NUR 131 - Exam 2

Which parental statement indicated effective learning regarding management of nocturnal enuresis in a 6-year-old child? *SELECT ALL THAT APPLY* a. "I should avoid giving my child fluids after dinner" b. "I should encourage my child to drink lots of water during the day" c. "I could make my child wear diapers during day hours while at school" d. "I should give my child diet soda instead of regular soda in the evening" e. "I should wake my child at the same time every night to use the bathroom"

a. "I should avoid giving my child fluids after dinner" b. "I should encourage my child to drink lots of water during the day" e. "I should wake my child at the same time every night to use the bathroom"

Which instruction would the nurse give to a client with renal calculi? *SELECT ALL THAT APPLY* a. "drink plenty of water" b. "have spinach soup every day" c. "substitute lemon juice for tea" d. "include high amounts of protein in the diet" e. "consume foods rich in omega-3 fatty acids"

a. "drink plenty of water" c. "substitute lemon juice for tea"

Which manifestation may indicate that the client with type 1 diabetes has insulin-induced hypoglycemia? *SELECT ALL THAT APPLY* a. excessive hunger b. weakness c. diaphoresis d. excessive thirst e. deep respirations

a. excessive hunger b. weakness c. diaphoresis

Which item would a nurse instruct a client with calcium oxalate kidney stones to limit the intake of when providing dietary teaching? a. sodium b. gravies c. red wines d. organ meat

a. sodium

In which age group is scoliosis usually identified? a. adolescence b. preadolescence c. early school years d. middle school years

b. preadolescence

A toddler is found to have coarctation of the aorta. Which finding would the nurse expect when taking the child's vital signs? a. irregular heartbeat b. weak femoral pulse c. thready radial pulses d. increased temperature

b. weak femoral pulse

A 3-month-old infant with tetralogy of Fallot suddenly becomes cyanotic and begins breathing rapidly. In which position would the nurse immediately place the infant? a. supine b. lateral c. knee-chest d. semi-fowler

c. knee-chest

Which purpose is rest, ice, compression, and elevation MOST helpful in an adolescent admitted with an acute hemophilia episode? a. encouraging immobilization b. decreasing swelling and inflammation c. providing pain relief and reducing anxiety d. controlling bleeding and retaining joint function

d. controlling bleeding and retaining joint function

The regulation of type 1 diabetes in an 8-year-old child is best attained with a combination of therapeutic modalities in addition to the administration of insulin. Which modalities would the nurse include in the teaching plan? *SELECT ALL THAT APPLY* a. dietary control b. regular exercise c. urine testing for glucose d. blood glucose monitoring e. use of oral hypoglycemic agents

a. dietary control b. regular exercise d. blood glucose monitoring

Which between-meal snack would the nurse recommend that the parent of a preschooler with a urinary tract infection offer their child? a. skim milk b. cranberry juice c. hard candy d. cream soup

a. skim milk

Which action would be appropriate to implement when collecting a 24-hour urine test? a. start the time of the test after discarding the first voiding b. discard the last voiding in the 24-hour period of the test c. insert a urinary retention catheter to promote the collection of urine d. strain the urine after each voiding before adding the urine to the container

a. start the time of the test after discarding the first voiding

Which potential consequence of repeated infections should the nurse consider when caring for a child with cystic fibrosis? a. increased irritability b. development of diabetes c. impaired academic ability d. depression of bone marrow

b. development of diabetes

A child with type 1 diabetes is receiving 15 units of regular insulin and 20 units of NPH at 7:00 AM each day. Which time would the nurse anticipate a hypoglycemic reaction from the NPH insulin to occur? a. before noon b. in the afternoon c. within 30 minutes d. during the evening

b. in the afternoon

Which postoperative care instructions would the nurse include when providing preoperative teaching for a client scheduled for a transurethral resection of the prostate (TURP)? a. the urine will be bright red for 24 to 48 hours b. spasms of the bladder occur during the first 24 to 48 hours c. to decrease bladder contractions, the Valsalva maneuver and Kegel exercises will be encouraged d. to maintain proper fluid balance, oral fluids are restricted during continuous urinary bladder irrigations

b. spasms of the bladder occur during the first 24 to 48 hours

A parent tells the clinic nurse that their 6-year-old child has been wetting the bed for the past 3 weeks. Previously there had been no problems. How would the nurse respond? a. "try to eliminate fluids after dinner" b. "children sometimes wet the bed when they're angry" c. "you did the right thing to bring your child in to be examined" d. "wake your child every few hours at night to go to the bathroom"

c. "you did the right thing to bring your child in to be examined"

