NCLEX PN: HEALTH IMPLICATIONS ACROSS THE LIFESPAN

Based on a birth weight of 7 lb and normal growth and development, the nurse would expect an infant to weigh how many pounds at the age of 2 months? 1. 11 lb 2. 15 lb 3. 18 lb 4. 9 lb

1. 11 lb A newborn should gain 1½ to 2 lb per month for the first 3 to 5 months.

Which foods would be limited on a low-cholesterol diet? 1. Egg yolks 2. Skim milk 3. Soy beans 4. Carrots

1. Egg yolks Animal products are limited on a low-cholesterol diet. This includes milk products, meat, cheese, and egg yolk. Soy proteins can be used in place of animal proteins for a low-cholesterol diet.

What is important to teach a client regarding self-care during radiation therapy? 1. Remove the skin dye markings between treatments. 2. Avoid exposure to the sun and do not remove the skin dye markings. 3. Reduce carbohydrate and protein intake during treatments. 4. Decrease fluid intake and increase carbohydrate intake after treatments.

2. Avoid exposure to the sun and do not remove the skin dye markings. The skin in the area of radiation is sensitive to sunlight; it is important to leave the markings on the skin so the radiologist will know the boundaries of the treatment area.

The DTaP immunization for infants should start at what age? 1. 4 months 2. 3 months 3. 2 months 4. 1 month

3. 2 months The hepatitis B vaccine is started at birth or shortly thereafter. The DTaP is started at 2 months.

At what age does a child begin to discriminate between the mother's face and a stranger's face? 1. 1 month 2. 6 weeks 3. 4 months 4. 30 weeks

3. 4 months Recognition of familiar faces begins around 4 months, especially recognition of the mother's face.

What is a common growth and development nursing assessment finding for a 3-year-old? 1. Builds a tower with up to three blocks 2. Boasts, tattles, and exaggerates 3. Walks upstairs with alternating feet 4. Is able to count on fingers

3. Walks upstairs with alternating feet Walking upstairs with alternating feet is a developmental milestone of the third year. Building a tower with up to three blocks is an accomplishment of a 15-month-old. A 5-year-old can count on his or her fingers.

The nurse explains a bone marrow aspiration procedure to a 5-year-old child. Which behavior of the child reflects effective teaching? 1. Appears calm as the nurse takes her for the procedure 2. Asks if she can have ice cream after the procedure 3. States that her blood is bad and the physician will make it better 4. Points at her doll, saying that they have to put a needle here to look at my blood

4. Points at her doll, saying that they have to put a needle here to look at my blood Dolls and puppets are effective teaching tools for the preschool-age child. Using the doll reflects the child's understanding of the procedure. Separation anxiety may be a problem when the child knows something is going to happen and she is separated from the parents. The child may also withdraw and appear calm even though she is anxious.

Varicella zoster vaccination should be administered at what age? 1. At birth 2. 1 month 3. 6 months 4. 12 months

4. 12 months The varicella zoster vaccine can be administered any time after 12 months of age.

A nurse is assessing a client receiving intravenous chemotherapy for stage IV breast cancer. The client's temperature is 100.6°F (38°C). The nurse should do which of the following? 1. Teach proper hand hygiene 2. Administer 1,000 mg of acetaminophen q4h 3. Instruct the client to use the incentive spirometer while awake 4. Immediately report assessment findings to primary health care provider.

4. Immediately report assessment findings to primary health care provider. Any fever equal to or greater than 100.4°F (38°C) is a sign of infection in the neutropenic client, which would be a priority for this client on chemotherapy and should be reported immediately to the health care provider. Neutropenic fever (≥100.4°F [38°C] and a neutrophil count <500/µL) is a medical emergency. Teaching hand hygiene is an important preventive practice. The temperature is too low to receive an NSAID.

A nurse is planning a teaching program for an older adult. Which of these strategies would take into consideration the learning needs of the older adult? 1. Provide written instructions because thinking slows and older adults forget verbal comments. 2. Present new material that involves the learning of new skills when the client can practice independently. 3. Provide for numerous opportunities for repetitive presentations to promote memory retention. 4. Provide opportunities and information that relate to client's actual experience and situations from other older adults with similar experiences.

4. Provide opportunities and information that relate to client's actual experience and situations from other older adults with similar experiences. Adult learner characteristics provide the basis for guiding education for both adults and older adults. Older adults learn best when experience can be called upon and when the topic is of immediate value and can be discussed and shared with others. Although adults may forget some recently presented information, their thinking does not slow. Repetition is a good strategy for older adults with cognitive problems, such as dementia. Teaching should be provided when there is readiness to learn, not when the client can practice independently, because this may not be a realistic goal.

A client diagnosed with cancer has lost his hair as a result of chemotherapy. The client asks the nurse if it will grow back. What will be the basis of the nursing response? 1. The dose and type of drug administered will be the determining factor for hair regrowth. 2. The hair loss is permanent regardless of any efforts to prevent it. 3. The hair will not grow back unless special measures were taken during chemotherapy. 4. The color and texture of the new hair may be different, but the hair loss is usually not permanent.

4. The color and texture of the new hair may be different, but the hair loss is usually not permanent. The nurse may inform the client that hair will probably grow back after all chemotherapy is complete but that the color and texture might be slightly different.

The nurse understands that the rash of roseola differs from that of rubella. Which statement is correct? 1. Rash of rubella is pruritic 2. Rash of roseola fades in 3 to 5 days 3. Rash of roseola starts on the trunk 4. Rash of rubella clears on the extremities, when facial rash erupts

3. Rash of roseola starts on the trunk The rash of roseola is an erythematous, maculopapular rash that appears on the trunk after an abrupt onset of fever and spreads to the extremities, neck, and face. It fades within 24 to 48 hours. The rash of rubella is a pink, maculopapular rash that begins on the face and spreads down to the trunk. Often the facial rash will disappear as the rash erupts on the extremities; the rash clears in 3 to 5 days.

Which comments by a parent would indicate the correct understanding of how to introduce solid foods to an infant? 1. To offer rice cereal and fruits together 2. That vegetables are usually the first food offered 3. That foods should be added one at a time 4. That apparent "spitting out" of food is to be expected until 7 months of age

3. That foods should be added one at a time It is important to introduce only one new food item per week so that any type of allergy to that particular food item can be detected. Iron fortified rice cereal is usually the first solid food given. It is introduced around 4 to 6 months. A common progression of food is cereal, vegetable, and then meat. Fruits may be introduced any time after cereals. Spitting out of foods relates to the "extrusion" reflex, which lasts only until about 4 months of age.

The nurse understands what major difference between benign tumors and malignant tumors? Malignant tumors 1. are encapsulated and immovable 2. grow at a faster rate 3. invade adjacent tissue and metastasize 4. cause death while benign ones do not

3. invade adjacent tissue and metastasize The primary difference between benign and malignant tumors is the ability of the malignant tumor to invade adjacent tissues and metastasize. Benign tumors tend to be encapsulated and both types of tumors can lead to death. The benign tumors can expand into normal organ function which may lead to death.

A client is hypertensive and is on a diet that is low in salt, cholesterol, and calories. Which client statement indicates the need for further teaching? 1. "I can eat frozen fruit and fresh vegetables." 2. "I'll buy water-packed tuna." 3. "I'll stop putting catsup on my potatoes." 4. "I'm going to decrease beef to one time a day."

4. "I'm going to decrease beef to one time a day." The client is on a low-cholesterol diet; beef should be eaten only two to three times a week, not every day. Eating more fruits, vegetables, and water-packed tuna will decrease sodium intake. Catsup is high in sodium.

Immunization for infants should start at what age? 1. 4 months 2. 3 months 3. 2 months 4. 1 month

4. 1 month Immunizations are started as early as 1 month (first dose of hepatitis B vaccine is recommended to be given before discharge from the hospital). The diphtheria-tetanus-acellular pertussis (DTaP) vaccine and inactivated polio vaccine (IPV) series are started at 2 months. Pneumococcal vaccine is also recommended for all children ages 2 to 23 months and for certain children ages 24 to 59 months. The final dose in the series should be given at age 12 months or older.

Which statement is correct regarding an adult receiving a tetanus immunization? 1. Administer a tetanus booster if it has been 2 years since the adult received a previous dose. 2. Administer a tetanus booster to all clients who have wounds. 3. Administer a single tetanus booster at age 65. 4. All adults should receive a tetanus booster every 10 years.

4. All adults should receive a tetanus booster every 10 years. The Centers for Disease Control (CDC) recommends a tetanus booster for all adults every 10 years.

Which clinical findings would indicate a deviation from the normal age-related changes in the neurological system and may indicate a need for further follow-up of the older client? 1. Decreased sense of touch 2. Increased tolerance of pain 3. Decreased short-term memory 4. Decreased ability to maintain balance

4. Decreased ability to maintain balance A decreased ability to maintain balance is a major safety issue and not a part of normal aging. The first three findings are normal age-related changes to the neurological system.

The nurse is caring for a client who is being treated with a temporary radioactive cervical implant. What will be an important nursing action? 1. Use only the special laundry containers that are placed in the client's room. 2. Flush the toilet at least twice when emptying the client's bedpan. 3. Carefully protect the radiation markings on the client's abdomen. 4. Do not spend an excessive amount of time at the client's bedside

4. Do not spend an excessive amount of time at the client's bedside Clients with temporary implants emit radioactivity while the implants are in place, so the nurse should limit the amount of time spent close to the client. No special laundry container is needed, and the toilet does not have to be flushed twice. The radiation is not systemic, so body fluids are not contaminated. The client's skin has no radiation markings.

What foods chosen by the client would indicate an understanding of nutritional teaching for wound healing? 1. Flavored gelatin, chicken soup, crackers 2. Cheese sandwich and potatoes 3. Chicken, green beans, chocolate pudding 4. Fish, tomatoes, rice

4. Fish, tomatoes, rice Protein and complex carbohydrates are necessary for wound healing. Foods containing empty calories, such as chocolate pudding and gelatin, would not be correct. The other options do not provide as much protein as fish. Chicken provides protein, but it is combined with chocolate pudding. The cheese sandwich selection provides more carbohydrates than protein. Remember, if one portion of an answer is incorrect, the entire answer is incorrect.

The nurse understands that which of the following is the causative agent of scarlet fever? 1. Herpes simplex virus 2. Bordetella organisms 3. Scarlatina fever virus 4. Group A β-hemolytic streptococci (GABHS)

4. Group A β-hemolytic streptococci (GABHS) The causative organism for scarlet fever is group A β-hemolytic streptococci (GABHS). Herpes simplex virus is the causative agent for cold sores and fever blisters. Bordetella organisms cause pertussis (whooping cough). Scarlet fever is not caused by a virus but by bacteria. Scarlatina is another name for scarlet fever.

