NCLEX questions

The nurse is preparing teaching for a client recovering from conjunctivitis. Which instruction should the nurse include when teaching about the care of the contact​ lenses? A) place clean lenses on a paper towel to dry B) wash hands before handling lenses C) keep contact lenses in place if signs of an irritation are present D) remove the lenses every morning

B ​Rationale: The nurse should teach the client to wash the hands before handling the lenses. The lenses should be removed before sleep. The lenses should be stored in the appropriate case. The lenses should not be worn if signs of an irritation are present.

The nurse is caring for a client who has signs of acute disseminated intravascular coagulation. Which intervention is​ appropriate? (Select all that​ apply.) A) Encourage ambulation. B) Administer analgesics and antianxiety​ medications, as ordered. C) Elevate the head of the bed. D) Encourage deep breathing and effective coughing exercises. E) Continuously monitor oxygen saturation.

B,C,D,E ​Rationale: Microclots in the pulmonary vasculature can cause impaired gas exchange. Bedrest reduces oxygen demand and cardiac workload. The head of the bed is elevated to promote diaphragmatic movement and alveolar ventilation. Monitoring oxygenation saturation measures gas exchange. Controlling pain and anxiety reduces respiratory rate and improves the quality of ventilation and gas exchange. Deep breathing and effective coughing clear airways and improve alveolar ventilation and oxygenation.

The nurse is caring for a client who has not responded to platelet and whole blood transfusions as treatment for acute disseminated intravascular coagulation​ (DIC). Which action should the nurse anticipate​ next? A) Coumadin therapy B) Unfractionated heparin therapy C) Low-molecular-weight heparin therapy D.) End-of-life protocol

C Rationale: Low-molecular-weight heparin has a lower risk of bleeding and organ failure when treating clients with DIC as compared to unfractionated heparin. Coumadin is not appropriate.​ End-of-life protocol is not indicated at this time.

During a health​ assessment, the nurse becomes concerned that an adolescent is at risk for developing conjunctivitis. Which behavior did the nurse assess to cause this​ concern? (Select all that​ apply.) A) client plays soccer on the school team B) client uses disposable eye makeup applicators C) client consumes milk three times a day with meals D) client wears extended wear contact lenses E) client uses a tanning bed twice a week

D, E ​Rationale: Conjunctivitis can be caused by exposure to ultraviolet light from the sun or tanning beds. Risk factors for the development of conjunctivitis include wearing​ extended-wear contact lenses. Playing soccer and consuming dairy products does not increase the risk of developing conjunctivitis. Using disposable eye makeup applicators would reduce this​ client's risk of developing conjunctivitis.

The emergency department nurse is preparing discharge instructions for a client with conjunctivitis related to herpes simplex. Which medication should the nurse include in the​ instructions? A) antibiotic eye drops B) topical antihistamine C) topical NSAID D) antiviral agent

D. (acyclovir) ​Rationale: Antiviral​ medication, like​ acyclovir, is important for the client with conjunctivitis from herpes simplex to prevent blindness. Antibiotic eyedrops would be indicated for a bacterial infection. Topical antihistamine and nonsteroidal​ anti-inflammatory drugs are used for allergic conjunctivitis.

The pediatric nurse explains to parents that acute otitis media is more common in infants and children than adults because of which attribute of a child's Eustachian tubes? A) Are shorter and straighter. B) Are undeveloped. C) Have fewer cilia. D) Are longer and curved.

A Explanation: A child's Eustachian tubes are shorter and straighter than those of an adult, not longer and curved. A child's Eustachian tubes are shorter and straighter than those of an adult; they are not underdeveloped. A child's Eustachian tubes are shorter and straighter than those of an adult. A child's Eustachian tubes are shorter and straighter than those of an adult; they do not have fewer cilia.

A client has completed a full course of antibiotics for acute otitis media. The nurse conducting a follow-up assessment determines whether medication therapy was effective by questioning the client about relief from which most common presenting symptom? A) Ear pain B) Nausea and vomiting C) Dizziness D) Impaired hearing

A Explanation: Dizziness is a secondary or associated symptom of acute otitis media. Hearing impairment is a secondary or associated symptom of acute otitis media. Nausea and vomiting is a secondary or associated symptom of acute otitis media. Ear pain is the most common symptom of otitis media that motivates clients to seek health care.

Which finding would the nurse expect to see when examining a child with conjunctivitis (pink eye)? A) Crusting of eyelids and eyelashes B) Severe eye pain C) Periorbital edema D) Serous drainage from the affected eye

A Explanation: Purulent exudate and crusting are characteristics of conjunctivitis. Conjunctivitis associated with foreign body can cause severe eye pain. Serous drainage and periorbital edema are not associated with conjunctivitis.

The school health nurse has seen three children who have symptoms compatible with bacterial conjunctivitis (pink eye). The nurse calls the parents to bring the children home. The nurse informs the parents that the children can safely return to school after what occurs? A) After seeing a physician and taking antibiotic therapy for 24 hours. B) If complications or sequelae do not occur. C) If they do not have any systemic symptoms. D) When the eyes stop tearing.

A Explanation: The child is no longer considered contagious after completing 24 hours of antibiotic therapy. Until 24 hours of antibiotic therapy, the child would be contagious.

A pediatric client has been diagnosed with otitis media. The nurse should place highest priority on teaching the parent which of the following? A) The importance of completing the full course of antibiotic therapy. B) About myringotomy and tympanostomy tube insertion. C) How to administer ear drops. D) About eliminating environmental allergens.

A Explanation: The nurse must emphasize the importance of completing the full course of antibiotic therapy, even though symptoms may have resolved before the antibiotic is finished.

The nurse teaches a mother to administer eardrops to her infant. After the session is finished, the nurse evaluates that the mother understands the information when the mother pulls the pinna of the ear in which direction? A) Back and down B) Up and back C) Up and forward D) Down and forward

A Explanation: The pinna is always pulled back and not forward. Pulling the pinna down and back straightens the auditory canal of an infant, permitting the instillation of eardrops. Pulling the pinna up and back is the proper method for straightening the canal of an adult client.

The nurse is conducting family therapy with a family in which one member has a progressively debilitating illness. Which comment by the nurse is most likely to facilitate the family's use of the healthy coping mechanism known as productive interdependence? A) "All of you should work as a team, both asking for and receiving help from the others." B) "If the family assumes all responsibility for decision making, this will reduce the ill person's stress level." C) "No single family member should always be in charge of decisions or caregiving." D) "All of you should work toward reducing conflict within the family

A Explanation: This statement conveys useful information, but the information relates to preventing caregiver role strain, rather than promoting interdependence. This statement conveys useful information and indicates that the family should be a team, but it does not suggest a specific route to productive interdependence for the family. This statement conveys the information that the ill person and the family all share responsibility for decision making. It further suggests that each person, including the client, should have an awareness of his or her capacities and limitations and ask for assistance as necessary. This statement suggests restricting the client?s independence and removing the client from the family team.

The nurse evaluates that a client is demonstrating appropriate technique for using ophthalmic medication when the client does which of the following? A) Cleanses crust from the eye by wiping from the inner canthus outward with a cotton ball. B) Cleanses crust from the eye by wiping from the inner canthus outward with a cotton swab. C) Cleanses crust from the eye by wiping from the outer canthus inward with a cotton ball. D) Cleanses crust from the eye by wiping from the outer canthus inward with a cotton swab.

A Explanation: Wiping from outer canthus to inner canthus is opposite of correct technique. Crust from eyes is cleansed using cotton balls, wiping from the inner canthus to the outer canthus. Swabs should not be used, as damage to the eye could occur.

The nurse is assessing a​ 5-year-old child who experienced the loss of an older sibling. Which behavior should be expected based on the​ child's developmental​ level? A) Watching out the window for the sibling to come home B) Yelling at the parents that the death is their fault C) Planting a tree in the back yard in memory D) Going into the​ sibling's room and playing with their toys

A Rationale: Children between the ages of 5-7 years old do not fully understand the concept of dying and that it is permanent.​ Therefore, watching out the window for the sibling to come home is a behavior that is appropriate for this developmental age. Planting a tree in the backyard in the​ sibling's memory and yelling at the parents by assigning blame are behaviors displayed by an adolescent. Going into the​ sibling's room to play with their toys would be appropriate for a toddler or​ preschool-aged child. Next Question

Which client population automatically receives prophylactic therapy for​ conjunctivitis? A) newborns B) pregnant women C) adolescents D) toddlers

A Rationale: Conjunctivitis is so common that all neonates born in the United States receive prophylactic treatment after delivery. Prophylactic treatment is not automatically provided to​ toddlers, adolescents, or pregnant women.