Which prescribed treatment would the nurse question when a client who has sickle cell anemia has been admitted with acute chest syndrome? a. oxygen administration b. daily folic acid tablet c. daily iron supplement d. morphine sulfate as needed

c. daily iron supplement

Which information would the nurse consider when planning care for the postoperative client who has a newly constructed conduit diversion (ileal conduit)? a. peristalsis of the small intestine segment assists with urine flow b. stool continuously oozes from the newly created ileal conduit c. ileal diversion conduits may provide urinary continence d. absorption of nutrients diminishes within the small intestines

c. ileal diversion conduits may provide urinary continence

The nurse is caring for a child who has an external fixation device on the leg. Which is the nurse's PRIORITY goal when providing pin care? a. easing pain b. minimizing scarring c. preventing infection d. avoiding skin breakdown

c. preventing infection

Which nursing intervention would help a client who exhibits physical symptoms when stressed? a. limiting discussions about the problem b. providing information regarding medical care c. teaching the client how to eliminate stress at home d. assisting the client in developing new coping mechanisms

d. assisting the client in developing new coping mechanisms

Which plan of care would the nurse provide for a newborn with hypospadias? a. preparing the infant for insertion of a cystostomy tube b. explaining to the parents the genetic basis for the defect c. keeping the infant's penis wrapped with petrolatum guaze d. giving the parents reasons why circumcision should not be performed

d. giving the parents reasons why the circumcision should not be performed

Which statement indicates to the nurse providing discharge medication education to a client prescribed warfarin that teaching was effective? a. "I will avoid taking aspirin and nonsteroidal anti-inflammatory drugs (NSAIDS)" b. "I will need to develop a more sedentary routine" c. "I will need to have regular complete blood counts to guide warfarin dosage" d. "Before going to the dentist, I will ask my health care provider for antibiotics"

a. "I will avoid taking aspirin and nonsteroidal anti-inflammatory drugs (NSAIDS)"

A 2-year-old child arrives at the emergency department after the sudden onset of a high fever, drooling, and respiratory destress. Which action would the nurse perform? *SELECT ALL THAT APPLY* a. assess the child's temperature b. start an intravenous line c. draw a blood sample for a complete blood count and differential d. examine the child's throat with a flashlight and tongue depressor for swelling e. assess the blood oxygen saturation; administer oxygen by mask if value is less than 94% f. ask the parents to remain in the waiting room during the examination and interventions

a. assess the child's temperature b. start an intravenous line c. draw a blood sample for a complete blood count and differential e. assess the blood oxygen saturation; administer oxygen by mask if value is less than 94%

Which intervention would the nurse include when developing a plan of care for a client with compartment syndrome? *SELECT ALL THAT APPLY* a. bivalve the cast b. apply cold compresses c. loosen the bandage applied d. evaluate the client's level of pain e. elevate the extremity above heart level

a. bivalve the cast c. loosen the bandage applied d. evaluate the client's level of pain

Which outcome indicated effective nursing care when a nurse assists an older adult in squirting warm water over the perineum? a. the client will not have nocturia b. the client will not have a bladder infection c. the client will not have a tendency to retain urine d. the client will not have urinary stress incontinence

c. the client will not have a tendency to retain urine

One principle to be followed for children with type 1 diabetes is to provide for the variability of the child's activity. Which would the nurse teach the child about how to compensate for increased physical activity? a. eat more food when planning to exercise more than usual b. take insulin in the morning when extra exercise is anticipated c. consume foods that contain sugar to compensate for the extra exercise d. an oral hypoglycemia, not injectable insulin, is necessary on days of heavy exercise

a. eat more food when planning to exercise more than usual

A client develops a deep vein thrombophlebitis in her leg 3 weeks after giving birth and is admitted for anticoagulant therapy. The nurse would anticipate developing a teaching plan for which anticoagulant? a. heparin b. warfarin c. clopidogrel d. enoxaparin

a. heparin

A client with a fractured hip is placed in traction until surgery can be performed. Which goal would the nurse explain as the purpose of the traction? a. relieving muscle spasm and pain b. preventing contractures from developing c. keeping the client from turning and moving in bed d. maintaining the limb in a position of external rotation

a. relieving muscle spasm and pain

Which nursing care plan is indicated for a child admitted to the hospital with pneumonia? a. rest b. exercise c. nutrition d. elimination

