345 FINAL part 1

Hyperchloremia Symptoms

Tachypnea, weakness, decreased cognitive ability, hypertension, dysrhythmias

Normal Range for Calcium

8.6-10.2

Imaginary playmates are beneficial to the preschool child because they: a. Take the place of social interactions. b. Take the place of pets and other toys. c. Become friends in times of loneliness. d. Accomplish what the child has already successfully accomplished.

ANS: C One purpose of an imaginary friend is to be a friend in time of loneliness. Imaginary friends do not take the place of social interactions but may encourage conversation. Imaginary friends do not take the place of pets or toys. They accomplish what the child is still attempting, not what has already been accomplished.

An appropriate nursing diagnosis for a child with a cognitive dysfunction who has a limited ability to anticipate danger is: a. Impaired Social Interaction. c. Risk for Injury. b. Deficient Knowledge. d. Ineffective Coping.

ANS: C The nurse needs to know that limited cognitive abilities to anticipate danger lead to risk for injury. Impaired social interaction is indeed a concern for the child with a cognitive disorder but does not address the limited ability to anticipate danger. Because of the child's cognitive deficit, knowledge will not be retained and will not decrease the risk for injury. Ineffective individual coping does not address the limited ability to anticipate danger.

Normal range Magnesium

1.3-2.3

Normal Range of Potassium

3.5-5

Which statement best describes a child who is abused by the parent(s)? a. Unintentionally contributes to the abusing situation b. Belongs to a low socioeconomic population c. Is healthier than the nonabused siblings d. Abuses siblings in the same way as child is abused by the parent(s)

ANS: A A childs temperament, position in the family, additional physical needs, activity level, or degree of sensitivity to parental needs unintentionally contributes to the abusing situation. Socioeconomic status is an environmentalcharacteristic. This child is less likely to be abused than one who is premature, disabled, or very young. The abused child does not in turn abuse his or her siblings.

The ability to mentally understand that 1 + 3 = 4 and 4 3 = 1 occurs in which stage of cognitive development? a. Concrete operations stage b. Formal operations stage c. Intuitive thought stage d. Preoperations stage

ANS: A By 7 to 8 years of age, the child is able to retrace a process (reversibility) and has the skills necessary for solving mathematical problems. This stage is called concrete operations. The formal operations stage deals with abstract reasoning and does not occur until adolescence. Thinking in the intuitive stage is based on immediate perceptions. A child in this stage often solves problems by random guessing. In preoperational thinking, the child is usually able to add 1 + 3 = 4 but is unable to retrace the process.

According to Piaget, the adolescent is in the fourth stage of cognitive development, or period of: a. Formal operations. b. Concrete operations. c. Conventional thought. d. Postconventional thought.

ANS: A Cognitive thinking culminates with capacity for abstract thinking. This stage, the period of formal operations, is Piagets fourth and last stage. The concrete operations stage usually develops between ages 7 and 11 years. Conventional and postconventional thought refer to Kohlbergs stages of moral development.

Teasing can be common during the school-age years. Which of the following does the nurse recognize as applying most to teasing? a. Can have a lasting effect on children b. Is not a significant threat to self-concept c. Is rarely based on anything that is concrete d. Is usually ignored by the child who is being teased

ANS: A Teasing in this age group is common and can have a long-lasting effect. Increasing awareness of differences, especially when accompanied by unkind comments and taunts from others, may make a child feel inferior and undesirable. Physical impairments such as hearing or visual defects, ears that stick out, or birth marks assume great importance.

A 14-year-old boy and his parents are concerned about bilateral breast enlargement. The nurses discussion of this should be based on knowing that: a. This is usually benign and temporary. b. This is usually caused by Klinefelters syndrome. c. Administration of estrogen effectively reduces gynecomastia. d. Administration of testosterone effectively reduces gynecomastia.

ANS: A The male breast responds to hormone changes. Some degree of bilateral or unilateral breast enlargement occurs frequently in boys during puberty. This is not a manifestation of Klinefelters syndrome. Administration of estrogen or testosterone will have no effect on the reduction of breast tissue and may aggravate the condition.

21.The health care provider has ordered a hypotonic intravenous (IV) solution to be administered. Which IV bag will the nurse prepare? a. 0.45% sodium chloride (1/2 NS) b. 0.9% sodium chloride (NS) c. Lactated Ringer's (LR) d. Dextrose 5% in Lactated Ringer's (D5LR)

ANS: A 0.45% sodium chloride is a hypotonic solution. NS and LR are isotonic. D5LR is hypertonic.

Nurses can prevent evaporative heat loss in the newborn by: a. Drying the baby after birth and wrapping the baby in a dry blanket. b. Keeping the baby out of drafts and away from air conditioners. c. Placing the baby away from the outside wall and the windows. d. Warming the stethoscope and the nurses hands before touching the baby

ANS: A Because the infant is wet with amniotic fluid and blood, heat loss by evaporation occurs quickly. Heat loss by convection occurs when drafts come from open doors and air currents created by people moving around. If the heat loss is caused by placing the baby near cold surfaces or equipment, it is referred to as a radiation heat loss. Conduction heat loss occurs when the baby comes in contact with cold objects or surfaces

29. Parent guidelines for relieving colic in an infant include: a. avoiding touching the abdomen. b. avoiding using a pacifier. c. changing the infant's position frequently. d. placing the infant where the family cannot hear the crying.

ANS: C Changing the infant's position frequently may be beneficial. The parent can walk holding the infant face down and with the infant's chest across the parent's arm. The parent's hand can support the infant's abdomen, applying gentle pressure. Gently massaging the abdomen is effective in some infants. Pacifiers can be used for meeting additional sucking needs. The infant should not be placed where monitoring cannot be done. The infant can be placed in the crib and allowed to cry. Periodically, the infant should be picked up and comforted.

27.The nurse is calculating intake and output on a patient. The patient drinks 150 mL of orange juice at breakfast, voids 125 mL after breakfast, vomits 250 mL of greenish fluid, sucks on 60 mL of ice chips, and for lunch consumes 75 mL of chicken broth. Which totals for intake and output will the nurse document in the patient's medical record? a. Intake 255; output 375 b. Intake 285; output 375 c. Intake 505; output 125 d. Intake 535; output 125

ANS: A Intake = 150 mL of orange juice, 60 mL of ice chips (but only counts as 30 since ice chips are half of the amount), and 75 mL of chicken broth; 150 + 30 + 75 = 255. Output = 125 mL of urine (void) and 250 mL of vomitus; 125 + 250 = 375.

1.A patient has dehydration. While planning care, the nurse considers that the majority of the patient's total water volume exists in with compartment? a. Intracellular b. Extracellular c. Intravascular d. Transcellular

ANS: A Intracellular (inside the cells) fluid accounts for approximately two thirds of total body water. Extracellular (outside the cells) is approximately one third of the total body water. Intravascular fluid (liquid portion of the blood) and transcellular fluid are two major divisions of the extracellular compartment.

A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth the infant is noted to have petechiae over the face and upper back. Information given to the infants parents should be based on the knowledge that petechiae: a. Are benign if they disappear within 48 hours of birth. b. Result from increased blood volume. c. Should always be further investigated. d. Usually occur with forceps delivery

ANS: A Petechiae, or pinpoint hemorrhagic areas, acquired during birth may extend over the upper portion of the trunk and face. These lesions are benign if they disappear within 2 days of birth and no new lesions appear. Petechiae may result from decreased platelet formation. In this situation the presence of petechiae is most likely a soft-tissue injury resulting from the nuchal cord at birth. Unless they do not dissipate in 2 days, there is no reason to alarm the family. Petechiae usually occur with a breech presentation vaginal birth.

33. With the goal of preventing plagiocephaly, the nurse should teach new parents to consider which intervention? a. Place the infant prone for 30 to 60 minutes per day. b. Buy a soft mattress. c. Allow the infant to nap in the car safety seat. d. Have the infant sleep with the parents.

ANS: A Prevention of positional plagiocephaly may begin shortly after birth by implementing prone positioning or "tummy time" for approximately 30 to 60 minutes per day when the infant is awake. Soft mattresses or sleeping with parents (co-sleeping) are not recommended because they put the infant at a higher risk for a sudden infant death incident. To prevent plagiocephaly, prolonged placement in car safety seats should be avoided.

26. Which toy is the most developmentally appropriate for an 18- to 24-month-old child? a. A push-pull toy b. Nesting blocks c. A bicycle with training wheels d. A computer

ANS: A Push-pull toys encourage large muscle activity and are appropriate for toddlers. Nesting blocks are more appropriate for a 12- to 15-month-old child. A bicycle with training wheels is appropriate for a preschool or young school-age child. A computer can be appropriate as early as the preschool years.

8. A nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess first for potential hyponatremia? a. A 34-year-old on NPO status who is receiving intravenous D5W b. A 50-year-old with an infection who is prescribed a sulfonamide antibiotic c. A 67-year-old who is experiencing pain and is prescribed ibuprofen (Motrin) d. A 73-year-old with tachycardia who is receiving digoxin (Lanoxin)

ANS: A Dextrose 5% in water (D5W) contains no electrolytes. Because the client is not taking any food or fluids by mouth (NPO), normal sodium excretion can lead to hyponatremia. The sulfonamide antibiotic, ibuprofen, and digoxin will not put a client at risk for hyponatremia.

Which information should the nurse teach families about reducing exposure to pollens and dust(Select all that apply)? a. Replace wall-to-wall carpeting with wood and tile floors. b. Use an air conditioner. c. Put dust-proof covers on pillows and mattresses. d. Keep humidity in the house above 60%. e. Keep pets outside.