Which factor should the nurse discuss with the parents of a stillborn infant prior to allowing them a​ viewing? A) The appearance of the newborn B) The need for taping the hands together C) Opportunity for a keepsake D) Time limitations for visit

A Rationale: The nurse should prepare the parents of a stillborn infant for the way the baby may appear. This includes maceration and discoloration of the skin. The nurse does not place a time limitation on the visit. After the infant has been​ born, the nurse can explore whether the parents would like keepsakes of the​ child, such as a​ picture, a lock of​ hair, or​ foot- or handprints. The​ newborn's hands are not taped together prior to viewing by the parents. Next Question

Which clinical manifestation would support a diagnosis of allergic​ conjunctivitis? A) itching B) photophobia C) yellow discharge D) sore throat

A ​Rationale: Allergic conjunctivitis causes itching to the eyes. Bacterial and viral conjunctivitis can cause sore throats and photophobia. Yellow discharge occurs with bacterial conjunctivitis.

Which treatment should the nurse question for a pregnant client diagnosed with otitis​ media? A) Amoxicillin B) Acetaminophen C) Warm compresses D) Humidified air

A ​Rationale: Any medication taken by a pregnant client would lead to fetal exposure.​ Therefore, the nurse would question the order for amoxicillin. Humidified​ air, acetaminophen, and warm compresses are safe during pregnancy.

The nurse assesses a client who is diagnosed with chronic disseminated intravascular coagulation​ (DIC). Which finding should the nurse suspect as the probable cause of the​ client's diagnosis? A) History of a cancerous tumor B) Chronic constipation C) Diminished bowel sounds D) History of nosebleeds

A ​Rationale: Chronic DIC develops​ slowly, over weeks or months. It lasts longer and typically is not diagnosed as quickly as acute DIC. Chronic DIC causes excessive blood​ clotting, but usually does not lead to bleeding. Nosebleeds would be unlikely with chronic DIC. Cancer is the most common cause of chronic DIC. Constipation and diminished bowel sounds are not generally associated with chronic DIC.

The client with which condition is at the greatest risk of developing acute disseminated intravascular​ coagulation? A) Third-degree burns and septic shock B) Gunshot wound to the distal arm C) Aortic aneurysm D) Bacterial pneumonia treated with antibiotics

A ​Rationale: Clients with severe sepsis and septic shock are at the greatest risk for developing acute DIC. Aortic aneurysm is a risk for chronic DIC. Gunshot wounds and bacterial infections are a risk for​ DIC, but sepsis is a greater risk

Which action by a client can increase the risk of developing barotitis​ media? A) Deep-sea diving B) Smoking cigarettes C) Swimming in a lake D) Bottle feeding while lying down

A ​Rationale: Deep-sea diving can increase the risk for barotitis media because this disorder occurs during changes in barometric pressure such as flying or deep diving. Swimming in a​ lake, cigarette​ smoking, and giving an infant a bottle at night when the infant is lying down all increase the risk of otitis​ media, not barotitis media

Which action by the client indicates an understanding of how to prevent transmission of​ conjunctivitis? A) Washing hands B) Using a handkerchief C) Sharing towels at home D) Rubbing the eyes

A ​Rationale: Good handwashing is imperative for preventing transmission of conjunctivitis. Rubbing the eyes can get the pathogen on the hands and transmit the infection. The client should be instructed to use disposable tissues or cotton​ balls, not a reusable handkerchief. The client should be instructed to not share towels.

The nurse assesses a client who has bacterial pneumonia and finds​ tachycardia, hypotension,​ oliguria, and acrocyanosis of a foot. Schistocytes are found in a complete blood​ count, and the​ D-dimer is elevated. Which collaborative action should the nurse​ anticipate? A) Heparin therapy B) Foot amputation C) Warfarin therapy D) Dialysis

A ​Rationale: The client has signs and symptoms of disseminated intravascular coagulation​ (DIC). Low-molecular-weight heparin is used to interfere with the clotting cascade and reduce the consumption of clotting factors by uncontrolled thrombosis. Warfarin is not used to treat DIC. Dialysis and amputation are not indicated at this time.

The home health nurse is caring for a client diagnosed with rheumatoid arthritis who was recently widowed. The client remarks that the death of the​ husband, the client is not motivated to cook nutritious meals that only the client will eat. Based on the​ client's remarks, the nurse should be concerned that the client maintains appointments with which interdisciplinary team​ member? A) Grief counselor B) Physical therapist C) Rheumatologist D) Registered dietician

A ​Rationale: The nurse should be concerned that the client maintains appointments with the grief counselor. Families with older adults are at the developmental stage at which the death of a spouse is common. They often need assistance to deal with their​ grief, which can lead to depression. Poor nutrition and lack of exercise can result from the underlying problem of depression. The family consisting of older adults needs coping mechanisms to adjust to​ aging, living​ alone, and the chronic illness that aging often brings. Even when physical ailments are​ treated, a​ family's wellness is at risk if the​ client's emotional,​ social, spiritual, and intellectual health is not addressed.

Which professional would benefit a child with repeated episodes of otitis media who presents with impaired verbal​ communication? A) Speech language pathologist B) Occupational therapist C) Primary healthcare provider D) Physical therapist

A ​Rationale: The speech language pathologist would be best to assist a child in developing better speech patterns and improved verbal communication. Physical therapy helps clients increase mobility and function and decrease pain. Occupational therapy helps to train clients in activities of daily living. The primary healthcare provider coordinates all care.

The nurse concludes that both clotting and bleeding occur during disseminated intravascular coagulation​ (DIC) due to which​ process? A) Excess release of thrombin uses up clotting factors quicker than they can be replaced. B) Only clotting occurs during​ DIC, as clotting factors are replaced and available to prevent excess bleeding. C) Activation of intrinsic pathways results in release of excess clotting factors. D) Tissue damage from bleeding uses up clotting factors quicker than they can be replaced.

A ​Rationale: Widespread activation of either the intrinsic or the extrinsic pathways results in excess release of thrombin. Thrombin and emboli cause tissue and organ damage. Clotting factors are consumed faster than they are​ replaced, leading to excessive bleeding.

Which instructions should the nurse provide the parents of an infant with chronic otitis media in order to prevent future infections? Select all that apply. A) The parents should avoid exposing their infant to tobacco smoke. B) The parent should refrain from allowing the baby to fall asleep with a pacifier. C) The parents should apply warm compresses to the ear daily. D) The parents should position the child supine for all feedings. E) The parents should routinely administer nasal decongestant drops to their infant.

A, B Explanation: • Medications such as a nasal decongestant would have side effects and should be avoided unless specifically needed.• Infants who feed in the supine position have an increased risk of otitis media.• Exposure to secondhand smoke increases incidence of otitis media so this should be avoided to reduce the risk of future episodes of otitis media.• Warm compresses will not prevent future infection.• Preventing the infant from falling asleep with a pacifier will also help because saliva from sucking can accumulate and enter the Eustachian tube.

Before devising an initial plan of care for a client with a chronic medical illness, the nurse should make which assessments of the client?Select all that apply. A) Anxiety level B) Nutritional intake C) Sleep pattern D) Aftercare plans E) Insurance status

A, B, C Explanation: If the client is not receiving adequate sleep, heightened symptoms of illness and psychological distress will occur. Sleep is a basic physiologic need. If the client is not receiving adequate nutrition, heightened symptoms of illness and psychological distress will occur. Nutrition is a basic physiologic need. If the client's anxiety level is significantly elevated, the client will not be able to focus on important information about the plan of care. Additionally, it will create physiologic stress responses that can intensify prior existing medical illness and complicate recovery. The nurse does not typically assess insurance status of clients, as this is responsibility of the medical social worker. Talking about aftercare plans is not appropriate when the nurse is establishing an initial plan of care. This discussion should take place later.

The nurse is assessing a client's coping behaviors during a psychological assessment and wishes to address factors that can contribute to depression. The nurse would ask the client about which priority item(s)?Select all that apply. A) Recent losses B) Number of siblings C) Substance abuse D) Occupation E) Level of income

A, C Explanation: Occupation is of interest when assessing lifestyle but does not directly relate to risk of depression. Substance abuse is of primary interest as a maladaptive coping strategy and is also associated with depression. Number of siblings is demographic information that is not associated with depression. Level of income relates to lifestyle, but not directly to risk for depression. One or more recent significant losses can increase the client's risk for developing depression.

