Chapter 26 - NUR 240 Review Questions
The nurse is assessing an adolescent with an annual physical. The mother reports that she has noticed a change in the child's behavior lately including mood swings, withdrawal from the family, and failing school grades. The mother does not know what to do and asks the nurse for guidance. What is the most appropriate guidance from the nurse? a) "Adolescents are generally difficult children. Sometimes punishment is necessary to make them change their attitudes." b) "These could be signs of substance abuse. Open communication and a referral to a counselor that specializes in substance abuse would be beneficial." c) "Let's admit your child to an acute care facility so that we can run more tests." d) "This is typical adolescent behavior. Ignore it and it will improve."
"These could be signs of substance abuse. Open communication and a referral to a counselor that specializes in substance abuse would be beneficial." Some signs of substance abuse in adolescents include mood swings, withdrawal from the family, and failing school grades. The other statements are inappropriate generalizations and do not address the problem. There is not enough evidence to suggest a need for hospital admission.
Which statement indicates that a family understands the teaching that has been provided by the nurse related to car seat safety for their 9-month-old infant? a) "We place our baby in a front-facing car seat in the front of the car so that he doesn't cry." b) "We place our baby in a front-facing car seat in the middle of the back seat of the car." c) "We place our baby in a rear-facing car seat in the front of the car so that we can see him in case he chokes." d) "We place our baby in a rear-facing car seat in the back seat of the car."
"We place our baby in a rear-facing car seat in the back seat of the car." The American Academy of Pediatrics recommends that all children from birth to 2 years of age remain in a rear-facing car seat in the back seat of the car until they are 2 years, or until they reach the maximum height and weight for the car seat
A staff development nurse is providing an in-service to a group of nurses on the use of restraints in health care facilities. What is an example of a chemical restraint? a) a geriatric chair with a tray b) a dose of an antipsychotic c) a dose of an analgesic d) side rails
A Dose of an antipsychotic Drugs that are used to control behavior and are not included in the person's normal medical regimen can be considered a chemical restraint. Side rails and a geriatric chair with a tray are examples of physical restraints. Analgesics address pain and are not a restraint.
A nurse is caring for older adult clients. Which is the most important safety issue in older clients? a) Drowning b) Poisoning c) Electrical injury d) Accidental falls
Accidental falls Nurses and caregivers should be aware that unintentional falls are the most important safety issue among older adult clients. Falls may result in major life-changing events, robbing the older person of independence.
An 18-year-old is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to: a) falls from beds. b) play-related injuries. c) falls from staircases. d) automobile accidents.
Automobile accidents. Adolescents are prone to injuries related to activities that involve high risk, such as driving. Adolescents tend to be impulsive and take unnecessary risks as a result of peer pressure.
A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning? a) Instruct the toddler not to go near the pool. b) Monitor the activities of the toddler. c) Avoid unattended baths for the toddler. d) Allow the child to swim with friends.
Avoid unattended baths for the toddler. The parents should not leave the toddler for an unattended bath. Toddlers are naturally inquisitive, and instructing them to stay away from the pool may make them more curious.
An administrative assistant of a large factory visits the medical unit and tells the nurse she is having pain in the right wrist, numbness in the index finger, and decreased mobility of the right hand. The nurse suspects the client has what? a) An infection in the bone b) A herniated cervical disc c) A fracture of the hand d) Carpal tunnel syndrome
Carpal tunnel syndrome Adults with jobs that require repetitive movement (typists, assembly line workers, supermarket checkers, computer operators) may develop carpal tunnel syndrome, a compression of the median nerve that causes pain and decreases hand mobility. A fracture would most likely be accompanied by symptoms including pain, swelling, and an inability to use the extremity. A herniated cervical disk would likely be accompanied by symptoms involving numbness and discomfort of the neck and arms.