ANS: A, B, C Carpets retain dust. To reduce exposure to dust, carpeting should be replaced with wood, tile, slate, or vinyl. These floors can be cleaned easily. For anyone with pollen allergies, it is best to keep the windows closed and to run the air conditioner. Covering mattresses and pillows with dust-proof covers will reduce exposure to dust. A humidity level above 60% promotes dust mites. It is recommended that household humidity be kept between 40% and 50% to reduce dust mites inside the house. Keeping pets outside will help to decrease exposure to dander, but will not affect exposure to pollen and dust.

Strict isolation is required for a child who is hospitalized with (select all that apply): a. Mumps. b. Chickenpox. c. Exanthema subitum (roseola). d. Erythema infectiosum (fifth disease). e. Parvovirus B19.

ANS: A, B, C, D Childhood communicable diseases requiring strict transmission-based precautions (Contact, Airborne, and Droplet Precautions) include diphtheria, chickenpox, measles, mumps, tuberculosis, adenovirus, Haemophilus influenzae type B, mumps, pertussis, plague, streptococcal pharyngitis, and scarlet fever. Strict isolation is not required for parvovirus B19.

Which play patterns does a 3-year-old child typically display (select all that apply)? a. Imaginary play b. Parallel play c. Cooperative play d. Structured play e. Associative play

ANS: A, B, C, E Children between ages 3 and 5 years enjoy parallel and associative play. Children learn to share and cooperate as they play in small groups. Play is often imitative, dramatic, and creative. Imaginary friends are common around age 3 years. Structured play is typical of school-age children.

Which concerns about parenthood are often expressed by visually impaired mothers(Select all that apply)? a. Infant safety b. Transportation c. The ability to care for the infant d. Missing out visually e. Needing extra time for parenting activities to accommodate the visual limitations

ANS: A, B, D, E Concerns expressed by visually impaired mothers include infant safety, extra time needed for parenting activities, transportation, handling other peoples reactions, providing proper discipline, and missing out visually. Blind people sense reluctance on the part of others to acknowledge that they have a right to be parents; however, blind parents are fully capable of caring for their infants.

A nurse is planning care for a 7-year-old child hospitalized with osteomyelitis. Which activities should the nurse plan to bring from the playroom for the child (select all that apply)? a. Paper and some paints b. Board games c. Jack-in-the-box d. Stuffed animals e. Computer games

ANS: A, B, E School-age children become fascinated with complex board, card, or computer games that they can play alone, with a best friend, or with a group. They also enjoy sewing, cooking, carpentry, gardening, and creative activities such as painting. Jack-in-the-box and stuffed animals would be appropriate for a toddler or preschool child.

Hearing loss is one of the genetic disorders included in the universal screening program. Auditory screening of all newborns within the first month of life is recommended by the American Academy of Pediatrics. Reasons for having this testing performed include (Select all that apply): a. Prevention or reduction of developmental delay. b. Reassurance for concerned new parents. c. Early identification and treatment. d. Helping the child communicate better. e. Recommendation by the Joint Committee on Infant Hearing

ANS: A, C, D, E New parents are often anxious regarding this test and the impending results; however, it is not the reason for the screening to be performed. Auditory screening is usually done before hospital discharge. It is important for the nurse to ensure that the infant receives the appropriate testing and that the test is fully explained to the parents. For infants who are referred for further testing and follow-up, it is important for the nurse to provide further explanation and emotional support. All other responses are appropriate reasons for auditory screening of the newborn. Infants who do not pass the screening test should have it repeated. If they still do not pass the test, they should have a full audiologic and medical evaluation by 3 months of age. If necessary, the infant should be enrolled in early intervention by 6 months of age

A nurse is recommending strategies to a group of school-age children for prevention of obesity. Which should the nurse include (select all that apply)? a. Eat breakfast daily. b. Limit fruits and vegetables. c. Have frequent family meals with parents present. d. Eat frequently at restaurants. e. Limit television viewing to 2 hours a day.

ANS: A, C, E The nurse should counsel school-age children to eat breakfast daily, have mealtimes with family, and limit television viewing to 2 hours a day to prevent obesity. Fruits and vegetables should be consumed in the recommended quantities, and eating at restaurants should be limited.

The nurse would identify which body systems as directly involved in the process of normal gas exchange? (Select all that apply.) a. Neurologic system b. Endocrine system c. Pulmonary system d. Immune system e. Cardiovascular system f. Hepatic system

ANS: A, C, E The neurologic system controls respiratory drive; the respiratory system controls delivery of oxygen to the lung capillaries; and the cardiac system is responsible for the perfusion of vital organs. These systems are primarily responsible for the adequacy of gas exchange in the body. The endocrine and hepatic systems are not directly involved with gas exchange. The immune system primarily protects the body against infection.

2. Motor vehicle injuries are a significant threat to young children. Knowing this, the nurse plans a teaching session with a toddler's parents on car safety. Which will she teach? (Select all that apply.) a. Secure in a rear-facing, upright, car safety seat. b. Place the car safety seat in the rear seat, behind the driver's seat. c. Harness safety straps should be fit snugly. d. Place the car safety seat in the front passenger seat equipped with an air bag. e. After the age of 2 years, toddlers can be placed in a forward-facing car seat.

ANS: A, C, E Toddlers younger than 2 years should be secured in a rear-facing, upright, approved car safety seat. After the age of 2 years, a forward-facing car seat can be used. Harness straps should be adjusted to provide a snug fit. The car safety seat should be placed in the middle of the rear seat. Children younger than 13 years should not ride in a front passenger seat that is equipped with an air bag.

The nurse can help a father in his transition to parenthood by: a. Pointing out that the infant turned at the sound of his voice. b. Encouraging him to go home to get some sleep. c. Telling him to tape the infants diaper a different way. d. Suggesting that he let the infant sleep in the bassinet

ANS: A Infants respond to the sound of voices. Because attachment involves a reciprocal interchange, observing the Test Bank - Maternal Child Nursing Care by Perry (6th Edition, 2017) 323 interaction between parent and infant is very important. Separation of the parent and infant does not encourage parent-infant attachment. Educating the parent in infant care techniques is important; however, the manner in which a diaper is taped is not relevant and does not enhance parent-infant interactions. Parent-infant attachment involves touching, holding, and cuddling. It is appropriate for a father to want to hold the infant as the baby sleeps.

While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is: a. 80 to 100 beats/min. c. 120 to 160 beats/min. b. 100 to 120 beats/min. d. 150 to 180 beats/min

ANS: C The average infant heart rate while awake is 120 to 160 beats/min. The newborns heart rate may be about 85 to 100 beats/min while sleeping. The infants heart rate typically is a bit higher when alert but quiet. A heart rate of 150 to 180 beats/min is typical when the infant cries

An adolescent teen has bulimia. Which assessment finding should the nurse expect? a. Diarrhea b. Amenorrhea c. Cold intolerance d. Erosion of tooth enamel

ANS: D Some of the signs of bulimia include erosion of tooth enamel, increased dental caries from vomited gastric acid, throat complaints, fluid and electrolyte disturbances, and abdominal complaints from laxative abuse. Diarrhea is not a result of the vomiting. It may occur in patients with bulimia who also abuse laxatives. Amenorrhea and cold intolerance are characteristics of anorexia nervosa, which some bulimics have. These symptoms are related to the extreme low weight.

The nurse is performing a gestational age and physical assessment on the newborn. The infant appears to have an excessive amount of saliva. The nurse recognizes that this finding: a. Is normal. b. Indicates that the infant is hungry. c. May indicate that the infant has a tracheoesophageal fistula or esophageal atresia. d. May indicate that the infant has a diaphragmatic hernia

ANS: C The presence of excessive saliva in a neonate should alert the nurse to the possibility of tracheoesophageal fistula or esophageal atresia

Excessive blood loss after childbirth can have several causes; the most common is: a. Vaginal or vulvar hematomas. b. Unrepaired lacerations of the vagina or cervix. c. Failure of the uterine muscle to contract firmly. d. Retained placental fragments.

ANS: C Uterine atony can best be thwarted by maintaining good uterine tone and preventing bladder distention. Although vaginal or vulvar hematomas, unpaired lacerations of the vagina or cervix, and retained placental fragments are possible causes of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause.

By what age would the nurse expect that most children could understand prepositional phrases such as under, on top of, beside, and in back of? a. 18 months b. 24 months c. 3 years d. 4 years

ANS: D At 4 years, children can understand directional phrases. Children 18 to 24 months and 3 years of age are too young.

By what age should concerns about pubertal delay be considered in boys? a. 12 to 12.5 years b. 12.5 to 13 years c. 13 to 13.5 years d. 13.5 to 14 years

ANS: D Concerns about pubertal delay should be considered for boys who exhibit no enlargement of the testes or scrotal changes by 13.5 to 14 years of age. Ages younger than 13.5 years are too young for initial concern.

Which common childhood communicable disease may cause severe defects in the fetus when it occurs in its congenital form? a. Erythema infectiosum b. Roseola c. Rubeola d. Rubella

ANS: D Rubella causes teratogenic effects on the fetus. There is a low risk of fetal death to those in contact with children affected with fifth disease. Roseola and rubeola are not dangerous to the fetus.

The most common cause of death in the adolescent age-group involves: a. Drownings. b. Firearms. c. Drug overdoses. d. Motor vehicles.

ANS: D The leading cause of all adolescent deaths in the United States is motor vehicle accidents. Drownings, firearms, and drug overdoses are major concerns in adolescence but do not cause the majority of deaths

Which behavior is not normally demonstrated in the 8-year-old child? a. Understands that his or her point of view is not the only one b. Enjoys telling riddles and silly jokes c. Understands that pouring liquid from a small to a large container does not change the amount d. Engages in fantasy and magical thinking

ANS: D The preschool child engages in fantasy and magical thinking. The school-age child moves away from this type of thinking and becomes more skeptical and logical. Belief in Santa Claus or the Easter Bunny ends in this period of development. School-age children enter the stage of concrete operations. They learn that their point of view is not the only one. The school-age child has a sense of humor. The childs increased language mastery and increased logic allow for appreciation of plays on words, jokes, and incongruities. The school-ag

In terms of fine motor development, what could the 3-year-old child be expected to do? a. Tie shoelaces. b. Use scissors or a pencil very well. c. Draw a person with seven to nine parts. d. Copy (draw) a circle.

