage the child to drink liquids. D. Administer an additional dose of regular insulin

C. Encourage the child to drink liquids.

A 16-year-old girl has return home following hospitalization for treatment of anorexia nervosa. The parents tell the family nurse performing a home visit that their child has always done everything to please them and they cannot understand her current stubbornness about eating. The nurse analyzes the family situation and determines it is characteristic of which relationship style? A. Differentiation B. Disengagement C. Enmeshment D. Scapegoating

C. Enmeshment

The client diagnosed with leukemia has central nervous system involvement. Which instructions should the nurse teach? A. Sleep with the head of the bed elevated to prevent increased intracranial pressure. B. Take an analgesic medication for pain only when the pain becomes severe. C. Explain that radiation therapy to the head may result in permanent hair loss. D. Discuss end-of-life decisions prior to cognitive deterioration.

C. Explain that radiation therapy to the head may result in permanent hair loss.

Which statement is correct about the rate of cell growth in relation to chemotherapy? A. Faster growing cells are less susceptible to chemotherapy. B. Nondividing cells are more susceptible to chemotherapy. C. Faster growing cells are more susceptible to chemotherapy. D. Slower growing cells are more susceptible to chemotherapy.

C. Faster growing cells are more susceptible to chemotherapy.

A patient is suspected to be suffering from Celiac Disease. The physician orders an endoscopy. If the patient has Celiac Disease, what finding will be discovered with the endoscopy? A. Over exaggerated intestinal villi B. Ulcerations in the small intestine, specifically the Jejunum C. Flat intestinal villi D. Cobble-stone appearance throughout the small intestine

C. Flat intestinal villi

Which nursing intervention is most appropriate for a client with anorexia nervosa during initial hospitalization on a behavioral therapy unit? A. Emphasize the importance of good nutrition to establish normal weight. B. Ignore the client's mealtime behavior and focus instead on issues of dependence and independence. C. Help establish a plan using privileges and restrictions based on compliance with refeeding. D. Teach the client information about the long-term physical consequence of anorexia.

C. Help establish a plan using privileges and restrictions based on compliance with refeeding.

Which of the following is not part of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnostic criteria for autism spectrum disorder (ASD)? A. Stereotyped or repetitive motor movements, use of objects, or speech B. Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment C. Hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person's developmental level D. Highly restricted, fixated interests that are abnormal in intensity or focus

C. Hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person's developmental level

A toddler with acute otitis media (AOM) is taking amoxicillin. The nurse should instruct the parents about which of the following? A. If the AOM does not resolve with amoxicillin, a myringotomy will be necessary. B. If the child is older than 24 months, a shorter course of antibiotics is sufficient. C. If the child improves clinically, continue the entire duration of antibiotics (10 to 14 days). D. If the child experiences ear pain, alternate acetaminophen (Tylenol) and ibuprofen for pain control.

C. If the child improves clinically, continue the entire duration of antibiotics (10 to 14 days).

A child with Reye syndrome is described in the nurse's notes as follows: 1200—comatose with sluggish pupils; when stimulated, demonstrates decerebrate posturing. 1400—unchanged except that now demonstrates decorticate posturing when stimulated. The nurse concludes that the child's condition is: A. Worsening and progressing to a more advanced stage of Reye syndrome. B. Worsening, and the child may likely experience cardiac and respiratory failure. C. Improving and progressing to a less advanced stage of Reye syndrome. D. Improving as the child's posturing reflexes are similar.

C. Improving and progressing to a less advanced stage of Reye syndrome.

. For the child with hypoplastic left heart syndrome, which drug may be given to allow the patent ductus arteriosus (PDA) to remain open until surgery? A. Furosemide B. Apresoline C. Indomethacin D. Penicillin

C. Indomethacin

Clay is an 8-year-old boy diagnosed with heart failure. Which of the following shows that he is strictly following the directed therapeutic regimen? A. Daily use of an antibiotics B. Pulse rate less than 50 beats/minute C. Normal weight for age D. Elevation in red blood cell (RBC) count

C. Normal weight for age

A nurse is caring for a 2-year-old with a new diagnosis of strabismus. Which intervention should the nurse anticipate? A. Eye drops in the abnormal eye B. Measurement of intraocular pressure (IOP) C. Patching the stronger eye D. Correction with laser surgery