The nurse is observing a client give a return demonstration of the administration of eye drops. Which actions, if taken by the client, indicates an understanding of this procedure?Select all that apply. A) The client pulls the lower lid of the eye down, forming a sac. B) The client cleanses the eye from inner canthus to outer canthus. C) The client instills the medication into the conjunctival sac. D) The client promotes drainage of the medication toward the inner canthus. E) The client cleanses the eyelid with cotton balls moistened with warm tap water.

A, B, C Explanation: The client should pull the lower lid of the eye down, forming a sac. The client should instill the medication into the conjunctival sac. The eye should be cleansed with sterile irrigating solution or sterile normal saline, not tap water, to decrease risk of contamination. The client should cleanse the eye from inner canthus to outer canthus. Drainage of the medication should be directed toward the outer canthus and gentle pressure should be applied to the inner canthus to prevent systemic absorption of the medication.

The nurse is examining the​ client's ear with an otoscope. Which quality of the​ client's tympanic membrane is most appropriate to include in the​ assessment? (Select all that​ apply.) A) Transparency B) Light reflex C) Mobility D) Diameter E) Color

A, B, C, E Rationale: Otoscopic examination includes assessment of the tympanic membrane to include​ color, transparency,​ mobility, presence of​ landmarks, and light reflex. Diameter of the tympanic membrane is not included in otoscopic assessment.

A client has disseminated intravascular coagulation​ (DIC). Which clinical manifestation should the nurse expect to​ observe? (Select all that​ apply.) A) Petechiae B) Clotting C) Bleeding D) Hypertension E) joint pain

A, B, C, E ​Rationale: Manifestations of DIC include​ bleeding, clotting,​ petechiae, and joint pain.​ Hypotension, not​ hypertension, is also a manifestation of DIC.

A client is diagnosed with diabetes mellitus has had multiple hospitalizations as a result of the disease. The​ client's spouse​ states, "I am exhausted. We have both gained weight and have not attended any social engagements since the diagnosis of​ diabetes." Based on the​ spouse's statement, which intervention is appropriate for the nurse to​ implement? (Select all that​ apply.) A) Teach the client and family about healthy forms of stress management. B) Provide resources for family counseling. C) Discuss with the client and family the benefits of exercise for stress relief and health. D) Inform the client and family of a diet center in town that has been successful for many individuals. E) Teach the client and family about healthy eating habits.

A, B, C, E ​Rationale: Providing resources for family​ counseling, nutritional​ teaching, and stress management information and explaining the benefits of exercise are the most appropriate interventions the nurse can implement. The promotion of a specific service is not an appropriate intervention. All referrals should be obtained in collaboration with the healthcare provider.

The nurse is teaching a group of expectant women about situations that increase an​ infant's risk of developing otitis media. Which situation should the nurse​ include? (Select all that​ apply.) A) Down syndrome B) Allergies C) Attending daycare D) Breastfeeding E) Using a pacifier

A, B, C, E ​Rationale: Risk factors for developing otitis media include having​ allergies, attending​ daycare, using a​ pacifier, and having preexisting medical conditions including Down syndrome. Breastfeeding appears to have a protective effect against the development of otitis media

Which instructions should the nurse include when teaching home-care of a child who has bilateral bacterial conjunctivitis? Select all that apply. A) Teach the child to wash hands frequently throughout the day B) Use of warm, moist disposable compresses to remove crusting C) Use of oral antihistamine medication to relieve eye itching D) Teach the parents to administer the antibiotic eye medication E) Use of topical anesthetics applied to relieve discomfort

A, B, D Explanation: • Crusting of dried exudate is common with bacterial conjunctivitis.• The use of antihistamines is not indicated in the management of bacterial conjunctivitis.• The use of topical anesthetics is not indicated in the management of bacterial conjunctivitis.• The parents will need to know how to administer the eye drops or ointment.• Washing the hands frequently will reduce the spread of the infection, which is hand-to-eye and spreads easily to other children.

Which home care measure should the nurse instruct the client to treat​ conjunctivitis? (Select all that​ apply.) A) Avoid reading. B) Wear sunglasses. C) Restrict protein intake. D) Avoid bright light. E) Increase activity.

A, B, D ​Rationale: Home care measures for the client with conjunctivitis include avoiding​ reading, avoiding bright​ lights, and wearing sunglasses. The client does not need to increase activity or restrict protein intake.

The nurse is caring for a child who is grieving the loss of a close grandparent. Which behavior observed by the nurse is a manifestation of the grieving​ process? (Select all that​ apply.) A) Irritability B) Bedwetting C) Increased socialization D) Changes in eating habits E) Changes in sleeping habits

A, B, D, E ​Rationale: Typical behavior changes in​ children, depending upon​ age, during the grieving process include​ regression, bedwetting,​ irritability, anger,​ aggression, changes in eating and sleeping​ habits, guilt, and​ decreased, not​ increased, socialization.

The nurse determined that a client with disseminated intravascular coagulation is experiencing pain. Which intervention should the nurse​ provide? (Select all that​ apply.) A) Handling extremities gently B) Applying cool compresses to painful joints C) Continuously monitoring oxygen saturation and oxygen administration as ordered D) Encouraging frequent turning and coughing E) Using standard pain scale to evaluate and monitor pain and analgesic effectiveness

A, B, E Rationale: Interventions for managing pain include using a standard pain scale to evaluate and monitor pain and analgesic​ effectiveness, handling extremities​ gently, and applying cool compresses to painful joints. Monitoring oxygen saturation and encouraging frequent turning and coughing will not assist the client with treatment of pain. These interventions are more appropriate for promoting effective tissue perfusion.

Which outcome should the nurse expect for a college student with​ conjunctivitis? (Select all that​ apply.) A) Prevents the spread of infection to the other eye B) Uses prescribed medication until symptoms subside C) Demonstrates appropriate hand hygiene D) Experiences no sensory complications E) Ingests 2000 mL of fluid each day

A, C, D Rationale: Outcomes of care for a​ college-age student with conjunctivitis include demonstrating appropriate hand​ hygiene, experiencing no sensory​ complications, and preventing the spread of infection to the other eye. There is no recommended intake of fluid for treatment of conjunctivitis. The client should use the full course of the medication and not stop when the symptoms subside.

The nurse is assessing a client suspected of having chronic disseminated intravascular coagulation​ (DIC). Which finding supports the​ diagnosis? (Select all that​ apply.) A) The client has excessive blood clotting. B) The client has multiple bruises on his skin. C) Development of DIC has taken months. D) The client has a history of cancer. E) The​ client's IV infusion site continues to ooze blood.

A, C, D ​Rationale: Chronic DIC may develop over a period of months or weeks and typically lasts longer. Chronic DIC is not diagnosed rapidly as in the case of the acute form. Excessive blood​ clotting, as opposed to​ hemorrhage, is usually seen with chronic DIC. Cancer is the most common cause of chronic DIC. Multiple bruises and an oozing IV site would be noted most often in clients with acute DIC.

The nurse is preparing an educational program about disseminated intravascular coagulation​ (DIC). Which condition should the nurse include as a risk factor for the development of this​ condition? (Select all that​ apply.) A) Preeclampsia B) Prolonged labor C) Fetal demise D) Septic abortion E) Primigravida

A, C, D ​Rationale: Pregnant clients are at risk for the development of acute DIC from the complications of​ preeclampsia, placental​ abruption, fetal​ demise, amniotic fluid​ embolism, and septic abortion. Prolonged labor and primigravida are not considered risk factors for the development of DIC.

The nurse is caring for a teenage client who was recently fitted for contacts who presents with conjunctivitis. Which risk factor may be associated with this​ adolescent? (Select all that​ apply.) A) improper hand hygiene B) participating in contact sports C) using old eye makeup D) wearing extended - wear contact lenses E) eating a balanced diet

A, C, D ​Rationale: The teenager is at risk of developing conjunctivitis from using old eye​ makeup, as bacteria easily grow in this medium. Performing proper hand hygiene when handling contacts is essential to the prevention of conjunctivitis caused by infection. There is no reason why the teenager who wears contact lenses needs to avoid contact sports. Eating a balanced diet is​ important, but not doing so is not a specific risk factor concerning the wearing of contact lenses. It is imperative that lenses be worn only for the prescribed time in order to avoid possible development of eye irritation or infection.