The nurse is caring for a child with a diagnosis of pertussis. Which of the following signs and symptoms would the nurse expect to observe? (Select all that apply.) 1. Koplik spots 2. Slapped-face appearance 3. Discrete rose-pink macule 4. High-pitched cough at night 5. Sneezing, cough, low-grade fever 6. Maculopapular red spots

4. High-pitched cough at night 5. Sneezing, cough, low-grade fever Pertussis or whooping cough has two stages: the catarrhal and paroxysmal. The catarrhal stage is characterized by sneezing, lacrimation, cough, and low-grade fever. The paroxysmal stage is characterized by cough most commonly at night that is a high-pitched crowing or "whoop" sounding. The clinical manifestations associated with erythema infectiosum, or fifth disease, include a slapped-face appearance and maculopapular spots. Discrete rose-pink macules are associated with exanthem subitum (roseola infantum). Koplik spots on the buccal mucosa are symptoms of measles (rubeola), along with fever, malaise, and rash (confluent maculopapules).

In performing an assessment on a 4-month-old, what would the nurse expect the infant to be able to do? 1. Sit steadily without support 2. Turn from back to abdomen 3. Grasp for objects 4. Hold head erect

4. Hold head erect Head in alignment with no support occurs around 4 to 5 months of age. At 8 months, infants should be able to sit steadily unsupported. Turning from back to abdomen occurs around 6 months of age, as does grasping for objects.

What is an important aspect of client teaching regarding external radiation therapy? 1. Remain isolated after treatments 2. Fast before the treatment 3. Schedule monthly treatments 4. Leave skin markings between treatments

4. Leave skin markings between treatments Skin markings are used by the radiotherapist to delineate the exact area of the body to be irradiated. Treatments are completed in a series and do not require fasting or any form of isolation.

What are the nursing interventions regarding the care of a client with a vaginal radium implant? 1. Clamp and drain the Foley catheter at intervals. 2. Provide a high-residue diet. 3. Place the client in a semiprivate room. 4. Raise the head of the bed no more than 20 degrees.

4. Raise the head of the bed no more than 20 degrees. Once the implant is in place, keeping it in the exact measured position without disruption is important. Strict bed rest is maintained. The head of the bed should be raised only slightly to accomplish this. A urinary retention catheter is placed to facilitate gravity drainage. The client should be in a private room. Constipation should be avoided, but a high-residue diet will increase the bulk of the stool and possibly dislodge the implant.

What is characteristic of the developmental socialization in an adolescent? 1. Not attracted to peer groups; prefers time alone. 2. Spends more time with siblings than peers. 3. Prefers to spend all time with members of immediate family. 4. Uses peer group as a standard against which to compare self.

4. Uses peer group as a standard against which to compare self. Peer groups, or other adolescents, are very important in the developmental phase of the adolescent. Solitary time (play) is usually found in the younger child, as is the time spent with family.

Which toy(s) would provide stimulation for a 3-month-old infant? 1. A mobile above the crib 2. A pull toy that rolls easily 3. Toys that make noise 4. Blocks of bright colors

1. A mobile above the crib A mobile above the crib is an appropriate toy for a 2- to 3-month-old infant; at this age, movements are jerky and uncoordinated. A pull toy or a moving toy is not encouraged until an infant is about 1-year-old. Noisemakers are enjoyed by the 6- to 12-month-old infant. The infant cannot grasp until about 1 year of age, so the blocks of many colors are not as appropriate.

The nurse is preparing to administer a series of vaccines to a child. What would the nurse identify as general contraindications to a child receiving a vaccine? (Select all that apply.) 1. Anaphylactic reaction to previous dose of the vaccines. 2. Moderate illness with or without a fever. 3. Family history of anaphylactic reaction to vaccines. 4. Immunodeficiency in a family member in direct contact with child. 5. Severe illness with fever. 6. The mother of the child is pregnant.

1. Anaphylactic reaction to previous dose of the vaccines. 5. Severe illness with fever. General contraindications to any vaccine include severe illness with or without fever and a history of an anaphylactic reaction to the vaccine. Family history, immunodeficiency in a family member, and pregnancy are not considered as general contraindications to a vaccine. Each vaccine has specific parameters regarding contraindications.

Which instruction should be included in the teaching plan of a client who does not like dairy products and rarely eats vegetables? 1. Calcium supplements may be necessary 2. Increase your protein intake 3. Do not exercise until your diet improves 4. Limit fluids on your diet

1. Calcium supplements may be necessary If an individual cannot ingest sufficient quantities of calcium in the diet (dairy products), calcium supplements are used.

An adult is placed on a 500-mg sodium diet. Which of the following foods should the nurse suggest when assisting this client to select a daily menu? (Select all that apply.) 1. Cooked rice and baked fish 2. Chicken and fresh fruit 3. Macaroni salad and milk 4. Marinated artichoke salad and beets 5. Spinach and carrot salad 6. Bacon and eggs

1. Cooked rice and baked fish 2. Chicken and fresh fruit 5. Spinach and carrot salad Foods that are high in sodium include foods that are processed, canned, and frozen (unless noted that the item is low sodium). Milk and beets naturally contain considerable sodium. Clients should be encouraged to use fresh ingredients and/or foods with no salt added. Clients should avoid convenience foods such as canned soups, entrees, vegetables, pasta and rice mixes, frozen dinners, instant cereal and puddings, and gravy sauce mixes.

The nurse understands that which procedure is an example of palliative surgery for cancer? 1. Gastrostomy 2. Colectomy 3. Nephrectomy 4. Craniotomy

1. Gastrostomy Gastrostomy is surgical insertion of a tube into the stomach for tube feedings when a client cannot eat. This is done for the cancer client as well as for the elderly client who cannot swallow, and thus is palliative care—providing comfort. The other procedures are removal of parts of body organs.

A parent comes to the clinic with their 4-month-old for routine immunizations. What immunizations will be administered at this time? (Select all that apply.) 1. IPV (poliovirus) 2. Rotavirus (RV) 3. DTaP (diphtheria, tetanus, acellular pertussis) 4. MMR (measles, mumps, rubella) 5. Hib (Haemophilus influenzae, type b) 6. PCV (pneumococcal conjugate vaccine)

1. IPV (poliovirus) 2. Rotavirus (RV) 3. DTaP (diphtheria, tetanus, acellular pertussis) 5. Hib (Haemophilus influenzae, type b) 6. PCV (pneumococcal conjugate vaccine) The IPV (inactivated polio vaccine), rotavirus (RV), DTaP (diphtheria, tetanus, and acellular pertussis), Hib (Haemophilus influenzae vaccine), and PCV (pneumococcal vaccination [PCV13]) are administered at 4 months. The MMR (measles, mumps, and rubella) and varicella vaccine are administered at 12 to 15 months.

The nurse is planning the care for a chronically ill pediatric client. What is important to understand about pediatric rehabilitation? 1. Identify strengths and needs of the child 2. Promote normal growth and development 3. Determine leisure activities to assist the child in transitioning to the facility 4. Determine what the child likes to do and provide those activities

1. Identify strengths and needs of the child In the case of chronically ill pediatric clients who require rehabilitation, it is important to focus on the strength and needs of the child. Families need to know what to expect and to be included in the rehabilitation plan. Because children are at various points in growth and development, incorporating strengths and needs into the overall plan must be a focal beginning point for the rehabilitation process. After the strengths and needs are identified, they are incorporated into the promotion of the child's growth and development. Although incorporating favorite leisure activities is certainly helpful, it may not necessarily promote rehabilitation.

The nurse is monitoring a client with cancer who has been receiving chemotherapy. What observations are associated with bone marrow depression? (Select all that apply.) 1. Increased bruising 2. Hematuria 3. Nosebleeds 4. Anemia 5. Clay colored stool 6. Nausea

1. Increased bruising 2. Hematuria 3. Nosebleeds 4. Anemia Clients with bone marrow depression have bleeding episodes (bruising, hematuria, nosebleeds, blood in the stool) and anemia due to the lack of the bone marrow to make red blood cells. Clay colored stools are associated with liver disease. Nausea is often a side effect of chemotherapy and other GI problems.

What would the nurse expect to find when exploring a 10-year-old's concept of death? 1. Knows that death is a final process. 2. Regards death as a temporary state of sleep. 3. Believes death is something that "just happens." 4. Thinks death only happens in the hospital.

1. Knows that death is a final process. By the age of 10 years, most children have developed the mental and emotional security to express an understanding of death as a final and inevitable outcome of life.

What are the current American Cancer Society dietary recommendations for cancer prevention? 1. Maintain a desirable body weight and eat a variety of foods, including fruits and vegetables and foods that are high in fiber. 2. Increase the amount of protein in the diet and drink a minimum of eight 8-ounce glasses of water. 3. Consume alcohol in small to moderate amounts, preferably wine and beer. 4. There are no dietary recommendations for the prevention of cancer.

1. Maintain a desirable body weight and eat a variety of foods, including fruits and vegetables and foods that are high in fiber. The American Cancer Society recommends the maintenance of a desirable body weight; research has shown an association between increased deaths from various cancers and varying degrees of being overweight. Another recommendation is to eat a wide variety of foods. A variety of fruits and vegetables should be included in the daily diet, because research has shown that there is an association between lower cancer rates and high fruit and vegetable consumption. High-fiber foods are also recommended; a lower risk for colon cancer is seen in those individuals who consume a high-fiber diet.

What nursing action should be included in the care plan of all clients with cancer? 1. Monitor and protect the client against infection. 2. Increase assessment for pulmonary involvement. 3. Assist the client to achieve a peaceful death. 4. Modify the environment to eliminate nausea.

1. Monitor and protect the client against infection. Because clients with cancer have suppressed immune systems and altered physical and mechanical barriers, the nurse should carefully observe and monitor for signs of infection.

What immunizations may be recommended for a teenager who is 10 years old? 1. Tetanus, diphtheria, tetanus, and acellular pertussis (Tdap) booster, influenza vaccination, and human papillomavirus (HPV) vaccine 2. Pneumococcal conjugate vaccine (PCV) and tetanus boosters 3. If the teenager is current with childhood immunizations, none are recommended. 4. Tetanus and diphtheria booster (Td) is a one-time recommendation at age 10 years.

1. Tetanus, diphtheria, tetanus, and acellular pertussis (Tdap) booster, influenza vaccination, and human papillomavirus (HPV) vaccine The recommendation for the general population is to have a tetanus booster about every 10 years. The childhood immunization schedule is for a DTaP booster to be given to school-age children (4 to 6 years). The Tdap is given if the child is greater than 7 years of age rather than the DTaP. The pneumococcal childhood vaccination series (PCV) should have been given from age 2 months through age 23 months. Human papillomavirus (HPV) series should be given to all adolescents aged 11-12 years. Influenza immunization is recommended yearly.