C. Patching the stronger eye

A male client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase should the nurse add to complete the nursing diagnosis statement? A. Related to visual field deficits B. Related to difficulty swallowing C. Related to impaired balance D. Related to psychomotor seizures

C. Related to impaired balance

A worried mother calls the nurse and tells her that her son has developed a horrible croupy cough and is having trouble breathing. Which of the following would be the best intervention for the nurse to recommend to the mother? A. Administer an analgesic to the boy B. Administer cough syrup to the boy C. Run a hot shower to fill the bathroom with steam and have the boy stay there D. Have the boy drink a full glass of water to clear out the mucus

C. Run a hot shower to fill the bathroom with steam and have the boy stay there

What signs and symptoms are present with angle-closure glaucoma? A. Patients are mainly asymptomatic B. Gradual loss of peripheral vision C. Sudden vision changes (halos around lights or blurred vision) D. No pain

C. Sudden vision changes (halos around lights or blurred vision)

A complication of Acute Lymphocytic Leukemia wherein the leukemic cells in the testes will not be destroyed by chemotherapy therefore irradiation is done leading to sterility: A. CNS involvement B. Renal Involvement C. Testicular Invasion D. Wilm's Tumor

C. Testicular Invasion

The labyrinth of the inner ear is responsible for maintaining the body's: A. binaural interaction. B. air conduction. C. equilibrium. D. pressure equalization.

C. equilibrium.

Situation: Clients with personality disorders have difficulties in their social and occupational functions. Clients with personality disorder will most likely: A. recover with therapeutic intervention B. respond to antianxiety medication C. manifest enduring patterns of inflexible behaviors D. Seek treatment willingly from some personally distressing symptoms

C. manifest enduring patterns of inflexible behaviors

Which statement below is CORRECT about glaucoma? A. "The vision loss that occurs with glaucoma is reversible with eye drop medications." B. "Glaucoma occurs due to decreased intraocular pressure, which damages the optic nerve." C. "Surgery can cure glaucoma." D. "A normal intraocular pressure is about 10-21 mmHg and is elevated in most patients with glaucoma."

D. "A normal intraocular pressure is about 10-21 mmHg and is elevated in most patients with glaucoma."

A highly agitated client paces the unit and states, "I could buy and sell this place." The client's mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this client's behavior? A. "Rates mood 8/10. Exhibiting looseness of association. Euphoric." B. "Mood euthymic. Exhibiting magical thinking. Restless." C. "Mood labile. Exhibiting delusions of reference. Hyperactive." D. "Agitated and pacing. Exhibiting grandiosity. Mood labile."

D. "Agitated and pacing. Exhibiting grandiosity. Mood labile."

A child with rheumatic fever will be arriving to the nursing unit for admission. On admission assessment, the nurse should ask the parents which question to elicit assessment information specific to the development of rheumatic fever? A. "Has the child complained of back pain?" B. "Has the child complained of headaches?" C. "Has the child had any nausea or vomiting?" D. "Did the child have a sore throat or fever within the last 2 months?"

D. "Did the child have a sore throat or fever within the last 2 months?"

A nursing student is teaching a patient and family about epilepsy prior to the patient's discharge. For which statement should you intervene? A. "You should avoid consumption of all forms of alcohol." B. "Wear you medical alert bracelet at all times." C. "Protect your loved one's airway during a seizure." D. "It's OK to take over-the-counter medications."

D. "It's OK to take over-the-counter medications."

The clinic nurse notes that the following several eye examinations, the physician has documented a diagnosis of legal blindness in the client's chart. The nurse reviews the results of the Snellen's chart test expecting to note which of the following? A. 20/20 vision B. 20/40 vision C. 20/60 vision D. 20/200 vision

D. 20/200 vision

Which patient below is NOT at risk for developing nephrotic syndrome? A. An 8 year old male with diabetes mellitus. B. A 5 year old female diagnosed with minimal change disease. C. A 10 year old male with Lupus. D. A 7 year old male recently diagnosed with Alport's Syndrome.