ANS: D Three-year-olds are able to accomplish the fine motor skill of drawing a circle. Tying shoelaces, using scissors or a pencil very well, and drawing a person with multiple parts are fine motor skills of 5-year-old children.

A 25-year-old gravida 1 para 1 who had an emergency cesarean birth 3 days ago is scheduled for discharge. As you prepare her for discharge, she begins to cry. Your initial action should be to a. Assess her for pain. b. Point out how lucky she is to have a healthy baby. c. Explain that she is experiencing postpartum blues. d. Allow her time to express her feelings.

ANS: D Although many women experience transient postpartum blues, they need assistance in expressing their feelings. This condition affects 50% to 80% of new mothers. There should be no assumption that the patient is in pain, when in fact she may have no pain whatsoever. This is blocking communication and inappropriate in this situation. The patient needs the opportunity to express her feelings first; patient teaching can occur later

Sources of Phosphate

All animal products

Plasma, the liquid constitute of blood, is correctly identified as which of the following? A. Interstitial fluid B. Intravascular fluid C. Intracellular fluid D. 40% of total body fluid

B

The nurse is responsible for teaching the patient regarding dietary choices to provide needed magnesium. Which food is a good source of magnesium? A. Apple B. Spinach C. Liver D. Squash

B

2. The nurse at the family planning clinic conducts a male history for infertility evaluation. Which finding has the greatest implication for this patient's care? a. Practice of nightly masturbation b. Primary anovulation c. High testosterone levels d. Impotence due to alcohol ingestion

ANS: D Factors affecting male infertility include impotence due to alcohol. Nightly masturbation and high testosterone levels do not have the greatest implication on male infertility in a patient with admitted alcohol issues. Primary anovulation refers to female infertility, so it is not a consideration for male infertility.

Anions

Bicarbonate, Chloride, Phosphate

Function of Calcium

Blood coagulation, Muscle contraction, bones, teeth,

Source of Sodium

Food; salt

Hyperphosphatemia Causes

Kidney failure, hypoparathyroidism

Function of Magnesium

Metab. Of carbs & protein, produces vasodilation in CV system

Source of Calcium

Milk, cheese, green veggies, small fish with bones

filtration

Passage of fluids through a permeable membrane ; Fluids move from an area of high-low pressure

To plan early intervention and care for an infant with Down syndrome, the nurse considers knowledge of other physical development exemplars such as a. cerebral palsy. b. failure to thrive. c. fetal alcohol syndrome. d. hydrocephaly.

ANS: D Hydrocephaly is also a physical development exemplar. Cerebral palsy is an exemplar of adaptive developmental delay. Failure to thrive is an exemplar of social/emotional developmental delay. Fetal alcohol syndrome is an exemplar of cognitive developmental delay.

Hyperbicarbonatemia Symptoms

Slow, shallow respirations

Cations

Sodium, Potassium, Calcium, Hydrogen, Magnesium

diffusion

Solutes (electrolytes) move freely throughout a solvent (water); Moves from areas of high concentration to areas of lower concentration

Function of potassium

Transmission of electrical impulses in muscles and nerves, cell building

Sensible fluid output

Urination, defecation, wounds

Hypophosphatemia Causes

alcohol withdrawal, hyperventilation, diuretics, diabetes

Thirst control center location

hypothalamus

Those unable to respond to the thirst mechanism are at risk for dehydration

infants, patients with neuro or psych deficits, and older adult

Hypermagnesemia Symptoms

n/v, weakness, loss of deep tendon reflexes, change in mental status

Non-electrolytes

no charge; glucose, urea etc

Hyperkalemia Causes

renal failure, medications, hyperaldosteronism

Normal Sodium Value

135-145

Normal Phosphate Range

2.5-4.5

Normal Bicarbonate Range

25-29

ECF

30% body fluid

Total body water

50-60%

ICF

70% body fluid

An 8-year-old girl tells the nurse that she has cancer because God is punishing her for being bad. She shares her concern that, if she dies, she will go to hell. The nurse should interpret this as being: a. A belief common at this age. b. A belief that forms the basis for most religions. c. Suggestive of excessive family pressure. d. Suggestive of a failure to develop a conscience.

ANS: A Children at this age may view illness or injury as a punishment for a real or imagined mystique. The belief in divine punishment is common at this age.

An adolescent girl tells the nurse that she has suicidal thoughts. The nurse asks her if she has a specific plan. Asking this should be considered: a. An appropriate part of the assessment. b. Not a critical part of the assessment. c. Suggesting that the adolescent needs a plan. d. Encouraging the adolescent to devise a plan.

ANS: A Routine health assessments of adolescents should include questions that assess the presence of suicidal ideation or intent. Questions such as Have you ever developed a plan to hurt yourself or kill yourself? should be part of that assessment. Threats of suicide should always be taken seriously and evaluated. Suggesting that the adolescent needs a plan and encouraging her to devise this plan would be inappropriate statements by the nurse.

9. Which characteristic best describes the gross motor skills of a 24-month-old child? a. Skips b. Rides tricycle c. Broad jumps d. Walks up and down stairs

ANS: D The 24-month-old child can go up and down stairs alone with two feet on each step. Skipping and the ability to broad jump are skills acquired at age 3. Tricycle riding is achieved at age 4.

Source of bicarbonate

Byproduct of metabolism

Hyperkalemia Symptoms

Cardiac arrest, skeletal muscle weakness, Irregular heart rhythm.

Hypocalcemia Causes

Causes: inadequate intake, impaired absorption, excessive loss

Hyponatremia Symptoms

Confusion, hypotension, edema, muscle cramps, dry skin

_____ have more ECF.

Infants

Hypokalemia Symptoms

Muscle cramps, weakness, Dysrhythmias

Hypomagnesemia Symtoms

Muscle weakness, hyperactive deep tendon reflexes, tetany, tremors

Hypocalcemia Symptoms

Numbness & tingling of fingers, toes, mouth; tetany, muscle cramps, seizures, Trousseau's sign

_____ and _____ have less body water.

Obese and women

Bicarbonate function

Regulates acid-base balance

Function of Sodium

Regulates fluid balance, Muscle contraction Nerve impulse transmission

Hypernatremia Symptoms

Restlessness, weakness, disorientation, Delusion, hallucinations

Source of Chloride

Salt, processed foods

Hyperphosphatemia Symptoms

Tetany, nausea, tachycardia, muscle weakness

Hyponatremia Causes

Vomiting, diarrhea, diuretics

Hypernatremia Causes

diarrhea, fluid loss, fluid deprivation

Hypomagnesemia Causes

diarrhea, gastric suctioning, alcohol withdrawal, burns, sepsis

Insensible fluid output

sweating, respirations

ICF electrolytes

•Potassium (K+) •Phosphorus (PO4ˉ)•Magnesium (Mg²+)

ECF electrolytes

•Sodium (Na+) •Chloride (Clˉ) •Calcium (Ca²+) •Bicarbonate (HCO3-)

Hypochloremia Symptoms

Hyperexcitability of muscles, tetany, hyperactive deep tendon reflexes, weakness, muscle cramps

Hypercalemia Symptoms

N/V, constipation, Bone pain, confusion, thirst, lethargy

Fluid-regulating processes

Osmosis •Diffusion •Active transport •Filtration

Which woman is most likely to experience strong afterpains? a. A woman who experienced oligohydramnios b. A woman who is a gravida 4, para 4-0-0-4 c. A woman who is bottle-feeding her infant d. A woman whose infant weighed 5 pounds, 3 ounces

ANS: B Afterpains are more common in multiparous women. Afterpains are more noticeable with births in which the uterus was greatly distended, as in a woman who experienced polyhydramnios or a woman who delivered a large infant. Breastfeeding may cause afterpains to intensify

*A patient has newly diagnosed hyperparathyroidism. What should the nurse expect to find during an assessment at the beginning of the nursing shift?* A. Lethargy and constipation from hypercalcemia B. Positive Trousseau's sign from hypercalcemia C. Lethargy and constipation from hypocalcemia D. Positive Trousseau's sign from hypocalcemia

*Answer: A* Rationale: Parathyroid hormone (PTH) shifts calcium from the bones into the extracellular fluid (ECF). Excessive PTH causes hypercalcemia, which is manifested by lethargy and constipation. A positive Trousseau's sign is characteristic of hypocalcemia rather than hypercalcemia. Answers that indicate hypocalcemia are not correct, because PTH moves calcium into the ECF.

Avg adult intake

2,600 mL per day • Ingested water - 1,300 mL per day • Ingested foods - 1,000 mL per day • Metabolic oxidation -300 mL per day

At 1 minute after birth, the nurse assesses the infant and notes a heart rate of 80 beats/minute, some flexion of the extremities, a weak cry, grimacing, and a pink body with blue extremities. The nurse would calculate an Apgar score of: ________

ANS: 5 Each of the five signs the nurse noted would score an Apgar of 1 for a total of 5. Signs include heart rate, respiratory effort, muscle tone, reflex irritability, and color. The highest possible Apgar score is 10.

What are modes of heat loss in the newborn (Select all that apply)? a. Perspiration b. Convection c. Radiation d. Conduction e. Urination

ANS: B, C, D Convection, radiation, evaporation, and conduction are the four modes of heat loss in the newborn. Perspiration and urination are not modes of heat loss in newborns

Vitamin A supplementation may be recommended for the young child who has: a. Mumps. b. Rubella. c. Measles (rubeola). d. Erythema infectiosum.