The parents of a​ 4-month-old infant with otitis media ask the nurse why the healthcare provider did not prescribe antibiotics. Under which parameter would the nurse explain that antibiotics are​ warranted? (Select all that​ apply.) A) Children over 6 months of age B) Pregnant clients in the third trimester C) Children with temperature over 39°C ​(102°​F) D) Adults with acute otitis media E) Children with otalgia for 48 hours

A, C, D, E Rationale: Because of the possibility of developing antibiotic​ resistance, healthcare providers do not prescribe antibiotics for the treatment of otitis media unless the following parameters are​ present: adults with acute otitis​ media, children over the age of 6 months with the presence of otalgia for longer than 48​ hours, or a temperature over​ 39°C (102°F). Antibiotics are not administered for otitis media for pregnant clients because of the risk of fetal harm.

The community health nurse is giving a presentation to a group of new mothers about infant wellness promotion. The nurse teaches about factors that increase an​ infant's risk of developing otitis media. Which item is most appropriate for the nurse to include in the​ presentation? (Select all that​ apply.) A) Pacifier use B) Breastfeeding C) Enlarged adenoids D) Allergic rhinitis E) Down syndrome

A, C, D, E ​Rationale: Factors that may increase an​ infant's risk of developing otitis media include Down​ syndrome, enlarged​ adenoids, allergic​ rhinitis, and pacifier use. Breastfeeding appears to be protective against otitis media.

Which risk factor should the nurse look for while performing an assessment on a client with a diagnosis of disseminated intravascular coagulation​ (DIC)? ​ (Select all that​ apply.) A) Presence of known malignant tumor B) History of diabetes mellitus C) Hematological disorder D) Recent abortion E) History of abnormal bleeding episodes

A, C, D, E ​Rationale: Risk factors include recent abortion​ (spontaneous or​ therapeutic), current​ pregnancy, presence of known malignant​ tumor, history of abnormal bleeding​ episodes, and a history of hematologic disorders. Diabetes mellitus is not considered a risk factor for the development of DIC.

The nurse is assessing a​ 5-year-old client who has recently lost a grandparent. The mother is requesting an antidepressant for the child to help with grieving. Which statement by the nurse is most appropriate in this​ situation? (Select all that​ apply) A) ​"Very few children require medications for​ depression." B) "I agree that an antidepressant is needed.​ I'll speak with your​ physician." C) ​"Antidepressants now could cause additional problems later in your​ child's life." D) "Antidepressants have few side​ effects, so a prescription here could truly be​ beneficial." E) ​"Antidepressants can actually interfere with your child developing their own coping​ mechanisms."

A, C, E ​Rationale: Children who are having trouble working through the grief process typically can benefit from nonpharmacologic options. Therapy or group counseling can be very effective. Most pediatric patients do not require medications for depression. In​ fact, antidepressants may interfere with the​ child's development of coping mechanisms and create additional problems in the future.

The nurse is teaching a course on grieving to new staff members. Which should the nurse include in the presentation as an expected manifestation of​ grief? (Select all that​ apply.) A) Selling the family home B) Becoming distrustful of others C) Having difficulty concentrating D) Experiencing auditory hallucinations E) Moving in with a friend or family member

A, C, E ​Rationale: Selling the family​ home, moving in with a friend or family​ member, and having difficulty concentrating are expected alterations or manifestations of grief. Becoming distrustful of others or experiencing auditory hallucinations are manifestations of complicated grief and require immediate intervention by the healthcare team.

The nurse is caring for a​ 10-year-old child diagnosed with type 1 diabetes. The client is the only child in a​ two-parent nuclear family. The parents of this client would most likely be working on which developmental task in the family​ lifecycle? (Select all that​ apply.) A) Managing increased time commitments B) Learning to manage parental tasks C) Managing the external influences of friends D) Planning for retirement E) Being involved in the​ child's sports,​ school, or clubs

A, C, E ​Rationale: The parents of a child would be working through Stage IV​ (family with​ school-age children). Developmental tasks at this stage of family development are facilitating peer relations and maintaining family dynamics while adjusting to outside influences. At this stage of family​ development, parents are involved with​ school-related activities,​ sports, clubs, and managing the external influences of friends. Learning to manage parenting tasks and responsibilities occurs in Stage II​ (childbearing). Planning for retirement occurs in Stage VII​ (middle-aged parents)

Which finding during an otoscopic exam of the tympanic membrane would confirm the presence of otitis​ media? (Select all that​ apply.) A) Bleeding B) Movement C) Bulging D) Semi-transparent E) Amber color

A, C, E ​Rationale: The tympanic membrane will be​ bulging, have possible​ bleeding, and be amber in color in a client with otitis media. Normal findings in a healthy eardrum include the ability to move and​ semi-transparent in color.

Which clinical manifestation displayed by the child would necessitate the insertion of tympanostomy​ tubes? (Select all that​ apply.) A) Serous otitis media lasting longer than 4 months B) Recurrent episodes of acute otitis media C) Severe otitis media unresponsive to antibiotics D) Barotitis media for those who frequently fly E) Persistent conductive hearing loss

A, E Rationale: The child who has persistent conductive hearing loss or serous otitis media that lasts longer than 4 months is a good candidate for tympanostomy tube insertion. Recurrent episodes of acute otitis media are treated with antibiotics and do not require tympanostomy tube insertion. Tubes are not used for barotitis media.​ Instead, lifestyle modifications are​ incorporated, such as decreasing the amount of flying. Neither antibiotics nor tympanostomy tubes are used in the treatment of severe otitis media.

The nurse is teaching a college student with conjunctivitis ways to prevent the spread of the infection. Which student statement indicates that teaching has been​ effective? (Select all that​ apply.) A) ​"I will not share my towels with anyone at​ school." B) "I will save my eye medicine to use if the other eye gets​ infected." C.) "I will share my eye medication with a friend with the same​ infection." D.) "I will keep my contact lenses in place until the infection​ heals." E.) "I will wash my hands after removing eye​ discharge.

A, E ​Rationale: Ways to prevent the spread of conjunctivitis to the other eye or to other people include not sharing personal items such as towels with others and washing the hands after removing eye discharge. Keeping contact lenses in place until the infection heals could cause the infection to get worse. Medication should not be saved to be used later if the other eye becomes infected. Medication should not be shared with others.

A child has been diagnosed with acute otitis media of the right ear. Which interventions should the nurse include in the plan of care [SATA] A) provide a soft diet B) position the child on the left side C) administer an antihistamine twice daily D) irrigate the right ear with normal saline every 8 hours E) instruct the parents about the need to administer the prescribed antibiotics for the full course of therapy F) administer ibuprofen for fever every 4 hours as prescribed and as needed

A, E, F

The nurse is caring for a client with disseminated intravascular coagulation​ (DIC). Which collaborative therapy should the nurse include in the​ client's care?​ (Select all that​ apply.) A) Monitoring for intracranial bleeding B) Monitoring need for mechanical ventilation C) Monitoring client allergies D) Monitoring intracranial pressure E) Monitoring for organ damage

A,B,D,E ​Rationale: Care of the client with DIC may include mechanical ventilation and control of organ damage from reduced tissue perfusion. Clients with DIC may develop intracranial bleeding resulting in altered levels of​ consciousness, damage to the respiratory​ center, and increased intracranial pressure. Monitoring for client allergies is an independent nursing intervention that would be implemented for all clients.

Disseminated intravascular coagulation​ (DIC) is triggered by an injury or agent that activates the clotting cascade. Which condition should the nurse identify as a trigger for the clotting​ cascade? (Select all that​ apply.) A) Bacterial infection B) Placenta previa C) Acute glomerulonephritis D) Head injury E) Acute leukemia

A,C,D,E Rationale: Tissue damage such as head​ injury, abruptio​ placenta, and acute leukemia can trigger DIC. Vessel damage such as acute glomerulonephritis can trigger DIC.​ Infections, bacterial or​ viral, can also trigger DIC. Placenta previa is not directly associated with DIC.

The mother of a 6 year old child arrives at a clinic because the child has been experiencing itchy, red, and swollen eyes. The nurse notes a discharge from the eyes and sends a culture to the laboratory for analysis. Chlamydial conjunctivitis is diagnosed. On the basis of the diagonosis, the nurse determines that which requires further investigation? A) possible trauma B) possible sexual abuse C) presence of an allergy D) presence of a respiratory infection

B

The nurse teaches a child with conjunctivitis measures to prevent the spread of infection. The nurse concludes that further teaching is needed when the child makes which statement? A) "I will wash my hands frequently." B) "I will carry a handkerchief with me so that I can wipe my eyes during the day." C) "I will use my own washcloth and towel, and not use my brother's." D) "I will use a tissue to clean my eye and then throw the tissue away."

