Exam 1 Mat/Peds
An infant is to receive intermittent gavage feedings via a nasogastric tube every 6 hours. The feeding tube was inserted with a previous feeding and remains in place. The nurse is preparing to administer the next scheduled feeding. Place the events in the proper sequence. a. Check the placement of the feeding tube. b. Position the infant on his right side with the head of the bed slightly elevated. c. Allow the feeding to come to room temperature. d. Flush the tube with water. e. Clamp the tube to prevent air from entering the stomach. f. Pour the solution into the barrel of the syringe.
C-Allow the feeding to come to room temperature. A-Check the placement of the feeding tube. F-Pour the solution into the barrel of the syringe. D-Flush the tube with water. E- Clamp the tube to prevent air from entering the stomach. B- Position the infant on his right side with the head of the bed slightly elevated. First make sure that the feeding solution is at room temperature. Then check the placement of the tube; once confirmed, pour the solution into the barrel of the syringe and allow it to flow in by gravity over 15 to 30 minutes. Before the syringe empties, flush the tube with water and then clamp the tube to prevent air from entering the stomach. Burp the infant as needed and then position him on his right side with the head of the bed slightly elevated to facilitate gastric emptying and reduce the risk of aspiration and regurgitation.
When giving parents guidance for the adolescent years, the nurse would advise the parents to: (Choose all that apply.) a. Accept the adolescent as a unique individual b. Provide strict, inflexible rules c. Listen and try to be open to the adolescent's views d. Screen all of his or her friends e. Respect the adolescent's privacy f. Provide unconditional love
a. Accept the adolescent as a unique individual c. Listen and try to be open to the adolescent's views e. Respect the adolescent's privacy f. Provide unconditional love The correct responses are A, C, E, and F. Adolescents need to be accepted as unique individuals. Parents should provide unconditional love, respect their privacy, and listen to them. Screening all of their friends and providing strict, inflexible rules would only lead to poor interactions between the parents and the adolescent.
Throughout life, a woman's most proactive activity to promote her health would be to engage in: a. Consistent exercise b. Socialization with friends c. Quality quiet time with herself d. Consuming water
a. Consistent exercise The correct response is A. Exercise is heart healthy, weight healthy, and emotionally healthy. The motto "Keep moving" is the basis for a healthy lifestyle, since it will help maintain an ideal weight, improve circulation, and improve moods. B is incorrect: socialization does not necessarily involve physical activity and would not be proactive in preserving health. C is incorrect: quiet time alone, although needed to reduce stress, reduces movement and may result in depression and weight gain. D is incorrect: water, although needed to hydrate the body, will not maintain circulation, prevent weight gain, or improve one's emotional mindset. Exercise will accomplish all three.
Which of the following is the major goal of genetic counseling? a. Diagnose and determine the role of heredity b. Reinforce previously presented test data c. Emphasize good communication skills d. Offer referral to community support groups
a. Diagnose and determine the role of heredity The correct response is "A" since the goals of genetic counseling include diagnosis, determining the role of genetics, assessing risks and options, and opening up lines of communication with the couple affected. The other responses (B, C, and D) are included in genetic counseling, but are not the major goals of it.
What is the best advice about nutrition for the toddler? a. Encourage cup drinking and give water between meals and snacks. b. Encourage unlimited milk intake, because toddlers need the protein for growth. c. Avoid sugar-sweetened fruit drinks and allow as much natural fruit juice as desired. d. Allow the toddler unlimited access to the sippy cup to ensure adequate hydration.
a. Encourage cup drinking and give water between meals and snacks. The correct response is A. The toddler should wean to the cup by age 12 to 15 months. Limit real fruit juice to 4 to 6 oz per day and milk to 16 to 24 oz per day, and give it with meals and snacks. Offer water between meals and snacks.
The mother of a 3-year-old is concerned about her child's speech. She describes her preschooler as hesitating at the beginning of sentences and repeating consonant sounds. What is the nurse's best response? a. Hesitancy and dysfluency are normal during this period of development. b. Reading to the child will help model appropriate speech. c. Expressive language concerns warrant a developmental evaluation. d. The mother should ask her child's physician for a speech therapy evaluation.
a. Hesitancy and dysfluency are normal during this period of development. The correct response is A. Preschoolers often have a period of dysfluency and hesitancy in their language development, but it usually resolves by about age 4 years.
When obtaining a blood test for pregnancy, which hormone would the nurse expect the test to measure? a. Human chorionic gonadotropin (hCG) b. Human placental lactogen (hPL) c. Follicle-stimulating hormone (FSH) d. Luteinizing hormone (LH)
a. Human chorionic gonadotropin (hCG) The correct response is A. hCG is produced by the trophoblast (outermost layer of the developing blastocyst) and maintains the ovarian corpus luteum (remainder of ovarian follicle after ovulation) by keeping levels of progesterone and estrogen elevated until the placenta can take over that function. hCG is secreted early after conception to signal that fertilization has taken place. Without fertilization, hCG is not detected. Thus, it is the basis for pregnancy tests. hPL is the hormone secreted by the placenta to prepare the breasts for lactation. It is also an antagonist to insulin, competing for receptor sites that force insulin secretion to increase to meet the body's demands. FSH is secreted by the anterior pituitary gland to stimulate the ovary to mature an ovum for ovulation. It is not detected during pregnancy tests. LH is secreted by the pituitary gland. An increase in LH occurs immediately before ovulation and is responsible for release of the ovum. It is not the basis for pregnancy tests.