D. A 7 year old male recently diagnosed with Alport's Syndrome.

A neurological consult has been ordered for a pediatric client with suspected petit mal seizures. The client with petit mal seizures can be expected to have: A. Short, abrupt muscle contraction B. Quick, bilateral severe jerking movements C. Abrupt loss of muscle tone D. A brief lapse in consciousness

D. A brief lapse in consciousness

What are examples of treatment for Tourette's? A. Neuroleptics B. Treatment to reduce urge to tic C. No treatment if Tourette's do not impair D. All of the above

D. All of the above

A preschool-age child undergoing chemotherapy experiences nausea and vomiting. Which of the following would be the best intervention to include in the child's plan of care? A. Administer tube feedings. B. Offer small, frequent meals. C. Offer fluids only between meals. D. Allow the child to choose what to eat for meals.

D. Allow the child to choose what to eat for meals.

Which of the following measures would be most effective in aiding bronchodilation in a child with laryngotracheobronchitis? A. Urging the child to continue to take oral fluids B. Administering an oral analgesic C. Teaching the child to take long, slow breaths D. Assisting with racemic epinephrine nebulizer therapy

D. Assisting with racemic epinephrine nebulizer therapy

The graduate nurse is caring for a family with a child who was recently diagnosed with autism spectrum disorder (ASD) and is discussing treatment options for the child. Which goal of collaborative therapy would require correction from the preceptor? A.Advocating for parent support and coping groups B. B. Use of focusing techniques and behavior management C. Implementing treatments that decrease maladaptive behaviors such as rigidity and stereotype D. Behavior modification through electroconvulsive therapy

D. Behavior modification through electroconvulsive therapy

A 16-year-old is placed in skeletal traction for treatment of a fractured femur. The nurse creates a plan of care and should include which intervention? A. Ensure that all ropes are outside the pulleys. B. Ensure that the weights are resting lightly on the floor. C. Restrict diversional and play activities until the child is out of traction. D. Check the primary health care provider's (PHCP's) prescriptions for the amount of weight to be applied.

D. Check the primary health care provider's (PHCP's) prescriptions for the amount of weight to be applied.

A pediatrician prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription? A. Obtains a weight B. Takes the temperature C. Takes the blood pressure D. Checks the amount of urine output

D. Checks the amount of urine output

A school-age child with type 1 diabetes mellitus has soccer practice and the school nurse provides instructions regarding how to prevent hypoglycemia during practice. Which should the school nurse tell the child to do? A. Eat twice the amount normally eaten at lunchtime. B. Take half the amount of prescribed insulin on practice days. C. Take the prescribed insulin at noontime rather than in the morning. D. Eat a small box of raisins or drink a cup of orange juice before soccer practice.

D. Eat a small box of raisins or drink a cup of orange juice before soccer practice.

The caregivers of a child report that their child had a cold and complained of a sore throat. When interviewed further they report that the child has a high fever, is very anxious, and is breathing by sitting up and leaning forward with the mouth open and the tongue out. The nurse recognizes these symptoms as those seen with which of the following disorders? A. Spasmodic laryngitis B. Tonsillitis C. Laryngotracheobronchitis D. Epiglottitis

D. Epiglottitis

A 7-year-old with type 1 diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note? A. Sweating and tremors B. Hunger and hypertension C. Cold, clammy skin and irritability D. Fruity breath odor and decreasing level of consciousness

D. Fruity breath odor and decreasing level of consciousness

During a well-child checkup for an infant with tetralogy of Fallot (TOF), the child develops severe respiratory distress and becomes cyanotic. The nurse's first action should be to: A. Lay the child flat to promote hemostasis. B. Lay the child flat with legs elevated to increase blood flow to the heart. C. Sit the child on the parent's lap, with legs dangling, to promote venous pooling. D. Hold the child in knee-chest position to decrease venous blood return.