ANS: C Evidence shows that vitamin A decreases morbidity and mortality associated with measles. Vitamin A will not lessen the effects of mumps, rubella, or fifth disease.

Which statement describing the first phase of the transition period is inaccurate? a. It lasts no longer than 30 minutes. b. It is marked by spontaneous tremors, crying, and head movements. c. It includes the passage of meconium. d. It may involve the infants suddenly sleeping briefly

ANS: D The first phase is an active phase in which the baby is alert. Decreased activity and sleep mark the second phase. The first phase is the shortest, lasting less than 30 minutes. Such exploratory behaviors include spontaneous startle reactions. In the first phase the newborn also produces saliva

Which of the following would the nurse use as the most reliable indicator of a patient's fluid balance status? A. I/O B. Skin turgor C. CBC D. Daily weight

D

active transport

Requires energy stored in cells to move solutes (electrolytes) throughout a solvent (water) •Adenosine triphosphate (ATP) • Transports chemical energy within cells for metabolism •Moves from areas of less concentration to areas of higher concentration

*A patient has a tumor that secretes excessive antidiuretic hormone (ADH). He is confused and lethargic. His partner wants to know how a change in blood sodium can cause these symptoms. What should the nurse teach the patient's partner?* A. Decreased sodium in the blood causes the blood volume to decrease so that not enough oxygen reaches the brain. B. Decreased sodium in the blood causes brain cells to swell so that they do not work as effectively. C. Increased sodium in the blood causes the blood volume to increase so that too much oxygen reaches the brain. D. Increased sodium in the blood causes brain cells to shrivel so that they do not work as effectively.

*Answer: B* Rationale: The normal action of ADH is renal reabsorption of water, which dilutes the blood. Excessive ADH causes hyponatremia, which is manifested by a decreased level of consciousness because the osmotic shift of water into the brain cells impairs their function. Hyponatremia does not decrease the blood volume. Answers that include increased sodium in the blood are incorrect because ADH excess causes hyponatremia rather than hypernatremia.

*A patient injured in an earthquake today when a wall fell on his legs received 9 units of blood an hour ago because he was hemorrhaging. Which laboratory value should the nurse check first when the report returns?* A. Serum sodium B. Serum potassium C. Serum total calcium D. Serum magnesium

*Answer: B* Rationale: The patient has two major risk factors for hyperkalemia: massive sudden cell death from a crushing injury (potassium shift from cells into the extracellular fluid) and massive blood transfusion (rapid potassium intake). Although massive blood transfusion may cause calcium and magnesium ions to bind to citrate in the blood, thereby decreasing the physiological availability of those ions, it does not decrease the total calcium or magnesium laboratory measurements. Clinically significant changes in serum sodium are the least likely in this patient.

*The home health nurse should assess a patient who has chronic diarrhea for which fluid and electrolyte imbalances? (select all that apply)* A. Extracellular fluid volume (ECV) excess B. Extracellular fluid volume (ECV) deficit C. Hypokalemia D. Hyperkalemia E. Hypocalcemia F. Hypercalcemia

*Answer: B, C, E* Rationale: Chronic diarrhea has a high risk of causing ECV deficit, hypokalemia, and hypocalcemia because it increases the fecal output of sodium-containing fluid, potassium, and calcium. Unless the intake of these substances increases appropriately, imbalances will occur. Excesses of ECV, potassium, and calcium are not likely, because the ECV, potassium, and calcium are being removed from the body.

*A patient has acute gastroenteritis with watery diarrhea. Which statement by this patient would indicate that the nurse's teaching has been effective?* A. "I should drink a lot of tap water today." B. "I need to take more calcium tablets today." C. "I should avoid fruits with potassium in them." D. "I need to drink liquids with some sodium in them."

*Answer: D* Rationale: Sodium-containing fluids are removed from the body by acute diarrhea and must be replaced to prevent an extracellular fluid volume (ECV) deficit. Drinking tap water will not prevent ECV deficit from diarrhea, because tap water does not contain enough sodium to hold the water in the extracellular compartment. Taking calcium tablets is an incorrect answer because hypocalcemia is characteristic of chronic diarrhea rather than acute diarrhea. Restricting fruits is an incorrect answer because diarrhea increases the potassium output and the potassium intake should be increased to balance it.

Kidney urine production

1.5 L

Normal Chloride Range

97-107

Hypokalemia Causes

: vomiting, gastric suctioning, diarrhea, diuretics

The nurse is admitting an older adult with decompensated congestive heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse should question which doctors order? a. Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr b. Furosemide (Lasix) 20 mg PO now c. Oxygen via face mask at 8 L/min d. KCl 20 mEq PO two times per day

ANS: A (A patient with decompensated heart failure has extracellular fluid volume (ECV) excess. The IV of 0.9% NaCl is normal saline, which should be questioned because it would expand ECV and place an additional load on the failing heart. Diuretics such as furosemide are appropriate to decrease the ECV during heart failure. Increasing the potassium intake with KCl is appropriate, because furosemide increases potassium excretion. Oxygen administration is appropriate in this situation of near pulmonary edema from ECV excess.)

Preschoolers fears can best be dealt with by which intervention? a. Actively involving them in finding practical methods to deal with the frightening experience b. Forcing them to confront the frightening object or experience in the presence of their parents c. Using logical persuasion to explain away their fears and help them recognize how unrealistic the fears are d. Ridiculing their fears so they understand that there is no need to be afraid

ANS: A Actively involving the child in finding practical methods to deal with the frightening experience is the best way to deal with fears. Forcing a child to confront fears may make the child more afraid. Preconceptual thought prevents logical understanding. Ridiculing fears does not make them go away.

Which activity is most appropriate for developing fine motor skills in the school-age child? a. Drawing b. Singing c. Soccer d. Swimming

ANS: A Activities such as drawing, building models, and playing a musical instrument increase the school-age childs fine motor skills. Singing is an appropriate activity for the school-age child, but it does not increase fine motor skills. The school-age child needs to participate in group activities to increase both gross motor skills and social skills, but group activities do not increase fine motor skills. Swimming is an activity that also increases gross motor skills.

Which aspect of cognition develops during adolescence? a. Capability to use a future time perspective b. Ability to place things in a sensible and logical order c. Ability to see things from the point of view of another d. Progress from making judgments based on what they see to making judgments based on what they reason

ANS: A Adolescents are no longer restricted to the real and actual. They also are concerned with the possible; they think beyond the present. During concrete operations (between ages 7 and 11 years), children exhibit the ability to place things in a sensible and logical order, the ability to see things from anothers point of view, and the ability to make judgments based on what they reason rather than just what they see.

A child has an evulsed (knocked-out) tooth. In which medium should the nurse instruct the parents to place the tooth for transport to the dentist? a. Cold milk b. Cold water c. Warm salt water d. A dry, clean jar

ANS: A An evulsed tooth should be placed in a suitable medium for transport, either cold milk or saliva (under the childs or parents tongue). Cold milk is a more suitable medium for transport than cold water, warm salt water, or a dry, clean jar.

Which statement is true about smoking in adolescence? a. Smoking is related to other high-risk behaviors. b. Smoking is more common among athletes. c. Smoking is less common when the adolescents parent(s) smokes. d. Smoking among adolescents is becoming more prevalent.

ANS: A Cigarettes are considered a gateway drug. Teenagers who smoke are 11.4 times more likely to use an illicit drug. Teens who refrain from smoking often have a desire to succeed in athletics. If a parent smokes, it is more likely that the teen will smoke. Cigarette smoking has declined among all groups since the 1990s.

Which is the most commonly used method in completed suicides? a. Firearms b. Drug overdose c. Self-inflected laceration d. Carbon monoxide poisoning

ANS: A Firearms are the most commonly used instruments in completed suicides among both males and females. For adolescent boys, firearms are followed by hanging and overdose. For adolescent females, overdose and strangulation are the next most common means of completed suicide. The most common method of suicide attempt is overdose or ingestion of potentially toxic substances such as drugs. The second most common method of suicide attempt is self-inflicted laceration. Carbon monoxide poisoning is not one of the more frequent forms of suicide completion.

A young adolescent boy tells the nurse he feels gawky. The nurse should explain that this occurs in adolescents because: a. Growth of the extremities and neck precedes growth in other areas. b. Growth is in the trunk and chest. c. The hip and chest breadth increases. d. The growth spurt occurs earlier in boys than it does in girls.

ANS: A Growth in length of the extremities and neck precedes growth in other areas, and, because these parts are the first to reach adult length, the hands and feet appear larger than normal during adolescence. Increases in hip and chest breadth take place in a few months, followed several months later by an increase in shoulder width. These changes are followed by increases in length of the trunk and depth of the chest. This sequence of changes is responsible for the characteristic long-legged, gawky appearance of early adolescent children. The growth spurt occurs earlier in girls than in boys.

Which statement is correct about childhood obesity? a. Heredity is an important factor in the development of obesity. b. Childhood obesity in the United States is decreasing. c. Childhood obesity is the result of inactivity. d. Childhood obesity can be attributed to an underlying disease in most cases.

ANS: A Heredity is an important fact that contributes to obesity. Identical twins reared apart tend to resemble their biologic parents to a greater extent than their adoptive parents. It is difficult to distinguish between hereditary and environmental factors. The rate of childhood obesity has increased so dramatically that it has now reached epidemic proportions. Inactivity is an important contributing factor; however, obesity is the result of a combination of a number of other factors. Fewer than 5% of all cases of obesity can be linked to underlying disease.

The nurse is using the Ballard scale to determine the gestational age of a newborn. Which assessment finding is consistent with a gestational age of 40 weeks? a. Flexed posture b. Abundant lanugo c. Smooth, pink skin with visible veins d. Faint red marks on the soles of the feet

ANS: A Term infants typically have a flexed posture. Abundant lanugo usually is seen on preterm infants. Smooth, pink skin with visible veins is seen on preterm infants. Faint red marks usually are seen on preterm infants.

