exam 2 adult health
A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention should the nurse suggest to alleviate the child's fears? 1.Encourage the child's parents to stay with the child. 2.Encourage play with other children of the same age. 3.Advise the family to visit only during the scheduled visiting hours. 4.Provide a private room, allowing the child to bring favorite toys from home.
1
A mother of a 5-year-old child tells the nurse that the child scolds the floor or table if the child hurts herself on the object. The nurse identifies the child as displaying signs of which stage of Piaget's theory of cognitive development? 1.Animism 2.Egocentric speech 3.Object permanence 4.Global organization
1
During data collection on a child for a well-child visit, a parent tells the nurse "We have a chore chart at our house. When our child does chores without prompting for 3 days in a row, the child gets an extra 30 minutes of screen time. So far, it seems to be working!" The nurse determines the child's behavior corresponds with which stage of Kohlberg's moral development? 1.Pre-conventional: Obtaining rewards 2.Pre-conventional: Avoiding punishment 3.Conventional: Obeying rules and regulations 4.Post-conventional: Making and keeping promises
1
The nurse has gathered data regarding an older client. The nurse recognizes that which indicator of fluid imbalance is least likely to be reliable for a client in this age group? 1.Thirst 2.Skin turgor 3.Intake-output differences 4.Appearance of oral mucosa
1
The nurse is asked to test the visual acuity of a client using a Snellen chart. The nurse prepares to perform the test, knowing that which procedure accurately identifies this visual acuity test? 1.The right eye is tested, followed by the left eye, and then both eyes are tested. 2.Both eyes are tested together, followed by the testing of the right and then the left eye. 3.The client is asked to stand at a distance of 40 feet from the chart and to read the largest line on the chart. 4.The client is asked to stand at a distance of 40 feet from the chart and to read the line that can be read 200 feet away by an individual with unimpaired vision.
1
The nurse is caring for a 14-year-old boy who is hospitalized and placed in Crutchfield traction. The child is having difficulty adjusting to the length of the hospital confinement. Which nursing action would be appropriate to meet the child's needs? 1.Let the child wear his own clothing when friends visit. 2.Allow the child to have his hair dyed if the parent agrees. 3.Allow the child to play loud music in the hospital room. 4.Allow the child to keep the shades closed and the room darkened at all times.
1
The nurse is preparing to administer a continuous tube feeding to a client with a nasogastric tube. The primary health care provider has prescribed an amount of 100 mL/hr. The tube feeding setup is an open system, a bag that has formula added at intervals. How much formula should the nurse plan to add to fill the feeding bag? 1.400 mL of formula 2.600 mL of formula 3.800 mL of formula 4.Enough formula to last for 8 hours
1
The nurse should implement which activity to promote reminiscence among older clients? 1.Having storytelling hours 2.Setting up pet therapy sessions 3.Displaying calendars and clocks 4.Encouraging client participation in a pottery class
1
The nurse is collecting data from a client who is suspected of having mittelschmerz. Which finding, on data collection, is most closely associated with this disorder? 1.Profuse vaginal bleeding 2.Pain that occurs during intercourse 3.Pain at the beginning of menstruation 4.Sharp pain located on the right side of the pelvis
4
The nurse is preparing the client for eye testing, and the examiner is planning to test the eyes using the confrontational method. What should the nurse tell the client about the purpose of the test? 1.Checks for glaucoma 2.Checks for color blindness 3.Examines pupil constriction 4.Examines visual fields or peripheral vision
4
The nurse is reinforcing dietary instructions to a client with tuberculosis who has lost weight. The nurse reinforces instructions for the client to increase intake of protein and vitamin C. The nurse determines that teaching has been effective when the client selects which food items in the daily diet? 1.Rice and fish 2.Eggs and bacon 3.Oatmeal and milk 4.Hamburger and oranges
4
The nurse is assisting to perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of data collection? Select all that apply. 1.Listening to lung sounds 2.Obtaining the client's temperature 3.Checking the strength of peripheral pulses 4.Obtaining information about the client's respirations 5.Performing a musculoskeletal and neurological examination 6.Asking the client about a family history of any illness or disease
124
The nurse is caring for a client at the end of life. Which gastrointestinal findings indicate that death is approaching? Select all that apply. 1.Nausea 2.Incontinence 3.Profuse diarrhea 4.Accumulation of gas 5.Abdominal distention
1245
The nurse is employed in a newborn nursery. The nurse is reviewing all medications prescribed for newborns to prevent toxicity due to which causes? Select all that apply. 1.The liver is immature. 2.The lungs are not developed. 3.Cerebral function is not fully developed. 4.The kidneys are smaller than those of adults. 5.The kidneys are less able to excrete medications 6.The neonate has more difficulty retaining body heat.