During pregnancy, which of the following should the expectant mother reduce or avoid? a. Raw meat or uncooked shellfish b. Fresh, washed fruits and vegetables c. Whole grains and cereals d. Protein and iron from meat sources
a. Raw meat or uncooked shellfish The correct response is A. Consuming raw meat can increase the pregnant woman's risk of picking up toxoplasmosis, a parasitic infection that can be passed on to her fetus. Although toxoplasmosis may go unnoticed in the pregnant woman, it may cause abortion or result in the birth of an infant with the disease. Uncooked shellfish may contain high levels of mercury, which can damage the fetal central nervous system. Some raw or undercooked can also be contaminated with Listeria, which may result in abortion, stillbirth, or severe illness of the newborn. Raw or undercooked food items should be avoided during pregnancy.
Which of the following combination contraceptives has been approved for extended continuous use? a. Seasonale b. Triphasil c. Ortho Evra d. Mirena
a. Seasonale The correct response is A. Seasonale is one of several FDA-approved long-term oral contraceptives that is packaged to provide 84 days of continuous protection. Although any oral contraceptive can be taken continuously, the FDA has not approved this, and it would be considered an "off-label" use. B is incorrect: this product has not gained FDA approval for continuous use; it is to be left in 3 weeks and then removed for 1 week to create monthly cycles. C is incorrect response: the FDA has not given approval to use this transdermal patch on a continuous basis; it is placed on the skin for 3 weeks and removed for 1 week. D is incorrect: this implantable device is protective for 5 years, but it is not a combination contraceptive; it releases synthetic progesterone only, not estrogen.
When teaching about HIV transmission, which of the following does the nurse explain that the virus cannot be transmitted by? a. Shaking hands b. Sharing drug needles c. Sexual intercourse d. Breastfeeding
a. Shaking hands The correct response is A. The HIV virus is not spread through casual contact between individuals. HIV is spread through unprotected sexual intercourse, breast-feeding, blood contact, or shared needles or sex toys. B is incorrect: HIV can be spread by sharing injection equipment because the user can come into contact with HIV-positive blood. C is incorrect: sexual intercourse (unprotected vaginal, anal, or oral) poses the highest risk of HIV transmission. D is incorrect: the newborn can receive the HIV virus through infected breast milk. HIV-positive women are advised not to breast-feed to protect their offspring from getting an HIV infection.
Which of the following are reasons that stealing occurs in school-age children? (Choose all that apply.) a. To escape punishment b. High self-esteem c. Low expectations of family/peers d. Lack of sense of property e. Strong desire to own something
a. To escape punishment d. Lack of sense of property e. Strong desire to own something The correct responses are A, D, and E. Stealing in the school-age years occurs for multiple reasons: to escape punishment, because of a lack of sense of propriety or ownership, and because of a strong desire to own something they do not have because of lack of money or refusal by parents. Stealing also occurs when a school-age child has low self-esteem and high expectations from his family or peers that the child cannot meet.
The father of a 2-month-old girl is expressing concern that his infant may be getting spoiled. The nurse's best response is: a. "She just needs love and attention. Don't worry; she's too young to spoil." b. "Consistently meeting the infant's needs helps promote a sense of trust." c. "Infants need to be fed and cleaned; if you're sure those needs are met, just let her cry." d. "Consistency in meeting needs is important, but you're right, holding her too much will spoil her."
b. "Consistently meeting the infant's needs helps promote a sense of trust." The correct response is B. Infants need to have both their physical needs (e.g., feeding, changing, clothing) and their emotional needs (e.g., attention, holding) met consistently so that they can develop a sense of trust, which is the basis for the later development of self-esteem.
A couple is considered infertile after how many months of trying to conceive? a. 6 months b. 12 months c. 18 months d. 24 months
b. 12 months The correct response is B. If EC is taken within 72 hours after unprotected sexual intercourse, pregnancy will be prevented by inhibiting implantation. The next morning would still afford time to take EC and not become pregnant. A is incorrect: it would be too late to use a spermicidal agent to prevent pregnancy, since the sperm have already traveled up into the female reproductive tract. C is incorrect: douching with vinegar and hot water 24 hours after unprotected sexual intercourse will not change the course of events; by then it is too late to prevent a pregnancy, and this combination would not be effective anyway. D is incorrect: a laxative will stimulate the gastrointestinal tract to produce defecation but will not disturb the reproductive tract, where fertilization takes place.
The nurse is caring for an infant who weighs 8.2 kg and is NPO and receiving IV fluid therapy. What rate does the nurse calculate as meeting the child's daily fluid requirements? a. 82 mL per hour b. 41 mL per hour c. 34 mL per hour d. 22 mL per hour
b. 41 mL per hour The correct response is B. The vastus lateralis is the preferred injection site for infants. An alternative is the rectus femoris. The deltoid muscle is not used in children until after the age of 4 to 5 years due to its small size. The dorsogluteal site is not used in children until they have been walking for at least 1 year.
Which facility fulfills the characteristics of a medical home? a. An urgent care center b. A primary care pediatric practice c. A mobile outreach immunization program d. A dermatology practice
b. A primary care pediatric practice The correct response is B. A primary care pediatric practice is most likely to fulfill the characteristics of a medical home (see Box 31.1). Answer "A" does not provide preventive care activities. Answer "C" would not provide for any care requiring hospitalization. Answer "D" is unlikely to provide service outside its area of expertise.
A woman with HPV is likely to present with which nursing assessment finding? a. Profuse, pus-filled vaginal discharge b. Clusters of genital warts c. Single painless ulcer d. Multiple vesicles on genitalia
b. Clusters of genital warts The correct response is B. The human papillomavirus (HPV) causes warts in the genital region. HPV is a slow-growing DNA virus belonging to the papilloma group. Types 6 and 11 usually cause visible genital warts. Other HPV types in the genital region (16, 18, 31, 33, and 35) are associated with vaginal, anal, and cervical dysplasia. A is incorrect: a pus-filled discharge is not typical of an HPV infection, but rather a chlamydial or gonococcal STI. C is incorrect: a single painless ulcer would be indicative of primary syphilis rather than an HPV infection. D is incorrect: multiple vesicles would indicate a herpes outbreak, not an HPV infection. The woman would also experience tingling, itching, and pain in the affected area.