A child has a diagnosis of rubeola. What is important information that the parents should understand? (Select all that apply.) 1. Use tepid baths to help increased temperature. 2. Encourage fluids to maintain hydration. 3. Control spread of infection by daily cleansing of lesions with alcohol. 4. Symptoms will continue to increase for 3 to 4 days after the rash has occurred. 5. Encourage bed rest and quiet activities. 6. Child is contagious for approximately 5 days after rash appears.

1. Use tepid baths to help increased temperature. 2. Encourage fluids to maintain hydration. 5. Encourage bed rest and quiet activities. 6. Child is contagious for approximately 5 days after rash appears. Tepid baths should be used to control fever. Fluids and bland foods should be encouraged. Alcohol, ice water, or aspirin should not be used. Daily bathing with antibacterial soap will assist to control infection; alcohol will be uncomfortable and will dry the skin. Symptoms usually begin to decrease on the second day after the rash appears. Child is contagious from 4 days before rash appears to 5 days after rash appears.

In caring for a client with cancer, the nurse is aware that one of the primary toxic effects of chemotherapy is 1. neutropenia 2. alopecia 3. gynecomastia 4. phagocytosis

1. neutropenia The key to this question is the phrase "primary toxic effect," not "general side effect." Neutropenia is the only toxic effect. Alopecia, gynecomastia, and phagocytosis are classified as side effects.

The parents of a 10-month-old who weighs 19 lb are asking about the positioning of their current car seat and whether they should change to a convertible car seat. The nurse should explain that the safest position for the car seat is 1. rear facing in back seat. 2. front facing in back seat. 3. front facing in front seat with airbag on passenger side. 4. rear facing in front seat if the air bag is disabled on the passenger side.

1. rear facing in back seat. Infants should ride facing rear of car until 1 year old, weight 9 to 10 kg (20 to 22 lb, depending on the model of the car seat), which provides the best protection for the infant's heavy head and weak neck. Infants are safest if the car seat is placed in the middle of the back seat. There should be a three- and five-point harness, so clips are not at neck or throat level but adjusted to be at mid-chest level. Infants should not be placed in the front seat, because severe injuries and deaths have occurred from air bags deploying on impact in the front passenger seat. To use a convertible car seat, the toddler must be at least 1 year old and weigh at least 9 kg (20 lb). Toddlers can use a convertible seat up to 18 kg (40 lb) or booster seat and can ride facing forward. Harness straps should be at or above toddler's shoulders.

A client who is 45 years old comes into the office for her yearly checkup. Which comment by the client would indicate to the nurse the need for further teaching? 1. "I know it is important to have a yearly checkup with a Pap test to check for cervical cancer." 2. "I do self-breast exams every month, so I won't need to do a mammogram until I am 50 years old." 3. "My mother had colon cancer. I am going to talk to the doctor about a colonoscopy." 4. "I have increased my dietary fiber, and I am exercising about an hour every day."

2. "I do self-breast exams every month, so I won't need to do a mammogram until I am 50 years old." Self-breast exams are encouraged but should not take the place of a yearly mammogram for all women 45 years old to 53. Women 55 years or older should have a clinical breast exam by a health care provider at least every 2 years. If the woman is at an increased risk because of family history of breast cancer, the mammograms may be started at an earlier age.

During a very hot summer day, a mother of a 4-month-old breast-fed infant calls the clinic to ask about giving her baby water because of the very warm weather. What would be an appropriate response? 1. "Offering water is okay, if the infant seems thirsty after breastfeeding." 2. "Providing additional water or fluids is not needed while breastfeeding." 3. "Including clear juices is better than water to promote adequate fluid intake." 4. "Offering water once or twice a day will help with insensible fluid loss because of the warm climate temperature."

2. "Providing additional water or fluids is not needed while breastfeeding." Infants, whether breast- or bottle-fed, do not require additional fluids, especially water or juice, during the first 4 months of life. Excessive intake of water in infants may result in water intoxication and hyponatremia. Juices provide empty calories for infants and should not be encouraged. Even in hot climates, additional water or fluids are not recommended for breast-fed infants.

The nurse explains to a young adult female client that the most common site for cancer development in women is which anatomical structure? 1. Ovaries 2. Breast 3. Cervix 4. Urinary bladder

2. Breast Breast cancer is the MOST common cause of cancer in women followed by lung, colorectal, and then cervical cancer. Carcinoma in situ is considered a preinvasive cervical carcinoma that can be diagnosed by Pap smear. Bladder cancer is the fourth most common type of cancer in men and the eighth most common in women.

What is the first sign of sexual maturation in females? 1. Onset of menstruation 2. Breast development 3. Appearance of pubic hair 4. Appearance of axillary hair

2. Breast development The first sign of sexual maturation in females is the development of breast buds (elevation of the nipples and areolae). As sexual development progresses, the appearance of pubic hair and axillary hair and the onset of menstruation occur.

Which food choices provide the highest calcium intake and are consistent with a low-salt dietary program for hypertension? 1. Cheese and macaroni, fresh fruit, milk shake 2. Cottage cheese, glass of skim milk, orange slices 3. Roast beef with whole-wheat bread, potato, vegetable salad 4. Cheeseburger, French fries, milk shake

2. Cottage cheese, glass of skim milk, orange slices Foods high in calcium include milk products, leafy green vegetables, fish, dried beans and peas, and citrus fruit. Yellow vegetables are not high in calcium. Pasta and breads are high in sodium. Rarely will nurses recommend a food that is fried or contains high amounts of simple sugars and fat.

Which pulmonary physiological change is commonly associated with the aging process? 1. Increased cough response 2. Decreased vital capacity 3. Decreased anteroposterior (A-P) diameter of thorax 4. Increase in residual of carbon dioxide

2. Decreased vital capacity A decrease in vital capacity, along with a 50% increase in residual volume, occurs during the aging process. Other aging changes include a less effective cough, impaired cilia action, and weaker respiratory muscles. Increased A-P diameter is associated with aging and found in clients with chronic obstructive pulmonary disorder (COPD). PO2 usually decreases, but PCO2 usually remains unchanged.

When obtaining a health history from an older adult client, which characteristics of the older client would it be important for the practical nurse to consider? 1. The older client responds to pain sensation more rapidly than does a younger client. 2. How well the client hears is important to consider when interviewing an older client. 3. The IQ of an older adult is declining; therefore, the nurse will need to repeat information. 4. An older client's response time to answering a question is just as quick as that of a young client.

2. How well the client hears is important to consider when interviewing an older client. When interviewing an older client, auditory acuity is the most common age-related aspect to take into consideration. It is important that the client hears and understands the questions. If he does not hear the question correctly, it will take longer for the client to respond, and the response may be inaccurate. The IQ may decline with dementia, but does not characteristically decline with age unless other factors are present.

Which assessment is a normal physiological change of the respiratory system that occurs with aging? 1. Decreased residual lung volume (RV) 2. Hyperresonance 3. Increased forced vital capacity (FVC) 4. Increased tactile fremitus

2. Hyperresonance A normal age-related change is an increase in the anteroposterior diameter that results in hyperresonance. Age-related changes result in an increase in RV and a decrease in FVC. Increased tactile fremitus is a deviation that is of diagnostic significance.

What psychosocial data would indicate that a 19-month-old child is demonstrating a nonadaptive reaction to hospitalization? 1. Cries when mother leaves. 2. Ignores mother when she arrives to visit. 3. Was previously potty-trained, but now urinates in bed. 4. Wants a night light in his room.

2. Ignores mother when she arrives to visit. Usually the toddler clings to the mother; as separation anxiety becomes intolerable, the child ignores the parent. At this stage, the child relates better to the staff and does not mind the absence of the parent. Being afraid of the dark is normal for a toddler at this age. Regressing to a previous level of development is not uncommon or abnormal.

The nurse understands that which immunization leads to long-lasting immunity? 1. Immune gamma globulin 2. Inactivated poliomyelitis (IPV) 3. Rho immune gamma globulin 4. Antivenom for black widow

2. Inactivated poliomyelitis (IPV) The advantages of an inactivated poliovirus vaccine (IPV) are its long-lasting immunity. Immune gamma globulin, Rho immune gamma globulin, and black widow antivenom are all temporary means of immunity.

The nurse would advise a young mother of a 5-month-old to include which foods in her infant's diet after the child is no longer breastfeeding? 1. Iron-rich formula and strained meats 2. Iron-rich formula 3. Whole milk and baby food 4. Low fat cow's milk

2. Iron-rich formula The American Academy of Pediatrics recommends that infants at age 5 months should receive iron-fortified formula if breastfeeding is discontinued. Solid foods (iron fortified cereals) may be introduced from 4 to 6 months. Strained meats and citrus fruit are not started until after the infant is eating cereals, generally around 6 months. Whole milk is not recommended until age 12 months, and skim milk is not recommended until after age 2 years.

The nurse is reviewing the daily serum laboratory results for a client who is receiving chemotherapy. Which laboratory finding would be important to report to the physician? 1. Hemoglobin 10 g/L 2. Leukocytes 3,000 mm3 3. BUN 25 mg/dL 4. Platelets 105,000 mm3

2. Leukocytes 3,000 mm3 Leukopenia puts the client at an increased risk of infection. The chemotherapy medication and/or dose may need to be changed. The hemoglobin is within lower limits of normal; the BUN is slightly elevated, but not significantly. The platelets are down, but the leukopenia is the priority concern.

A mother expresses concern that her 1-year-old son refuses solid food and that his diet consists mostly of milk and simple carbohydrates. What would be important for the nurse to discuss with the mother regarding the child's nutrition? 1. Exclude milk from the child's diet until he begins to like other foods. 2. Offer him small amounts of meat and vegetables before offering him milk. 3. Withhold desserts until he has eaten his vegetables. 4. Mix strained meat and vegetables into the milk.

2. Offer him small amounts of meat and vegetables before offering him milk. Children at this age are prone to anemia, especially when milk is offered frequently. Therefore, holding milk (not excluding it) and other liquids until after solid food is offered prevents the child from "filling up" on the liquid.

Which breakfast selections would best meet the postoperative client's nutritional needs once solid food is allowed? 1. Pancakes, bagel, and orange juice 2. Poached egg on toast, orange, and milk 3. Bagel, jelly, banana, and apple juice 4. Whole-wheat toast, cereal, and an apple

2. Poached egg on toast, orange, and milk A diet that is high in protein, calories and vitamin C is necessary for wound healing.