B Explanation: The infected area should be cleansed with a disposable tissue after a single use. Handwashing is important to prevent the spread of infection. Items that come in contact with the infected eye are considered contaminated.

A client reports dizziness and nausea after self-administration of ear drops. After discussing the client's usual medication administration procedure, the nurse determines that which of the following is likely the cause of these symptoms? A) The client warms the medication bottle before administering the medication. B) The client does not warm the medication bottle before administering the medication. C) The client is administering the medication too quickly. D) The client is experiencing a hypersensitivity reaction to the medication.

B Explanation: The internal ear is sensitive to temperature extremes. Administration of cold medication into the ear can cause dizziness and nausea. To avoid these conditions, the client should warm the medication to body temperature before administering the eardrops. This is a correct action to prevent the symptoms noted. The dizziness is unrelated to hypersensitivity. The dizziness is unrelated to speed of administration.

The nurse is assessing a 14-month-old toddler admitted for a bilateral myringotomy and placement of tympanostomy tubes. Which instrument should the nurse use to obtain an accurate temperature? A) A rectal thermometer with disposable plastic sheath. B) A tympanic thermometer with disposable speculum. C) An oral thermometer with disposable plastic sheath. D) A temperature strip placed on the child's forehead.

B Explanation: The tympanic method is preferred because it is quick, accurate, and convenient, even after a myringotomy. An oral temperature can be obtained on a cooperative child age 3 and older. A rectal temperature is obtained as a last resort, when other methods are not possible. A temperature strip on the forehead is not preferred as it may not be the most precise.

The nurse is caring for a client diagnosed with placental abruption who now has disseminated intravascular coagulation​ (DIC). Which statement correctly explains why this client is at risk for​ DIC? A) Amniotic fluid embolism. B) Leaked fluid is similar to a coagulation factor. C) Onset of infection. D) Septic shock due to blood loss.

B Rationale: Leakage of fluid similar to a coagulation factor from a placental abruption can trigger DIC. Onset of infection and amniotic fluid embolism are not the greatest risk. Hemorrhagic shock is caused by blood​ loss, not septic shock.

The nurse is caring for a child diagnosed with sickle cell disease. The child comes to the clinic with the​ child's grandparents and parents for​ follow-up care. In the assessment​ interview, the parents mention that they are both looking for work. Which nursing intervention is most appropriate for this​ family? A) Creating an ecomap with the family B) Facilitating connections with community resources C) Creating a genogram with the family D) Providing care for the child with less family involvement

B Rationale: This family is at risk due to stressors related to serious illness and financial issues. The appropriate nursing intervention would be to facilitate connections with community resources that can assist the family in addressing their immediate​ needs, such as employment. Family ecomaps and genograms are tools to use for assessment to help create a plan of care. Intergenerational family support may be a major strength for this family.

The nurse is planning care for a client who is experiencing overwhelming grief and loss after the death of a parent. Which intervention by the nurse may help reduce the​ client's anxiety? A) Encouraging the client to resume regular activities when ready B) Referring the client to a grief​ therapist, group​ therapy, or bereavement group C) Teaching family members to encourage the​ client's expressions of grief D) Teaching about safe administration and side effects of medications

B ​Rationale: A referral to an individual or group that can provide expert guidance about coping with loss and assistance with linking with additional resources will help this client begin to process grief and help reduce anxiety. Teaching about medications and side effects is appropriate only when the client is prescribed antianxiety or other medications to treat stress. Teaching family members to encourage the​ client's expressions of grief and encouraging the client to resume activities when ready are appropriate interventions to facilitate the​ client's grief work.

Which pharmacologic therapy may be indicated for a client who is diagnosed with postpartum depression following a perinatal​ loss? A) Blood transfusion B) Hormone therapy C) Antibiotics D) Intravenous​ (IV) fluids

B ​Rationale: Antidepressants and hormone therapy are the two choices of pharmacologic therapy used for postpartum depression that can occur after a perinatal loss. Antibiotics would be used for a client that had an infection. IV therapy and a blood transfusion are not appropriate treatment methods for postpartum depression related to perinatal loss.

A​ 36-year-old client recently had an elective abortion. The client does not wish to share this experience with their family members. Which type of grief is this client likely to be​ experiencing? A) Developmental B) Disenfranchised C) Anticipatory D) Complicated

B ​Rationale: Disenfranchised grief occurs when the person is unable to acknowledge the loss to​ others; this is the type of grief that often occurs for clients who have an abortion. Complicated grief occurs when coping strategies have not been successful. Anticipatory grief is grief that is experienced before the event occurs. Developmental​ losses, not​ grief, are associated with development​ stages, such as aging.

Which clinical manifestation should the nurse assess for in a client with a diagnosis of chronic conjunctivitis related to scarring of the conjunctival​ eyelid? A) moderately dilated pupils B) entropion C) blurred vision D) cloudy corneas

B ​Rationale: Entropion develops from chronic conjunctivitis. Entropion causes the lashes and the eyelids to curve inward. Blurred​ vision, cloudy​ corneas, and moderately dilated pupils occur with acute​ angle-closure glaucoma.

A client with a diagnosis of chronic disseminated intravascular coagulation​ (DIC) is being discharged home. Which statement by the client requires the nurse to follow​ up? A) "I should call my healthcare provider if I have excessive​ bleeding." B) "The effects of the disorder will resolve​ completely." C) "I understand home healthcare will visit me to monitor the​ infusion." D) "I will need to be on a portable infusion pump of​ heparin."

B ​Rationale: Even though the immediate crisis is​ resolved, the client may continue to have effects from​ DIC, such as impaired tissue integrity. Subcutaneous injections of heparin or a portable infusion pump may be required. The healthcare provider should be called for excessive bleeding or recurrent clotting. A referral should be made to home healthcare for IV maintenance assistance.

While recovering from​ delivery, the mother of the newborn asks the nurse why the baby needs so much medication to treat a herpes simplex virus of the eye. Which response by the nurse is most​ appropriate? A) "The cornea can​ perforate, and the child will be​ blind." B) ​"Corneal scarring and permanent vision loss can​ occur." C) ​"The eyelashes will fail to​ develop, and the eye will not be​ protected." D) ​"A detached retina can​ occur, and the baby will need​ surgery."

B ​Rationale: Inappropriate treatment of conjunctivitis caused by the herpes simplex virus can cause corneal scarring and permanent vision loss. Gonococcus bacterium conjunctivitis is a medical emergency because the infection can cause corneal perforation. The herpes simplex virus does not cause a detached retina. The herpes simplex virus does not affect eyelash development.

The nurse is caring for a child in the clinic who presented for a wellness visit. The nurse notes that the​ child's father is impatient and speaks sharply to the child. The father mentions that his wife died 6 months ago. Which intervention is most important for the nurse to include during the interview​ process? A) Discussing setting limits with the child B) Assessing for signs of complicated grief C) Encouraging the father to demonstrate more parental warmth D) Providing information regarding parenting styles

B ​Rationale: It is important to assess how the family is coping with the loss to prevent abuse and to promote family competence following this major family alteration. The nurse can provide teaching about healthy coping strategies and facilitate referral to a grief counselor as well as other professional resources. Parenting​ styles, emotional​ availability, family communication​ patterns, discipline, and limit setting are factors that impact family development. These are at play in this parent-child ​interaction, and they should be noted in the​ nurse's assessment.

During a home​ visit, the nurse identifies conjunctivitis in both eyes of a​ 14-day-old infant. Which additional information does the nurse need to determine the cause of this​ infant's eye​ infection? A) Frequency that the infant breastfeeds B) Results of​ mother's testing for sexually transmitted infections C) Detergent that is used to clean the​ baby's clothing D) Type of shampoo that is being used on the infant

B ​Rationale: Ophthalmia neonatorum is conjunctivitis that develops in an infant under the age of 30 days. It is usually acquired from coming in contact with vaginal discharge with bacterial organisms such as Chlamydia trachomatis and Neisseria gonorrhoeae during a vaginal delivery. The nurse needs to review results of the​ mother's screening for sexually transmitted infections to determine the cause of this​ infant's conjunctivitis. Frequency of​ breastfeeding, type of​ shampoo, and detergent used will not help determine the cause of the​ infant's conjunctivitis.