15
A caregiver states that the client eats only about 25% of the food that is offered and is losing weight. The caregiver asks the nurse about feeding the client by a tube into the stomach. Which initial response by the nurse would be appropriate? 1."Tube feedings are only for long-term feeding problems." 2."Tube feedings can provide adequate amounts of required nutrients." 3."Tube feedings often result in complications such as aspiration pneumonia." 4."Tube feedings are not helpful in cases of intractable vomiting or severe diarrhea."
2
A client who has recently been started on enteral feedings begins to complain of abdominal cramping, followed by passage of two liquid stools. The nurse notes that the client has abdominal distention as well. The nurse reviews the nutritional content on the label of the can to see if it contains which ingredient? 1.Maltose 2.Lactose 3.Sucrose 4.Fructose
2
A licensed practical nurse (LPN) is assisting a high school nurse in conducting a session with female adolescents regarding the menstrual cycle. After the session has been completed, the LPN recognizes the adolescents have understood the teaching if the adolescents identify the normal duration of the menstrual cycle is about how many days? 1.14 days 2.28 days 3.30 days 4.45 days
2
A mother of a 3-year-old is concerned because the child is still insisting on a bottle at nap time and at bedtime. The nurse should make which suggestion to the mother? 1."Allow the bottle if it contains juice." 2."Allow the bottle if it contains water." 3."Do not allow the child to have the bottle." 4."Allow the bottle during naps but not at bedtime."
2
The mother of a 4-year-old who was recently hospitalized brings the child to the clinic for a follow-up visit. The mother tells the nurse that the child has begun to wet the bed and that it started when the child was brought home from the hospital. The mother is concerned and asks the nurse what to do. Which nursing response is appropriate? 1."You need to discipline the child." 2."This is a normal occurrence following hospitalization." 3."The child probably has developed a urinary tract infection." 4."We will need to discuss this behavior with the primary health care provider."
2
The nurse has reinforced information to the mother of a toddler regarding toilet training. Which statement by the mother would indicate a need for further teaching? 1."I should wait until my child is at least 24 months old." 2."I should have my child sit on the potty until my child urinates." 3."I know that my child will develop bowel control before bladder control." 4."I know my child is ready to begin toilet training if my child can walk well."
2
The nurse is assessing the pain in a 3-year-old child after an appendectomy. Which pain scale should the nurse use? 1.Numeric scale 2.Poker child tool 3.FACES pain rating scale 4.The child is too young to be able to express the pain.
2
The nurse is checking a dark-skinned client for the presence of petechiae. Which body area is best for the nurse to check in this client? 1.Sclera 2.Oral mucosa 3.Soles of the foot 4.Palms of the hand
2
The nurse prepares to discharge a fifty-year-old client who is experiencing family-related stress. Which goal does the nurse include to help the client achieve the primary developmental task? 1.Improve the client's acceptance of aging. 2.Assist the client resume her familial role. 3.Develop the client's critical thinking skills. 4.Adjust her lifestyle to ease stress response.
2
The nurse is providing information to unlicensed assistive personnel (UAP) regarding caring for the older adult. The nurse determines the UAP understands the information provided if the UAP identifies which situation portrays ageism? 1.Informing the older adult of their rights 2.Allowing older adults to make decisions 3.Accepting differences among older adults 4.Advising older adults to forgo aggressive treatment
4
The nurse is participating in a care plan session for a client with a terminal illness. Which nursing actions should be included? Select all that apply. 1.Follow standard care plans for end-of-life care. 2.Respond to requests from the client and family promptly. 3.Support the client's decision-making in order to promote client control. 4.Discuss sensitive topics quickly and efficiently to avoid upsetting the client and family. 5.Provide information about what to expect during the dying process to the client and family.