Which of these best describes guidelines for syrup of ipecac administration? 1. Is the safest poison control agent to use. 2. Should not be used routinely. 3. Should be used when corrosive acids have been ingested. 4. Is the drug of choice when a poison is ingested in the home.

2. Should not be used routinely. It is recommended by several agencies that syrup of ipecac no longer be used routinely as poison treatment in the home and that clinicians advise parents to discard any ipecac they have in the house, which is a fundamental change in the approach to the treatment of poisoning in children.

What are appropriate toys for an 18-month-old infant to have for play while in a croup tent? 1. Rattles 2. Stacking rings 3. Crayons and coloring book 4. Soap bubbles

2. Stacking rings Stacking rings are a good manipulative toy for a toddler and will not be adversely affected by the humid environment.

A client on a low-sodium diet is brought a meal tray. Which food should be removed? 1. Baked sweet potato 2. Stuffed olives 3. Baked chicken 4. Grapes

2. Stuffed olives Foods that are smoked, salted (e.g., olives), or canned are HIGH in sodium. The other options are freshly prepared and are not high in sodium.

Which of these signs indicates the onset of puberty in male adolescents? 1. Appearance of pubic hair 2. Testicular enlargement 3. Appearance of axillary hair 4. Nocturnal emissions

2. Testicular enlargement Testicular enlargement signifies the onset of puberty in male adolescents. As sexual development progresses, the appearance of pubic and axillary hair and the onset of nocturnal emissions occur as testosterone levels increase.

Which is not a consideration when providing care to a client receiving internal radiotherapy? 1. Time spent with the client 2. The organ that is being irradiated 3. The distance from the radiation source 4. Shielding used by the caregiver

2. The organ that is being irradiated Exposure is a concern when caring for a client undergoing internal radiotherapy. This is based on time, distance, and shielding to determine the amount of radioactive exposure the nurse may receive. The specific organ is not a factor.

The nurse understands that the childhood communicable diseases that require isolation are which of the following? (Select all that apply.) 1. Impetigo 2. Varicella zoster 3. Diphtheria 4. Scarlet fever 5. Mumps 6. Fifth disease

2. Varicella zoster 3. Diphtheria 4. Scarlet fever 5. Mumps Childhood communicable diseases requiring isolation are diphtheria, measles, varicella zoster, tuberculosis, adenovirus, Haemophilus influenzae type b, mumps, influenza, Mycoplasma pneumoniae, pertussis, plague, streptococcal pharyngitis, pneumonia, scarlet fever, and chickenpox. Impetigo and fifth disease do not require isolation.

A client is scheduled for a colonoscopy and is to take clear liquids only for 6 hours before the procedure. What comment by the client would indicate to the nurse that the client does NOT understand the concept of clear liquids? 1. "I can have beef or chicken broth." 2. "Lemon-, orange-, or lime-flavored gelatin is okay." 3. "I can have a small amount of vanilla ice cream." 4. "I can have tea and coffee with sugar."

3. "I can have a small amount of vanilla ice cream." Ice cream is not a clear liquid. The gelatins are okay; frequently, red-colored gelatin is prohibited. Coffee and tea are both acceptable with sugar, but not with cream in the coffee.

A client who has had a myocardial infarction is discharged on a low-sodium, low-cholesterol diet. Which comment by the client would indicate to the nurse that he needs further diet teaching? 1. "I can prepare foods with canola oil." 2. "I can spice my foods with fresh herbs." 3. "I will have three servings of bread daily." 4. "I need to eat only lean beef, pork, and chicken."

3. "I will have three servings of bread daily." Bread and bakery products are most often a source of significant sodium and clients are generally encouraged to avoid them.

Before a well-baby checkup in the pediatrician's office, an 8-month-old infant is sitting contentedly on the mother's lap, chewing a toy. When preparing to examine this infant, which step should the nurse do first? 1. Measure the head circumference. 2. Obtain body weight and height. 3. Auscultate heart and lung sounds. 4. Check pupillary response.

3. Auscultate heart and lung sounds. While the infant is quiet, it is important to auscultate the heart and lungs. Placing a tape measure on the infant's head, shining a light in the eyes, or undressing the infant before weighing may cause distress, which could make auscultating the heart and lungs, as well as the rest of the examination, more difficult.

What advice should the nurse give a mother who reports, during a routine well-child exam, that her 5-month-old (weight of 15 lb) who was sleeping all night at 3 months of age is now waking up in the middle of the night hungry? The nurse obtains a diet history that reveals that the infant is taking six 6-oz bottles of formula in a 24-hour period and has 2 tablespoons of rice cereal in the morning. 1. Increase the amount of formula at each feeding to 8 oz. 2. Stop giving the child formula and switch to homogenized milk. 3. Decrease the amount of formula to 32 oz in 24 hours and add fruits, cereals, and juices. 4. Continue the same amount of formula and introduce a variety of baby foods.

3. Decrease the amount of formula to 32 oz in 24 hours and add fruits, cereals, and juices. Consumption of 32 oz of formula per day is usually an indicator of the need for solids. Formula or breast milk is recommended for the first year of life. If the child is not satisfied with formula or breast milk, then solids may be introduced. Iron fortified rice cereal is usually the first solid added; then vegetables may be added next. Some practitioners prefer to add vegetables before fruits. Introduction of solids usually occurs around 4-6 months of age; this infant is not satisfied with formula, so solids need to be increased.

Unless contraindicated by chronic illnesses, what immunizations are recommended for all clients over 50 years old who have had the recommended series of childhood vaccinations? 1. MMR boosters 2. IPV booster every 10 years 3. Influenza vaccine every year and tetanus booster every 10 years 4. Hepatitis A and B boosters every 10 years

3. Influenza vaccine every year and tetanus booster every 10 years Recommendations from the Centers for Disease Control and Prevention (CDC) are for an influenza vaccine annually and a tetanus booster every 10 years. Pneumococcal vaccine is also recommended for clients between the ages of 19 and 65 years. For persons older than 65 years, a one-time revaccination of pneumococcal vaccine is recommended if they were vaccinated more than 5 years previously and were less than 65 years at the time of the primary vaccination. The other vaccinations are not appropriate for the adult who has had the series of childhood immunizations.

A client reports being lactose intolerant. The nurse would recommend which foods? 1. Broiled fish, fresh fruits, and vegetables 2. Whole-grain breads, rice, and ice cream 3. Lean red meat, dried fruits, and yogurt 4. Whole-wheat pasta with cheese and milk

1. Broiled fish, fresh fruits, and vegetables Lactose is contained in milk and milk products. "Broiled fish, fresh fruits, and vegetables" is the only answer that does not have a milk product (ice cream, yogurt, cheese, milk) included.

A client is being discharged after a cholecystectomy. The nurse would determine the client understood the dietary teaching regarding a low fat diet if which foods were selected? 1. Broiled fish, green beans, and an apple 2. Avocado salad, whole milk, and white bread 3. Pork chops, gravy, carrots, and grapes 4. Whole-wheat rolls with butter, potatoes, and steak

1. Broiled fish, green beans, and an apple The client will need to decrease fat intake after surgery. Broiled fish, green beans, and an apple are healthy low-fat foods.

A father calls the clinic regarding his 6-year-old child who has been diagnosed with chickenpox and has extensive lesions. The child is uncomfortable, and the lesions are itching. What would be the best nursing response? 1. Apply calamine lotion and provide cool baths without soap. 2. Apply warm packs to the vesicles and increase fluids. 3. Use warm baths with bactericidal soap. 4. Give aspirin to decrease irritation and itching.

1. Apply calamine lotion and provide cool baths without soap. Keep the child cool and provide calamine lotion. Increasing warmth may increase the number of vesicles, as well as increase irritation. Increasing fluids is appropriate, but the warm packs and warm bath will irritate the vesicles. Soap is not recommended. Aspirin should not be given to children with viral infections.

A preschool-age child is admitted to the hospital for treatment of pneumonia. The mother is embarrassed because the child has wet the bed, which he has not done since he was toilet-trained. Which response by the nurse would be most appropriate? 1. "This happens quite often with children when they are admitted to the hospital. When he feels better, his toileting skills will return to normal." 2. "My, how embarrassing for you to have your child do this. Don't worry. We see this all the time." 3. "Bedwetting is often a side effect of the antibiotic medication that your child is receiving. When the medicine is finished, his toileting skills will return to normal." 4. "I will be sure to report the bedwetting to the physician, because it may require additional tests to determine the cause."

1. "This happens quite often with children when they are admitted to the hospital. When he feels better, his toileting skills will return to normal." Children often regress during hospitalization. Regression may coincide with a stressful family situation. Behavior such as toilet-training may temporarily be lost but will return when the child feels better and returns home to a normal routine. Antibiotics do not typically cause incontinence. The other responses do not involve therapeutic communication.

The mother of a 3-month-old infant is concerned because her baby seems to sleep most of the time. The nurse's response is based on the knowledge that a 3-month-old infant usually spends 1. 10 hours sleeping in a 24-hour period. 2. 15 to 16 hours sleeping in a 24-hour period. 3. 18 to 19 hours sleeping in a 24-hour period. 4. most of the 24 hours sleeping, waking only to eat.

1. 10 hours sleeping in a 24-hour period. Normally, 3-month-old infants sleep 9-11 hours in a 24-hour period. Most infants do not begin sleeping through the night (six to eight hours periods) without waking until about three months of age, or until they weigh 12 to 13 lb. One reason for this is the small stomach capacity of newborns and infants that causes them to wake every few hours to eat.

An older adult has cancer and is on several chemotherapy drugs. They are nauseous, and an antiemetic medication is prescribed. When is the best time to administer this medication? 1. 30 minutes before chemotherapy 2. With meals 3. Early in the morning 4. PRN as requested by the patient

1. 30 minutes before chemotherapy Antiemetic drugs are administered 30 to 60 minutes before chemotherapy and then at appropriate intervals throughout the expected duration of nausea and vomiting.

The nurse is screening clients waiting to receive an influenza vaccine. Which client would the nurse question receiving the vaccination? 1. A 48-year-old woman with a fever of 102°F orally. 2. A 30-year-old man who has cholelithiasis. 3. A 65-year-old man with congestive heart failure. 4. A 70-year-old woman who has type 2 diabetes.

1. A 48-year-old woman with a fever of 102°F orally. The nurse would question giving the influenza vaccine to the client with a moderate illness, with a fever. Clients with chronic pulmonary and cardiac problems should receive the vaccine when they are in a healthy state, not when they are compromised. The options contain no indication that any of the clients are compromised with their chronic conditions. Do not make the clients any sicker than the question is presenting them.

