Unit 7 - 2nd sem lifespan final

The nurse is planning care for a child with respiratory syncytial virus (RSV) bronchiolitis. Which interventions should the nurse include in the child's plan of care to address the nursing diagnosis Impaired Gas Exchange? (Select all that apply.) A. Administer oxygen as prescribed. B. Monitor vital signs and pulse oximetry. C. Provide frequent rest periods. D. Weigh daily. E. Weigh diapers

A, B

During a home​ visit, the nurse assesses a​ 2-year-old child. Which factor should the nurse identify as putting the child at risk for contracting respiratory syncytial virus​(RSV)? (Select all that​ apply.) A. Both parents work low-paying jobs. B. The toddler shares a drinking cup with older brother. C. Both parents smoke cigarettes. D. The toddler watches television 4 hours a day. E. The toddler wears clean but rumpled pants and shirt.

A, B, C

The nurse is planning care for the parents of an infant who died as the result of sudden infant death syndrome. Which collaborative interventions does the nurse plan for when providing care to these parents? (Select all that apply). A. A psychosocial assessment B. A visit from the chaplain C. A grief counselor referral D. A psychotherapist referral E. A respiratory therapist referral

A, B, C, D

The nurse prepares a teaching tool about substance abuse in older adults. Which information should the nurse​ include? (Select all that​ apply.) A. Depression and alcohol abuse are disorders frequently found in clients who completed suicide. B. Older people are more likely to use prescription medicines. C. Alcohol and other substances can make it difficult to diagnose medical problems. D. Individuals can have substance abuse problems at any age. E. is more likely to be recognized in older adults.

A, B, C, D

Which types of prescription medications have high potential for abuse. SATA A. benzodiazapines B. amphetamines C. sedatives/hypnotics D. NSAIDS E. opioids

A, B, C, E

An older adult client is admitted with pneumonia. Which manifestations would the nurse expect to find when assessing this client? (Select all that apply). A. Tachypnea B. Fever C. Increased appetite D. Cough E. Head, body, and muscle aches

A, B, D

A client is admitted with injuries sustained from a domestic dispute. When planning care, the nurse will include which short-term interventions? Select all that apply. A. Determine immediacy of danger. B. Improve quality of life by increasing self-esteem. C. Explore options for self-development. D. Explore options for help. E. Convey safety.

A, D, E

Which of the following are schedule I drugs with no current approved medical use? A. MDMA B. Amphetamines C. Barbiturates D. Cocaine E. PCP F. LSD

A, E, F

The nurse is planning care for a pregnant client with a substance abuse disorder. Which intervention should the nurse identify to specifically address imbalanced nutrition in this​ client? (Select all that​ apply.) A. Monitor meal intake. B. Monitor vital signs daily. C. Educate on negative effects of substances on fetal health. D. Educate on negative effects of substances on body. E. Assess for signs of infection. F. Obtain daily weight.

A, F Rationale: Weighing the client and monitoring meal intake are appropriate interventions for a client with a nutritional deficit. Assessment of signs of infection and vital signs would be appropriate for a risk for infection. The client has a potential for enhanced knowledge when educated on the effects of substance use on the body and on fetal​ health, but they are not related to nutrition imbalances.

The nurse is providing discharge teaching to a client recovering from pneumonia. Which client statement indicates that additional teaching is needed? A. "The pneumococcal vaccine protects against bacterial pneumonia." B. "I will get the influenza vaccine every year." C. "I will get the pneumococcal vaccine every fall." D. "I can't get the influenza vaccine due to my allergy to eggs."

C. "I will get the pneumococcal vaccine every fall."

The nurse is interviewing a client and assessing risk for abuse and violence. Which of the following clients has the highest risk? A. 69 yo M, living in an assisted living center B. 5 yo M, that recently had a sibling born C. 20 yo F, that is pregnant with an alcoholic boyfriend D. 38 yo F, in a same-sex relationship

C. 20 yo F, that is pregnant with an alcoholic boyfriend

An infant with respiratory syncytial virus (RSV) bronchiolitis is prescribed intubation to maintain an adequate airway. Who will the nurse collaborate with to maintain the endotracheal tube and ventilation? A. A play therapist B. The primary healthcare provider C. A respiratory therapist D. An advanced practice nurse

C. A respiratory therapist Infants who need endotracheal intubation will be closely cared for by the respiratory therapist. The advanced practice nurse, primary healthcare provider, and play therapist are not responsible for maintaining the client's endotracheal tube and ventilation.

