1230 Final Exam Review
The mother of a 2-month-old is concerned that she may be spoiling her baby by picking her up when she cries. Which of the following would be the nurse's best response?
"Babies need to be held and cuddled; you won't spoil her this way"
A primigravid client at 36 weeks' gestation with PROM is to be discharged home on bed rest with follow-up by the nurse. After instruction about care while at home, which client statement indicates effective teaching?
"I should contact my HCP if my temperature is 100.4 F (38 C ) or higher."
Cultural competence is the process of
Acquiring specific knowledge, skills, and attitudes
What stress response can you expect from a patient with blood sugar of 50 mg/dl?
Blood pressure will increase
Which of the following suggestions should the nurse offer the parents of a 4-year-old boy who resists going to bed at night?
"Read him a story and allow him to play quietly in his bed until he falls asleep."
After teaching a group of parents about accident prevention for school-agers, which of the following statements by the group would indicate the need for more teaching?
"School-agers are unable to understand potential dangers around them."
Which statement by the client indicates an understanding of the teaching regarding the use of corticosteroids during preterm labor?
"The corticosteroids may help my baby's lungs mature."
April is diagnosed with systemic lupus erythematosus. Which instruction would be included in the teaching plan for the client?
"Wear large-brimmed hats when exposed to the sun."
After suction and evacuation of a complete hydatidiform mole, the 28-year-old multigravid client asks the nurse when she can become pregnant again. The nurse would advise the client not to become pregnant again for at least how long?
12 months
At which of the following ages would the nurse expect to administer the varicella zoster vaccine to child?
12 months
By the end of which of the following would the nurse most commonly expect a child's birth weight to triple?
12 months
When teaching a mother about introducing solid foods to her child, which of the following indicates the earliest age at which this should be done?
4 months-Solid foods are not recommended before age 4 to 6 months because of the sucking reflex and the immaturity of the gastrointestinal tract and immune system.
Nurse Mary Jean is assisting in administering immunizations at a health care clinic. The nurse understands that an immunization will provide:
Acquired immunity from disease
A child age 7 was unable to receive the measles, mumps, and rubella (MMR) vaccine at the recommended scheduled time. When would the nurse expect to administer MMR vaccine?
At age 10
What type of relaxation technique does Lyza uses if a machine is showing her pulse rate, temperature and muscle tension which she can visualize and assess?
Biofeedback
The client is in stress because he was told by the physician he needs to undergo surgery for removal of tumor in his bladder. Which of the following are effects of sympatho- adreno-medullary response by the client?
Constipation,Hyperglycemia, Increased blood pressure
What are the stages of dying according to Elizabeth Kubler-Ross?
Denial, anger, bargaining, depression, and acceptance.
While performing physical assessment of a 12 month- old, the nurse notes that the infant's anterior fontanel is still slightly open. Which of the following is the nurse's most appropriate action?
Do nothing because this is a normal finding for the age.
Which of the following aspects of psychosocial development is necessary for the nurse to keep in mind when providing care for the preschool child?
Fear of body mutilation is a common preschool fear-the child has mastered a sense of autonomy and goes on to master a sense of initiative. During this period, the child commonly experiences more fears than at any other time.
When providing care to clients with varied cultural backgrounds, it is imperative for the nurse to recognize that:
Generalizations about the behavior of a particular group may be inaccurate
What should the nurse do when planning nursing care for a client with a different cultural background? The nurse should:
Identify how these cultural variables affect the health problem
Which statement would best explain the role of the nurse when planning care for a culturally diverse population? The nurse will plan care to:(check all that apply)
Include care that is culturally congruent with the staff from predetermined criteria, Provide care while aware of one's own bias, focusing on the client's individual needs rather than the staff's practices
When assessing a child with a cleft palate, the nurse is aware that the child is at risk for more frequent episodes of otitis media due to which of the following?
Ineffective functioning of the Eustachian tubes
Which clinical manifestation would cause the nurse to suspect that the client is diagnosed with systemic lupus erythematosus?
Joint edema and tenderness
When discussing normal infant growth and development with parents, which of the following toys would the nurse suggest as most appropriate for an 8-month-old?
Large blocks
While performing a neurodevelopmental assessment on a 3-month-old infant, which of the following characteristics would be expected?