A father brings his 4-year-old child to the community clinic immediately after the child ingested a small bottle of aspirin. What is the priority nursing action? 1. Administer activated charcoal 2. Give 16 oz of orange juice 3. Give 8 oz of milk 4. Give 30 mL of syrup of ipecac, followed by a glass of water

1. Administer activated charcoal Activated charcoal would be administered to act as a cathartic. There is controversy about the safety of administering syrup of ipecac in the home as well as in the emergency department. A gastric gavage may be indicated, and activated charcoal can be administered via nasogastric tube if the child is young or if the older child cannot tolerate swallowing the black liquid. Orange juice or milk would not help the situation.

A client diagnosed with metastatic lung cancer has severe vomiting after each administration of the chemotherapy. What would be an important nursing intervention for this client? 1. Administer an antiemetic about an hour before the treatment. 2. Determine the client's food preferences and encourage them if he is not nauseated. 3. Offer carbonated beverages and bland foods during the chemotherapy. 4. Increase fluids and encourage client to drink caloric supplements.

1. Administer an antiemetic about an hour before the treatment. An antiemetic will help to decrease the nausea and help to decrease the anticipation of the nausea. It is important to determine the client's food preferences; however, this does not address the problem with nausea. Offering the client food or drink during the chemotherapy may increase the nausea. Increasing fluids and fluid supplements does not address the nausea. The question does not indicate a problem with nutrition.

The nurse is screening a group of clients regarding the administration of the herpes zoster vaccination. Which statement is true about which clients should receive a herpes zoster vaccination? 1. All clients over 60 years old should receive the vaccination. 2. Only adult clients who have reported an outbreak of herpes zoster (shingles) should receive the vaccination. 3. Clients aged 40 to 60 years should receive the initial vaccination with a booster in 6 months. 4. All clients over 50 years old who do not have any history of herpes zoster (shingles) should receive the vaccination.

1. All clients over 60 years old should receive the vaccination. According to CDC 2014 adult immunization guidelines, all clients 60 years of age or older should receive the herpes zoster vaccination regardless of whether or not they report an episode of shingles or herpes zoster. Clients with a chronic condition should receive the vaccination unless there is a specific contraindication for the condition.

A mother arrives at the office with her 9-month-old infant for a well-baby check. What observation would cause the most concern? 1. Cannot sit alone without support 2. Shows no interest in walking 3. Anterior fontanel remains open 4. Does not respond to name

1. Cannot sit alone without support A 9-month-old infant should be able to sit alone without support. The other options—shows no interest in walking, anterior fontanel remains open, and does not respond to name—are expected at this stage of growth.

A client arrives to the clinic with a penetrating wound received while clearing lumber. What is the priority nursing action? 1. Cleanse the wound with an antiseptic solution. 2. Notify the client's occupational health nurse. 3. Determine what medications the client is taking. 4. Determine when client received last tetanus injection.

1. Cleanse the wound with an antiseptic solution. The wound should be cleansed to prevent infection. The client may need a tetanus injection; however, that can wait until later. The nurse can determine the medications the client is on after cleansing the wound and obtain a history of the client's health problems, including medications.

In doing an assessment on a 3-week-old infant, what would the nurse expect the infant to be able to do? 1. Smile indiscriminately 2. Turn from side to side 3. Grasp for objects 4. Hold head erect

1. Smile indiscriminately At 3 weeks, infants may smile indiscriminately. Turning from side to side occurs around 2 to 3 months of age. Grasping for objects occurs around 6 months. Holding the head in alignment with no support occurs around 4 to 5 months of age.

A client prescribed antineoplastic therapy is experiencing nausea and vomiting. What is the best nursing action? 1. Give antiemetics and check for dehydration 2. Administer oral care and assess for mouth lesions 3. Decrease fluid intake and moisten dry food 4. Record daily weights and encourage small meals

1. Give antiemetics and check for dehydration Physiological needs must be addressed first. The other options may be used for this client; however, the emesis and possibility of dehydration must be addressed first. Consider giving antiemetics before antineoplastic treatments if possible.

The nurse is assessing an 8-month-old infant in an immunization clinic. The nurse knows that by 8 months the child should have had which immunizations? 1. Hepatitis B first and second doses, all of the DTaP (diphtheria, tetanus, acellular pertussis) series, two doses of IPV, pneumococcal conjugate vaccine (PCV), and rotavirus (RV) 2. All of the DTaP and polio series; measles, mumps, and rubella (MMR); and pneumococcal vaccine 3. DTaP first and second doses, MMR first dose, all of the hepatitis B series 4. Varicella, DTaP first dose, and hepatitis B first dose

1. Hepatitis B first and second doses, all of the DTaP (diphtheria, tetanus, acellular pertussis) series, two doses of IPV, pneumococcal conjugate vaccine (PCV), and rotavirus (RV) Standard immunizations are two doses of hepatitis B series, all of the initial DTaP series, two doses of IPV (inactivated poliovirus vaccine), the rotavirus vaccine (RV), and a pneumococcal conjugate vaccine (PCV). MMR and varicella vaccines are not given until 12 to 15 months of age.

The nurse is planning the care for an older adult client being admitted to a long-term care facility. What is most important for the nurse to include in the plan? 1. Obtain information regarding how the client is cared for at home. 2. Encourage activities to assist the client to adapt to the unit routine. 3. Explain to the family the importance of maintaining contact with the client. 4. Determine what the client likes to do and provide those activities.

1. Obtain information regarding how the client is cared for at home. In the case of chronically ill clients (older adult clients, adults, and children), it is important to support and continue the same kind of care and activities they have at home. The focus of long-term care is to maintain and enhance the function of the client. In order to do this, it is necessary to determine how independent clients have been and then preserve and promote their level of independence. This allows for reintegration of children and young adults into families and helps decrease confusion and stress in older adult clients.

The client who has a chronic hematological disorder with anemia is recovering from a stroke. How will this client's rehabilitation activities differ from those of other clients after a stroke? 1. The client will require more frequent rest periods. 2. The client's vital signs must be measured before and after each rehabilitation session. 3. The client with anemia is at greater risk of experiencing the complication of a second stroke. 4. This client is less likely to regain cognitive skills.

1. The client will require more frequent rest periods. Anemia is characterized by reduced red blood cell (RBC) production, which will affect oxygen delivery. Exertion while learning how to ambulate with a cane or walker may cause episodes of shortness of breath, leading to hypoxia. The lack of RBC-carrying capacity caused by the hematological disorder makes this client less tolerant of activity. The rehabilitation schedule must take into consideration this client's reduced capacity for exercise by providing more frequent rest periods and shorter sessions of physical activity.

Parents of a child ask the nurse how their child could catch chickenpox. The nurse's response would be based on what principle of disease transmission? 1. The organism is spread by droplets when a child sneezes or coughs. 2. Drinking after other children may transmit the organism. 3. Indirect contact with an infected person 4. The transmission of the disease is spread by direct contact with infected animals

1. The organism is spread by droplets when a child sneezes or coughs. Chickenpox (varicella zoster) is transmitted by droplets carried through coughing or sneezing. It is not transmitted by a vector such as mosquitoes or fleas. The condition is not transmitted by person-to-person contact.

The nurse finds the client's radiation implant in the bed. What is the best nursing action? 1. Using tongs, replace it in the lead container in the room. 2. Immediately evacuate the client and all others from the room. 3. Wearing gloves, replace the implant into the body cavity. 4. Call radiation control to come pick up the implant

1. Using tongs, replace it in the lead container in the room. Whenever a client is treated with a radiation implant, there should always be a lead container and tongs in the room in which to place the radiation source if it should become dislodged. Getting the client away from the radiation source is most important to prevent skin irradiation. The room does not need to be evacuated. If gloves are ever used, they must be lead-lined.

The nurse is caring for a child who may have ingested excessive amounts of lead. What test will confirm a diagnosis of lead poisoning? 1. Venous blood sample for determination of lead level 2. Bone marrow aspiration for lead levels 3. Computed axial tomography (CAT) scan to determine lead deposits 4. Biopsy of small intestine for determination of lead levels

1. Venous blood sample for determination of lead level The only way to determine the lead level is to obtain a venous blood sample. The early stages of lead poisoning rarely show symptoms. Lead lining of the gums is a late symptom and would not be an early, acute finding. Bone marrow aspirations are for blood dyscrasias.

The nurse understands that chickenpox (varicella) is characterized by which symptoms? 1. Vesicles that rupture, many with scabs in various degrees of healing 2. Erythematous, fine macular rash on the trunk 3. Pustules that are primarily on the trunk and filled with purulent fluid 4. Papules that are confined to the face and trunk

1. Vesicles that rupture, many with scabs in various degrees of healing The rash from varicella typically contains vesicles in varying stages of healing, all present on the body at the same time. They are not filled with pus unless there is a secondary infection present.

A client is being referred to the hospice nurse for care. The nurse explains to the client and the family that the primary goal of hospice differs from the goal of traditional care in that hospice care 1. provides support to the family and to the client with a terminal illness 2. is only delivered at home, so that no extraordinary means are initiated to prolong life 3. provides a Medicare-supported pain regimen so pain medications are affordable 4. more readily recognizes advance directives related to the "right to die"

1. provides support to the family and to the client with a terminal illness Hospice care provides compassion, concern, and support for the dying client and family. It may or may not be delivered in the home. Pain control is an issue for the hospice, as well as for any client with cancer.

A client is started on a series of chemotherapy. The client indicates to the nurse that she is concerned about losing her hair and wants to know how it can be prevented. What is the best nursing response? 1. "Don't worry about that, it happens to most people on chemotherapy." 2. "It cannot be prevented; however, protect your scalp when in the sun, and do not use a hairdryer." 3. "Drink plenty of fluids and increase your intake of fiber while on chemotherapy." 4. "Shampoo your hair daily and scrub your scalp to increase circulation and prevent further hair loss."

2. "It cannot be prevented; however, protect your scalp when in the sun, and do not use a hairdryer." The client should protect her scalp and remaining hair by wearing a hat and protecting her head from sunlight. She should not use a curling iron, hot rollers, hair dryer, or anything that could potentially damage her scalp. She should very gently massage her scalp when shampooing, not scrub it. The hair loss will probably still occur; however, this will assist to avoid damage to the scalp.

A child with a severe immunodeficiency is admitted to the hospital with a diagnosis of rubeola. What type of precautions is important for the nurse to implement? 1. Standard precautions 2. Contact precautions 3. Wound precautions 4. Airborne precautions

4. Airborne precautions Rubeola is a virus that is spread via respiratory droplets. Airborne precautions include all of the standard precautions plus precautions specific to respiratory communicability.