A 9-month-old infant's mother is questioning why cow's milk is not recommended in the first year of life as it is much cheaper than formula. What rationale does the nurse include in her response? a. It is permissible to substitute cow's milk for formula at this age as he is so close to 1 year old. b. Cow's milk is poor in iron and does not provide the proper balance of nutrients for the infant. c. As long as the mother provides whole milk, rather than skim, she can start cow's milk in infancy. d. If the mother cannot afford the infant formula, she should dilute it to make it last longer.
b. Cow's milk is poor in iron and does not provide the proper balance of nutrients for the infant. The correct response is B. Although whole milk contains a sufficient quantity of fat, cow's milk is inappropriate for use in infancy as it does not provide the appropriate balance of nutrients (especially iron) and may overload the infant's renal system with inappropriate amounts of sodium, protein, and minerals. Cow's milk use should be delayed until 1 year of age. Infant formula should always be reconstituted according to the manufacturer's recommendations
The successful resolution of developmental tasks for the school-age child, according to Erikson, would be identified by: a. Learning from repeating tasks b. Developing a sense of worth and competence c. Using fantasy and magical thinking to cope with problems d. Developing a sense of trust
b. Developing a sense of worth and competence The correct response is B. School-age children develop a sense of worth and competence. Toddlers learn from repeating tasks. Preschoolers use fantasy and magical thinking. It is in infancy that the child develops a sense of trust.
What has the most influence in deterring an adolescent from beginning to drink alcohol? a. Drinking habits of parents b. Drinking habits of peers c. Drinking philosophy of adolescent's culture d. Drinking philosophy of adolescent's religion
b. Drinking habits of peers The correct response is B. The teenager's peer group has the greatest influence on his or her behavior. If peers are drinking, the teenager will be at greater risk of drinking.
In developing a weight-loss plan for an adolescent, which would the nurse include? (Choose all that apply.) a. Have parents make all of the meal plans. b. Eat slowly and place the fork down between each bite. c. Have the family exercise together. d. Refer to an adolescent weight-loss program. e. Keep a food and exercise diary.
b. Eat slowly and place the fork down between each bite. c. Have the family exercise together. d. Refer to an adolescent weight-loss program. e. Keep a food and exercise diary. The correct responses are B, C, D, and E. These are steps that promote weight loss in adolescents. Adolescents want to be involved in the process, so having parents make all of the meal plans would not promote acceptance by the adolescent.
What event occurs during the proliferative phase of the menstrual cycle? a. Menstrual flow starts b. Endometrium thickens c. Ovulation occurs d. Progesterone secretion peaks
b. Endometrium thickens The correct response is B. Under the influence of estrogen, the uterine lining (endometrium) thickens and grows in preparation for the implantation of a conceptus if that occurs or to be sloughed off during the menses.
1. The predominant anterior pituitary hormones that orchestrate the menstrual cycle include: a. Thyroid-stimulating hormone (TSH) b. Follicle-stimulating hormone (FSH) c. Corticotropin-releasing hormone (CRH) d. Gonadotropin-releasing hormone (GnRH)
b. Follicle-stimulating hormone (FSH) The correct response is B. FSH is secreted from the anterior pituitary gland to initiate the development of the ovarian follicles and the secretion of estrogen within the ovarian cycle. A is incorrect: TSH stimulates the thyroid gland and plays a limited role in the menstrual cycle. C is incorrect: CRH is released from the hypothalamus, not the anterior pituitary gland. D is incorrect: GnRH is released from the hypothalamus to stimulate the release of FSH and LH from the anterior pituitary gland.
A pregnant client close to term comes into the clinic for an exam. The woman complains about experiencing shortness of breath. The nurse knows that this complaint can be explained as the: a. Fetus is needing more oxygen now that his/her size is larger. b. Fundus of the uterus is high and pushing the diaphragm upwards. c. Woman is experiencing an allergic reaction because of high histamine levels. d. Oxygen partial pressure concentration is lower in the third trimester.
b. Fundus of the uterus is high and pushing the diaphragm upwards. The correct response to this question is "B" because of anatomical changes that affect breathing. The growing gravid uterus displaces the diaphragm upward which forces the entire thoracic cavity to compensate by increasing its dimensions so that more air can be inspired. Shortness of breath develops in most women during the last month of pregnancy. Response "A" is incorrect since the placenta is essentially the "lungs" for the growing fetus and thus the exchange of oxygen and carbon dioxide takes place there, not via the maternal respiratory system. Response "C" is incorrect since there isn't a histamine response in a normal pregnancy to cause an allergy. Response "D" is incorrect since the partial pressure of oxygen increases throughout pregnancy, not lessens.
A client comes to the clinic for pregnancy testing. The nurse explains that the test detects the presence of which hormone? a. Human placental lactogen (hPL) b. Human chorionic gonadotropin (hCG) c. Follicle stimulating hormone (FSH) d. Thyroid stimulating hormone (TSH)
b. Human chorionic gonadotropin (hCG) The correct response to this question is B because the goal of the Human Genome Project, which was started in 1990, was to map, sequence, and identify the functions of all human genes to advance genetic testing and gain a better understanding of human diseases. Linking genes to diseases, understanding underlying causes of diseases, and measuring the impact of certain chromosomes on prevention are all potential outcomes of the Human Genome Project, not the original goal of it.
To gain cooperation from a toddler, what is the best approach by the nurse? a. Immediately pick the toddler up from the mother's lap. b. Kneel in front of the toddler while he or she is on the mother's lap. c. Do the nursing tasks quickly so the toddler can play. d. Ask the toddler if it is okay if you begin the needed task.
b. Kneel in front of the toddler while he or she is on the mother's lap. The correct response is B. Being at the toddler's level and allowing the toddler to stay with his mother allow him to feel more secure. If the toddler perceives the nurse to be nonthreatening, the nurse is more likely to gain cooperation. Toddlers ordinarily answer "no," so asking the toddler's permission is not helpful. Simply jumping in and starting the task without allowing the toddler to warm up will threaten the child.