Lifting of head and chest when prone
Which of the following information, when voiced by the mother, would indicate to the nurse that she understands home care instructions following the administration of a diphtheria, tetanus, and pertussis injection?
Measures to reduce fever
Which of the following would the nurse do first for a 3- year-old boy who arrives in the emergency room with a temperature of 105 degrees, inspiratory stridor, and restlessness, who is leaning forward and drooling?
Notify the physician immediately and prepare for intubation- The child is exhibiting classic signs of epiglottitis, always a pediatric emergency. The physician must be notified immediately and the nurse must be prepared for an emergency intubation or tracheostomy.
The nurse admitting a preterm newborn to the nursery should assess the newborn for which of the following?
Respiratory distress
If parents keep a toddler dependent in areas where he is capable of using skills, the toddler will develop a sense of which of the following?
Shame
Which of the following best describes parallel play between two toddlers?
Sitting near each other while playing with separate dolls
Estrada, the Philippine president, has been unexpectedly impeached and was out of office before the end of his term. He is in what type of crisis?
Situational-unexpected crisis that arises suddenly in response to an external event or a conflict concerning a specific circumstance
Which of the following should the nurse suspect when noting that a 3-year-old is engaging in explicit sexual behavior during doll play?
The child is acting out personal experiences-the child has been exposed to such behavior, and sexual abuse should be suspected.
You are caring for a Muslim woman who has just given birth to a baby boy. Her husband and family are at the bedside. As a culturally competent nurse, you are aware that (SATA)
The patient may prefer caregivers to be female, The words "Allah-o-Akbar" may be whispered into the baby's right ear
When helping a person through grief work, the nurse knows
The sequencing of stages of grief may occur in order, they may be skipped, or they may reoccur.
Which of the following assessment findings would lead the nurse to suspect Down syndrome in an infant?
Transverse palmar crease
When assessing an 18-month-old, the nurse notes a characteristic protruding abdomen. Which of the following would explain the rationale for this finding?
Underdeveloped abdominal muscles
When teaching parents about the child's readiness for toilet training, which of the following signs should the nurse instruct them to watch for in the toddler?
Verbalizes desire to go to the bathroom
A client presents to the OB triage unit with no prenatal care and painless bright red vaginal bleeding. Which interventions are most indicated?
applying external fetal monitor and completing a physical assessment-Possible placenta previa.
A 29-year-old multigravida at 37 weeks' gestation is being treated for severe preeclampsia and has magnesium sulfate infusing at 3g/hr. To maintain safety for this client, the priority intervention is
assess reflexes, clonus, visual disturbances, and headache
A nurse is completing a prenatal assessment on a woman who is 28 weeks pregnant with gestational hypertension. Which findings should be reported to the primary care provider? SATA
dull headache, blurred vision, 1+ urine protein
On arrival at the ED, a client tells the nurse that she suspects that she may be pregnant but has been having a small amount of bleeding and has severe pain in the lower abdomen. The client's BP is 70/50 mm Hg and her pulse rate is 120 bpm. The nurse notifies the primary HCP immediately because of the possibility of:
ectopic pregnancy
Based on an understanding of plantar creases in the newborn, the nurse assess plantar creases immediately after birth because:
fluid loss may give the appearance of more plantar creases
The nurse caring for a large-for-gestational-age newborn monitors blood glucose to detect hypoglycemia as the result of
hyperinsulinemia
When caring for a newborn who is small-for- gestational-age, the nurse understands that the newborn is at risk for hypoglycemia due to
limited glycogen stores
A client at 4 weeks postpartum tells the nurse that she cannot cope any longer and is overwhelmed by her newborn. The baby has old formula on her clothes and under her neck. The mother does not remember when she last bathed the baby and states that she does not want to care for the infant. The nurse should encourage the client and her husband to call their HCP because the mother should be evaluated further for:
postpartum depression
A multigravid client at 34 weeks' gestation is being treated with indomethacin to halt preterm labor. If the client gives birth to a preterm infant, the nurse should notify the nursery personnel about this therapy because of the possibility for which complication?
pulmonary hypertension-The nurse would notify the nursery about tocolytic therapy with indomethacin because the drug can lead to premature closure of the ductus arteriosus, resulting in pulmonary hypertension.