What is the primary rationale for maintaining adequate hydration in clients with pneumonia? A. It helps maintain urine output to clear toxins from the blood. B. It helps increase blood pressure to maintain perfusion to vital organs. C. It helps keep the airway clear by making secretions easier to expectorate. D. It helps keep the mucus membranes moist to prevent further infection.

C. It helps keep the airway clear by making secretions easier to expectorate. Maintaining adequate hydration can help in all four of these areas depending on the nature of the client's condition. However, for clients with pneumonia, the most important reason to maintain adequate hydration is that this helps keep secretions in the lungs thin, which makes them easier to expectorate. This helps keep the airway clear, which is a priority for clients with pneumonia.

The mother of a 5-month-old baby, who attends daycare, is concerned because the child has developed a runny nose, cough, and low-grade fever over the last few days. These symptoms are consistent with which condition? A. Common cold B. Meningitis C. Respiratory syncytial virus (RSV) bronchiolitis D. Bronchitis

C. Respiratory syncytial virus (RSV) bronchiolitis The typical clinical presentation of respiratory syncytial virus (RSV) bronchiolitis in otherwise healthy children begins 3-5 days after exposure to the virus. The early signs of a mild infection include rhinorrhea or a runny nose, cough, irritability, and a low-grade fever for 1-3 days. A fever is not associated with the common cold. A runny nose and cough are not symptoms associated with meningitis. Bronchitis has a distinctive cough and may or may not be associated with a fever.

What information should the nurse include when teaching parents of pediatric clients about ways to decrease the spread of influenza? (Select all that apply.) A. The importance of withholding immunizations for children with compromised immune B. "Cover your cough" education C. Where to obtain the influenza vaccine D. An explanation of appropriate hand hygiene E. Methods for safe food preparation and storage

B, C, D

The nurse is working in a primary care setting. Which clients should the nurse identify as being at high risk for influenza or its complications? (Select all that apply). A. A 35-year-old man with a severe allergy to eggs B. A 3-year-old with cystic fibrosis C. A 20-year-old healthcare worker D. A 25-year-old pregnant woman at 20 weeks' gestation E. A 65-year-old woman

B, C, D, E

Which is true of abuse regardless of the specific type? (select all) A. abuse is limited to actual and visible injury B. it's often associated with substance abuse C. the abused person will seek help when they are injured D. it's about power and control E. the perpetrators are always male

B, D

Which child has a risk factor for developing otitis media? (Select all that apply.) A. A 14-year-old child who lives on a farm. B. An 18-month-old child who attends daycare while his parents work. C. A newborn that is breastfeeding exclusively. D. A 10-year-old child who plays baseball and soccer. E. A 5-year-old child who stays with her grandmother who smokes.

B, E

A toddler with otitis media is prescribed amoxicillin clavulanate 250 mg/5 mL three times daily by mouth for 10 days. What should the nurse teach the mother about this medication? A. "It is OK to stop the antibiotic if the child begins to feel better." B. "Give the antibiotic for the full 10 days as prescribed." C. "It is important to measure the prescribed dose in a household teaspoon." D. "Be sure to administer a double loading dose of the medication when you get home."

B. "Give the antibiotic for the full 10 days as prescribed."

The nurse is reviewing diagnostic and laboratory studies performed for a client with influenza. Which result should the nurse recognize as being consistent with influenza? A. Decreased sodium level B. Decreased white blood cell count C. Fluid-filled lungs on chest x-ray D. Increased BUN

B. Decreased white blood cell count

The nurse is collecting health information when a client states that they have had frequent thoughts of suicide. What follow-up question would help identify the level of risk for this person? A. Are there stressors in your life? B. Do you have a plan to commit suicide? C. How would suicide help your situation? D. How long have you felt this way?

