NCLEX question
Which intervention should a parent use to treat their child's croup at home? a. Give them a decongestant b. Give them an antibiotic from the last time they had croup c. Have them sleep in a dry room d. Take them outside
d. Take them outside Rationale: It can reduce mucosal swelling
A client has been diagnosed with with Graves' Disease. The nurse monitors for which signs and symptoms indicating complications of the disorder? (Select all that apply) A. Fever B. Severe weakness C. Cough D. Jaundice
A, B, D Rationale ○Fever, severe weakness and jaundice are all signs of a thyroid storm, which is a complication of Graves' disease.
A teenage girl who was diagnosed with SLE 3 years ago comes to the clinic for a routine appointment and tells the nurse "I hate going to gym class because I'm the only one that has to take rest breaks throughout class." An appropriate nursing diagnosis for this patient is: A.Activity intolerance related to fatigue and joint pain B.Impaired skin integrity related to malar butterfly rash C.Social isolation related to embarrassment of side effects of SLE D.Impaired social interaction related to poor social skills
A. Activity intolerance related to fatigue and joint pain
The nurse is caring for a client diagnosed with meningitis. Which collaborative intervention should be included in the plan of care? A. Administer antibiotics. B. Obtain a sputum culture. C. Monitor the pulse oximeter. D. Assess intake and output.
A. Administer antibiotics. Rational: A nurse administering antibiotics is a collaborative intervention because the HCP must write an order for the intervention; nurses cannot prescribe medications unless they have additional education and licensure and are nurse practitioners with prescriptive authority.
A nurse is caring for an infant who has an epispadias. Which of the following findings should the nurse expect? (Select all that apply.) A) Bladder exstrophy B) Inability to retract foreskin C) Widened pubic symphysis D) Urethral opening on the dorsal side of the penis E) Pain
A) Bladder exstrophy C) Widened pubic symphysis D) Urethral opening on the dorsal side of the penis Rational: These are all expected finding for this condition.
The nurse analyzes the laboratory values of a child with leukemia receiving chemotherapy. The nurse notes that the platelet count is 19,500 mm3. On the basis of this laboratory result, which intervention should the nurse include in the plan of care? A. Initiate bleeding precautions B. Monitor closely for signs of infection C. Monitor the temperature every 4 hours D. Initiate protective isolation precautions
A. Initiate bleeding precautions
A child is suspected of having rheumatic fever, what criteria will help confirm the diagnoses? A. The presence of at least 2 major manifestations or one minor manifestation B. A dry painful itchy rash over the extremities of the body C. There are no signs or symptoms of rheumatic fever D. Exposure to a child diagnosed with rheumatic fever
A Rationale-A diagnosis of rheumatic fever is made by using the Jones criteria in the presence of at least 2 major manifestations or one minor manifestation because of a wide variety of symptoms are associated with rheumatic fever and other illnesses.
Which specific nursing interventions are implemented in the care of a child with leukemia who is at risk for infection? Select all that apply. A. Maintain the child in a semi private room. B. Reduce exposure to environmental organisms. C. Use strict aseptic technique for lol procedures. D. Ensure that anyone entering the room wears a mask. E. Apply firm pressure to a needlestick area for at least 10 minutes.
A and C
What are common clinical features of DMD, select all that apply A) Positive Grower Maneuver B) Increased Swallowing C) Learning Disabilities D) Waddling Gait
A positive grower maneuver C learning disabilities D waddling gate A, C, D are common clinical features. Patients with DMD would have decreased swallowing and increased drooling.
A 5-month-old breastfed infant is successfully rehydrated with oral rehydration solutions (ORS) for acute diarrhea. What instructions to the mother about breastfeeding should be included by the nurse? A. Continue breastfeeding B. Stop breastfeeding until breast milk is cultured C. Stop breastfeeding until diarrhea is absent for 24 hours D. Express breast milk and dilute with sterile water before feeding
A. Continue breastfeeding
An assessment of a 7-month-old infant with a hemoglobin level of 6.5 mg/dL is likely to reveal an infant who is A. Lethargic, pale, and irritable B. Thin, energetic, and sleeps little C. Anorexic, vomiting, and has watery stools D. Flushed, fussy, and tired
A. Lethargic, pale, and irritable
A nurse is asked from a concerned parent "How did my child develop rheumatic fever?" What is the nurse's best response? A. "It just happens with no warning." B. "Not following through with antibiotic treatments for Group A strep or not being properly treated can lead to rheumatic fever." C. "Coming into contact with a child diagnosed with rheumatic fever since it is extremely contagious." D. "I have never heard of rheumatic fever before?"
B Rationale-Rheumatic fever characteristically manifests 2 to 6 weeks after an untreated or partially treated group A beta- hemolytic streptococcal infection of the upper respiratory tract. It is important to teach patients to finish all their prescribed antibiotics.