The nurse suspects that a patient who has severe sepsis now has disseminated intravascular coagulation​ (DIC). Which​ finding, if​ observed, helps confirm this​ suspicion? A) Polyuria B) Petechiae C) Bradycardia D) Clear breath sounds

B ​Rationale: Petechiae is a symptom of DIC due to the impaired clotting mechanism leading to bleeding and impaired tissue perfusion. Oliguria or anuria would be​ expected, as would tachycardia. Decreased breath​ sounds, tachypnea, and pleural friction rub are clinical manifestations of DIC.

The nurse is assessing a client suspected of having acute disseminated intravascular coagulation​ (DIC). Which assessment finding supports the​ diagnosis? (Select all that​ apply.) A) A history of a malignant tumor B) Pale, cool extremities C) Bleeding at the IV insertion site D) Multiple bruises on various skin surfaces E) A history of thyroid disease

B, C, D Rationale: Bleeding may result in multiple bruises on various skin surfaces and mucous membranes. Puncture sites such as those from injections or intravenous infusions may ooze blood when a client has DIC.​ Pale, cool extremities may be noted when a client is bleeding because blood is diverted back to major organs to maintain oxygenation. History of a malignant tumor supports the diagnosis of chronic DIC. Thyroid disease is not a known risk factor for acute DIC.

The nurse is performing an assessment on a newly admitted client with cancer to a nursing care facility. Which observation leads the nurse to suspect the client has acute​ conjunctivitis? (Select all that​ apply.) A) dry eyes B) reddened eyes C) mucoid discharge D) itchy eyes E) photophobia

B, C, D, E Rationale: Manifestations of acute conjunctivitis include itchy​ eyes, photophobia, reddened​ eyes, and watery or mucoid discharge. Dry​ eyes, though often a complaint of an older​ adult, is not an observation made for the diagnosis of conjunctivitis. Next Question

A client with bacterial conjunctivitis is experiencing copious amounts of purulent eye drainage. Which treatment should the nurse expect to be prescribed for this​ client? (Select all that​ apply.) A) topical antihistamines B) eye irrigations C) antibiotic eye drops D) eyelid soaks E) warm clean cloths

B, C, D, E ​Rationale: Eyelid soaks before cleansing promote comfort and aid in the removal of crusts and exudate. Eye irrigations remove copious purulent secretions. Warm clean cloths assist with the removal of drainage. Antibiotic eye drops are prescribed for clients experiencing bacterial conjunctivitis. Topical antihistamines are used for allergic conjunctivitis.

The nurse preceptor is teaching a new graduate nurse about the plan of care for the adult client experiencing acute otitis media. Which class of medication should the nurse include as the most appropriate class of pharmacologic agents commonly used to treat the adult client with otitis​ media? (Select all that​ apply.) A) Anesthetics B) Antipyretics C) Antibiotics D) Antihistamines E) Analgesics

B, C, D, E ​Rationale: Treatment of acute otitis media in the adult client commonly includes antibiotic therapy. Pharmacologic measures used for symptomatic relief may include​ analgesics, antipyretics, and antihistamines. For treatment of acute otitis media in the pediatric​ client, topical anesthetic eardrops may be prescribed for pain relief if the tympanic membrane is intact.

The nurse is preparing instructions for a client diagnosed with viral conjunctivitis. Which should the nurse include in this​ teaching? (Select all that​ apply.) A) Soak the eyelids with a warm cloth. B) Wash hands after touching the eyes. C) Use a wet cloth to remove eye drainage. D) Apply cool compresses. E) Avoid bright lights.

B, C, D, E ​Rationale: Treatment of viral conjunctivitis includes using cool​ compresses, avoiding bright​ lights, using infection control techniques such as washing hands after touching the​ eyes, and removing eye discharge with a wet cloth. Soaking the eyelids with a warm cloth is part of the treatment for bacterial conjunctivitis.

The nurse is evaluating the lab results for a client suspected of having disseminated intravascular coagulation​ (DIC). Which laboratory finding supports the​ diagnosis? (Select all that​ apply.) A) Elevated hemoglobin B) Increased fibrin degradation products C) Decreased platelet count D) The presence of schistocytes E) Shortened prothrombin time

B, C, DX ​Rationale: Laboratory findings that support a diagnosis of DIC include the presence of​ schistocytes, a decreased platelet​ count, and an increase in fibrin degradation products or fibrin split products. The client with DIC would not have an elevated hemoglobin or shortened prothrombin time

The nurse is caring for an infant experiencing a third incidence of otitis media in 6 months. Which question should the nurse ask the parents to determine the cause of these​ infections? (Select all that​ apply.) A) "Have you noticed any bleeding or ear​ drainage?" B) "Do you or anyone else in your house​ smoke?" C) "In what position do you hold the baby to​ eat?" D) "Has your baby been more irritable​ lately?" E) "Do you breastfeed or​ bottle-feed your​ infant?"

B, C, E ​Rationale: An infant who is exposed to cigarette smoke is at higher risk of developing otitis media. The position of the infant during feedings can cause otitis media. Babies should be positioned upright to prevent feedings from refluxing into the eustachian tubes. Breastfeeding provides more immune properties and decreases the risk of otitis media. Increased irritability and bleeding or ear drainage are clinical manifestations of otitis media. They are not preventive measures.

The nurse is caring for a client who is recently divorced. Which intervention is appropriate when divorce alters a family​ structure? (Select all that​ apply.) A) Being alert to signs of intense grief reactions B) Teaching the client about the importance of health maintenance and nutrition C) Discussing healthy coping mechanisms for stress D) Considering the nature of the loss E) Providing information about counseling and support groups

B, C, E ​Rationale: Family-focused interventions that are appropriate when divorce alters the family include discussing healthy coping mechanisms for​ stress, providing information about counseling and support​ groups, and providing teaching about the importance of health maintenance and nutrition. Nursing assessments include considering the nature of loss and being alert to the signs of intense grief reactions.

The nurse is working with a family whose father passed away and discovers that the​ 9-year-old child is worried that the other parent may die. Which behavior noted in the child supports this​ finding? (Select all that​ apply.) A) The child enjoys going to school every day B) The child sleeps in the​ parent's bed at night C) The child goes over to​ friends' houses to play D) The child prefers to stay at home all the time E) The child stays awake at night to watch the parent sleep

B, D, E ​Rationale: Children who have lost a parent become worried that they will lose the other parent. Their behaviors center on spending time with the remaining​ parent, including sleeping in the​ parent's bed, staying home all the​ time, and staying awake at night to watch the parent sleep. Enjoying going to school and​ friends' houses do not indicate a fear of losing the other parent.

What is the most appropriate intervention by the nurse who is caring for an infant with acute otitis media and a fever of 39.3°C (102.7°F)? A) Provide sponging with cool water to reduce fever. B) Encourage the baby's intake of solids to maintain adequate caloric intake. C) Offer fluids frequently to prevent dehydration. D) Swaddle the baby in layers of blankets to promote comfort and prevent chills.

C Explanation: It is contraindicated to sponge with cool water, which could lead to shivering and higher temperature. Intake of solid food is less important than preventing dehydration. A febrile infant will experience higher fever if blankets are added. A febrile infant is at risk for dehydration from larger-than-normal insensible fluid losses.

What should the nurse include in the teaching plan for the parents of an infant with acute otitis media? A) Antibiotics can be discontinued when the infant is afebrile. B) Orange juice and other fruit juices should be eliminated from the diet. C) When bottle-feeding, the infant should be maintained in an upright position. D) Cigarette smoke in the home is not a significant risk factor in acute otitis media.

C Explanation: The full 10- to 12-day course of antibiotic therapy must be administered. A higher incidence of acute otitis media is noted in infants who are bottle-fed in a horizontal position. There is no relationship between the ingestion of fruit juices and acute otitis media. A higher incidence of acute otitis media is noted in infants who live in homes with smokers.