a. rest

A client with nephrotic syndrome has been receiving prednisone for 1 week. Which information in the child's record indicated to the nurse that the medication has been effective? *SELECT ALL THAT APPLY* a. weight loss b. lower blood pH c. decreased lethargy d. increased urine output e. decreased blood pressure

a. weight loss c. decreased lethargy d. increased urine output

While caring for a terminally ill child, the nurse notes that the parent visits have become less frequent. Which would the nurse do to resolve this situation? a. ask the parent why they are visiting so seldom b. accept the parent's need to maintain a distance at this time c. explain to the parents why visiting is so important to their child d. suggest to the parent that they visit more often while spending less time at each visit

b. accept the parent's need to maintain a distance at this time

Which medications would the nurse anticipate teaching the parent about for a preschooler newly diagnosed with cystic fibrosis? *SELECT ALL THAT APPLY* a. steroids b. antibiotics c. antihistamines d. pancreatic enzymes e. fat-soluble vitamins

b. antibiotics d. pancreatic enzymes e. fat-soluble vitamins

Which nursing intervention would be contraindicated for a client who has a fracture and has compartment syndrome? *SELECT ALL THAT APPLY* a. splitting the cast in half b. applying cold compresses c. reducing the traction weight d. loosening the client's bandage e. elevating the extremity above heart level

b. applying cold compresses e. elevating the extremity above heart level

Which symptoms would the nurse observe in a client with hyperglycemia and ketoacidosis? *SELECT ALL THAT APPLY* a. irritability b. dry skin c. diaphoresis d. increased thirst e. deep, rapid breathing

b. dry skin d. increased thirst e. deep, rapid breathing

An infant is admitted to the pediatric unit with bronchiolitis caused by respiratory syncytial virus (RSV). Which intervention would the nurse provide for the infant? *SELECT ALL THAT APPLY* a. limiting fluid intake b. instilling saline nose drops c. maintaining contact precautions d. nasal suctioning to remove mucous e. administering inhaled bronchodilators

b. instilling saline nose drops c. maintaining contact precautions d. nasal suctioning to remove mucous

Which clinical finding can the nurse expect to identify when assessing a client with varicose veins? *SELECT ALL THAT APPLY* a. discolored toenails b. reports of leg fatigue c. localized heat in a calf d. reddened areas on a calf e. tortuous veins in the legs f. pain in lower extremities when standing

b. reports of leg fatigue e. tortuous veins in the legs f. pain in lower extremities when standing

After the home health nurse has taught a client with asthma how to use the peak flow meter, which statement by the client needs correction? a. "I will record the highest reading of 3" b. "I will use the peak flow meter while standing" c. "I will take a deep breath before blowing into the peak flow meter" d. "I will repeat the test in 15 minutes if the reading is in the red zone"

d. "I will repeat the test in 15 minutes if the reading is in the red zone"

Which treatment would the nurse anticipate when caring for an infant with heart failure? a. open heart surgery b. cardiac stress test c. aggressive intravenous fluid infusions d. medications that are prescribed for both children and adults

d. medications that are prescribed for both children and adults

Which is the PRIORITY information for the nurse to include in discharge instructions to the parent of a child who has undergone surgical correction of hypospadias? a. ensuring that the child's privacy is maintained b. increasing the time that the catheter is clamped c. maintaining the surgically implanted tension device d. teaching parents how to care for the catheterization system

d. teaching parents how to care for the catheterization system

A client with type 1 diabetes has dry, hot, flushed skin; a fruity odor to the breath; and is having Kussmaul respirations. Which complication does the nurse suspect that the client is experiencing? a. ketoacidosis b. somogyi phenomenon c. hypoglycemic reaction d. hyperosmolar nonketotic coma

a. ketoacidosis

Which is true about the effect of grief and loss in toddlers? a. they show resilience after a loss b. they express a sense of change in sleeping c. they understand the concepts of permanence d. they get disrupted in developing an autonomous sense of self

b. they express a sense of change in sleeping

Which response to hospitalization would the nurse expect in a 4-year-old child? a. anger, resentment over depersonalization, and loss of peer support b. boredom, depression over separation from family, and fear of death c. out-of-control behavior, regression to overdependency, and fear of bodily mutilation d. intense panic, loss of security over separation from parent, and low frustration tolerance

c. out-of-control behavior, regression to overdependency, and fear of bodily mutilation