D. Hold the child in knee-chest position to decrease venous blood return.

The following are goals in managing asthma, EXCEPT: A. Avoidance of allergen by environmental control, B. Skin testing C. Hypo-sensitization to identified allergens D. Increase fluid intake to flush out the organisms E. Relief of symptoms by pharmacologic agents

D. Increase fluid intake to flush out the organisms

The nurse is preparing to administer a dose of bisacodyl (Dulcolax). In explaining the medication to the patient, the nurse would explain that it acts in what way? A. Increases bulk in the stool B. Lubricates the intestinal tract to soften feces C. Increases fluid retention in the intestinal tract D. Increases peristalsis by stimulating nerves in the colon wall

D. Increases peristalsis by stimulating nerves in the colon wall

The nurse closely observes the client who has been displaying aggressive behavior. The nurse observes that the client's anger is escalating. Which approach is least helpful for the client at this time? A. Acknowledge the client's behavior B. Maintain a safe distance from the client C. Assist the client to an area that is quiet D. Initiate confinement measures

D. Initiate confinement measures

The nurse is caring for a patient who is scheduled for a biopsy of a tumor. The patient asks what distinguished a benign tumor from a malignant tumor. Which info should the nurse provide? A. Benign tumors are usually composed of more rapidly growing cells B. Benign tumors are incapable of causing damage to surrounding tissues or organs C. Whereas malignant tumors are usually encapsulated, benign tumors lack specific form D. Malignant tumors are composed of disorganized, abnormal cells that may spread to other parts of the body

D. Malignant tumors are composed of disorganized, abnormal cells that may spread to other parts of the body

All of the following are true regarding Tourette's Syndrome, EXCEPT: A. Although persistent/chronic tic disorder is either vocal or motor tics, Tourette syndrome is an inherited syndrome of motor and one or more phonic vocal tics. B. It occurs three times more frequently in boys than in girls, and because it is inherited, often, there is some other form of movement disorder in another family member. C. Typically, the age at onset is between 4 and 6 years, peaking in severity around the ages of 10 to 12 years, with motor tics usually occurring before vocal tics. D. None of the above

D. None of the above

A child with type 1 diabetes mellitus is brought to the emergency department by the mother, who states that the child has been complaining of abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer which type of intravenous (IV) infusion? A. Potassium infusion B. NPH insulin infusion C. 5% dextrose infusion D. Normal saline infusion

D. Normal saline infusion

A 15-year-old has a right femur fracture caused by a motor vehicle crash and is placed in skin traction temporarily until surgery can be performed. During assessment, the nurse notes that the dorsalis pedis pulse is absent on the right foot. Which action should the nurse take? A. Administer an analgesic. B. Release the skin traction. C. Apply ice to the extremity. D. Notify the primary health care provider.

D. Notify the primary health care provider.

A child who has undergone spinal fusion for scoliosis complains of abdominal discomfort and begins to have episodes of vomiting. On further assessment, the nurse notes abdominal distention. On the basis of these findings, the nurse should take which action? A. Administer an antiemetic. B. Increase the intravenous fluids. C. Place the child in a Sims' position. D. Notify the primary health care provider.

D. Notify the primary health care provider.

A nurse is collecting data about a child who has been admitted to the hospital with a diagnosis of seizures. The nurse checks for causes of the seizure activity by: A. Testing the child's urine for specific gravity B. Asking the child what happens during a seizure C. Obtaining a family history of psychiatric illness D. Obtaining a history regarding factors that may occur before the seizure activity

D. Obtaining a history regarding factors that may occur before the seizure activity

A 2-year-old is to be admitted in the pediatric unit. He is diagnosed with febrile seizures. In preparing for his admission, which of the following is the most important nursing action? A. Order a stat admission CBC. B. Place a urine collection bag and specimen cup at the bedside. C. Place a cooling mattress on his bed D. Pad the side rails of his bed.

D. Pad the side rails of his bed.

A nurse is assisting with data collection from an infant who has been diagnosed with hydrocephalus. If the infant's level of consciousness diminishes, a priority intervention is: A. Taking the apical pulse B. Taking the blood pressure C. Testing the urine for protein D. Palpating the anterior fontanel

D. Palpating the anterior fontanel

Which method should not be used to treat enuresis in children? A. Behavior modification B. Enuresis Alarm C. Wearing a Diaper D. Punish the child in the morning following bedwetting

D. Punish the child in the morning following bedwetting

Nurse Kenny is aware that the symptoms that distinguish post-traumatic stress disorder from other anxiety disorder would be: A. Avoidance of situation & certain activities that resemble the stress B. Depression and a blunted affect when discussing the traumatic situation C. Lack of interest in family & others D. Re-experiencing the trauma in dreams or flashback