235
The nurse needs to increase the calcium in the diet of a client who is lactose intolerant. Which food items should the nurse encourage? Select all that apply. 1.Milk 2.Tofu 3.Cheese 4.Broccoli 5.Sardines 6.Mustard greens
2456
A client has a diagnosis of hyperphosphatemia. The nurse reinforces instructions by telling the client to eliminate which items from the diet? Select all that apply. 1.Tea 2.Fish 3.Cocoa 4.Coffee 5.Chicken
25
A nursing student is assigned to care for a hospitalized 2-year-old child. The nursing instructor reviews the plan of care with the student and asks the student to identify the expected behavior of the child in regard to separation anxiety. Which statement by the student indicates an understanding of separation anxiety that can occur in a 2-year-old child? 1."The child will withdraw." 2."Separation anxiety is not an issue in a 2-year-old." 3."The child may ignore the parents when they visit." 4."Two-year-olds usually adjust well to hospitalization."
3
An older client has been prescribed digoxin. The nurse determines that which age-related change would place the client at risk for digoxin toxicity? 1.Decreased salivation and gastrointestinal motility 2.Decreased muscle strength and loss of bone density 3.Decreased lean body mass and glomerular filtration rate 4.Decreased cardiac output and decreased efficiency of blood return to the heart
3
The mother of a 2-year-old child asks the nurse if it is all right to give the child a bottle at naptime. Which response by the nurse is appropriate? 1."At this age, the child may have a bottle at any time." 2."A bottle may be given if the child isn't taking fluids well during the day." 3."You may give the child a bottle if necessary, but if you do, it should contain water." 4."The child may have a bottle at naptime, but it is best not to give a bottle at bedtime."
3
The mother of an infant newly diagnosed with cystic fibrosis is being taught proper nutritional needs for the infant. The nurse determines that the mother understands nutritional needs when the mother gives which response? 1."I know that my infant needs to drink predigested formula until she has her stool pattern developed." 2."When I begin feeding my infant cereal, I will make sure to warm the cereal and administer the pancreatic enzyme mixed in." 3."I know I need to monitor my infant's stools, and if there are more than four stools a day, I will increase the pancreatic enzyme." 4."I will make sure that I give my infant fat-free milk as a supplement to her predigested formula, because she is not able to digest fat."
3
The nurse employed in a well-baby clinic is reinforcing nutrition instructions to the mother of a 1-month-old infant. Which instruction should the nurse provide the mother? 1.Introduce strained fruits one at a time. 2.Introduce strained vegetables one at a time. 3.Offer breast milk or formula as the main food. 4.Offer rice cereal mixed with breast milk or formula.
3
The nurse is caring for an older client who is terminally ill. Which signs indicate to the nurse that death may be imminent? 1.Flushed and warm skin 2.Eupnea and normal body temperature 3.Irregular, noisy breathing and cold, clammy skin 4.Presence of swallowing reflex and active bowel sounds
3
The nurse is performing a safety assessment in the home of a mother with two children. The ages of the children are 1 and 3 years. Which observation noted during the assessment would present the greatest hazard to the children? 1.A small dog as a house pet 2.The water heater set above 120° F 3.Toys with small loose parts in the playroom 4.A gate placed at the stairs of the second floor
3
The nurse is told by an older woman that she has begun to be incontinent of urine at night and now drinks no fluids after 6.00 pm. Which is the nurse's best response? 1."Incontinence is to be expected in old age." 2."Older people do not need as much fluid intake as younger people." 3."Incontinence at any age should be evaluated by your primary health care provider." 4."That's a good idea; you're the best judge of how much fluid you should or should not drink."