Which intervention would the nurse undertake before a scheduled intravenous pyelogram (IVP) for a client with a renal disorder? *SELECT ALL THAT APPLY* a. ensure that the consent form has been signed b. assess the client for iodine sensitivity c. have the client remove all metal objects d. administer an enema or cathartic to the client e. instruct the client to lie still during the procedure

a. ensure that the consent form has been signed b. assess the client for iodine sensitivity d. administer an enema or cathartic to the client

Which education would the nurse provide the parent of a 3-year-old child who has recurrent acute spasmodic laryngitis (spasmodic croup) about why this is a disorder of young children? a. they have small airways b. they are mouth breathers c. they have immature immune systems d. they are prone to upper respiratory infections

a. they have small airways

Which nursing intervention is CORRECT for a client in skeletal traction? a. add and remove weights as the client desires b. assess the pin sites at least every shift and as needed c. ensure that the knots in the rope are tied to the pulley d. perform range-of-motion to joints proximal and distal to the fracture at least once a day

b. assess the pin sited at least every shift and as needed

Which nursing intervention would be important for the nurse to implement when caring for an adolescent child with acute glomerulonephritis (AGN)? a. assess for dysuria b. inspect for jaundice c. monitor for HTN d. test vomitus for occult blood

c. monitor for HTN

Which would the nurse incorporate into the plan of care for a child hospitalized with acute glomerulonephritis (AGN)? *SELECT ALL THAT APPLY* a. weighing daily b. restricting fluids c. monitoring intravenous therapy d. instituting isolation precautions e. checking the blood pressure hourly

a. weighing daily b. restricting fluids

The parent of a 2.5-year-old child whose older sibling recently died tells the nurse that their child has started to hit them and refuses to go to bed at night. Which explanation would the nurse provide the parent? a. the child fears dying while asleep b. the child is seeking the parent's attention c. the child is in the "terrible twos" developmental stage d. the child is reacting to anxiety within the household

d. the child is reacting to anxiety within the household

Which clinical manifestation would lead the nurse to contact the health care provider regarding the potential development of acute osteomyelitis? *SELECT ALL THAT APPLY* a. presence of a foot ulcer b. temperature of 102 F c. erythema of the affected area d. tenderness of the affected area e. drainage from the affected area

b. temperature of 102 F c. erythema of the affected area d. tenderness of the affected area

An 8-year-old child is found to have Legg-Calve-Perthes disease and will be required to wear an abduction brace 23 hours a day and engage in non-weight-bearing activity. Which activity would the nurse teach the parent to do? a. have the child transfer to a wheelchair using the unaffected leg b. explain that kneeling, but not standing, on the affected leg is permitted c. perform range-of-motion exercises of the lower extremities twice a day d. allow the child to use crutches as long as the four-point gait is used for walking

a. have the child transfer to a wheelchair using the unaffected leg

Which manifestation would the nurse include when the parents of a child who has just been diagnosed with hemophilia A ask what symptoms of bleeding should they look for in the future? *SELECT ALL THAT APPLY* a. nosebleeds b. blood in the urine c. painful and swollen joints d. easy bruising e. frequent fevers f. fast clotting of injuries g. dark-colored tarry stools

a. nosebleeds b. blood in the urine c. painful and swollen joints d. easy bruising g. dark-colored tarry stools

Which information would the nurse include when teaching a client with varicose veins about ligation and stripping surgery? a. plaque from within the veins is scraped b. the dilated saphenous veins are removed c. superficial veins are sown together into deep veins d. an umbrella filter is placed in the large affected veins

b. the dilated saphenous veins are removed

The parents and two siblings of a 6-week-old infant are grieving the infant's death as a result of sudden infant death syndrome (SIDS). Which short-term goal would the nurse have for this family? a. identifying the problems that they will be facing as a result of the loss of the infant b. accepting that there was nothing that they could have done to prevent the infant's death c. including the infant's siblings in the events and grieving in the wake of the infant's death d. seeking out other families who have lost infants to SIDS and obtaining support from them

c. including the infant's siblings in the events and grieving in the wake of the infants death

Which parent education would the nurse provide to the parents of a newborn placed in a Pavlik harness for developmental dysplasia of the hips? a. avoid undershirts or diapers under the harness b. the harness may be adjusted as needed as the baby grows c. apply lotion or baby powder under the harness to prevent skin breakdown d. avoid using the legs to lift the infant's buttocks when changing the diaper at bath time

d. avoid using the legs to lift the infant's buttocks when changing the diaper at bath time