The mother of two sons, ages 6 and 9, states they want to play on the same baseball team. As the school nurse, what advice would you give their mother? a. Having the boys on the same team will make it more convenient for the mother. b. Levels of coordination and concentration differ, so the boys need to be on different teams. c. Put the boys on the same team because they are both school-age children. d. It is best to avoid putting the boys on the same team to prevent sibling rivalry.
b. Levels of coordination and concentration differ, so the boys need to be on different teams. The correct response is B. With age, concentration and coordination increase, so the 9-year-old would be operating at a higher level of maturity.
The mother of a 4-year-old asks for advice on using time-out for discipline with her child. What advice should the nurse give the mother? a. If spanking is not working, then time-out is not likely to be helpful either. b. Place the child in time-out for 4 minutes. c. Use time-out only if removing privileges is unsuccessful. d. The child should stay in time-out until crying ceases.
b. Place the child in time-out for 4 minutes. The correct response is B. The generally accepted guidelines recommend keeping the child in time-out for 1 minute per year of age.
When administering ear drops to a 2-year-old, which action would be most appropriate? a. Tell the child that the drops are to treat his infection. b. Pull the pinna of the child's ear down and back. c. Have the child turn his head to the opposite side after giving the drops. d. Massage the child's forehead to facilitate absorption of the medication.
b. Pull the pinna of the child's ear down and back. The correct response is B. When administering ear drops to a child under age 3, the nurse should pull the pinna of the ear down and back. The nurse should explain the reason for the ear drops to the child at a level that the child can understand, and it is doubtful that a 2-year-old would understand the term "infection." Once the drops are given, the child should remain in the same position for several minutes to ensure that the medication remains in the ear canal. The nurse should massage the area anterior to the affected ear to facilitate passage of the medication into the ear canal.
Which activities will promote weight loss in an obese school-age child? (Choose all that apply.) a. Unlimited computer and TV time b. Role modeling by family c. Becoming active in sports d. Eating unstructured meals e. Involving child in meal planning and grocery shopping f. Drinking three glasses of water per day
b. Role modeling by family c. Becoming active in sports e. Involving child in meal planning and grocery shopping The correct responses are B, C, and E. Inactivity while watching TV and playing computer games leads to weight gain. Sports facilitate the expenditure of calories while the child is participating in age-appropriate activities; unstructured mealtimes lead to increased consumption of fast foods and decreased role modeling by parents. The family needs to eat regular meals. Involving the child in meal preparation and grocery shopping facilitates interest in the weight-loss project. Intake of water increases metabolism and creates a feeling of fullness.
An infant boy is at your facility for his initial health supervision visit. He is 2 weeks old and responds to a bell during his examination. You review all his birth records and find no documentation that a newborn hearing screening was performed. What is the best action by the nurse? a. Do nothing; responding to the bell proves the infant does not have a hearing deficit. b. Schedule the infant immediately for newborn hearing screening. c. Ask the mother to observe for signs that the infant is not hearing well. d. Screen again with the bell at the infant's 2-month health supervision visit.
b. Schedule the infant immediately for newborn hearing screening. The correct response is B. Guidelines for infant hearing screening recommend universal screening with ABR or EOAE by 1 month of age (see Table 31.3). All the other answers rely on behavioral observation. Studies have shown that behavioral observation is not a reliable method of screening for hearing loss.
Which of the following activities will increase a woman's risk of cardiovascular disease if she is taking oral contraceptives? a. Eating a high-fiber diet b. Smoking cigarettes c. Taking daily multivitamins d. Drinking alcohol
b. Smoking cigarettes The correct response is B because smoking cigarettes causes vasoconstriction of the blood vessels, increasing peripheral vascular resistance and thus elevating blood pressure. These vascular changes increase the chances of CVD by placing additional pressure on the heart to pump blood with increasing vessel resistance. A is incorrect since fiber would be a positive diet addition and assist with elimination patterns and prevent straining, which stresses the heart. C is an incorrect response because vitamins do not cause narrowing of the vessel lumen, which places an additional burden on the heart. D is an incorrect response since alcohol produces vasodilation and reduces blood pressure. Alcohol in moderation is said to be good for the heart.
Which is associated with early adolescence? (Choose all that apply.) a. Uses scientific reasoning to solve problems b. Still at times wants to be dependent upon parents c. Incorporates own set of morals and values d. Is influenced by peers and values memberships in cliques
b. Still at times wants to be dependent upon parents d. Is influenced by peers and values memberships in cliques The correct responses are B and D. During early adolescence (11 to 14 years of age), adolescents are in conflict over becoming independent from their parents. They still at times want the role of the parents to be as it was during the school-age years. They are influenced by peers and value membership in cliques. Adolescents develop scientific reasoning and incorporate their own set of morals and values in middle and late adolescence.
What factors would change during a pregnancy if the hormone progesterone were reduced or withdrawn? a. The woman's gums would become red and swollen and would bleed easily. b. The uterus would contract more and peristalsis would increase. c. Morning sickness would increase and would be prolonged. d. The secretion of prolactin by the pituitary gland would be inhibited.
b. The uterus would contract more and peristalsis would increase The correct response is B. Progesterone is an essential hormone to maintain the pregnancy and prevent early labor. Progesterone decreases systemic vascular resistance early in pregnancy, leading to a decline in blood pressure. It causes relaxation of the uterus and gastrointestinal smooth muscle, resulting in delayed gastric emptying and calming of the uterus. This relaxation mechanism is vital to reduce uterine contractions.