The nurse working in an ambulatory surgery center would instruct the client to avoid which activity after undergoing a myringotomy? A) Softball B) Gardening C) Swimming D) Bowling

C Explanation:Activities such as gardening that do not risk water getting into the surgical ear are acceptable and pose no risk to the client. Myringotomy is a surgical procedure that perforates the tympanic membrane to allow drainage from the middle ear. Postoperatively, the client should avoid getting water into the ear canal, which could potentially enter the middle ear. Activities such as softball that do not risk water getting into the surgical ear are acceptable and pose no risk to the client. Activities such as bowling that do not risk water getting into the surgical ear are acceptable and pose no risk to the client. Prev Next Reset Notes Answer Review Save Exam Grade Exam

At the conclusion of a fluorescein​ stain, a client is diagnosed with conjunctivitis. Which test result should the nurse expect to be documented in the​ client's medical​ record? A) fluorescein stain orange B) Fluorescein stain yellow and blue C) Fluorescein stain green D) Fluorescein stain absence of color

C Rationale: A fluorescein stain uses a slit lamp to identify the presence of corneal ulcerations or abrasions. These injuries will appear green when stained. There will be an absence of color in conjunctivitis. The fluorescein stain does not cause areas of injury to turn​ orange, yellow, or blue.

A client presents to the clinic with inflammation of the inner ear. How should the nurse communicate this condition to​ colleagues? A) ​"Otitis externa" B) "Otitis media" C) "Labyrinthitis" D) "Swimmer's ear"

C Rationale: Inflammation of the inner ear is called otitis​ interna, or labyrinthitis. Inflammation of the middle ear is referred to as otitis media. Inflammation of the ear canal is called otitis​ externa, or​ swimmer's ear.

Which pathogen is the most common causative agent of otitis​ media? A) Escherichia coli B) Pseudomonas aeruginosa C) Streptococcus pneumoniae D) Methicillin-resistant Staphylococcus aureus ​(MRSA)

C Streptococcus pneumoniae is the most common cause of otitis media. Others include Haemophilus influenzae and Moraxella catarrhalis. Escherichia​ coli, Pseudomonas​ aeruginosa, and MRSA cause other infections such as urinary tract or wound infections.

The nurse is caring for an infant with ventricular septal defect​ (VSD) with a very small opening. Which treatment does the nurse anticipate the child will​ require? A) Administration of prostaglandin E1 B) Oral propranolol C) Monitor with periodic echocardiograms D) Surgery to patch the hole

C ​Rationale: Most small VSDs close spontaneously within the first 6 months of life. Treatment is​ conservative, such as watching and​ waiting, when there are no other complications present. Patching is not necessary with a small defect. Propranolol is not administered for​ VSD, but to manage a hypercyanotic episode. Prostaglandin E1 is used to maintain an open patent ductus arteriosus to encourage oxygenation in an infant.

The parents of a child present to the urgent care center reporting the child is tugging on the right ear. Which question should the nurse ask to determine the​ cause, based on the​ parents' observation? A) "Did your child receive the influenza​ immunization?" B) "Does your child drink from a bottle or sippy​ cup?" C) "Has your child had an upper respiratory​ infection?" D) ​"When did you first notice the symptoms​ start?"

C ​Rationale: Upper respiratory infections are a causative factor for the development of otitis media in children because of the angle of the eustachian tubes.​ So, the nurse should ask about recent upper respiratory infections. It is important for the nurse to ask when the symptoms​ began, but this will not determine the cause. Drinking from a bottle rather than a sippy cup does not lead to otitis media. Bottle feeding at night is a risk factor for frequent infections. Whether or not the child has received the flu vaccine is not a causative factor for otitis media.

Which statement by the client indicates a need for further teaching about how to care for contact lenses to prevent​ conjunctivitis? A) "I need to clean the contact lens container every​ day." B) "I should rinse the contacts with sterile​ saline." C) ​"It is okay to sleep with the contacts in​ occasionally." D) ​"It is necessary to wash my hands before touching the​ contacts."

C ​Rationale: When the client states it is okay to occasionally sleep with the contacts in​ place, this is inaccurate and requires correction. The statements of rinsing the contacts with sterile​ saline, cleaning the contact lens container​ daily, and washing hands before touching the contacts are correct and do not require more teaching.

Which measures would be beneficial for the nurse to include in collaborative management of a client who has conjunctivitis? Select all that apply. A) Cold eye compresses B) Opioid analgesics C) Antibiotic therapy D) Dark sunglasses E) Careful handwashing

C, D, E Explanation: • Warm compresses, not cold, should be used as part of the management of conjunctivitis. Warm compresses help relieve discomfort and reduce inflammation by increasing circulation to the area.• Careful hand hygiene is effective in reducing the risk of transmitting the infection to others.• Antibiotic therapy kills the bacteria that are responsible for the eye infection.• Dark sunglasses are helpful in reducing photophobia.• Although there is eye discomfort, there is no need for strong analgesics such as opioid

Which information should the nurse plan to include for a teaching session regarding health promotion and prevention of otitis media with a group of new​ mothers? (Select all that​ apply.) A) "Encourage pacifier​ use." B.) "Use child care​ centers." C) "Know signs of ear​ infection." D) "Promote breastfeeding." E) "Keep infants away from​ smoke."

C, D, E Rationale: The nurse should instruct parents to report signs of otitis​ media, such as ear​ tugging, fever, increased​ irritability, and poor appetite. Breastfeeding decreases the risk of otitis media.​ Therefore, the nurse would promote breastfeeding over bottle feeding.​ Second-hand smoke exposure can cause otitis media in children. The nurse should instruct the parents to smoke outside the buildings in which the child is staying. Child care centers have greater numbers of​ children, and otitis media can spread more easily. It is better to use​ in-home child care. Pacifier use increases the incidence of otitis​ media; therefore, the nurse would discourage the use of pacifiers. Next Question

The nurse educator is teaching a class about pharmacologic agents that are used in the prevention and treatment of otitis media in children. Which statement is most appropriate to​ include? (Select all that​ apply.) A) ​"Oral prednisone is always​ prescribed." B) "Treatment always includes​ antibiotics." C) ​"Vaccines may help reduce the risk of developing otitis​ media." D) ​"Amoxicillin is the drug of choice for treatment of pediatric otitis​ media." E) "Topical anesthetic eardrops may be​ prescribed."

C, D, E ​Rationale: Treatment of acute otitis media in children may or may not include antibiotics. If antibiotics are​ indicated, amoxicillin is the​ first-line therapy for children. Topical anesthetic eardrops may be prescribed for pain relief if the tympanic membrane is intact. Immunizations such as the Haemophilus influenzae type B​ (Hib) vaccine and pneumococcal vaccine appear to decrease the incidence of otitis media caused by these pathogens. Treatment of serous otitis media may include an​ anti-inflammatory drug​ (for example, oral prednisone for 7​ days) to reduce mucosal edema of the eustachian tube.

The nurse refers the family of a terminally ill client to a grief support group. The nurse explains that such groups provide members opportunity for which of the following?Select all that apply. A) Elimination of intense emotions B) Recognition of interpersonal difficulties with the client C) Increased social connectivity D) Decreased feelings of loss E) Increased opportunity for expression of emotions

C, E Explanation: It is likely that increased social connectivity would result in increased social support, since the other persons in the group would also be dealing with grief issues. The work of grieving is best accomplished in a compassionate and supportive emotional environment. Grief support groups are aimed at helping a person to recognize, express, and cope with strong emotions, not eliminate them. Grief support groups are aimed at helping a person to recognize, express, and cope with strong emotions. It is normal for a grieving person to feel intense emotions. Feelings of loss are normal in grief responses. Grief groups acknowledge this and support healthy expression of these feelings, which must be fully expressed and dealt with so the person can progress healthily through all stages of grieving. Grief counseling does not focus on the deceased, but rather on the survivor and the survivor's coping.

The client has been diagnosed with a life-changing medical illness. When planning care for this client, the nurse should give priority to assessing for which of the following as part of the process of grief and loss? A) Apathy B) Euphoria C) Anorexia D) Anger

D Explanation: Anger is included in the stages of mourning, as clients grieve for what has been lost. Although clients may experience multiple emotional feelings in response to the diagnosis of a life-changing medical illness, anger is one of the most common ones because of the sudden and often dramatic change in lifestyle. Anorexia might occur but is not considered a stage of grief and mourning that the client could be expected to go through after hearing of a life-changing illness. Apathy might occur but is not considered a stage of grief and mourning that the client could be expected to go through after hearing of a life-changing illness. Euphoria is not a manifestation of grieving; this finding would be expected as part of bipolar disorder.

A 15-month-old child diagnosed with conjunctivitis has been prescribed an antibiotic ointment. In teaching the mother to administer this drug, the nurse should recommend which technique? A) Wait until the child is asleep to instill the ointment. B) Use sterile gauze to apply the ointment to the lids. C) Place the ointment on a swab and spread across closed lids. D) Mummy the child to prevent accidental injury.