A client has developed stomatitis while receiving chemotherapy. What would be an appropriate intervention to suggest for the pain associated with the stomatitis? 1. Use lemon-flavored glycerin swabs. 2. Apply antacid coating solutions and viscous lidocaine. 3. Brush oral plaques off with a soft toothbrush. 4. Have client swish mouth with a weak hydrogen peroxide solution

2. Apply antacid coating solutions and viscous lidocaine. Ulcerations in the mouth (stomatitis) can occur when a client is receiving chemotherapy medication. Alleviation of the pain can be achieved by administering systemic analgesics, as well as coating agents such as antacids. Frequent saline rinses are encouraged. Lemon-glycerin swabs may irritate the mucosa and lead to further pain, as would trying to remove oral plaques.

A 11-month-old child is in a private room for treatment of burns. Which intervention can best meet the developmental needs of the child? 1. Have the same nurse assigned to the child to provide continuity of care. 2. Ask that a familiar adult be available to room with the child. 3. Determine the toddler's favorite cartoon shows. 4. Bring a brightly colored balloon to the toddler's crib

2. Ask that a familiar adult be available to room with the child. It is important for a familiar adult to be present all of the time, not only to provide emotional support but also to meet the child's safety and developmental needs. This particular age is when the toddler is most susceptible to separation anxiety. A toddler is likely to be apprehensive toward unfamiliar adults, so although the same nurse being assigned to the toddler may promote continuity of care, it is not the best answer. Determining favorite television cartoon shows is a poor substitute for human contact. A balloon is a safety hazard for a toddler.

In treating the cancer client, what would the nurse identify as the primary goal of the chemotherapeutic drugs? 1. Prevent all future relapses. 2. Assist the client into remission. 3. Decrease intervals between exacerbations. 4. Increase the positive effects of radiation.

2. Assist the client into remission. The main goal is to get the client into remission. Medications may be discontinued after three years of remission.

A client's breast cancer is being treated with external radiation therapy. What will be important for the nurse to understand regarding skin care of the area? 1. Use mild soap and do not rub with abrasive materials. 2. Check with the health care provider about skin care to the radiated area. 3. Expose the area to sunshine to maximize healing. 4. Wear clothing and bras that provide support for the area.

2. Check with the health care provider about skin care to the radiated area. The skin of the treated area is FRAGILE and EASILY DAMAGED. It is important to check with the health care provider to determine how to provide skin care to the radiated area. Often, a mild soap and thorough rinsing with warm water is sufficient cleansing, but can be contraindicated in some situations. A hydrophilic moisture lotion can be used for drying, the area should not be exposed to sun, and clothing should be loose and nonbinding.

An 8-year-old boy is hospitalized for continued intravenous treatments for his leukemia. He is on a regular diet, but he eats very little. He tells the nurse he wants a hamburger, French fries, and a milk shake. What is the best nursing action? 1. Encourage him to eat his vegetables and reward him with ice cream. 2. Request these foods from the dietary department. 3. Explain to him how important it is for him to eat a healthy diet. 4. Find out his favorite dessert and provide that when he eats his regular diet.

2. Request these foods from the dietary department. Loss of appetite is common when children are chronically ill with leukemia. The foods he likes are nutritious and the nurse should attempt to supplement his favorite foods with fruits and vegetables. Request the favorite foods and offer fruit as well.

A client comes to the emergency department with a deep penetrating wound he received in the garden. What is the best nursing action? 1. Administer gamma globulin IM 2. Rinse the wound with antibiotic solution 3. Anticipate notifying poison control for plant toxicology 4. Determine when client received his last tetanus immunization

2. Rinse the wound with antibiotic solution Deep penetrating wounds that are contaminated by soil, dust, or excreta containing Clostridium tetani are the cause of tetanus, or lockjaw. First, the wound should be thoroughly cleansed, then the nurse should determine when the client received his last tetanus immunization. As a rule, clients will receive a tetanus booster as a safeguard.

At what age is the MMR vaccination recommended to be started? 1. At birth 2. At 1 month 3. At 6 months 4. At 12 months

4. At 12 months The MMR is not started until the child is 1 year old; the immune system cannot respond effectively to the vaccination until this age.

A healthy 40-year-old adult is at the office for a routine yearly examination. The client shares with the nurse that, "My mother had cancer of the colon and I'm concerned about my risk factors for cancer". What would be important for the nurse to discuss with this client? 1. Plan to schedule a colon biopsy to screen for the presence of cancer. 2. Current screening procedures recommends for clients with a family history of cancer. 3. Have a colonoscopy within the next few weeks to establish a baseline for screening. 4. Change your diet to include an increase in vegetables, whole grain fiber, and a decrease in fat.

2. Current screening procedures recommends for clients with a family history of cancer. The client is at an increased risk and should be advised regarding what screening procedures are available. The doctor will need to get more detailed information regarding the history of cancer in the family. A colon biopsy may or may not be done during a colonoscopy. A colonoscopy should be done around age 50 but can be done at an earlier age if indicated. However, it is does not need to be done in the next few weeks. Dietary changes are important, but a dietary history should be evaluated, and it does not address the need for early screening in clients with a family history of cancer.

The nurse is assessing the nutritional status of an 85-year-old client. What would the nurse identify as common physiological changes associated with aging? 1. Increased peristalsis 2. Decreased absorption of iron 3. Maintenance of normal fat metabolism 4. Increased drug metabolism

2. Decreased absorption of iron Decreased production of hydrochloric acid, which occurs with aging, leads to decreased absorption of iron and vitamin B12. Fat absorption would decrease, as would peristalsis and drug metabolism.

The nurse is assessing a 6-month-old infant in an immunization clinic. The nurse knows that by 6 months, the infant should have had which immunizations? 1. Varicella, diphtheria, polio, hepatitis B, pneumococcal 2. Diphtheria, acellular pertussis, tetanus, hepatitis B, polio 3. Polio, measles, mumps, rubella, diphtheria, tetanus 4. Varicella, measles, mumps, rubella, diphtheria, pneumococcal

2. Diphtheria, acellular pertussis, tetanus, hepatitis B, polio DTaP, polio, pneumococcal, hepatitis B, and the influenza vaccination are required immunizations by age 6 months. Varicella and MMR are not given until the infant is 1 year old.

A client has been prescribed furosemide for treatment of a diagnosed heart condition. What foods should the client be encouraged to eat? 1. Breads and fortified cereals 2. Dried fruits and juices 3. Leafy green vegetables 4. Lean red meat and whole grains

2. Dried fruits and juices The client should be encouraged to eat dried fruits (raisins, apricots) and vegetables (beans, broccoli), as well as drink juices (orange juice) to increase his intake of potassium, which is being lost from the diuretic.

The nurse is serving a food tray to a client who has glomerulonephritis and azotemia. Which food selection would the nurse question? 1. Bread and rice 2. Dried peaches and apricots 3. Bran muffin and eggs 4. Apples and cucumbers

2. Dried peaches and apricots The INCREASED POTASSIUM found in dried fruits (peaches and apricots) is CONTRAINDICATED in client with increased potassium and blood urea nitrogen levels. These clients may also be on a decreased protein intake as well; however, in this question the potassium is the most important nutrient to exclude.

A client is 85 years old. Which dietary modification should the nurse consider due to the client's age? 1. Increase calorie intake 2. Increase dietary intake of calcium and vitamins C and A 3. Increase intake of bland foods 4. Omit fluids with meals

2. Increase dietary intake of calcium and vitamins C and A Increased dietary intake of calcium, vitamin C, and vitamin A is needed because alterations with age disrupt the ability to store, use, and absorb these substances. Calories are usually decreased due to decreased activity. Taste is frequently altered, and clients will prefer foods with more seasonings. Fluids with meals and during the day should be encouraged unless there is a specific problem affecting/restricting fluid intake.

A client is receiving chemotherapy for lung cancer. The nurse understands that the medication may be nephrotoxic. What is an important nursing action? 1. Encourage fluids to increase the acidity of urine. 2. Monitor daily weight and intake and output. 3. Decrease fluids to reduce edema formation. 4. Monitor the urinalysis for the level of bacteria.

2. Monitor daily weight and intake and output. The fluid balance needs to be carefully monitored in order to determine renal changes that may impact intake and output as well as fluid retention. Baseline fluid balance should be determined when the client is started on the chemotherapy.

The nurse is caring for the older adult and wants to address nutritional concerns related to inadequate protein intake. What food should be recommended for a client with a history of myocardial infarction? 1. Eggs 2. Nonfat milk 3. Cereal 4. Carrots

2. Nonfat milk Eggs contain fat; however, the nonfat milk is a source of protein but not fat.

The nurse at the women's, infant's, and children's center recommends which strategies to provide a 12-month-old infant with nutrients for growth? 1. Exclude milk from the infant's diet until he or she begins to like other foods. 2. Offer the infant small amounts of meat and vegetables before offering milk. 3. Withhold desserts until the infant has eaten his or her vegetables. 4. Mix strained meat and vegetables into the milk given to the infant.

2. Offer the infant small amounts of meat and vegetables before offering milk. Children at this age are prone to anemia, especially when milk is offered frequently. Therefore, holding milk and other liquids until after solid food is offered prevents the child from "filling up" on the liquid.

The nurse is serving a bland diet to a client. Which foods would the nurse question? 1. Milkshake 2. Orange juice 3. Baked potato 4. Cream of wheat

2. Orange juice A bland diet is very nonirritating and usually consists of white foods. There are very few brightly colored foods on a bland diet. A milkshake, baked potato, and cream of wheat are bland in color and in taste; therefore, orange juice is different and makes it the correct answer.

A cancer client expresses fear regarding dying in pain. Which nursing action is most appropriate? 1. Tell the client that worrying about pain makes it worse. 2. Reassure the client that good pain control is available. 3. Explain pain control theories. 4. Inform the client that pain is a part of illness.

2. Reassure the client that good pain control is available. Many people fear dying in unbearable pain. Clients can be reassured that there are now very sophisticated treatments for pain control. The most effective pain regimen possible will be used for the client's comfort.

The nurse is assessing a client who has recently begun external radiation. What is a nursing observation that confirms the presence of early side effects of the radiation? 1. A gradual weight loss and GI disturbances 2. Skin erythema followed by dry desquamation 3. Vertigo when sitting up quickly 4. Excoriation and blisters on the affected skin

2. Skin erythema followed by dry desquamation Abnormal skin pigmentation, erythema, and dry desquamation may develop within a few days of beginning the radiation treatment. Wet desquamation may occur with progression of the radiation treatment; however, the skin would not have blisters. Vertigo may be a sign of orthostatic hypotension associated with hypovolemia. Weight loss occurs, but this is not caused the radiation; it is most often due to the malignancy.

A client is 5 days postoperative for a mastectomy. The client has expressed an intense dislike for hospital food, and her appetite is unusually poor. What is important for the nurse to explain to the client? 1. An intravenous line with sugar water will have to be inserted if she will not eat. 2. The lack of food, especially protein, will interfere with her wound healing. 3. When she is discharged she will need to gain back the weight she lost during hospitalization. 4. No one enjoys hospital food, so it is fortunate she is not hungry.

