QT 1 Missed Questions

The nurse is discussing growth and development with the parents of a 4-year-old child. The nurse identifies which type of play as characteristic of this age group?

"Associative play."

The nurse cares for clients in a drug rehabilitation facility. Which complication of IV drug abuse is the nurse most likely to observe?

"Cellulitis." most narcotic addicts do not inject sterile purified material with aseptic techniques; cellulitis is a common complication because of skin popping or using an infected drug apparatus

The nurse cares for the client admitted with a diagnosis of a stroke and facial paralysis. Nursing care is planned to prevent which complication?

"Corneal abrasion." client will be unable to close eye voluntarily; when facial nerve (cranial nerve VII) is affected, the lacrimal gland will no longer supply secretions that protect the eye

The 7-year-old child is seen in the clinic with a diagnosis of pituitary dwarfism. Which clinical manifestation is the nurse most likely to observe?

"Delicate features." appear younger than chronological age

A client with an endotracheal tube requires suctioning. Which statement is an accurate description of how the nurse performs the procedure?

"Inserts the suction catheter until resistance is met, and then withdraws it slightly. Applies suction intermittently as the catheter is withdrawn." insert suction catheter until resistance is met without applying suction, withdraw 0.4 to 0.8 inches (1 to 2 cm), and apply intermittent suction with twirling motion

A postoperative cataract client is cautioned about not making sudden movements or bending over. The nurse understands that the rationale for this recommendation is to prevent which complication?

"Pressure on the ocular suture line." sudden changes in position, constipation, vomiting, stooping, or bending over increase the intraocular pressure and put pressure on the suture line

A client comes to the outpatient psychiatric clinic for treatment of a fear of heights. The nurse knows that phobias involve which behaviors?

"Projection and displacement." projection (attributing one's thoughts or impulses to another) and displacement (shifting of emotion concerning person or object to another neutral or less dangerous person or object)

Which observation suggests to the nurse the client has developed an Addisonian crisis?

"Restlessness and rapid, weak pulse."

The 6-month-old is brought to the clinic for a well-baby checkup. During the exam, the nurse expects to observe which assessment findings?

"Sitting with support. Playing peek-a-boo. Rolling from back to abdomen."

The nurse cares for an older client scheduled for a colon resection this morning. The nurse notes the client had polyethylene glycol-electrolyte solution and a soapsuds enema the previous evening. This morning the client passes a medium amount of soft brown stool. Which conclusion by the nurse is most accurate?

"The bowel preparation is incomplete." colon should not have remaining soft stool

Which statement is documented by the nurse to reflect a client's emotional adjustment to being hospitalized in the intensive care unit?

"The client constantly calls for nurses and cries uncontrollably." gives an objective description of the client's behavior and affect

The parents of a child diagnosed with hemophilia ask the nurse to explain the cause of the disease. Which response by the nurse is best?

"The mother transmits the gene to her son." hemophilia is a sex-linked disorder

The nurse leads a parenting class for a group of expectant clients. How many extra calories a day does the nurse advise the clients to consume to support breastfeeding?

500. milk production requires an increase of 500 calories per day

The nurse on a psychiatric unit of the hospital declines the client's request to organize a party on the unit for the client's friends. The client becomes angry and uses abusive language toward the nurse. Which statement indicates the nurse has an understanding of the client's behavior?

Abusive language is one of the behaviors symptomatic of the client's illness. symptoms will respond to treatment

The child is in the early stages of nephrotic syndrome. The nurse discusses which dietary change with the parents?

Adequate protein, low sodium intake. if child can tolerate the protein intake, then this diet is encouraged to speed healing; sodium is usually restricted

The middle-aged client is admitted to an inpatient psychiatric unit. The client reports a family member is trying to steal the client's property. The client is diagnosed with paranoid disorder. The nurse suspects the client is demonstrating which symptom?

Delusions of persecution. client has delusions of persecution; delusion is a strongly held belief that is not validated by reality; the idea that a family member is trying to steal property is a belief not validated by reality

The client had a kidney transplant yesterday, and the client's adult child has come to visit. The nurse instructs the adult child to take which action?

Perform good hand washing. good hand washing is the most effective method of reducing infection; very important with immunosuppressed clients

Several days after the delivery of a stillborn, the parents say, "We wish we could talk with other couples who have gone through this trauma." Which response by the nurse is best?

SHARE will provide you with this opportunity." SHARE is a support group for parents who have lost a newborn or have experienced a miscarriage

The nurse prepares the older client for an intravenous pyelogram (IVP). The client asks the nurse to explain the reason why the procedure is performed. The nurse's response is based on which explanation?

The health care provider is able to examine the urinary tract by x-ray. x-rays of entire urinary tract taken, evaluates kidney function

The client develops a postoperative infection and receives ceftriaxone sodium IV every day. It is most important for the nurse to monitor for which changes?

The surface of the tongue. cephalosporin, long-term use of ceftriaxone sodium can cause overgrowth of organisms; monitoring of tongue and oral cavity is recommended

The outpatient clinic nurse cares for an elderly client diagnosed with type 1 diabetes. Because the client is unwilling to perform blood glucose monitoring, the client tests urine for glucose and acetone. The nurse knows that blood glucose monitoring is preferred over urine testing for glucose because of which reason?

"The renal threshold for glucose is elevated in the elderly." the level at which glucose starts to appear in the urine increases, leading to false-negative readings; results in elevated glucose levels

At 32 weeks gestation, the client has an order for an ultrasound. The nurse determines that the client understands the procedure if the client makes which statement?

"The results will inform us of the baby's size." ultrasound detects the size, growth patterns, and gestational age

Which symptoms alert the nurse to consider an alcohol problem in a client hospitalized for a physical illness?

"Tremors. Elevated temperature. Nocturnal leg cramps."

The nurse cares for a client diagnosed with gastric reflux due to a hiatal hernia. The client asks the nurse why food and fluids should be withheld just before going to bed. Which response by the nurse is most appropriate?

"You are less likely to awaken during the night with heartburn if the stomach is empty." full stomach is more likely to slide (reflux) through the hernia, causing regurgitation and heartburn

The nurse knows that cortisol is responsible for which action?

Converting proteins and fat into glucose. action of cortisol; is also an anti-inflammatory agent

The health care provider inserts a temporary pacemaker in a client following a myocardial infarction. The nurse knows that which outcome is the primary purpose of the pacemaker?

Increases the cardiac output. acts to regulate cardiac rhythm