The nurse is caring for a hospitalized 30-month-old who is resistant to care, is angry, and yells "no" all the time. The nurse identifies this toddler's behavior as a. problematic, as it interferes with needed nursing care. b. normal for this stage of growth and development. c. normal because the child is hospitalized and out of his routine.
b. normal for this stage of growth and development. The correct response is B. Negativism is characteristic of the stage, no matter what the situation (hospital or home).
The nurse is providing anticipatory guidance to the mother of a 6-month-old infant. What is the best instruction by the nurse in relation to the infant's oral health? a. "Start brushing her teeth after all the baby teeth come in." b. "Use a washcloth with toothpaste to clean her mouth." c. "Clean your baby's gums, then new teeth, with a washcloth." d. "Rinse your baby's mouth with water after every feeding."
c. "Clean your baby's gums, then new teeth, with a washcloth." The correct response is C. The infant's mouth should be cleansed with a damp washcloth as should the baby's new teeth. It is important to clean the mouth and the teeth in order to prevent dental caries. Toothpaste is unnecessary in infancy. Rinsing the infant's mouth would present a safety hazard.
During the health interview, the mother of a 4-month-old says, "I'm not sure my baby is doing what he should be." What is the nurse's best response? a. "I'll be able to tell you more after I do his physical." b. "Fill out this developmental screening questionnaire and then I can let you know." c. "Tell me more about your concerns." d. "All mothers worry about their babies. I'm sure he's doing well."
c. "Tell me more about your concerns." The correct response is C. An underlying tenet of the medical home is the partnership between the family and the nurse. The mother has intimate knowledge of the infant and can provide invaluable information. Her concerns provide the structure for the nurse's assessment. Answer "A" cuts the health interview short and dismisses any contributions the mother can make. Answer "B" is incorrect because a screening questionnaire is no substitute for a developmental assessment. Answer "D" cuts off the communication between the mother and the nurse.
To confirm a finding of primary syphilis, the nurse would observe which of the following on the external genitalia? a. A highly variable skin rash b. A yellow-green vaginal discharge c. A nontender, indurated ulcer d. A localized gumma formation
c. A nontender, indurated ulcer The correct response is C. The classic chancre in primary syphilis can be described as a painless, indurated ulcer-like lesion at the site of exposure. A is incorrect: a highly variable rash is characteristic of secondary syphilis, not primary. B is incorrect: this is more descriptive of a trichomoniasis vaginal infection rather than primary syphilis, which manifests with a chancre on the external genitalia. D is incorrect: a localized gumma formation on the mucous membranes, such as the lips or nose, is characteristic of late syphilis, along with neurosyphilis and cardiovascular syphilis.
A 4-year-old child is having a vision screening performed. Which screening chart would be best for determining the child's visual acuity? a. Snellen b. Ishihara c. Allen figures d. CVTME
c. Allen figures The correct response is C. The Allen figures chart is reliable for assessing visual acuity in a preschooler. Although the Snellen chart can be used if the child has a good knowledge of the alphabet, that is not an expectation for a 4-year-old child. The Ishihara and CVTME charts are designed to assess color vision discrimination and not visual acuity (see Table 31.4).
After teaching a group of students about fertilization, the instructor determines that the teaching was successful when the group identifies which as the usual site of fertilization? a. Fundus of the uterus b. Endometrium of the uterus c. Distal portion of fallopian tube d. Follicular tissue of the ovary
c. Distal portion of fallopian tube The correct response to this question is C, because scientists have determined that conception/fertilization occurs in the upper portion of the fallopian tube. A is an incorrect response because this is where implantation takes place after fertilization has occurred. B is an incorrect response because this describes the inner lining of the uterus, where implantation takes place; not where fertilization of the ovum and sperm occurs. D is an incorrect response because the sperm does not travel outside the fallopian tube to the ovary, but rather meets the ovum for purposes of fertilization in the fallopian tube.
Sperm maturation and storage in the male reproductive system occur in the: a. Testes b. Vas deferens c. Epididymis d. Seminal vesicles
c. Epididymis The correct response is C. The function of the epididymis is to store and mature sperm until ejaculation occurs. A is incorrect: the testes manufacture sperm and send them to the epididymis for storage and continued maturation. B is incorrect: the main function of the vas deferens is to rapidly squeeze the sperm from their storage site (epididymis) into the urethra. D is incorrect: the function of the seminal vesicles is to secrete an alkaline fluid rich in fructose and prostaglandins to help provide an environment favorable to sperm motility and metabolism.
A nurse is working in a women's health clinic. Which woman would genetic counseling be most appropriate for? a. Had her first miscarriage at 10 weeks b. Is 30 years old and planning to conceive c. Has a history with a close relative with Down syndrome d. Is 18 weeks pregnant with a normal triple screen result
c. Has a history with a close relative with Down syndrome The correct response is C. The family history plays a critical role in identifying genetic disorders. A history of a previous child, parents, or close relative with an inherited disease, congenital abnormalities, metabolic disorders, developmental disorders, or chromosomal abnormalities can indicate an increased risk of genetic disorders, therefore referral to genetic counseling is appropriate.
The nurse is preparing to teach a class to a group of middle-aged women regarding the most common vasomotor symptoms experienced during menopause and possible modalities of treatment available. Which of the following would be a vasomotor symptom experienced by menopausal women? a. Weight gain b. Bone density c. Hot flashes d. Heart disease
c. Hot flashes The correct response is C. The only two vasomotor symptoms listed are night sweats and hot flashes. The remainder of the symptoms listed (fatigue, confusion, forgetfulness, irritability, loss of libido, and appetite) can be symptoms of menopause, but are not classified as vasomotor ones.