2. The lack of food, especially protein, will interfere with her wound healing. Protein-calorie malnutrition causes a deficiency in energy for protein synthesis. The usual manifestations include poor wound healing. It would also be important for the nurse to consider cultural implications as to how an increase in protein can be achieved (e.g., determining favorite foods, family bringing in food).

The nurse understands that appropriate treatment for a child with roseola infantum includes 1. antiviral medications, fluids, and rest 2. antipyretic medications, rest, and hydration 3. antibiotics, hydration, and rest 4. hospitalization, antipyretics, and IV fluid replacement

2. antipyretic medications, rest, and hydration The primary treatment for roseola infantum is supportive, including control of fever, adequate rest, and hydration. There is no preventive care, antiviral medication, or immunization available.

The nurse understands that the food guide (MyPlate) is a 1. nutrient guide that categorizes foods by their fiber content 2. basic message is about healthy eating and portion control 3. food guide that emphasizes higher intakes of protein than presently consumed 4. nutrient guide aimed to promote weight loss by controlling intake of fat-soluble vitamins

2. basic message is about healthy eating and portion control The MyPlate is the new focus of categorizing the five major food groups according to the proportions that persons should eat daily to maintain nutritional balance and reduce the risk of diet-related diseases. MyPlate is not a therapeutic diet for any specific health condition, such as weight loss.

The nurse is assisting a client with Parkinson's disease and the family with discharge planning. A priority home care goal for this client would be to 1. maintain proper positioning to prevent contractures 2. promote daily activity and independence 3. encourage use of laxatives to prevent constipation 4. decrease fluid intake to prevent aspiration

2. promote daily activity and independence Maintaining independence is a primary goal for this client. It is important to plan for daily activity and to promote as much independence in activities of daily living (ADLs) and independent activities of daily living (IADLs) as much as possible. Positioning should not be an emphasis, but active and passive range of motion should be. Fluid intake should be increased to maintain good hydration. Constipation should initially be prevented with increased fluids and dietary fiber.

An appropriate treatment for overweight children younger than 8 years would include which actions? 1. Administer an appetite suppressant 2. Eliminate all carbohydrates in the diet 3. Plan a program of activity and exercise 4. Use vitamin therapy and herbal teas

3. Plan a program of activity and exercise An appropriate approach for a child of this age is a well-balanced diet, activity, and exercise for weight reduction. This allows for a slow approach to weight loss that incorporates healthy habits.

Planning anticipatory guidance is an important nursing function. Considering the teaching for the family of an 18-month-old child, which comment by the mother indicates she understands safety concerns? 1. "I will keep an eye on her all of the time and won't let her out of my sight." 2. "When she says 'no-no,' then she understands right and wrong." 3. "I will need to be sure that the locks on the medicine cabinet are secure." 4. "I'll be sure to give her syrup of ipecac whenever she swallows any poison."

3. "I will need to be sure that the locks on the medicine cabinet are secure." Having medications and other dangerous cleaning materials and chemicals locked away in secure areas is an important safety issue for toddlers. It is not advisable to induce vomiting without calling the local poison control center first to be sure that it is okay to have the toddler vomit. Often, ingested materials may be corrosive, and induction of vomiting would not be an appropriate nursing action.

A mother brings her 5-year-old child to the wellness clinic with a rash covering the child's body. The nurse recognizes the rash as chickenpox when noting what characteristic? 1. Cluster of small blisters 2. Raised, reddened areas on the upper trunk 3. A maculopapular rash 4. Petechiae

3. A maculopapular rash Chickenpox is characterized by a maculopapular rash consisting of fluid-filled vesicles, which form crusts or scabs. Measles is associated with small, irregular red spots. Petechiae are found with DIC, Rocky Mountain spotted fever, meningococcal meningitis, and subacute bacterial endocarditis.

The nurse is administering a DTaP immunization to a 4-month-old infant. The parents are concerned about possible reactions. What is important for the nurse to tell the parents? 1. Reactions to DTaP are very rare and they should not be worried about it. 2. Gastrointestinal problems can be relieved by keeping the child on clear liquids for 6 hours. 3. Administer acetaminophen if the child has a fever, and put ice on the injection site. 4. A rash may occur over the trunk; there should be no problem with itching.

3. Administer acetaminophen if the child has a fever, and put ice on the injection site. A slight fever and discomfort at the injection site are not uncommon reactions; acetaminophen is the medication of choice. Do not use aspirin and do not tell the child's parents "not to worry." The correct response acknowledges the parents' concern and gives them information regarding the care of the child.

A client is continuing his recovery from extensive surgery at home. The nurse instructs the client to increase his intake of which foods to promote healing? 1. Tomatoes, rice, whole-wheat cereal 2. Milk, poultry, yellow vegetables 3. Red meat, oranges, green beans 4. Liver, corn, eggs

3. Red meat, oranges, green beans The client needs an increased intake of protein and vitamin C to promote healing. Red meat, citrus fruits, and green vegetables will give the highest amounts of these elements from the selections offered.

The mother of an adolescent talks with the nurse about her concerns that something is wrong with her son, because she found him masturbating in the bathroom. What is the nurse's best response? 1. Confront your son by telling him that this is something that he should not be doing at his age. 2. Tell your son that he should wash his hands afterward to prevent the spread of sexually transmitted disease. 3. Masturbation is a healthy and normal part of sexual development. 4. Next time, knock on the door before entering to save him from possible embarrassment.

3. Masturbation is a healthy and normal part of sexual development. Masturbation provides an opportunity for sexual exploration, stress reduction, and recognition of sexual development. It is not appropriate to instill fear related to myths, such as warts growing on hands. Knocking on the door is correct, but the mother should not just enter after knocking, because entering the bathroom violates her son's personal boundaries.

A preschool child is diagnosed with chickenpox. The mother is concerned about how long the child will be contagious. On what principle will the nursing response be based? 1. The child will be contagious until the fever has subsided and all lesions are healed. 2. The contagious period will extend to approximately 1 week after the lesions have healed. 3. One day before appearance of the lesions until all lesions have crusted is considered the most contagious period. 4. The most contagious period is approximately 7 to 10 days after onset or until the lesions are dried.

3. One day before appearance of the lesions until all lesions have crusted is considered the most contagious period. The most contagious period is the day before the child is breaking out to the time when all the lesions have crusted. The INCUBATION period usually ranges from 2 to 3 weeks, or around 13 to 17 days.

A client has been receiving chemotherapy treatments and has developed ulcerations on the oral mucosa and lips. What is an important nursing intervention to assist the client with the ulcerations of the mouth? 1. Carefully floss after each meal to remove all food particles. 2. Use half-strength hydrogen peroxide as an oral rinse after each meal. 3. Rinse the mouth with a normal saline solution before and after each meal and before bedtime. 4. Leave dentures in the mouth to facilitate cleaning them and decreasing bacteria

3. Rinse the mouth with a normal saline solution before and after each meal and before bedtime. Normal saline is recommended for a mouthwash. It can be used frequently during the day and at mealtime. Hydrogen peroxide should not be used. The dentures should be removed after each meal for careful cleansing. The nurse should carefully examine the client's mouth for any irritation that could be caused by the dentures. Dentures should not be worn if they are causing irritation and damage to the gums.

A child diagnosed with hemophilia is admitted to the pediatric unit for treatment. The nurse encourages fantasy play, role-playing with dolls and puppets, and participation in his own care. The nurse understands that this developmental approach is most appropriate for which age group? 1. Toddler 2. Preschool-age child 3. School-age child 4. Adolescent

3. School-age child Fantasy playing, daydreaming, making collections, and producing crafts and artwork are examples of characteristics of play for the school-age child. Because the school-age child is also able to participate in self-care, using dolls and puppets is especially helpful for the school-age hospitalized child. With the focus on motor skills, the toddler enjoys push-pull toys and games of peek-a-boo. The preschool-age child is involved with imitative and dramatic play, such as dress-up, housekeeping toys, and trains. The adolescent enjoys role-playing in various situations.

The clinic nurse is discussing nutrition with the parents of a 10-month-old infant. The nurse determines that the infant is in the 97th percentile for weight and age. The parents want to begin giving the infant skimmed or low-fat milk. What is the best nursing response? 1. Begin rotating formula and low-fat milk at age 12 months. 2. Low-fat milk can be started at this time. 3. Skimmed or decreased-fat milk should not be given to children until 2 years of age. 4. It is important to keep children on formula until they are 36 months old.

3. Skimmed or decreased-fat milk should not be given to children until 2 years of age. Skim milk or low-fat milk can be given to a child after 2 years of age. Prior to 2 years the sodium and electrolytes in skim/low-fat milk are too concentrated and there are not enough essential fatty acids. Before the age of 2 years, either formula or breast milk is preferred. Depending on family characteristics, the nurse may want to review with the parents the type and amount of solid food the infant is eating, as well as the amount of formula consumed.

A client is receiving chemotherapy with several antineoplastic agents. Which nursing observation is considered a common side effect of chemotherapy? 1. Slow, slurred speech 2. Increased leukocytes on CBC 3. Stomatitis resulting in oral ulcers 4. Sinus bradycardia

3. Stomatitis resulting in oral ulcers A common side effect of chemotherapy is stomatitis. It may be manifested as inflammation of the gums and ulcerations in the mouth. There is a decrease in leukocytes, making the client less resistive to infection. Slow heart rate (bradycardia) is not common in cancer therapy; irregularities in the pulse may occur with electrolyte imbalances secondary to chemotherapy. The slowed speech may occur with hypercalcemia as a complication involving the parathyroid gland.

A school-age child has a history of an appendectomy and is now scheduled for an open reduction and internal fixation of the femur. What would be appropriate for preoperative teaching? 1. Have the mother read the child a story to reduce anxiety before the surgery. 2. Ask the child how she felt after the last surgery. 3. Suggest role-playing and provide appropriate materials. 4. Tell the child that she will return with just a cast on and that it will not hurt.

3. Suggest role-playing and provide appropriate materials. School-age children need concrete experiences; hence a pediatric orientation program would be most appropriate in this situation. Having materials or props with which to role-play would be very beneficial in the preoperative care for this child. Role-playing is appropriate with the child who can verbalize and talk about her activities, especially since she has a history of prior hospitalization. Never lie to the child about what is going to happen.

A parent calls the outpatient clinic and states that his 2-year-old just took an unknown amount of various medications. The child is sleepy, and the parent is having a difficult time arousing the child. What would be the best instructions to the parent? 1. Administer syrup of ipecac to induce vomiting. 2. Call the poison control center and describe the medications the child took. 3. Transport the child immediately to the closest ED. 4. Have the parent describe the medication the child ingested.