Matt, age 14 years, seems to be always eating, although his weight is appropriate for his height. The best explanation for this is: a. This is normal because of increase in body mass. b. This is abnormal and suggestive of future obesity. c. His caloric intake would have to be excessive. d. He is substituting food for unfilled needs.

ANS: A In adolescence, nutritional needs are closely related to the increase in body mass. The peak requirements occur in the years of maximal growth. The caloric and protein requirements are higher than at almost any other time of life. This describes the expected eating pattern for young adolescents as long as weight and height are appropriate; obesity and substitution of food for unfilled needs are not concerns.

In terms of cognitive development, the 5-year-old child would be expected to: a. Use magical thinking. b. Think abstractly. c. Understand conservation of matter. d. Be able to comprehend another persons perspective.

ANS: A Magical thinking is believing that thoughts can cause events. Abstract thought does not develop until school- age years. The concept of conservation is the cognitive task of school-age children ages 5 to 7 years. Five-year- olds cannot understand anothers perspective.

Which statement characterizes moral development in older school-age children? a. They are able to judge an act by the intentions that prompted it rather than just by the consequences. b. Rules and judgments become more absolute and authoritarian. c. They view rule violations in an isolated context. d. They know the rules but cannot understand the reasons behind them.

ANS: A Older school-age children are able to judge an act by the intentions that prompted the behavior rather than just by the consequences. Rules and judgments become less absolute and authoritarian. Rule violation is likely to be viewed in relation to the total context in which it appears. Both the situation and the morality of the rule itself influence reactions.

A common characteristic of those who sexually abuse children is that they: a. Pressure the victim into secrecy. b. Are usually unemployed and unmarried. c. Are unknown to victims and victims families. d. Have many victims that are each abused only once.

ANS: A Sex offenders may pressure the victim into secrecy, regarding the activity as a secret between us that other people may take away if they find out. Abusers are often employed upstanding members of the community. Most sexual abuse is committed by men and persons who are well known to the child. Abuse is often repeated with the same child over time. The relationship may start insidiously without the child realizing that sexual activity is part of the offer.

25.A nurse is administering a diuretic to a patient and teaching the patient about foods to increase. Which food choices by the patient will best indicate successful teaching? a. Milk and cheese b. Potatoes and fresh fruit c. Canned soups and vegetables d. Whole grains and dark green leafy vegetables

ANS: B Potatoes and fruits are high in potassium. Milk and cheese are high in calcium. Canned soups and vegetables are high in sodium. Whole grains and dark green leafy vegetables are high in magnesium

A 9-year-old girl often comes to the school nurse complaining of stomach pains. Her teacher says that she is completing her schoolwork satisfactorily, but lately she has been somewhat aggressive and stubborn in the classroom. The school nurse should recognize this as: a. Signs of stress. b. Developmental delay. c. A physical problem causing emotional stress. d. Lack of adjustment to the school environment.

ANS: A Signs of stress include stomach pains or headache, sleep problems, bed-wetting, changes in eating habits, aggressive or stubborn behavior, reluctance to participate, or regression to early behaviors. This child is exhibiting signs of stress, not developmental delay, a physical problem, or lack of adjustment.

Which is the most significant factor in distinguishing those who commit suicide from those who make suicidal attempts or threats? a. Social isolation b. Level of stress c. Degree of depression d. Desire to punish others

ANS: A Social isolation is a significant factor in distinguishing adolescents who will kill themselves from those who will not. It is also more characteristic of those who complete suicide than of those who make attempts or threats. Level of stress, degree of depression, and desire to punish others are contributing factors in suicide, but they are not the most significant factor in distinguishing those who complete suicide from those who attempt suicide.

A nurse is teaching adolescent boys about pubertal changes. The first sign of pubertal change seen with boys is: a. Testicular enlargement. b. Facial hair. c. Scrotal enlargement. d. Voice deepens.

ANS: A The first sign of pubertal changes in boys is testicular enlargement in response to testosterone secretion, which usually occurs in Tanner stage 2. Slight pubic hair is present and the smooth skin texture of the scrotum is somewhat altered. As testosterone secretion increases, the penis, testes, and scrotum enlarge. During Tanner stages 4 and 5, rising levels of testosterone cause the voice to deepen and facial hair appears at the corners of the upper lip and chin.

A useful skill that the nurse should expect a 5-year-old child to be able to master is to: a. Tie shoelaces. b. Use a knife to cut meat. c. Hammer a nail. d. Make change from a quarter.

ANS: A Tying shoelaces is a fine motor task typical of 5-year-olds. Using a knife to cut meat is a fine motor task of a 7- year-old. Hammering a nail and making change from a quarter are fine motor tasks of an 8- to 9-year-old.

The nurse is caring for an adolescent brought to the hospital with acute drug toxicity. Cocaine is believed to be the drug involved. Data collection should include the: a. Mode of administration. b. Actual content of the drug. c. Function the drug plays in the adolescents life. d.Adolescents level of interest in rehabilitation.

ANS: A When the drug is questionable or unknown, every effort must be made to determine the type, amount of drug taken, the mode and time of administration, and factors relating to the onset of presenting symptoms. Because the actual content of most street drugs is highly questionable, this information would be difficult to obtain. It is helpful to know the pattern of use but not essential during this emergency. This is an inappropriate time for an evaluation about the level of interest in rehabilitation.

The teaching plan for a 3-year-old child who is at risk for developmental delay should include which of these instructions for the parents? a. Encourage play as your child is exploring his or her surroundings. b. Insist that your child discuss various points of view, not just his or her own. c. Discuss world events with your child to foster language development. d. Actively encourage your child to read lengthy books to expedite reading and writing abilities.

ANS: A A 3-year-old child is going to use play to learn and discover the surrounding environment. Children at this age are egocentric and often are unable to see the world from any perspective other than their own. Very young children are not able to understand and comment on world events because their thinking has not advanced to abstract reasoning yet. A 3-year-old child is likely unable to read. Asking a child to perform an activity that is beyond his or her developmental abilities will likely result in frustration at not being able to complete the task.

As related to the normal functioning of the renal system in newborns, nurses should be aware that: a. The pediatrician should be notified if the newborn has not voided in 24 hours. b. Breastfed infants likely will void more often during the first days after birth. c. Brick dust or blood on a diaper is always cause to notify the physician. d. Weight loss from fluid loss and other normal factors should be made up in 4 to 7 days.

ANS: A A newborn who has not voided in 24 hours may have any of a number of problems, some of which deserve the attention of the pediatrician. Formula-fed infants tend to void more frequently in the first 3 days; breastfed infants void less during this time because the mothers breast milk has not come in yet. Brick dust may be uric acid crystals; blood spotting could be caused by withdrawal of maternal hormones (pseudomenstruation) or a circumcision. The physician must be notified only if there is no apparent cause of bleeding. Weight loss from fluid loss may take 14 days to regain

17.A nurse is caring for a patient with peripheral intravenous (IV) therapy. Which task will the nurse assign to the nursing assistive personnel? a. Recording intake and output b. Regulating intravenous flow rate c. Starting peripheral intravenous therapy d. Changing a peripheral intravenous dressing

ANS: A A nursing assistive personnel (NAP) can record intake and output. An RN cannot delegate regulating flow rate, starting an IV, or changing an IV dressing to an NAP.

During which phase of maternal adjustment will the mother relinquish the baby of her fantasies and accept the real baby? a. Letting go c. Taking in b. Taking hold d. Taking on

ANS: A Accepting the real infant and relinquishing the fantasy infant occurs during the letting-go phase of maternal adjustment. During the taking-hold phase the mother assumes responsibility for her own care and shifts her attention to the infant. In the taking-in phase the mother is primarily focused on her own needs. There is no taking-on phase of maternal adjustment

A new mother states that her infant must be cold because the babys hands and feet are blue. The nurse explains that this is a common and temporary condition called: a. Acrocyanosis. c. Harlequin color. b. Erythema neonatorum. d. Vernix caseosa

ANS: A Acrocyanosis, or the appearance of slightly cyanotic hands and feet, is caused by vasomotor instability, capillary stasis, and a high hemoglobin level. Acrocyanosis is normal and appears intermittently over the first 7 to 10 days. Erythema toxicum (also called erythema neonatorum) is a transient newborn rash that resembles flea bites. The harlequin sign is a benign, transient color change in newborns. Half of the body is pale, and the other half is ruddy or bluish red with a line of demarcation. Vernix caseosa is a cheeselike, whitish substance that serves as a protective covering

To promote parent-child attachment with a healthy newborn, what should the nurse do? a. Encourage close physical contact as soon as possible after birth. b. Do not allow the newborn to remain with parents until the second hour after delivery. c. Never leave the newborn alone with the mother during the first 8 hours after delivery. d. Isolate the newborn in the nursery during the first hour after delivery.

ANS: A After immediate physical evaluation and application of identification bracelets, the nurse promotes the parents' and newborn's need for close physical contact. Early parent-child interaction encourages parent-child attachment. Most healthy newborns are awake and alert for the first half-hour after birth. This is a good time for parent-child interaction to begin. No evidence in the question stem suggests that the baby cannot be left alone with the parents during the first 8 hours, or that the baby should remain in the nursery during the first hour.

Which patient finding would the nurse identify as being a risk factor for altered transport of oxygen? a. Hemoglobin level of 8.0 b. Bronchoconstriction and mucus c. Peripheral arterial disease d. Decreased thoracic expansion

ANS: A Altered transportation of oxygen refers to patients with insufficient red blood cells to transport the oxygen present. Bronchoconstriction and decreased thoracic expansion (spinal cord injury) would result in impairment of ventilation. Peripheral vascular disease would result in inadequate perfusion.