3
The nurse prepares to take a blood pressure (BP) on a school-age child. Where should the nurse place the blood pressure cuff to obtain an accurate measurement? 1.One half the distance between the antecubital fossa and the shoulder 2.One third the distance between the antecubital fossa and the shoulder 3.Two thirds the distance between the antecubital fossa and the shoulder 4.One quarter the distance between the antecubital fossa and the shoulder
3
The nurse who is assisting in a weight loss program prepares to monitor a client's weight. The client receives education about caloric intake and weight reduction. In order to lose 2 pounds per week the caloric intake should be decreased by how many calories per day? 1.100 calories 2.500 calories 3.1000 calories 4.1500 calories
3
The nurse is admitting a 10-month-old infant who is being hospitalized for a respiratory infection. The nurse develops a plan of care for the infant and includes which intervention? 1.Keeping the infant as quiet as possible 2.Restraining the infant to prevent tubes from being dislodged 3.Placing small toys in the crib to provide stimulation for the infant 4.Providing a consistent routine such as touching, rocking, and cuddling throughout the hospitalization
4
The nurse should plan which to encourage autonomy in the client who is a resident in a long-term care facility? 1.Choosing meals 2.Decorating the room 3.Scheduling haircut appointments 4.Allowing the client to choose social activities
4
A newly pregnant client is asking how to prevent neural-tube birth defects. The nurse reinforces which food choices to include in the diet? Select all that apply. 1.Milk 2.Peanuts 3.Oranges 4.Broccoli 5.Egg yolks 6.Grapefruit
346
A client is admitted to a long-term care facility with the diagnosis of weight loss secondary to anorexia. The primary health care provider inserts a nasogastric tube and prescribes a tube feeding of a standard formula feeding to run at 50 mL/hr. The nurse plans care, knowing that which is true regarding enteral feedings? 1.Enteral feedings are a frequent cause of sepsis. 2.Tube feedings should be refrigerated until just before use. 3.The caloric value of enteral feedings is generally 5 to 10 kcal/mL. 4.Enteral feedings require the normal digestive capabilities of the gastrointestinal (GI) tract.
4
A client is having problems with blood clotting. Which food item should the nurse encourage the client to eat? 1.Legumes 2.Citrus fruits 3.Vegetable oils 4.Green, leafy vegetables
4
A client's vision is tested with a Snellen chart. The results of the test are documented as 20/60. How should the nurse interpret this result? 1.The client is legally blind. 2.The client's vision is normal. 3.The client can read at a distance of 60 feet what a client with normal vision can read at 20 feet. 4.The client can read at a distance of 20 feet what a client with normal vision can read at 60 feet.
4
A pediatric nurse is caring for a hospitalized toddler. The nurse determines that which play activity would be appropriate for the toddler? 1.Listening to music 2.Playing peek-a-boo 3.Hand sewing a picture 4.Playing with a push-pull toy
4
A young adult college student begins to throw objects, shout insults, and stamp his feet after an instructor returned his work, noting it was substandard. Using Erikson's theory of personality development, which developmental stage has this individual unsuccessfully mastered? 1.Initiative vs. guilt 2.Industry vs. inferiority 3.Identity vs. role confusion 4.Autonomy vs. shame and doubt
4
The nurse determines a child is in the "preoperational" phase of Piaget's cognitive developmental theory when the child makes which statement? 1."I know all of my multiplication tables by memory". 2."The ball is gone," when a ball disappears out of sight. 3."I'll use a map to help me find my way in a new town". 4."The moon follows me, and goes to bed when I go to bed".
4
The nurse employed in a well-baby clinic is collecting data on the language and communication developmental milestones of a 4-month-old infant. Based on the age of the infant, the nurse expects to note which highest level of developmental milestones? 1.Cooing sounds 2.Use of gestures 3.Babbling sounds 4.Interest in sounds
4
The parents of an 8-year-old child tell the nurse that they are concerned about the child because the child seems to be more attentive to friends than anyone else. Which is the appropriate nursing response? 1."You need to be concerned." 2."You need to monitor the child's behavior closely." 3."You need to praise the child more often to stop this behavior." 4."At this age, the child is developing his or her own personality."
4