Which of the following contraceptive methods offers protection against sexually transmitted infections (STIs)? a. Oral contraceptives b. Withdrawal c. Latex condom d. Intrauterine system
c. Latex condom The correct response is C. It creates a mechanical barrier so that bacteria and viruses cannot gain access to the internal reproductive tract and proliferate. A is incorrect: there is no barrier or protection offered by taking an oral pill. Oral contraceptives offer protection against pregnancy by preventing ovulation, but none against STIs. B is incorrect: since an infected partner can still transmit the infection through pre-ejaculate fluids, which may contain an active STI. D is incorrect: an IUD offers no barrier to prevent entrance of bacteria or viruses into the internal reproductive tract. Because it is an internal device, the string emerging from the external uterine os can actually enhance STI infiltration into the uterus in susceptible women.
The nurse is preparing to teach a class to a group of middle-aged women regarding the most common vasomotor symptoms experienced during menopause and possible modalities of treatment available. Common vasomotor symptoms would include which of the following? a. Chronic fatigue and confusion b. Forgetfulness and irritability c. Night sweats and hot flashes d. Decrease in sexual response and appetite
c. Night sweats and hot flashes The correct response is C because vasomotor symptoms of menopause are usually described as night sweats and hot flashes. Vasomotor symptoms are the most commonly reported menopausal symptoms by women. These symptoms are associated with estrogen deficiency. Frequently, these symptoms can be controlled by lifestyle changes. Response A is incorrect as these symptoms are not directly related to menopause and can be associated with numerous other etiologies such as anemia or dementia. Response B is incorrect because they may be underlining symptoms of a variety of other pathologies such as stroke, sleep deficiency, or early Alzheimer disease. Response D is incorrect due to the fact that the hormone testosterone has more influence over sexual drive and response, but falling levels of estrogen may be associated indirectly. A decrease in appetite is not directly related to menopause and may be caused by a variety of other factors.
The nurse is caring for a hospitalized 4-year-old who insists on having the nurse perform every assessment and intervention on her imaginary friend first. She then agrees to have the assessment or intervention done to herself. The nurse identifies this preschooler's behavior as: a. Problematic; the child is old enough to begin to have a basis in reality. b. Normal, because the child is hospitalized and out of her routine. c. Normal for this stage of growth and development. d. Problematic, as it interferes with needed nursing care.
c. Normal for this stage of growth and development. The correct response is C. Imaginary friends help the preschooler cope with stress in his or her life.
What is the first step in determining a couple's risk for a genetic disorder? a. Observing the client and family over time b. Conducting extensive psychological testing c. Obtaining a thorough family health history d. Completing an extensive exclusionary list
c. Obtaining a thorough family health history The correct response to this question is C, because uncovering an individual's family history can identify previous genetic disorders that have a high risk for recurrence in subsequent generations. A is an incorrect response to this question because observing a patient and their family would be costly and unproductive to diagnose a genetic disorder. This observation would have to take place over several generations to yield results. B is an incorrect response because psychological testing might not uncover genetic predispositions to disorders. D is an incorrect response because excluding the numerous genetic conditions would be a time-consuming and tedious task.
Which of the following is an example of an autosomal dominant disorder? a. Phenylketonuria b. Tay-Sachs disease c. Polycystic kidney disease d. Cystic fibrosis
c. Polycystic kidney disease The correct response is "C" because polycystic kidney disease is an example of an autosomal dominant disease because the gene carrying the mutation is located on one of the autosomes of the affected parent and the affected person has a 50% chance of passing the abnormal gene to each of the children. Responses "A," "B," and "D" are all autosomal recessive inheritance disorders that need both parents must carry the abnormal gene and their offspring has a 25% probability of inheriting the two mutant genes.
The mother of a 15-month-old is concerned about a speech delay. She describes her toddler as being able to understand what she says, sometimes following commands, but using only one or two words with any consistency. What is the nurse's best response to this information? a. The toddler should have a developmental evaluation as soon as possible. b. If the mother would read to the child, then speech would develop faster. c. Receptive language normally develops earlier than expressive language. d. The mother should ask her child's physician for a speech therapy evaluation.
c. Receptive language normally develops earlier than expressive language. The correct response is C. Young toddlers understand far more language than they can actually express themselves.
Reva Rubin identified four major tasks that the pregnant woman undertakes to form a mutually gratifying relationship with her infant. What is "binding in"? a. Ensuring safe passage through pregnancy, labor, and birth b. Seeking acceptance of this infant by others c. Seeking acceptance of self as mother to the infant d. Learning to give of oneself on behalf of the infant
c. Seeking acceptance of self as mother to the infant The correct response is C. Seeking acceptance of self as mother to the infant is the basis for establishing a mutually gratifying relationship between mother and infant. This "binding in" is a process that changes throughout the pregnancy, starting with the mother's acceptance of the pregnancy and then the infant as a separate entity. Ensuring safe passage through pregnancy, labor, and birth focuses on the mother initially and her concern for herself. As the pregnancy progresses, the fetus is recognized and concern for its safety becomes a priority. The mother-infant relationship is not the mother's concern yet. Seeking acceptance of this infant by others includes the world around the mother and how they will integrate this new infant into their world. The infant-maternal relationship is not the focus in this task. Learning to give of oneself on behalf of one's infant focuses on delaying maternal gratification, focusing on the infant's needs before the mother's needs.
Parents of an 8-month-old girl express concern that she cries when left with the babysitter. How does the nurse best explain this behavior? a. Crying when left with the sitter may indicate difficulty with building trust. b. Stranger anxiety should not occur until toddlerhood; this concern should be investigated. c. Separation anxiety is normal at this age; the infant recognizes parents as separate beings. d. Perhaps the sitter doesn't meet the infant's needs; choose a different sitter.
c. Separation anxiety is normal at this age; the infant recognizes parents as separate beings. The correct response is C. As the infant realizes she is separate from her parents, it may distress her when the parents leave, as she understands they are no longer with her.