A school nurse is aware of poisoning risks in the adolescent population. Poisoning in this age group is most often related to: a) experimentation with drugs and inhalants. b) malfunction of a carbon monoxide monitor in the home. c) the ingestion of substances in the home that contain lead. d) exposure to toxic fumes in the home.
Experimentation with drugs and inhalants.
One of the leading causes of death in the United States, particularly in southwestern states, is drowning. How can the nurse assist in lowering this statistic? a) Implement drowning-prevention strategies. b) Educate children in cardiopulmonary resuscitation. c) Require fencing around all pools. d) Begin swim lessons with toddlers.
Implement drowning-prevention strategies.
The unlicensed personnel tells the nurse that a client is very confused and trying to get out of bed without assistance. What is the appropriate action by the nurse?
Initiate use of a bed alarm. The nurse should attempt to prevent the client confused client from getting out of bed by themselves to prevent a fall using the least restrictive action first.
A nurse working in a long-term care facility institutes interventions to prevent falls in the older adult population. Which intervention would be an appropriate alternative to the use of restraints for ensuring client safety and preventing falls? a) Involve family members in the client's care. b) Keep the client sedated with tranquilizers. c) Maintain a high bed position so the client will not attempt to get out unassisted. d) Allow the client to use the bathroom independently.
Involve family members in the client's care. Family members are an invaluable resource in assessing a client's risk for a fall because they can provide information regarding periods of weakness, confusion/disorientation, and a history of unreported falls.
Which topic should a public health nurse emphasize when educating older adults on reducing their risk of poisoning? a) keeping medications in clearly labeled containers b) hidden sources of lead in the household environment c) avoiding the use of alternative and complementary therapies d) alternatives to chemical-based cleaning supplies
Keeping medications in clearly labeled containers Medication overdoses are among the more common sources of poisoning in older adults, a phenomenon that can be reduced by ensuring that medications are in clearly labeled containers to avoid administration errors
What best describes the nurse's role in disaster preparedness? a) Administration of all of the medications b) Performance of all of the skills such as IV insertion and wound care c) Multiple roles including triage and the distribution of resources d) Counseling the victims and families
Multiple roles including triage and the distribution of resources Nurses will perform multiple roles when assisting with a disaster, including triage, procedures, counseling, and distribution of resources.
A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which intervention should the nurse implement to ensure electrical safety? a) Tape the electrical cord of the pump to the floor. b) Obtain a three-prong grounded plug adapter. c) Use an extension cord to provide freedom of movement. d) Run the electrical cord of the pump under the carpet.
Obtain a three-prong grounded plug adapter.
A client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which of the following measures would be a high priority recommendation for this client? a) Raising all the side rails of the bed b) Placing the client in a bed with a bed alarm c) Providing a bed that is elevated from the floor d) Using restraints on the client to prevent a fall
Placing the client in a bed with a bed alarm
What is the primary role of the nurse in the care of clients that experience domestic violence? a) Calling the police b) Identifying health education and counseling measures for the family c) Providing prompt recognition of the potential or actual threat to safety d) Serving as a witness in court
Providing prompt recognition of the potential or actual threat to safety The nurse is often the initial health care provider in contact with an abused child or a battered woman or man. Prompt recognition of the potential or actual threat to safety is crucial, and the nursing assessment may play a vital role in identifying a harmful environment.
A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which action should the nurse take? a) Extinguish the fire. b) Confine the fire. c) Pull the fire alarm lever. d) Evacuate the unit.
Pull the fire alarm lever. The nurse should pull the fire alarm lever. As per the RACE principle of fire management, the flow of activities should be rescue, alarm, confine, and extinguis
The acronym health care workers use to remember the safety procedures in the event of fire is: a) SILT (surround; initiate; liberate; transfer). b) DAME (defend; action; move; evaluate). c) RACE (rescue; alarm; confine; evacuate). d) RATE (relocate; advise; transport; extinguish).
RACE (rescue; alarm; confine; evacuate).