B. Do you have a plan to commit suicide?

A teen aged female presents to the Emergency Department in the early morning hours with a friend. The patient is lethargic, febrile, and tachycardic. The friend states that she thinks her friend was sexually assaulted at a party that night. What are the highest priority interventions for the nurse to perform? A. Apply painful stimulation to assess LOC and administer IV fluids B. ECG, IV, and regulate body temperature C. Give antipyretic medication and prepare for a sexual assault examination D. Gather more information about the assault from the client and notify police

B. ECG, IV, and regulate body temperature

Hallucinogenic Mushrooms are know to have which long lasting effect? A. Fungal infections B. Flashbacks and psychosis C. Drowsiness and CNS depression D. Tremors and ataxia

B. Flashbacks and psychosis

A client is "dropped off" at the Emergency Department by an unknown bystander. The client is unconscious with a respiratory rate of 4 breaths per minute. Pupils are dilated and slow to respond to light. The nurses suspects a potential drug overdose. After providing ventilatory support and obtaining IV access the nurse then plans on which emergent intervention? A. Give nitroglycerin (Nitro-Bid) 0.4 mg SL B. Give naloxalone HCL (Narcan) 0.4 mg IVP C. Give epinephrine 1 mg IVP D. CPR beginning with chest compressions

B. Give naloxalone HCL (Narcan) 0.4 mg IVP

A client is admitted to the emergency department after overdosing on phencyclidine (PCP). Based on this information, which nursing action is appropriate? A. Restrain client and alert security. B. Initiate seizure precautions and give benzodiazapines C. Obtain an ECG and establish IV access D. Perform gastric lavage or induce vomiting.

B. Initiate seizure precautions and give benzodiazapines

The nurse is caring for a client that has a history of suicidal idealizations. Which of the following would pose the greatest risk for successful suicide attempt? A. Male contemplating the use of a firearm and which one to buy B. Male with a detailed plan to hang himself with rope he just purchased C. Female teen that broke up with her boyfriend and has no other friends D. Female that has watched suicides on the internet

B. Male with a detailed plan to hang himself with rope he just purchased

A client is admitted to the emergency department with signs of drug use. The client reports ingesting Percocet and is currently experiencing respiratory depression. Based on this information, which prescription should the nurse anticipate for this client? A. Haldol B. Naloxone C. Vitamin B12 D. Diazepam

B. Naloxone

A client has completed the full course of antibiotics prescribed to treat otitis media. Which primary manifestation of the disorder will be relieved as evidence that treatment has been effective? A. Nausea and vomiting B. Pain C. Impaired hearing D. Dizziness

B. Pain Ear pain is the most common symptom of otitis media that motivates the client to seek healthcare. Secondary symptoms associated with the disease include dizziness, impaired hearing, and nausea and vomiting.

A pediatric nurse is caring for an 8-month-old client. While making rounds, the nurse enters the room and finds the infant's father violently shaking the infant. The father attempts to make it appear as though the infant was choking. Upon further assessment, the nurse notes bruised areas on the infant's arms and legs. What is a priority action for the nurse to take? A. Discuss what the nurse witnessed with the other nurses. B. Report what the nurse witnessed and assessed to the authorities. C. Call security to remove the father from the room. D. Discuss what the nurse witnessed with the infant's mother.

B. Report what the nurse witnessed and assessed to the authorities.

Necrosis of respiratory epithelial cells and shedding of serous and ciliated cells of the upper respiratory tract produce which common symptom of influenza? A. Cough B. Rhinorrhea C. Malaise D. Coryza

B. Rhinorrhea

Which of the following terms refers to a physiologic need for a substance that the client cannot control and that results in withdrawal symptoms if the substance is withheld? A. Addiction B. Dependence C. Tolerance D. Codependence

B. dependance

Because of the way the influenza virus is transmitted from person to person, nurses who are working with clients with influenza should implement A. contact precautions. B. droplet precautions. C. reverse isolation precautions. D. airborne precautions.

B. droplet precautions Influenza is spread through droplets when the client sneezes or coughs. Therefore, droplet precautions should be used. Reverse isolation precautions limit the number of people who come in contact with the client that is immunocompromised. Airborne precautions are used for tuberculosis and other infections that are airborne. Contact precautions are used when the nurse is at risk of contacting infected body fluids such as stool or wound drainage.