The nurse is teaching a young adult couple about promoting the health of their 8-year-old child. The nurse knows that the parents understand the developmental stage their child is in according to Erikson when they state, "We should a. Provide proper support for learning new skills." b. Encourage devoted relationships with others." c. Limit choices and provide harsh punishment for mistakes." d. Not leave our child at school for longer than 3 hours at a time."

ANS: A An 8-year-child would be in the industry versus inferiority stage of development. During this stage, the child needs to be praised for accomplishments such as learning new skills. Developing devoted relationships is part of the identity versus role confusion stage, usually occurring during puberty. During the autonomy versus shame and doubt stage, limiting choices and harsh punishment lead to feelings of shame and doubt. Separation anxiety is usually a part of the trust versus mistrust stage.

A woman gave birth to a 7-pound, 6-ounce infant girl 1 hour ago. The birth was vaginal, and the estimated blood loss (EBL) was approximately 1500 mL. When assessing the womans vital signs, the nurse would be concerned to see: a. Temperature 37.9 C, heart rate 120, respirations 20, blood pressure (BP) 90/50. b. Temperature 37.4 C, heart rate 88, respirations 36, BP 126/68. c. Temperature 38 C, heart rate 80, respirations 16, BP 110/80. d. Temperature 36.8 C, heart rate 60, respirations 18, BP 140/90.

ANS: A An EBL of 1500 mL with tachycardia and hypotension suggests hypovolemia caused by excessive blood loss. An increased respiratory rate of 36 may be secondary to pain from the birth. Temperature may increase to 38 C during the first 24 hours as a result of the dehydrating effects of labor. A BP of 140/90 is slightly elevated, which may be caused by the use of oxytocic medications

Rho immune globulin will be ordered postpartum if which situation occurs? a. Mother Rh?2-, baby Rh+ c. Mother Rh+, baby Rh+ b. Mother Rh?2-, baby Rh?2- d. Mother Rh+, baby Rh?2-

ANS: A An Rh?2- mother delivering an Rh+ baby may develop antibodies to fetal cells that entered her bloodstream when the placenta separated. The Rho immune globulin works to destroy the fetal cells in the maternal circulation before sensitization occurs. If mother and baby are both Rh+ or Rh?2- the blood types are alike, so no antibody formation would be anticipated. If the Rh+ blood of the mother comes in contact with the Rh?2- blood of the infant, no antibodies would develop because the antigens are in the mothers blood, not the infants.

The nurse should immediately alert the physician when: a. The infant is dusky and turns cyanotic when crying. b. Acrocyanosis is present at age 1 hour. c. The infants blood glucose level is 45 mg/dL. d. The infant goes into a deep sleep at age 1 hour

ANS: A An infant who is dusky and becomes cyanotic when crying is showing poor adaptation to extrauterine life. Acrocyanosis is an expected finding during the early neonatal life. This is within normal range for a newborn. Infants enter the period of deep sleep when they are about 1 hour old.

30. A 16 months old, falls down a few stairs and then gets up and "scolds" the stairs as if they caused the fall. This is an example of which of the following? a. Animism b. Ritualism c. Irreversibility d. Delayed cognitive development

ANS: A Animism is the attribution of life-like qualities to inanimate objects. By scolding the stairs, the toddler is attributing human characteristics to them. Ritualism is the need to maintain sameness and reliability. It provides a sense of comfort to the toddler. Irreversibility is the inability to reverse or undo actions initiated physically. Steven is acting in an age-appropriate manner.

New parents express concern that, because of the mothers emergency cesarean birth under general anesthesia, they did not have the opportunity to hold and bond with their daughter immediately after her birth. The nurses response should convey to the parents that: a. Attachment, or bonding, is a process that occurs over time and does not require early contact. b. The time immediately after birth is a critical period for people. c. Early contact is essential for optimum parent-infant relationships. d. They should just be happy that the infant is healthy

ANS: A Attachment, or bonding, is a process that occurs over time and does not require early contact. The formerly accepted definition of bonding held that the period immediately after birth was a critical time for bonding to occur. Research since has indicated that parent-infant attachment occurs over time. A delay does not inhibit the process. Parent-infant attachment involves activities such as touching, holding, and gazing; it is not exclusively eye contact. A response that conveys that the parents should just be happy that the infant is healthy is inappropriate because it is derogatory and belittling

The self-destruction of excess hypertrophied tissue in the uterus is called: a. Autolysis. c. Afterpain. b. Subinvolution. d. Diastasis.

ANS: A Autolysis is caused by a decrease in hormone levels. Subinvolution is failure of the uterus to return to a nonpregnant state. Afterpain is caused by uterine cramps 2 to 3 days after birth. Diastasis refers to the separation of muscles.

The nurse knows that a priority reason for being knowledgeable about biophysical developmental theories is to a. Understand how the physical body grows. b. Predict definite patterns of cognitive development. c. Anticipate how patients' social behaviors develop. d. Describe the process of psychological development.

ANS: A Biophysical development refers to how our physical bodies grow and change. Nurses and other health care providers are able to quantify and compare the changes that occur as a newborn infant grows into adulthood against established norms to detect abnormalities. Biophysical development refers to physical growth, not cognitive development, social behaviors, or psychological development.

A collection of blood between the skull bone and its periosteum is known as a cephalhematoma. To reassure the new parents whose infant develops such a soft bulge, it is important that the nurse be aware that this condition: a. May occur with spontaneous vaginal birth. b. Happens only as the result of a forceps or vacuum delivery. c. Is present immediately after birth. d. Will gradually absorb over the first few months of life

ANS: A Bleeding may occur during a spontaneous vaginal delivery as a result of the pressure against the maternal bony pelvis. The soft, irreducible fullness does not pulsate or bulge when the infant cries. Low forceps and other difficult extractions may result in bleeding. However, cephalhematomas can also occur spontaneously. The swelling may appear unilaterally or bilaterally and is usually minimal or absent at birth. It increases over thefirst 2 to 3 days of life. Cephalhematomas disappear gradually over 2 to 3 weeks. A less common condition results in calcification of the hematoma, which may persist for months

Knowing that the condition of the new mothers breasts will be affected by whether she is breastfeeding, nurses should be able to tell their clients all the following statements except: a. Breast tenderness is likely to persist for about a week after the start of lactation. b. As lactation is established, a mass may form that can be distinguished from cancer by its position shift from day to day. c. In nonlactating mothers colostrum is present for the first few days after childbirth. d. If suckling is never begun (or is discontinued), lactation ceases within a few days to a week.

ANS: A Breast tenderness should persist for 24 to 48 hours after lactation begins. That movable, noncancerous mass is a filled milk sac. Colostrum is present for a few days whether the mother breastfeeds or not. A mother who does not want to breastfeed should also avoid stimulating her nipples

The best reason for recommending formula over breastfeeding is that: a. The mother has a medical condition or is taking drugs that could be passed along to the infant via breast milk. b. The mother lacks confidence in her ability to breastfeed. c. Other family members or care providers also need to feed the baby. d. The mother sees bottle-feeding as more convenient.

ANS: A Breastfeeding is contraindicated when mothers have certain viruses, are undergoing chemotherapy, or are using/abusing illicit drugs. A lack of confidence, the need for others to feed the baby, and the convenience of bottle-feeding are all honest reasons for not breastfeeding, although further education concerning the ease of breastfeeding and its convenience, benefits, and adaptability (expressing milk into bottles) could change some minds. In any case the nurse must provide information in a nonjudgmental manner and respect the mothers decision. Nonetheless, breastfeeding is definitely contraindicated when the mother has medical or drug issues of her own.

According to the recommendations of the American Academy of Pediatrics on infant nutrition: a. Infants should be given only human milk for the first 6 months of life. b. Infants fed on formula should be started on solid food sooner than breastfed infants. c. If infants are weaned from breast milk before 12 months, they should receive cows milk, not formula. d. After 6 months mothers should shift from breast milk to cows milk.

ANS: A Breastfeeding/human milk should also be the sole source of milk for the second 6 months. Infants start on solids when they are ready, usually at 6 months, whether they start on formula or breast milk. If infants are weaned from breast milk before 12 months, they should receive iron-fortified formula, not cows milk

10.The patient has an intravenous (IV) line and the nurse needs to remove the gown. In which order will the nurse perform the steps, starting with the first one? 1. Remove the sleeve of the gown from the arm without the IV. 2. Remove the sleeve of the gown from the arm with the IV. 3. Remove the IV solution container from its stand. 4. Pass the IV bag and tubing through the sleeve. a. 1, 2, 3, 4 b. 2, 3, 4, 1 c. 3, 4, 1, 2 d. 4, 1, 2, 3

ANS: A Change regular gowns by following these steps for maximum speed and arm mobility: (1) To remove a gown, remove the sleeve of the gown from the arm without the IV line, maintaining the patient's privacy. (2) Remove the sleeve of the gown from the arm with the IV line. (3) Remove the IV solution container from its stand, and pass it and the tubing through the sleeve. (If this involves removing the tubing from an EID, use the roller clamp to slow the infusion to prevent the accidental infusion of a large volume of solution or medication.)

A child has a chronic, nonproductive cough and diffuse wheezing during the expiratory phase of respiration. This suggests: a. Asthma. c. Bronchiolitis. b. Pneumonia. d. Foreign body in the trachea.

ANS: A Children with asthma usually have these chronic symptoms. Pneumonia appears with an acute onset and fever and general malaise. Bronchiolitis is an acute condition caused by respiratory syncytial virus. Foreign body in the trachea will manifest with acute respiratory distress or failure and maybe stridor.

A new mother asks whether she should feed her newborn colostrum, because it is not real milk. The nurses most appropriate answer is: a. Colostrum is high in antibodies, protein, vitamins, and minerals. b. Colostrum is lower in calories than milk and should be supplemented by formula. c. Giving colostrum is important in helping the mother learn how to breastfeed before she goes home. d. Colostrum is unnecessary for newborns.