3. Transport the child immediately to the closest ED. The child has ingested an unknown type and amount of medication and may be under the influence of central nervous system (CNS) depressants. The child should be transported immediately to an ED. Syrup of ipecac should not be administered to a child who is at increased risk of aspiration from vomiting. Time should not be wasted at this point in calling poison control or in describing the medications. If possible, the parent should bring the medicine containers to the ED.

Combined therapy of radiation and chemotherapy can have a significant therapeutic impact on the survival of an individual with cancer. The nursing priority for these clients includes measures to 1. monitor for acute renal tubular necrosis 2. control nausea and vomiting 3. prevent infection 4. maintain hydration and nutrition

3. prevent infection The statistics indicate that infection is the most common cause of morbidity in clients with cancer. Good hand-washing, monitoring white blood cell counts, checking temperatures (watching for elevations), and providing protective isolation when needed (when clients are severely immunosuppressed) are the primary measures to prevent infection.

In the older adult client (over 60 years), what will the nurse identify as normal growth and development activities? 1. Increased ability to move from concrete to abstract thinking 2. Peer group becomes more important. 3. Physiological status begins to decline. 4. A restructure and reorganization of family and social activities

4. A restructure and reorganization of family and social activities The older adult begins to restructure his role in the family and begins to reorganize social activities. The importance of the peer group and moving from concrete to abstract thinking is more characteristic of the adolescent. The physiological decline begins at age 30, but continues for the older adult.

Stomatitis has developed in the oral mucosa of a client receiving chemotherapy. What would the nurse encourage the client to do? 1. Drink grapefruit juice before and after meals. 2. Use a regular over-the-counter mouthwash. 3. Discontinue chemotherapy until stomatitis heals. 4. Brush teeth with a soft toothbrush after meals and before bedtime

4. Brush teeth with a soft toothbrush after meals and before bedtime Brushing teeth with a soft toothbrush after meals and before bedtime helps to reduce the possibility of secondary infection by mechanically removing food residue, which could cause bacterial growth and infection. Grapefruit juice may irritate the mucosa. It is not appropriate for the nurse to suggest that the client discontinue the chemotherapy. Stomatitis is a common, almost expected problem for clients receiving chemotherapy.

The mother of a newborn asks when she can begin to give her infant some fruits. What is the best response? 1. Begin cereals at 3 months, then begin fruits at 6 months. 2. Start fruits as the first solids at 6 months, then vegetables. 3. Fruits can be started at 3 months, followed by cereal. 4. Cereals are started at 5 to 6 months, followed by fruit.

4. Cereals are started at 5 to 6 months, followed by fruit. The American Academy of Pediatrics recommends that infants at age 5 months should receive iron-fortified formula if breastfeeding is discontinued. Solid foods (iron fortified cereals) may be introduced from 5 to 6 months. Strained meats and citrus fruit are not started until after the infant is eating cereals, generally around 6 months.

A nurse is discussing with a client the need to eat a high-protein diet. The nurse knows the client understands the diet when the client selects which foods from the hospital menu? 1. Cheeseburger, French fries, and coffee 2. Grilled cheese sandwich, green salad, and tea 3. Chicken and rice soup, whole wheat crackers, and milk 4. Chicken breast sandwich, sliced cheese, and milk

4. Chicken breast sandwich, sliced cheese, and milk Meat and dairy products are high in complete protein. The other options have a high-protein food but also contain other foods that do not contain protein (green salad, whole wheat crackers) or are not healthy foods (French fries).

The nurse is serving a dietary tray to a client who has a bland diet ordered. What item on the tray would the nurse question? 1. Cream soup 2. Cottage cheese 3. White bread 4. Corn

4. Corn A bland diet does not have any fiber and has minimal seasonings and all foods are while. Corn has a husk and is a high-fiber food; it is not included on a bland diet. The other options are appropriate for a bland diet.

As the nurse plans care for the older adult female client, considerations related to incontinence include which physiological characteristic? 1. Decreased vascularity of the bladder mucosa 2. Increased urethral closing pressure 3. Increased ability to concentrate urine 4. Decreased bladder capacity

4. Decreased bladder capacity Decreased bladder capacity along with decreased ability to concentrate urine and decreased urethral closing pressure AFTER MENOPAUSE lead to incontinence in women. Other factors include depression, decreased mobility, decreased vision, and lack of attention to bladder cues of fullness.

A child with a severe immunodeficiency is admitted to the hospital with a diagnosis of rubella. What types of precautions are important for the nurse to implement? 1. Standard precaution 2. Airborne and protective precaution 3. Wound precaution 4. Droplet and contact precaution

4. Droplet and contact precaution Rubella is a virus that is spread via respiratory droplets and direct contact. Droplet and contact precautions include all of the standard precautions plus precautions specific to respiratory communicability. Rubella is not transmitted via airborne, being around the person will not create an increased risk; the respiratory droplets from the infected client must be inhaled.

As the dying process progresses, a client with metastatic cancer experiences severe weakness. What is a therapeutic nursing intervention? 1. Administer pain medication more frequently 2. Determine the client's attitude towards death 3. Place the client in a private room 4. Institute comfort measures

4. Institute comfort measures When the client experiences severe weakness, there is decreased sensation and need for pain medication; however, other measures need to be instituted to keep the client as comfortable as possible. Warmth, presence of others, or music may provide comfort to the client.

The nurse is teaching the family about the treatment plan for an adolescent diagnosed with infectious mononucleosis. What would be important for the nurse to teach the client and her parents regarding the acute phase of infectious mononucleosis? 1. Avoid exercise during acute phase 2. Apply steroidal cream to areas of rash 3. Take all of antibiotic prescribed 4. Maintain adequate bed rest

4. Maintain adequate bed rest The treatment of mononucleosis includes bed rest while the client has a fever and myalgia (10 to 14 days), supportive acetaminophen or ibuprofen, warm saline gargles, and throat lozenges or spray. The client should avoid strenuous exercise and contact sports because of the increased risk of splenic rupture. Steroidal cream is not recommended for the rash; it is self-limiting. Antibiotics are not recommended during the initial phase. About 95% of clients with mononucleosis recover uneventfully with supportive treatment.

The nurse is caring for a client recently admitted to a long-term care facility. The client is experiencing episodes of confusion and recent memory loss. The client frequently cannot find her room. What is the best nursing action? 1. Place the client in a room close to the nurses' station so she can be easily observed. 2. Encourage the client to go to the dining room and have meals with other residents. 3. Spend some time talking with the client about her family and her plans for returning home. 4. Place the client's picture on the door of her room and ask the family to provide personal items.

4. Place the client's picture on the door of her room and ask the family to provide personal items. The client needs visual stimulation that will help to orient her to her surroundings and to where she lives. Clients will recognize their pictures and be able to identify articles from home, pictures, or personal items in their rooms. Placing the client close to the nurses' station does not assist in orienting her. The client should be encouraged to eat her meals in the dining room or in the company of other residents, but this does not help her in finding her room. It is important for the nurse to spend some time with the client; however, with recent memory loss, the benefits are limited.

The nurse understands that if excessive amounts of water-soluble vitamins are ingested, which of the following happens? 1. The body will store what is not used in muscle and fat tissue. 2. The body will attach them to proteins and circulate. 3. The excess will be stored in the liver until needed. 4. The excess will be excreted in the urine.

4. The excess will be excreted in the urine. Water-soluble vitamins are excreted in the urine, in contrast to fat-soluble vitamins, which can have toxic levels because they are stored in the body. The water-soluble vitamins are B and C. The fat-soluble vitamins are A, D, E, and K.

The measles, mumps, and rubella (MMR) vaccine is not administered to infants younger than 12 months. Why is this vaccination not recommended for this group of children? 1. Children younger than 12 months have a greater risk for an adverse reaction. 2. This group of children is not at high risk for contact with diseases. 3. The child's immune response is not mature enough to respond to the vaccination. 4. The immune system of the child will not respond effectively to the vaccination.

4. The immune system of the child will not respond effectively to the vaccination. The child younger than 12 months still has some circulating maternal antibodies that could affect the child's response to the immunization. The child's immune system may not be adequately mature, but the immune system not responding effectively is more specific to the situation. This group of children is at high risk for contact with diseases, and they do not have an increased risk for an adverse reaction.

A parent expresses concerns about a child's 4-month immunizations, stating that the infant's leg was warm to the touch, slightly swollen, and red. What should the nurse explain before administering the next set of immunizations? 1. Because of the response the last time, the diphtheria, tetanus, and acellular pertussis (DTaP) booster will not be given at this time. 2. Only half of the prescribed dose will be given, which will prevent the postimmunization reaction. 3. It is important to wait for 6 months before administering the next set in the series. 4. These are expected results; it is not an unusual reaction to the immunization.

4. These are expected results; it is not an unusual reaction to the immunization. After an immunization, an infant typically has local inflammatory changes at the site, along with a mild temperature elevation. The parent may also note that the child is cranky and irritable. Immunizations would never be given in a half dose.

At the head start center, the nurse assesses a toddler, 12 to 24 months old. The nurse will choose this activity to provide a distraction. 1. Musical mobile above head 2. Rattle 3. Tricycle 4. Wagon

4. Wagon Toddlers enjoy motion toys, such as pull toys, riding toys, and wagons. Because of refining fine-motor movement, play activities such as finger paints, interlocking blocks, and large-piece puzzles would help these skills. Musical mobiles and rattles are better suited as toys for infants. The child does not develop coordination to pedal a tricycle until around 3 to 4 years old.

The father of a 12-year-old boy tells the nurse that he is concerned about his son's weight—"he is getting fat." The child is at the 50th percentile for height and the 75th percentile for weight on the growth chart. The most appropriate nursing response would be to 1. reassure the father that the son is not "fat." 2. assess the family for the presence of obesity. 3. suggest a high-protein, low-calorie, low-fat diet. 4. explain that this is typical of the growth pattern of boys at this age.

4. explain that this is typical of the growth pattern of boys at this age. It is normal for boys at this age to appear heavier before they get their "growth spurt." Reassuring the father, although appropriate, is not the best response. Because the findings are within normal limits, it would not be necessary to assess the family for the presence of obesity. Low-calorie, low-fat diets are contraindicated for the growing child.

The nurse in a long-term care facility would expect the elderly client to be most confused and disoriented 1. on arising in the morning 2. when ambulating during the day 3. when sitting alone in the afternoon 4. on awakening during the night

4. on awakening during the night During the night, there is a lack of stimulation and a lack of personnel to establish a relationship between time and place. The client will be most confused when awakening in the middle of the night.