The body structure that provides a route by which infections organisms can enter the middle ear to cause otitis media is the A. nasopharynx. B. eustachian tube. C. sinus cavity. D. tympanic membrane.

B. eustachian tube

The clinic nurse is educating a group of new moms on the risk factors and prevention of respiratory syncytial virus (RSV). What should the nurse stress as the best way to prevent RSV? A. Adequate fluid intake B. Hand washing C. Administering antibiotics D. Monitoring temperature

B. hand washing

The nurse is caring for a client who refuses treatment for otitis media. The nurse correctly teaches the client that she is at increased risk for developing which condition? A. Otitis externa B. Meningitis C. Pneumonia D. Influenza

B. meningitis The bacterial infection from otitis media may migrate internally, leading to the development of bacterial meningitis. Otitis media is not known to cause external otitis. Otitis media does not cause pneumonia or influenza

An older adult client asks the nurse what can be done to decrease the risk of developing pneumonia. Which responses by the nurse are most appropriate? (Select all that apply). A. "Drinking alcohol in moderation will reduce your risk." B. "Once per day, you should eat yogurt that is supplemented with L. casei immunitas cultures." C. "There is nothing you can do to decrease your risk of pneumonia in the future." D. "Eliminating habits like smoking can help." E. "You can get the pneumonia vaccination, which may help decrease your risk in the future."

D, E

The pediatric nurse is providing education to a new mother regarding ways to decrease the risk of sudden infant death syndrome (SIDS). Which statement by the nurse is appropriate? A. "Make sure the baby has a soft blanket and pillow when sleeping." B. "You should keep the baby with you at all times to assess for apnea." C. "SIDS has been linked to immunizations. I recommend that you avoid immunizing your baby." D. "It is recommended that you place your baby on his back for sleep."

D. "It is recommended that you place your baby on his back for sleep."

A client who is attending a Narcotics Anonymous (NA) program asks the nurse what the most important initial goal of attending the meetings is. How should the nurse respond? A. "The most important initial goal is to take a personal moral inventory." B. "The most important initial goal is to pay for crimes committed." C. "The most important initial goal is to learn problem-solving skills." D. "The most important initial goal is to admit that you have a problem."

D. "The most important initial goal is to admit that you have a problem."

The mother of an 8-month-old baby who has developed respiratory syncytial virus (RSV)/bronchiolitis wants to know which factors contribute to the risk of contracting RSV. Which response by the nurse is appropriate? A. "There is no way to avoid the illness." B. "It is seen more frequently in children who do not attend daycare." C. "There is a higher risk in children who are being breastfed." D. "There is a higher risk in children who are exposed to secondary cigarette smoke."

D. "There is a higher risk in children who are exposed to secondary cigarette smoke."

The nurse is providing supportive care for the parents of an infant who died from sudden infant death syndrome (SIDS). Which action by the nurse is appropriate? A. Interviewing the parents to determine the cause of the SIDS incident B. Advising the parents that an autopsy is not necessary C. Refraining from recommending support groups until after the investigation D. Contacting the family's spiritual leader for support

D. Contacting the family's spiritual leader for support

Which medication is commonly used for medical procedures but is also widely abused? A. MDMA B. MDPV/mephedrone C. Gamma Hydroxybutyrate D. Ketamine

D. Ketamine

A client comes in to the ED transported by EMS from a rave party. She has a pacifier on a ribbon around her neck and is wearing a party dress. She is in and out of consciousness, is hypertensive and hyperthermic. She has dry mucous membranes with warm dry skin. The astute nurse realizes these findings as signs that she likely has been using which drug? A. Cocaine or nose candy B. Mushrooms or Caps C. GHB or Cherry Meth D. MDMA or Ecstasy

D. MDMA or Ecstasy

The nurse observes a toddler, admitted with possible respiratory syncytial virus (RSV) bronchiolitis, grunting with expiration. Which action by the nurse is appropriate? A. Lay the child on his back. B. Assist the child to clear the nasal passages. C. Limit fluids. D. Suction the airway to relieve the obstruction.