A nurse is providing a teaching to the parent of a 12-year-old boy, who is receiving radioactive iodine therapy, which characteristics most accurately describes the use of this treatment? (select all that apply). A. "RAI blocks the conversion of T3 and T4". B."It decreases thyroid hormone secretion by destroying the thyroid tissue". C."This treatment will be administered via continuous IV infusion". D."Radioactive iodine therapy might cause hypothyroidism". E."This treatment takes 2 to 3 weeks to destroy the thyroid tissue".
B and D Rationale: radioactive iodine therapy could result in hypothyroidism over time and decreased thyroid hormone secretion due to thyroid gland irradiation.
Billy came into the ED and was diagnosed with severe dehydration. What are some nursing interventions for Billy? Select all that apply. a. apple juice b. Sodium Chloride Bolus c. Pedialyte d. Lactated Ringers e. Gatorade
B, C, D sodium chloride, pedialyte, lactated ringers
A nurse in an Intensive Care Unit (ICU) is assessing a female client who had a thyroidectomy 48 hour ago for Chvostek's sign and Trousseau's sign because the presence of these would indicate which of the following? A.Hyperkalemia B.Hypocalcemia C.Hypokalemia D.Hypercalcemia
B. Hypocalcemia
After going through some education with a mother regarding treatment of her son's Croup which statement indicates she needs further education? A. I will use a cool-mist humidifier B. I will limit the amount of fluids he drinks C. It's cooler outside, I'll take him outside for a few minutes N. I will run a hot shower and sit with him in the steam-filled bathroom for 10 minutes
B. I will limit the amount of fluids he drinks
A child was just diagnosed with Rheumatic Fever, what is the most serious complication of Rheumatic Fever? A. Strep throat B. Joint pain C. Rheumatic Heart Disease D. High fever
C Rationale- Rheumatic Heart Disease causes long term inflammation to the heart and permeant heart valve damage.
A 25 year old female has just been started on an iron supplementation for iron deficiency anemia, which of the following manifestations is a priority: A. Upset stomach B. Dark/tarry stool C. Hemoglobin level of 10.0 g/dL D. Hematocrit level of 42.4%
C. Hemoglobin level of 10.0 g/dL
Croup is a virus that causes a child's airway to swell, what are the classic signs and symptoms. Select all that apply a. Barking cough b. Cough usually worsens during the day c. Stridor and retractions d. Cyanosis
a. Barking cough c. Stridor and retractions Rationale: Cough usually worsens at night and Cyanosis only occurs in severe cases
The parents of a preschooler diagnosed with muscular dystrophy are asking questions about the course of their child's disease. The nurse should tell them which of the following? A) Muscular dystrophy is a disorder associated with progressive degeneration of muscles, resulting in relentless and increasing weakness B) The weakness that the child is experiencing will probably not increase C) The child will be able to function normally and require no special accommodations D) The extent of degeneration depends on performing daily physical therapy
A. Muscular dystrophy is a disorder associated with progressive degeneration of muscles, resulting in relentless and increasing weakness It is a progressive disease and is not cured with physical therapy or medications, it will continue to get worse over time, and the child will need assistance as time goes on.
A nurse has just finished teaching about SLE with a newly diagnosed 12 year old girl and her mother, the nurse determines teaching has been effective when the girl states: A."I will never be able to wear makeup on my face because it will make the rash worse." B."I won't take my medication on the days I feel well and do not have any symptoms." C."I don't need to worry about wearing warm socks because my feet will always be cold no matter what I do." D. "If I cannot avoid sun exposure, I need to make sure to wear sunscreen
A."If I cannot avoid sun exposure, I need to make sure to wear sunscreen."
A nurse is performing an assessment on a child admitted to the hospital with Isonatremic dehydration. Which clinical manifestations should the nurse expect? Select all that apply. A. Mild thirst B. skin turgor poor C. dry skin D. decreased urine output E. Body temperature cold
All of the above
The nurse is assigned to care for a newly hospitalized child who was just diagnosed with SLE. Which medication should the nurse expect the physician to prescribe? A.A broad spectrum antibiotic B.A corticosteroid C.An opioid analgesic D.A stool softener
B. A corticosteroid
A nurse is talking to the family of a child who was diagnosed with chickenpox. Which statement below represents understanding of the teaching? A. I will let my child go back to school tomorrow. B. My child is not contagious if they do not have a fever. C. My child is contagious until all blisters/lesions have crusted over. D. My child is contagious until the first blisters/lesions have crusted over.