D. Re-experiencing the trauma in dreams or flashback

A 4-year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first? A. Place the child in the nearest bed B. Administer IV medication to slow down the seizure C. Place a padded tongue blade in the child's mouth D. Remove the child's toys from the immediate area

D. Remove the child's toys from the immediate area

9. A client with bipolar disorder, manic type, exhibits extreme excitement, delusional thinking, and command hallucinations. Which of the following is the priority nursing diagnosis? A. Anxiety B. Impaired social interaction C. Disturbed sensory-perceptual alteration (auditory) D. Risk for other-directed violence

D. Risk for other-directed violence

A client diagnosed with bipolar disorder, who has taken lithium carbonate (Lithane) for 1 year, presents in an emergency department with severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms? A. Symptoms indicate consumption of foods high in tyramine. B. Symptoms indicate lithium carbonate discontinuation syndrome. C. Symptoms indicate the development of lithium carbonate tolerance. D. Symptoms indicate lithium carbonate toxicity.

D. Symptoms indicate lithium carbonate toxicity.

A child is having a tonic-clonic seizures. What should the nurse do first? A. Elevate the head of the bed. B. Restrain the client's arms and legs. C. Place a tongue blade in the client's mouth. D. Take measures to prevent injury.

D. Take measures to prevent injury.

You're observing a patient self-administer eye drops for the treatment of glaucoma. Which finding below requires you to re-educate the patient on how to administer eye drops correctly? A. The patient refrains from blinking after instilling the eye drops. B. The patient washes hands before and after administering the eye drops. C. The patient uses a tissue to catch any medication that drips out of the eye after administration of the drops. D. The patient places the drops of medication directly on the eye via the cornea.

D. The patient places the drops of medication directly on the eye via the cornea.

The client jumps up and throws a chair out of the window. He was restrained after his behavior can no longer be controlled by the staff. Which of these documentations indicates the safeguarding of the patient's rights? A. There was a doctor's order for restraints/seclusion B. The patient's rights were explained to him. C. The staff observed confidentiality D. The staff carried out less restrictive measures but were unsuccessful.

D. The staff carried out less restrictive measures but were unsuccessful.

All of the following are management of Exstrophy of the Bladder, EXCEPT: A. Surgical closure of the bladder and the anterior abdominal wall, and construction of a urethra B. Bladder mucosa should be kept moist and covered with plastic wrap to prevent the bladder surface both from drying out and from adhering to bedclothes C. Sponge bathe rather than tub bathe the infant to prevent water from entering the ureters and becoming a source of infection. D. The treatment is surgical correction of the obstruction before glomerular or tubular destruction occurs.

D. The treatment is surgical correction of the obstruction before glomerular or tubular destruction occurs.

The nurse analyzes the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse notes that the platelet count is 20,000/ul. Based on the laboratory result, which intervention will the nurse document in the plan of care? A. Monitor closely for signs of infection B. Monitor the temperature every 4hours C. Initiate protective isolation precautions D. Use soft small toothbrush for mouth care

D. Use soft small toothbrush for mouth care

Chemotherapy dosage is frequently based on total body surface area (BSA), so it is important for the nurse to do which of the following before administering chemotherapy? A. Measure abdominal girth B. Calculate BMI C. Ask the client about his/her height and weight D. Weigh and measure the client on the day of medication administration

D. Weigh and measure the client on the day of medication administration

Which of the following manifestations would be directly associated with Hodgkin's disease? A. bone pain B. generalized edema C. petechiae and purpura D. painless, enlarged lymph nodes

D. painless, enlarged lymph nodes

A child is administered oxybutynin (Ditropan) following surgical repair of a hypospadias. The purpose of this drug is to: A. prevent nausea and vomiting. B. stimulate kidney function. C. acidify urine. D. relieve bladder spasms.

D. relieve bladder spasms.

A client has been admitted to the hospital with a diagnosis of acute glomerulonephritis. During history taking the nurse first asks the client about a recent history of: A. bleeding ulcer B. deep vein thrombosis C. myocardial infarction D. streptococcal infection

D. streptococcal infection