D. Suction the airway to relieve the obstruction.

The nurse is teaching the mother of an infant with otitis media to manage the associated fever and pain. Which instruction by the nurse is correct? A. Feed the baby solid foods. B. Swaddle the baby in blankets. C. Bathe the baby with cool water. D. Administer acetaminophen.

D. administer acetaminophen Swaddling the baby with blankets is not going to reduce the fever or help the pain. The baby may not be of the age to take solid foods. Acetaminophen will help reduce the child's fever and reduce the pain. Bathing with cool water is not an appropriate intervention to reduce the fever of a baby

The nurse includes information in a presentation that sudden infant death syndrome​ (SIDS) remains unexplained after other possible causes have been ruled out. The nurse understands that which procedure is used to rule out the possible causes of​ SIDS? A. Lab analysis B. Genetic mapping C. Chest​ x-ray D. Autopsy

D. autopsy

A common effect from using lysergic acid diethylamide (LSD) also know as angel dust, is that even after the person stops using they may still experience A. sudden cardiac death. B. sexual dysfunction and infertility. C. motivational disturbances. D. disturbing flashbacks and hallucinations.

D. disturbing flashbacks and hallucinations.

The nurse correctly explains to a young mother that bottle-feeding an infant in the upright position may help to prevent which infectious health problem? A. Influenza B. SIDS C. Sinus infection D. Otitis media

D. otitis media Infants and small children who are bottle-fed in a supine position have a greater probability of developing otitis media because the eustachian tube opens when the child sucks, and the horizontal angle provides easy access to the middle ear. Children are not prone to sinus infection during infancy as the result of feeding position. SIDS and Influenza are no related to feeding positions.

Which is the best description of the abuse cycle? A. aggressive behavior- violent episode- honeymoon phase- relapse B. honeymoon phase- violent episode- resolution C. tensions build- violent episode- silent phase- open window D. tensions build- violent episode- honeymoon phase

D. tensions build- violent episode- honeymoon phase

There are new health concerns related to cannabis and THC. These concerns are primarily centered on which of these? A. The risk of cancer is lower from smoking marijuana than tobacco. B. The new availability of cannabis extracts for topical use has severe addictive properties. C. The progressive increase in THC concentrations in various preparations. D. Legalization in several states causes health inequities.

C. The progressive increase in THC concentrations in various preparations. The THC content has progressively increased since the '90's which was roughly 3.7%. Newer methods of using and the various preparations, now deliver THC in the 80% range. This has unknown consequences on the brain. The perceived inequities are not of concern. CBD oil topical application does not produce a "high" and has not increased addiction. Cancer risk from smoking cannabis may actually be higher than tobacco in most cases.

A teen casually admits to the nurse during a health history that he sometimes sneaks into his father's dental office and "huffs the laughing gas". What caution should the nurse give to this client about using inhalants? A. This practice will lead to dependence and tolerance. B. This practice is harmless but should be avoided because it is illegal. C. This practice is very dangerous and can cause sudden death. D. Nitrous oxide is not harmful, but other inhalants are toxic.

C. This practice is very dangerous and can cause sudden death.

The primary cells involved in infection by respiratory syncytial virus (RSV) are the A. macrophages and monocytes of the bronchioles and alveoli. B. smooth muscle cells in the bronchi and bronchioles. C. squamous epithelial cells of the bronchioles and alveoli. D. granular pneumonocytes in the alveoli.

C. squamous epithelial cells of the bronchioles and alveoli. Respiratory syncytial virus infects the squamous epithelial cells of the bronchioles and alveoli. It does not infect smooth muscle cells, granular pneumonocytes (the surfactant-secreting cells), or the macrophages and monocytes.

The nurse is caring for a client who presents with acute malaise, muscle aches, and fever. Which additional assessment findings should the nurse recognize as consistent with influenza? (Select all that apply.) A. Nonproductive cough B. Difficulty urinating C. Dizziness D. No history of vaccinations within the past 12 months E. Hypotension

A, D

The nurse is teaching a pregnant client regarding the risk factors related to sudden infant death syndrome​ (SIDS). Which statement by the nurse is​ appropriate? (Select all that​ apply.) A. ​"If your family has a history of​ SIDS, the risk for SIDS​ increases." B. "If your child is exposed to smoke in the​ home, the risk for SIDS​ increases." ​C. "If your child is a​ girl, the risk for SIDS​ increases." D. ​"If your child is born​ premature, the risk for SIDS​ increases." E. If your child shares your bed during​ sleep, the risk for SIDS​ increases."