A nurse is preparing discharge education for a client with a newborn baby. What is the highest priority item that must be included in the education plan? a) Restrain the baby in a car seat. b) Lock all cabinets that contain cleaning supplies. c) Give warm bottles of formula to the baby. d) Keep all pots and pans in lower cabinets.
Restrain the baby in a car seat.
Which reason best explains why adolescents behave in an unsafe manner despite knowledge of a particular activity's risk? a) Poor judgment b) Past experience c) Social pressure d) Normal rebellion
Social pressure
The nurse is caring for an 80-year-old patient who was admitted to the hospital in a confused and dehydrated state. After the patient got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this patient? a) Take the restraints off, stay with her, and talk gently to her. b) Leave the restraints on and talk with her, explaining that she must calm down. c) Talk with the patient's family about taking her home because she is out of control. d) Sedate her with sleeping pills and leave the restraints on.
Take the restraints off, stay with her, and talk gently to her. Physical restraints increase the possibility of the occurrence of falls, skin breakdown and contractures, incontinence, depression, delirium, anxiety, aspiration respiratory difficulties, and even death.
The nurse is working at a local elementary school. A mother arrives to pick up her 6-year-old son and has her 2-year-old daughter in tow. Based on the nurse's developmental knowledge of toddlers, which behavior would most concern the nurse? a) The 2-year-old and 6-year-old each holding the mother's hand. b) The 6-year-old riding a bike on the playground with his friend. c) The 2-year-old helping mom to open the front door of the school. d) The 2-year-old leaning against the screen of a window in a classroom.
The 2-year-old leaning against the screen of a window in a classroom.
A nurse is using the QSEN competency of evidence-based practice when caring for clients. What is an example of this competency? a) The nurse manager holds an in-service for staff to teach them the safe operation of a new piece of equipment. b) The nurse researches best current practices for prevention of the spread of infection in physician offices. c) The nurse works with other health care team members to provide care for a client diagnosed with Alzheimer's disease. d) The nurse uses computer-generated care plans for client care.
The nurse researches best current practices for prevention of the spread of infection in physician offices. The QSEN model specifies the integration of best current evidence with clinical expertise, along with client and family preferences and values, for delivery of optimal health care.
The nurse recognizes that assessment for sensory-perceptual alterations is a priority for which client? a) an 84-year-old male with four recent driving violations b) a 12-year-old male who sprained his wrist skateboarding c) a 42-year-old female who is a single mom with a sick child home from school d) a 16-year-old pregnant female who has morning sickness
An 84-year-old male with four recent driving violations An older adult with multiple driving infractions may be having difficulty with sensory-perceptual alterations due to aging changes such as glaucoma, cataracts, presbyopia, presbycusis, cognition, or response time impairments
A school-aged child is admitted to the Emergency Room with the diagnosis of a concussion following a collision when playing football. After the collision, the parents state that he was "knocked out" for a few minutes before recognizing his surroundings. What is the priority assessment when the nurse first sees the patient? a) Evaluation of all of his cranial nerves b) Initiation of a peripheral intravenous (IV) line for fluid administration c) Assessment of vital signs and respiratory status d) Assessment of head circumference
Assessment of vital signs and respiratory status Assessment after a head injury includes immediate evaluation of airway, breathing, and circulation. Therefore, assessment of vital signs and respiratory status is a priority for this client. Head circumference is only beneficial in children less than two years old and/or with open fontanels. Evaluation of all of his cranial nerves does not take priority over cardiopulmonary assessment, and assessment comes before intervention in the nursing process and more assessment is needed for this client before the need for an IV line is determined
The nurse is creating a plan of care for the older adult that has multiple medications and a difficult time reading medication labels due to poor eyesight. What is the most appropriate nursing diagnosis to include in this client's plan of care? a) Risk for falls related to immobility b) Risk for poisoning related to poor eyesight and the inability to read medication labels c) Altered sensory perception related to decreased visual acuity d) Risk for injury related to substance abuse
Risk for poisoning related to poor eyesight and the inability to read medication labels