2. Which glands are located on either side of the female urethra and secrete mucus to keep the opening moist and lubricated for urination? a. Cowper's b. Bartholin's c. Skene's d. Seminal
c. Skene's The correct response is C. Skene's glands are located close to the urethral opening and secrete mucus and lubricate during urination and sexual intercourse. A is incorrect: Cowper's glands are located on either side of the male urethra, not the female urethra. B is incorrect: Bartholin's glands are located on either side of the vaginal opening and secrete alkaline mucus that enhances the viability of the male sperm. D is incorrect: seminal glands are pouch-like structures at the base of the male urinary bladder that secrete an alkaline fluid to enhance the viability of the male sperm.
Which of the following is a presumptive sign or symptom of pregnancy? a. Restlessness b. Elevated mood c. Urinary frequency d. Low backache
c. Urinary frequency The correct response is C. Urinary frequency occurs during early pregnancy secondary to pressure on the bladder by the expanding uterus. This is one of the presumptive signs of pregnancy. Restlessness or elevated mood is not a sign of pregnancy. As hormones increase during pregnancy, the mood might change, but it is not indicative of pregnancy. Low backache is frequently experienced by many women during the third trimester of pregnancy secondary to the change in their center of gravity, but it is not a presumptive sign of pregnancy.
What comment by a woman would indicate that a diaphragm is not the best contraceptive device for her? a. "My husband says it is my job to keep from getting pregnant." b. "I have a hard time remembering to take my vitamins daily." c. "Hormones cause cancer and I don't want to take them." d. "I am not comfortable touching myself down there."
d. "I am not comfortable touching myself down there." The correct response is D. This vaginal barrier contraceptive device is a dome-shaped rubber cup with a flexible rim that needs to be inserted into the woman's vagina before sexual intercourse. The dome of the diaphragm covers the cervix and the spermicidal cream or jelly applied to the rim prevents sperm from entering the cervix. Women who use this method of contraception must be able to insert the device in their vaginas before each sex act for it to be effective. If the woman is uncomfortable "touching" herself, this is not going to be a successful method and another method should be utilized.
The mother of a 3-month-old boy asks the nurse about starting solid foods. What is the most appropriate response by the nurse? a. "It's okay to start puréed solids at this age if fed via the bottle." b. "Infants don't require solid food until 12 months of age." c. "Solid foods should be delayed until age 6 months, when the infant can handle a spoon on his own." d. "The tongue extrusion reflex disappears at age 4 to 6 months, making it a good time to start solid foods."
d. "The tongue extrusion reflex disappears at age 4 to 6 months, making it a good time to start solid foods." The correct response is D. As the tongue extrusion reflex disappears, the infant is better able to accept the spoon and learn to take solid foods.
The nurse is counseling a couple, one of whom is affected by an autosomal dominant disorder. They express concerns about the risk of transmitting the disorder. What is the best response by the nurse regarding the risk that their baby may have for the disease? a. "You have a one in four (25%) chance." b. "The risk is 12.5%, or a one in eight chance." c. "The chance is 100%." d. "Your risk is 50%, or a one in two chance."
d. "Your risk is 50%, or a one in two chance." The correct response is D. Autosomal dominant inheritance occurs when a single gene in the heterozygous state is capable of producing the phenotype. The affected person generally has an affected parent and an affected person generally has a 50% chance of passing the abnormal gene to each of his or her children.
As the school nurse conducting screening for vision in a 6-year-old child, you would refer the child to a specialist if the visual acuity in both eyes is: a. 20/20 b. 20/25 c. 20/30 d. 20/50
d. 20/50 The correct response is D. Visual acuity of 20/20 is not expected until 7 years of age.
The nurse is providing teaching about accidental poisoning to the family of a 3-year-old. The nurse understands that a child of this age is at increased risk of accidental ingestion due to which sensory alteration? a. A lack of fully developed hearing. b. A less discriminating sense of touch. c. Visual acuity that has not fully developed. d. A less discriminating sense of taste.
d. A less discriminating sense of taste. The answer is D. Less discriminating sense of taste. The young preschooler may have a less discriminating sense of taste than the older child, making him or her at increased risk for accidental ingestion. A less discriminating sense of touch and developing visual acuity would not increase the risk. Hearing is intact at birth and it does not increase the child's risk for accidental ingestion.
A feeling expressed by most women upon learning they are pregnant is: a. Acceptance b. Depression c. Jealousy d. Ambivalence
d. Ambivalence The correct response is D. The feeling of ambivalence is experienced by most women when they question their ability to become a mother. Feelings fluctuate between happiness about the pregnancy and anxiety and fear about the prospect of new responsibilities and a new family member. Acceptance usually develops during the second trimester after fetal movement is felt by the mother and the infant becomes real to her. Depression is not a universal feeling experienced by most women unless there is a past history of underlying depression experienced by the woman. Jealousy is not a universal feeling of pregnant women. It can occur in partners, because attention is being diverted from them to the pregnancy and the newborn.
The most common cause of menstrual abnormality in a reproductive-age woman is: a. Ectopic pregnancy b. Coagulopathy c. Carcinoma d. Anovulation
d. Anovulation The correct response is "D" because abnormal uterine bleeding typically occurs when menstrual ovulation doesn't occur within the monthly cycle. Chronic anovulation causes a variety of abnormal bleeding patterns. Response "A" is incorrect because amenorrhea would be present secondary to the pregnancy, although misplaced. Response "B" is incorrect because other symptoms would be present due to a coagulation problem systemically. Response "C" is incorrect since most uterine cancers occur in postmenopausal women, not reproductive-aged women.
A 5-year-old child is not gaining weight appropriately. Organic problems have been ruled out. What is the priority action by the nurse? a. Allow the child unlimited access to the sippy cup to ensure adequate hydration. b. Encourage sweets for the extra caloric content. c. Teach the mother about nutritional needs of the preschooler. d. Assess the child's usual intake pattern at home.
d. Assess the child's usual intake pattern at home. The correct response is D. The nurse must first assess the child's current intake to determine if there is a deficiency.