A, B, D, E

A patient seeks care following a sexual assault. The medical facility notifies the rape team including a sexual assault nurse examiner (SANE) to conduct an assessment. What are the reasons for having a special team to conduct this examination and treatment? (select all that apply) A. This process properly collects evidence and preserves the chain of evidence B. These specialists have specific training on how to manage the care of the patient and evidence. C. This team will determine if a crime was committed and notify law enforcement. D. Criminal laws require this team to gather evidence and information from the patient. E. This team focuses on this patient and allows the other health care team members to care for all other patients during the exam.

A, B, E

The nurse is caring for a client who develops a fever and productive cough after abdominal surgery. Which orders should the nurse expect from the healthcare provider? (Select all that apply). A. Mucolytic B. Antibiotics C. Bronchial washing for culture D. Airborne precautions E. Sputum cultures

A, B, E

The nurse is providing care to a client diagnosed with respiratory syncytial virus (RSV) bronchiolitis. Which assessment finding indicates that treatment has been effective? A. Client respiratory rate within normal limits for age B. Client coughing copious amounts of green sputum and requires occasional suctioning C. Client resting in bed with limited interest in play or activities D. Client ingesting small amounts of clear fluids when encouraged

A. Client respiratory rate within normal limits for age Evidence that care is effective would include normal rate, rhythm, and quality of the breathing patterns for the client's age. The client who is resting in bed with limited interest in play or activities is not demonstrating an improvement in respiratory status. The client who is ingesting small amounts of fluids might still be experiencing thickened secretions. If the client is coughing copious amounts of green sputum and requiring occasional suctioning, the interventions have not been effective, as the child still needs assistance with clearing the airway

A nurse who works in the emergency department is caring for a client who has overdosed on cocaine. The nurse should be aware of these expected assessment findings: A. Dysrhythmias and respiratory distress. B. Heart failure and electrolyte imbalances C. Hallucinations and out-of-body sensations D. Respiratory depression and hypoxia

A. Dysrhythmias and respiratory distress.

Which interventions should the nurse incorporate into the plan of care for a client diagnosed with influenza? A. Placing droplet and contact precaution signs on the client's room door B. Placing a ventilator in the room C. Placing the client in a negative air flow room D. Notifying other departments of the diagnosis

A. Placing droplet and contact precaution signs on the client's room door

A client admitted from home is diagnosed with​ community-acquired pneumonia. Which organism does the nurse suspect is the cause of this​ infection? A. Pneumococcus B. Staphylococcus aureus C. Pneumocystis jiroveci D. Escherichia coli

A. Pneumococcus

Which intervention should the nurse carry out to manage fever in a client with pneumonia? A. Promote frequent rest periods to increase energy reserve. B. Use ice packs and a tepid bath every 2 hours. C. Increase the temperature of the room environment to prevent shivering. D. Restrict fluids during periods of hyperthermia because of the risk of electrolyte imbalance.

A. Promote frequent rest periods to increase energy reserve.

A patient involved in a high speed MVC presents via ambulance to the ED. Paramedics describe the crash as a roll-over wherein the driver (this patient) was ejected from the vehicle. The patient was ambulatory on scene. Based on the mechanism of injury, the nurse should suspect A. life threatening injuries including spine fractures and internal organ trauma. B. drug use and sensory impairment. C. no injuries since the patient could ambulate and is alert and oriented. D. minor injuries possible but nothing life threatening.

A. life threatening injuries including spine fractures and internal organ trauma.

Which statements about COVID-19 are true? (more than one answer) A. The virus came from contaminated bat meat B. The best way to avoid becoming infected is to horde toilet paper C. There is no medication treatment D. The best test is a real time PCR E. There is no vaccine with full FDA approval

C, D, E