C - My child is contagious until all blisters/lesions have crusted over. Rationale - Chickenpox can be spread to other people if theycome in contact withthe fluid that is in the blisters/lesions. All blisters/lesions need to be crusted over and healing to avoid spread of chickenpox
A nurse is providing discharge teaching to the guardian of an infant following hypospadias repair. Which of the following instructions should the nurse include? A) Clamp infant's catheter for 30 min each day B) Give the infant a tub bath once a day C) Apply antibacterial ointment to the infant's penis once a day D) Decrease the infant's fluid intake for 3 days
C) Apply antibacterial ointment to the infant's penis once a day Rational: Nurse should instruct the guardian to apply the antibacterial ointment to the infant's penis to reduce the risk of infection.
When should repair of structural defects take place? A) After child is toilet trained B) After puberty when anatomy is fully developed C) Ideally between 6-15 months of age D) Shortly after birth before discharge
C) Ideally between 6-15 months of age Rational: Done at this time because of anatomical development/more skin but before 3 years to minimize impact on body image and promote healthy development
A nurse is caring for a child who has muscular dystrophy. For which of the following findings should the nurse assess? (Select All that Apply) A) Purposeless, involuntary, abnormal movements B) Spinal defect and saclike protrusion C) Muscular weakness in lower extremities D) Unsteady, wide-based or waddling gait E) Upward slant to the eyes
C) Muscular weakness in lower extremities D) Unsteady, wide-based or waddling gait Purposeless involuntary movements are a result of tardive dyskinesia and is not a symptom of DMD Spinal defect with a sack like protrusion is found in a disorder called spina bifiada. Upward slanting eyes are a common physical feature of trisomy 21 and not associated with DMD
A nurse is educating a parent of a child who has chickenpox. Which of the following shows understanding of the teaching? A."I will bathe my child in a hot bath to soothe itching" B."I will give my child aspirin to control the fevers" C."I will have my child wear oven mitts to help keep from scratching the blisters" D."I will use her favorite scent of lotion to hydrate the skin and reduce the risk for scratching"
C- Scratching with nails increases the risk for infection. It is beneficial to put oven mitts or socks over the child's hands to keep them from scratching their blisters. ▪It is important to use lukewarm water, as hot water can further irritate the chickenpox. It is also important to not use aspirin because it has been linked to Reyes Syndrome in children with chickenpox. The parent should also avoid using scented lotion and sick to a non-scented lotions such as calamine lotion or petroleum jelly. That being said, the answer must be C.
A 6 year old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and protective isolation procedures are initiated. The grandmother of the child visits and brings a fresh bouquet of flowers picked from her garden, and asks the nurse for a vase for the flowers. Which response should the nurse provide to the grandmother? A. "I have a vase in the utility room, and will get it for you." B. "I will get the vase and watch it well before you put the flowers in it." C. "The flowers from your garden are beautiful, but should not be placed in the child's room at this time." D. "When you bring the flowers into the room, place them on the bedside stand as far away from the child as possible."
C. "The flowers from your garden are beautiful, but should not be placed in the child's room at this time."
The wife of the client diagnosed with septic meningitis asks the nurse, "I am so scared. What is meningitis?" Which statement would be the most appropriate response by the nurse? A. "There is bleeding into his brain causing irritation of the meninges." B. "A virus has infected the brain and meninges, causing inflammation." C. "This is a bacterial infection of the tissues that cover the brain and spinal cord." D. "This is an inflammation of the brain parenchyma caused by a mosquito bite."
C. "This is a bacterial infection of the tissues that cover the brain and spinal cord." Rational: Septic meningitis refers to meningitis caused by bacteria; the most common form of bacterial meningitis is caused by the Neisseria meningitidis bacteria.
Three days following intracranial surgery a client develops fever, nuchal rigidity, and headache. The nurse would suspect A. Cerebral emboli B. Extradural hematoma C. Meningitis D. Diabetic neuropathy
C. Meningitis Rational: The classic manifestations of meningitis are nuchal rigidity (rigidity of the neck), Brudzinski's sign and Kernig's sign, and photophobia. Intracranial surgery places the client at high risk of developing meningitis.
A 10 year old child has been diagnosed with Iron Deficiency Anemia. What statements by the parents imply a good understanding about the teachings concerning treatment? (Select all that apply) A. "My child can take the iron supplements with chocolate milk so it will taste better." B. "My child should avoid contact sports" C. "My child should take iron supplements with her fruit juice with breakfast" D. "My child may have black stools while taking iron supplements" E. "My child should brush their teeth after taking oral iron supplements"
D, E. "My child may have black stools while taking iron supplements" E. "My child should brush their teeth after taking oral iron supplements"
What would be the best diagnostic test for Reyes syndrome. A) Liver biopsy B) CT or MRI C) Blood pressure D) CBC E) A & B
E. Liver biopsy and CT/MRI