D Explanation: Applying ointment to the eyes of a sleeping child would increase the child's fears. Children at 15 months of age cannot understand the necessity of cooperating with medication administration. Mummying the child reduces the risk of injury from the ointment tip and promotes adequate dosing. The ointment is instilled in the lower conjunctival sac, not on the lids. The medication is squeezed from the tube, not applied with gauze.

The nurse visits the home of a child with bilateral bacterial conjunctivitis. What should the nurse emphasize when teaching the parent about the care of the child? A) Instill ophthalmic corticosteroid medication to reduce inflammation B) Instill topical anesthetic drops to relieve discomfort C) Administer oral antihistimine medication to relieve eye itching D) Use warm, moist, disposable compresses to remove crusting

D Explanation: Crusting of dried exudate is common with bacterial conjunctivitis and it is important for the child's vision and safety that the crusts are removed. Warm, moist wipes aid in comfort and they need to be disposable to reduce the risk of transmitting the infection to others in the home. Oral antihistamines are not needed to manage bacterial conjunctivitis. Ophthalmic corticosteroids are not used to decrease the inflammatory response, although antibiotics will be used to kill the bacteria. Topical anesthetics are not needed to manage eye discomfort.

Which action is appropriate when the nurse administers an opthalmic medication to a client? A) Rub the eye with a cotton ball after instillation. B) Wait 10 seconds between drops. C) Drop the medication onto the eyeball. D) Apply pressure to the inner canthus while administering the medication.

D Explanation: The medication should be dropped into the lower conjunctival sac. The nurse should apply pressure to the inner canthus (nasolacrimal duct) for at least 30 seconds after instillation, according to agency procedure, to prevent systemic absorption of the medication. The eye should not be rubbed after instillation of the medication. The nurse should wait from 1 to 5 minutes between drops, depending on the medication and manufacturer's recommendations.

Which action, if observed by the nurse, demonstrates appropriate client technique for self-administering an ophthalmic medication? A) Administers two different ophthalmic solutions 2 minutes apart. B) Administers ophthalmic ointment 2 minutes after ophthalmic solution. C) Administers ophthalmic solution 5 minutes after ophthalmic ointment. D) Administers two different ophthalmic solutions 5 minutes apart.

D Explanation: The recommended wait time between administrations of two ophthalmic solutions is five minutes. If an ophthalmic ointment is instilled, the waiting time is ten minutes between the ointment and the next medication. After an ophthalmic solution is instilled, the waiting time is five minutes between the solution and the next medication.

Which is the priority in nursing assessment of the client prior to administering the first dose of an ophthalmic medication? A) The client's eye and vision status B) The client's understanding of the action of the medication C) The understanding of the purpose of the medication D) The client's history of hypersensitivity to medication

D Explanation: This is important to the nursing assessment of the client; however, avoiding reactions to the medication is the priority. Assessment of allergies and reactions to medications is essential when administering a new medication. Hypersensitivity responses can occur with ophthalmic medications, and severe adverse reactions can occur with hypersensitivity to the medication, because it is systemically absorbed.

The nurse is caring for an adult client with acute otitis media and plans to develop a teaching plan on the prevention of further infections. Which assessment increases the​ client's risk of otitis​ media? A) Recent bout of basilar pneumonia B) Frequent flying for business trips C) Receipt of recommended vaccinations D) Swimming and water activities

D Rationale: Any activity that increases exposure to​ water, such as swimming and water​ activities, can lead to acute otitis media. Frequent flying increases the risk of barotitis​ media, not acute otitis media. Upper respiratory infections such as bronchitis increase the risk of acute otitis media. These would not include lower respiratory infections such as pneumonia. It is important to receive recommended vaccinations to help prevent otitis media.

The nurse is caring for a​ 7-year-old child whose older sibling passed away. Which response should the nurse monitor in the​ child? A) Loss of independence may occur B) Loss often includes a loss of health C) Loss becomes a part of normal development D) Loss may impair development

D ​Rationale: A child who experiences a loss may have developmental impairments. The other descriptions reflect the ways in which grief can affect​ adults, not children

The nurse is developing a plan of care for the child who has experienced multiple episodes of otitis media and now presents with conductive hearing loss. Which goal would be appropriate for this​ child? A) The child will report relief of pain after treatment. B) The child will be​ infection-free after completion of treatment. C) The caregivers will administer medications as prescribed. D) The child will have normal motor and language development.

D ​Rationale: A child with new conductive hearing loss should still meet developmental milestones for growth and development. These include normal motor and language development. Receiving pain relief and being​ infection-free after treatment are goals related to otitis​ media, but not related to conductive hearing loss. Encouraging caregivers to administer medications appropriately is an important​ goal; however, it is unrelated to hearing los

The emergency department nurse is caring for an infant with suspected bacterial conjunctivitis. Which collaborative intervention should the nurse prepare to​ perform? A) administering NSAID B) obtaining a chest x ray C) establishing IV access for antibiotic therapy D) gathering a culture of the eye discharge

D ​Rationale: Culture and sensitivity testing is likely to be completed on the infant with suspected bacterial conjunctivitis in order to establish the culprit organism and treat with the best indicated antibiotic. There is no indication that a chest​ x-ray is needed. Nonsteroidal​ anti-inflammatory drugs are used for the discomfort of allergic conjunctivitis. Antibiotic therapy will be​ topical, not intravenous.

The nurse is caring for a client with suspected disseminated intravascular coagulation​ (DIC). Which diagnostic test result supports the diagnosis of​ DIC? A) Increased platelet count B) Decreased​ D-dimer C) Decreased fibrin degradation products D) Normal fibrinogen levels

D ​Rationale: Fibrinogen levels may be normal or even decreased in circumstances where elevated levels are expected.​ D-dimer will be elevated in both acute and chronic DIC. Decreased platelet count and the presence of schistocytes on the CBC indicate DIC. Fibrin degradation products will be increased as a result of fibrinolysis.

A client presents with bleeding behind the tympanic membrane. Which term should the nurse use when documenting this​ condition? A) Myringotomy B0 Vertigo C) Insufflation D) Hemotympanum

D ​Rationale: Hemotympanum refers to bleeding into or behind the tympanic membrane. Vertigo refers to a sensation of whirling or rotating. Insufflation is the introduction of air into a body region or​ cavity, such as the ear. A myringotomy is a surgical procedure that involves incision of the tympanic membrane.

Which therapy will the healthcare provider prescribe for the client with chronic disseminated intravascular coagulation​ (DIC)? A) Fresh frozen plasma B) Aspirin regimen C) Whole blood D) Heparin

D ​Rationale: Heparin may be administered by continuous infusion using a portable pump if needed for​ long-term therapy, as in the client with chronic DIC. OK

The nurse is conducting a support group for parents who have experienced the loss of a child. The clients are talking among themselves. Which behavior noted by the nurse indicates that a client is experiencing complicated​ grief? A) The client has difficulty concentrating and staying on task B) The client reports eating only​ 25% of meals C) The client verbalizes having difficulty sleeping D) The client talks to people who​ aren't there

D ​Rationale: Individuals with complicated grief may experience auditory hallucinations. Sleep​ disturbances, loss of​ appetite, and difficulty concentrating are symptoms of normal grief

Which clinical manifestation should the nurse expect when caring for a child with acute otitis​ media? (Select all that​ apply.) A) Increased mobility of tympanic membrane B) Increased appetite C) Slow onset of symptoms D) Pulling at ear E) Bulging tympanic membrane

D, E Rationale: Acute otitis media typically has a fast onset. Manifestations of acute otitis media in children may include pulling at the affected ear and poor feeding. On otoscopic​ examination, findings associated with acute otitis media include a bulging tympanic membrane that demonstrates decreased mobility or immobility.

Which intervention should the nurse suggest to the parents of a toddler with recurrent​ conjunctivitis? A) Admonish the toddler for rubbing. B) Have the toddler wear sunglasses when outside. C) Ask for oral antibiotics instead of eye drops. D) Place mittens on the toddler.

​D Rationale: A toddler may not understand the importance of not wiping his or her eyes to prevent infection spread.​ Therefore, the nurse would instruct the parents to put mittens on the toddler and could even make it a game. The nurse would not instruct the parents to admonish the​ child, as a toddler may not understand why this cannot be done. Conjunctivitis is treated with antibiotic eye drops. Systemic antibiotics are not effective. Sunglasses may help provide​ comfort, but they do not prevent spread of conjunctivitis.