ANS: A Colostrum is important because it has high levels of the nutrients needed by the neonate and helps protect against infection. Supplementation is not necessary; it will decrease stimulation to the breast and decrease the production of milk. It is important for the mother to feel comfortable in this role before discharge; however, the importance of the colostrum to the infant is the top priority. Colostrum provides immunities and enzymes necessary to cleanse the gastrointestinal system, among other things.

Discharge instruction, or teaching the woman what she needs to know to care for herself and her newborn, officially begins: a. At the time of admission to the nurses unit. b. When the infant is presented to the mother at birth. c. During the first visit with the physician in the unit. d. When the take-home information packet is given to the couple

ANS: A Discharge planning, the teaching of maternal and newborn care, begins on the womans admission to the unit, continues throughout her stay, and actually never ends as long as she has contact with medical personnel

During infant/child development, play is best recognized as a. A means to interact with the environment and relate to others. b. Independent of cognitive and social development. c. Nonexploratory and simply play. d. Too soon to achieve milestones.

ANS: A During infancy, play is a meaningful set of activities through which the child interacts with the environment and relates to others. Play provides opportunities for development of cognitive, social, and motor skills. Much of infant play is exploratory as infants use their senses to observe and examine their own bodies and objects of interest in their surroundings. Adults facilitate infant learning by planning activities that promote the development of milestones and by providing toys that are safe for the infant to explore with the mouth and manipulate with the hands.

The nurse is assessing a patient's differential white blood cell count. What implications would this test have on evaluating the adequacy of a patient's gas exchange? a. An elevation of the total white cell count indicates generalized inflammation. b. Eosinophil count will assist to identify the presence of a respiratory infection. c. White cell count will differentiate types of respiratory bacteria. d. Level of neutrophils provides guidelines to monitor a chronic infection.

ANS: A Elevation of total white cell count is indicative of inflammation that is often due to an infection. Upper respiratory infections are common problems in altering a patient's gas exchange. Eosinophil cells are increased in an allergic response. Neutrophils are more indicative of an acute inflammatory response. White cells do not assist to differentiate types of respiratory bacteria. Monocytes are an indicator of progress of a chronic infection.

A pregnant woman wants to breastfeed her infant; however, her husband is not convinced that there are any scientific reasons to do so. The nurse can give the couple printed information comparing breastfeeding and bottle-feeding. Which statement is most accurate? Bottle-feeding using commercially prepared infant formulas: a. Increases the risk that the infant will develop allergies. b. Helps the infant sleep through the night. c. Ensures that the infant is getting iron in a form that is easily absorbed. d. Requires that multivitamin supplements be given to the infant

ANS: A Exposure to cows milk poses a risk of developing allergies, eczema, and asthma. Bottle-feeding using commercially prepared infant formulas helps the infant sleep through the night is a false statement. Iron is better absorbed from breast milk than from formula. Commercial formulas are designed to meet the nutritional needs of the infant and resemble breast milk.

During hospitalization, the nurse should encourage the parents of an 8-month-old infant to a. Provide as much care as possible. b. Not worry about attachments because the infant is too young to develop them. c. Remember that infants cannot differentiate a stranger from a familiar person. d. Relax and allow nursing staff to care for the child at all times.

ANS: A Extended separations from parents complicate the attachment process and increase the number of caregivers with whom the infant must interact. Ideally, the parents provide most of the care during hospitalizations. Close attachment to the primary caregivers, most often parents, usually occurs by this age. Infants seek out these persons for support and comfort during times of stress. By 8 months, most infants are able to differentiate a stranger from a familiar person and respond differently to the two.

The nursing student correctly explains health promotion teaching points for parents of toddlers when she states a. "Setting consistent, firm limits will help the child cope with the frustration of learning self-control." b. "Slower development of motor skills prevents the child from participating in self-care activities." c. "Toddlers have a natural sense of right and wrong and know when they do something wrong." d. "Temper tantrums should never be tolerated, and toddlers need to do what they are told."

ANS: A Firm consistent limits, patience, and support allow toddlers to develop socially acceptable behaviors and to cope with the frustration of learning self-control. Rapid development of motor skills allows the child to participate in self-care activities such as feeding, dressing, and toileting. Because children's moral development is closely associated with their cognitive abilities, the moral development of toddlers is only beginning. Toddlers do not understand concepts of right and wrong. Temper tantrums result when parental restrictions frustrate toddlers. Parents need to provide toddlers with graded independence, allowing them to do things that do not result in harm to themselves or others.

24. Which is the most fatal type of burn in the toddler age-group? a. Flame burn from playing with matches. b. Scald burn from high-temperature tap water. c. Hot object burn from cigarettes or irons. d. Electric burn from electrical outlets.

ANS: A Flame burns from matches and lighters represent one of the most fatal types of burns in the toddler age-group. Scald burns from water, hot object burns from cigarettes or irons, and electric burns from outlets are all significant causes of burn injury. The child should be protected from these causes by reducing the temperature of the hot water in the home, keeping objects such as cigarettes and irons away from children, and placing protective guards over electrical outlets when not in use.

The nurse providing couplet care should understand that nipple confusion results when: a. Breastfeeding babies receive supplementary bottle feedings. b. The baby is weaned too abruptly. c. Pacifiers are used before breastfeeding is established. d. Twins are breastfed together.

ANS: A Nipple confusion can result when babies go back and forth between bottles and breasts, especially before breastfeeding is established in 3 to 4 weeks, because the two require different skills. Abrupt weaning can be distressing to mother and/or baby but should not lead to nipple confusion. Pacifiers used before breastfeeding is established can be disruptive, but this does not lead to nipple confusion. Breastfeeding twins requires some logistical adaptations, but this should not lead to nipple confusion

When utilizing Freud's psychoanalytical/psychosocial theory, the nurse recalls that a. Adult personality is the result of resolved conflicts between sources of sexual pleasure and the mandates of reality. b. Development occurs throughout the life span and focuses on psychosocial stages. c. The genital stage precedes the phallic stage of development. d. Problems evident in adult life are due to early successes and resolution of earlier developmental stages.

ANS: A Freud believed that adult personality is the result of how an individual resolved conflicts between sources of sexual pleasure and the mandates of reality. Freud had a strong influence on Erik Erikson, but Erikson's theory differed from Freud's in that it focused on psychosocial stages rather than psychosexual stages. Freud's five stages of psychoanalytical development in sequential order include oral, anal, phallic, latency, and genital. The phallic stage precedes the genital stage. In theory, problems in adult life would be due to unresolved conflicts and failures.

Parents have been asked by the neonatologist to provide breast milk for their newborn son, who was born prematurely at 32 weeks of gestation. The nurse who instructs them about pumping, storing, and transporting the milk needs to assess their knowledge of lactation. Which statement is valid? a. A premature infant more easily digests breast milk than formula. b. A glass of wine just before pumping will help reduce stress and anxiety. c. The mother should pump only as much as the infant can drink. d. The mother should pump every 2 to 3 hours, including during the night

ANS: A Human milk is the ideal food for preterm infants, with benefits that are unique in addition to those received by term, healthy infants. Greater physiologic stability occurs with breastfeeding compared with formula feeding. Consumption of alcohol during lactation is approached with caution. Excessive amounts can have serious effects on the infant and can adversely affect the mothers milk ejection reflex. To establish an optimal milk supply, the mother should be instructed to pump 8 to 10 times a day for 10 to 15 minutes on each breast

4.The nurse administers an intravenous (IV) hypertonic solution to a patient. In which direction will the fluid shift? a. From intracellular to extracellular b. From extracellular to intracellular c. From intravascular to intracellular d. From intravascular to interstitial

ANS: A Hypertonic solutions will move fluid from the intracellular to the extracellular (intravascular). A hypertonic solution has a concentration greater than normal body fluids, so water will shift out of cells because of the osmotic pull of the extra particles. Movement of water from the extracellular (intravascular) into cells (intracellular) occurs when hypotonic fluids are administered. Distribution of fluid between intravascular and interstitial spaces occurs by filtration, the net sum of hydrostatic and osmotic pressures.

The nurse is discussing storage of breast milk with a mother whose infant is preterm and in the special care unit. What statement would indicate that the mother needs additional teaching? a. I can store my breast milk in the refrigerator for 3 months. b. I can store my breast milk in the freezer for 3 months. c. I can store my breast milk at room temperature for 8 hours. d. I can store my breast milk in the refrigerator for 3 to 5 days.

ANS: A If the mother states that she can store her breast milk in the refrigerator for 3 months, she needs additional teaching about safe storage. Breast milk can be stored at room temperature for 8 hours, in the refrigerator for 3 to 5 days, in the freezer for 3 months, or in a deep freezer for 6 to 12 months. It is accurate and does not require additional teaching if the mother states that she can store her breast milk in the freezer for 3 months, at room temperature for 8 hours, and in the refrigerator for 3 to 5 days.

In the recovery room, if a woman is asked either to raise her legs (knees extended) off the bed or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed, most likely she is being tested to see whether she: a. Has recovered from epidural or spinal anesthesia. b. Has hidden bleeding underneath her. c. Has regained some flexibility. d. Is a candidate to go home after 6 hours

ANS: A If the numb or prickly sensations are gone from her legs after these movements, she has likely recovered from the epidural or spinal anesthesia.

A nurse is conducting an in-service on asthma. Which statement is the most descriptive of bronchial asthma? a. There is heightened airway reactivity. b. There is decreased resistance in the airway. c. The single cause of asthma is an allergic hypersensitivity. d. It is inherited.