A 15-month-old girl is having her first health supervision visit at your facility. Her mother has not brought a copy of the child's immunization record but believes she is fully immunized: "She had immunizations 3 months ago at the local health department." Which would be the best action by the nurse? a. Ask the mother to bring the records to the 18-month health supervision visit. b. Start the "catch-up" schedule because there are no immunization records. c. Keep the child at the facility while the mother returns home for the records. d. Call the local health department and verify the child's immunization status.
d. Call the local health department and verify the child's immunization status. The correct response is D. Contacting the agency provides several benefits. It allows the nurse's facility to have a copy of the child's immunization record for the permanent records. It also avoids repeating vaccinations unnecessarily. Answer "A" is incorrect because accepting the mother's recollection of the infant's immunization status puts the infant at risk of not being fully immunized. This would be a "missed opportunity" by the nurse to provide needed vaccinations. The scenario may also be repeated at the 18-month well-child visit if the mother again forgets the record. Answer "B" is inappropriate because contacting the other facility is an option. Needlessly immunizing the infant increases risk to the child and wastes health care resources. Answer "C" is inappropriate because the child would be very anxious while the mother was gone.
A 3-year-old child is to receive a medication that is supplied as an enteric-coated tablet. What is the best nursing action? a. Crush the tablet and mix it with apple sauce. b. Dissolve the medication in the child's milk. c. Place a pill in the posterior part of the pharynx and tell the child to swallow. d. Check with the prescriber to see if an alternative form can be used.
d. Check with the prescriber to see if an alternative form can be used. The correct response is D. A 3-year-old would typically have difficulty swallowing tablets, pills, or capsules. Therefore, the nurse should check with the prescriber to see if an alternative form, such as a liquid, is available. If not, then a different medication may need to be ordered. Enteric-coated medication should not be crushed or dissolved because this would interfere with the action of the drug. No medication should ever be mixed with an essential food for the child.
A sexually active 19-year-old presents to the clinic with postcoital bleeding, dysuria, and a yellow discharge. Her cervix upon exam is red and friable. What might the nurse suspect? a. Cervical cancer b. A tampon injury c. Primary syphilis d. Chlamydia
d. Chlamydia The correct response is "D" because these clinical manifestations are typical of a chlamydia infection (postcoital bleeding, dysuria, frequency, vaginal discharge, cervical tenderness with easily induced bleeding). Response "A" is incorrect because it would be rare to have cervical cancer at such a young age and the symptoms presented are not suggestive of this diagnosis. Response "B" is incorrect because the presenting symptoms are not suggestive of a cervical injury. Response "C" is incorrect because primary syphilis would present with a chancre lesion at the site where the bacteria entered the body, typically the vulva.
The nurse's discharge teaching plan for the woman with PID should reinforce which of the following potentially life-threatening complications? a. Involuntary infertility b. Chronic pelvic pain c. Depression d. Ectopic pregnancy
d. Ectopic pregnancy The correct response is D. A ruptured tubal pregnancy secondary to an ectopic pregnancy can cause life-threatening hypovolemic shock. Without immediate surgical intervention, death can result. A is incorrect: involuntary infertility may be emotionally traumatic, but it is not life-threatening. B is incorrect: chronic pelvic pain secondary to adhesions is unpleasant but typically isn't life-threatening. C is incorrect: depression may be caused by the chronic pain or involuntary infertility but is not life-threatening.
Which hormone is produced in high levels to prepare the endometrium for implantation just after ovulation by the corpus luteum? a. Estrogen b. Prostaglandins c. Prolactin d. Progesterone
d. Progesterone The correct response is D. Progesterone is the dominant hormone after ovulation to prepare the endometrium for implantation. A is incorrect: estrogen levels decline after ovulation, since it assists in the maturation of the ovarian follicles before ovulation. Estrogen levels are highest during the proliferative phase of the menstrual cycle. B is incorrect: prostaglandin production increases during the follicular maturation and is essential during ovulation but not after ovulation. C is incorrect: prolactin is inhibited by the high levels of estrogen and progesterone during pregnancy; when their levels decline at birth, an increase in prolactin takes place to promote lactation.
Which of the following fish should be limited in a pregnant woman's diet because of the high mercury content? a. Salmon b. Cod c. Shrimp d. Sword fish
d. Sword fish The correct response to this question is "D" because sword fish typically contains high levels of mercury when compared to other fish species which should be avoided during pregnancy. Responses "A," "B," and "C" are fish that have been assessed as having low levels of mercury.
A 2-year-old is having a temper tantrum. What advice should the nurse give the mother? a. For safety reasons, the toddler should be restrained during the tantrum. b. Punishment should be initiated, as tantrums should be controlled. c. The mother should promise the toddler a reward if the tantrum stops. d. The tantrum should be ignored as long as the toddler is safe.
d. The tantrum should be ignored as long as the toddler is safe. The correct response is D. Ignoring tantrums is the best method for discouraging them. Any additional attention received because of the outburst may only contribute to another occurrence in the future.
Which of the following measures helps prevent osteoporosis? a. Supplementing with iron b. Sleeping 8 hours nightly c. Eating lean meats only d. Walking daily
d. Walking daily The correct response is D. Weight-bearing exercise is an excellent preventive measure to preserve bone integrity, especially the vertebral column and hips. Walking strengthens the skeletal system and prevents breakdown that leads to osteoporosis. A is incorrect: iron does not prevent bone breakdown; while iron supplementation will build up blood and prevent anemia, it has a limited effect on bones. B is incorrect: being in the horizontal position while sleeping is not helpful to build bone. Weight-bearing on long bones helps to maintain their density, which prevents loss of bone matrix. C is incorrect: protein gained from eating lean meats helps the body to build tissue and muscles but has a limited effect on maintaining bone integrity or preventing loss of bone density.