ANS: A In bronchial asthma, spasm of the smooth muscle of the bronchi and bronchioles causes constriction, producing impaired respiratory function. In bronchial asthma, there is increased resistance in the airway. There are multiple causes of asthma, including allergens, irritants, exercise, cold air, infections, medications, medical conditions, and endocrine factors. Atopy or development of an immunoglobulin E (IgE)mediated response is inherited but is not the only cause of asthma.

Part of the health assessment of a newborn is observing the infants breathing pattern. A full-term newborns breathing pattern is predominantly: a. Abdominal with synchronous chest movements. b. Chest breathing with nasal flaring. c. Diaphragmatic with chest retraction. d. Deep with a regular rhythm

ANS: A In normal infant respiration the chest and abdomen rise synchronously, and breaths are shallow and irregular. Breathing with nasal flaring is a sign of respiratory distress. Diaphragmatic breathing with chest retraction is a sign of respiratory distress. Infant breaths are not deep with a regular rhythm

The mother-baby nurse is able to recognize reciprocal attachment behavior. This refers to: a. The positive feedback an infant exhibits toward parents during the attachment process. b. Behavior during the sensitive period when the infant is in the quiet alert stage. c. Unidirectional behavior exhibited by the infant, initiated and enhanced by eye contact. d. Behavior by the infant during the sensitive period to elicit feelings of falling in love from the parents.

ANS: A In this definition, reciprocal refers to the feedback from the infant during the attachment process. This is a good time for bonding; however, it does not define reciprocal attachment. Reciprocal attachment applies to feedback behavior and is not unidirectional.

In many hospitals new mothers are routinely presented with gift bags containing samples of infant formula. This practice: a. Is inconsistent with the Baby Friendly Hospital Initiative. b. Promotes longer periods of breastfeeding. c. Is perceived as supportive to both bottle-feeding and breastfeeding mothers. d. Is associated with earlier cessation of breastfeeding

ANS: A Infant formula should not be given to mothers who are breastfeeding. Such gifts are associated with earlier cessation of breastfeeding. Baby-Friendly USA prohibits the distribution of any gift bags or formula to new mothers

21. What is the leading cause of death during the toddler period? a. Injuries b. Infectious diseases c. Congenital disorders d. Childhood diseases

ANS: A Injuries are the single most common cause of death in children ages 1 through 4 years. It is the period of highest death rate from injuries of any childhood age-group except adolescence. Infectious and childhood diseases are less common cause of deaths in this age-group. Congenital disorders are the second leading cause of death in this age-group.

Jean Piaget's cognitive developmental theory focuses on four stages of development, including a. Formal operations. b. Intimacy versus isolation. c. Latency. d. The postconventional level.

ANS: A Jean Piaget's theory includes four stages in sequential order: sensorimotor, preoperational, concrete operations, and formal operations. Intimacy versus isolation is part of Erik Erikson's psychosocial theory of development. Latency is stage 4 of Freud's five-stage psychosexual theory of development. The postconventional level of reasoning is part of Kohlberg's theory of moral development.

A primiparous woman is to be discharged from the hospital tomorrow with her infant girl. Which behavior indicates a need for further intervention by the nurse before the woman can be discharged? a. The woman leaves the infant on her bed while she takes a shower. b. The woman continues to hold and cuddle her infant after she has fed her. c. The woman reads a magazine while her infant sleeps. d. The woman changes her infants diaper and then shows the nurse the contents of the diaper.

ANS: A Leaving an infant on a bed unattended is never acceptable for various safety reasons. Holding and cuddling the infant after feeding and reading a magazine while the infant sleeps are appropriate parent-infant interactions. Changing the diaper and then showing the nurse the contents of the diaper is appropriate because the mother is seeking approval from the nurse and notifying the nurse of the infants elimination patterns.

Nurses can assist parents who are trying to decide whether their son should be circumcised by explaining: a. The pros and cons of the procedure during the prenatal period. b. That the American Academy of Pediatrics (AAP) recommends that all newborn boys be routinely circumcised. c. That circumcision is rarely painful and any discomfort can be managed without medication. d. That the infant will likely be alert and hungry shortly after the procedure

ANS: A Many parents find themselves making the decision during the pressure of labor. The AAP and other professional organizations note the benefits but stop short of recommendation for routine circumcision. Circumcision is painful and must be managed with environmental, nonpharmacologic, and pharmacologic measures. After the procedure the infant may be fussy for several hours, or he may be sleepy and difficult to awaken for feeding

15. Parents tell the nurse that their toddler eats little at mealtimes, only sits at the table with the family briefly, and wants snacks "all the time." The nurse should recommend what intervention to the parents? a. Give her planned, frequent, and nutritious snacks. b. Offer rewards for eating at mealtimes. c. Avoid snacks so she is hungry at mealtimes. d. Explain to her in a firm manner what is expected of her.

ANS: A Most toddlers exhibit a physiologic anorexia in response to the decreased nutritional requirement associated with the slower growth rate. Parents should assist the child to develop healthy eating habits. The toddler is often unable to sit through a meal. Frequent nutritious snacks are a good way to ensure proper nutrition. To help with developing healthy eating habits, food should not be used as positive or negative reinforcement for behavior. The child may develop habits of overeating or eat nonnutritious foods in response.

Normal physical findings in a healthy newborn include a. Sporadic motor movements. b. Cyanosis of the feet and hands for the first 48 hours. c. Triangle-shaped anterior fontanel. d. Weight of 4800 grams.

ANS: A Movements in the newborn are generally sporadic, but they are symmetric and involve all four extremities. Cyanosis of the hands and feet is normal for the first 24 hours, not 48 hours. The diamond shape of the anterior fontanel and the triangular shape of the posterior fontanel are found between the unfused bones of the skull. The expected, normal weight of a healthy newborn is between 2700 and 4000 grams (6 to 9 pounds).

When the infants behaviors and characteristics call forth a corresponding set of maternal behaviors and characteristics, this is called: a. Mutuality. c. Claiming. b. Bonding. d. Acquaintance

ANS: A Mutuality extends the concept of attachment to include this shared set of behaviors.Bonding is the process over time of parents forming an emotional attachment to their infant. Mutuality refers to a shared set of behaviors that is a part of the bonding process. Claiming is the process by which parents identify their new baby in terms of likeness to other family members and their differences and uniqueness. Like mutuality, acquaintance is part of attachment. It describes how parents get to know their baby during the immediate postpartum period through eye contact, touching, and talking.

The nurse would identify which patient condition as a problem of impaired gas exchange secondary to a perfusion problem? a. Peripheral arterial disease of the lower extremities b. Chronic obstructive pulmonary disease (COPD) c. Chronic asthma d. Severe anemia secondary to chemotherapy

ANS: A Perfusion relates to the ability of the blood to deliver oxygen to the cellular level and return the carbon dioxide to the lung for removal. COPD and asthma are examples of a ventilation problem. Severe anemia is an example of a transport problem of gas exchange.

A 25-year-old patient is brought to the hospital by police after crashing his car in a high-speed chase when trying to avoid arrest for spousal abuse. What should the nurse do? a. Question the patient about drug use. b. Offer the patient a cup of coffee to calm his nerves. c. Be aware that substance abuse is usually obvious. d. Deal with the issue at hand, and put off asking about previous illnesses.

ANS: A Reports of arrests because of driving while intoxicated, wife or child abuse, or disorderly conduct are reasons for the nurse to investigate the possibility of drug abuse more carefully. Caffeine is a naturally occurring legal stimulant that stimulates the central nervous system and is not the choice for calming nerves. Substance abuse is not always diagnosable, particularly in its early stages. The nurse may obtain important information by making specific inquiries about past medical problems, changes in food intake or sleep patterns, and problems of emotional lability.

The acid-base status of a patient is dependent on normal gas exchange. Which patient would the nurse identify as having an increased risk for the development of respiratory acidosis? a. Chronic lung disease with increased carbon dioxide retention b. Acute anxiety, hyperventilation, and decreased carbon dioxide retention c. Decreased cardiac output with increased serum lactic acid production d. Gastric drainage with increased removal of gastric acid

ANS: A Respiratory acidosis is caused by an increase in retention of carbon dioxide, regardless of the underlying disease. A decrease in carbon dioxide retention may lead to respiratory alkalosis. An increase in production of lactic acid leads to metabolic acidosis. Removal of an acid (gastric secretions) will lead to a metabolic alkalosis.

A hospital has a number of different perineal pads available for use. A nurse is observed soaking several of them and writing down what she sees. This activity indicates that the nurse is trying to: a. Improve the accuracy of blood loss estimation, which usually is a subjective assessment. b. Determine which pad is best. c. Demonstrate that other nurses usually underestimate blood loss. d. Reveal to the nurse supervisor that one of them needs some time off

ANS: A Saturation of perineal pads is a critical indicator of excessive blood loss, and anything done to aid in assessment is valuable. The nurse is noting the saturation volumes and soaking appearances. It is possible that the nurse is trying to determine which pad is best, but it is more likely that the nurse is noting saturation volumes and soaking appearances to improve the accuracy of blood loss estimation. Nurses usually overestimate blood loss, if anything

Which of these manifestations, if identified in a school-aged child during a routine assessment, should a nurse associate with a possible developmental delay or problem? a. Withdrawn demeanor and verbalizes that he has no friends b. Absence of secondary sex characteristics c. Lack of peer relationships d. Curiosity about his or her sexuality

ANS: A School-aged children should begin to develop friendships and to socialize with others. Interaction with peers allows them to define their own accomplishments in relation to others as they work to develop a positive self-image. The absence of secondary sex characteristics is a major concern of adolescents, not school-aged children, because physical evidence of maturity encourages the development of masculine and feminine behaviors in the adolescent. Lack of peer relationships is also a concern of adolescents, not of school-aged children, because adolescents seek a group identity to fulfill their esteem and acceptance needs. Today many researchers believe that school-aged children have a great deal of curiosity about their sexuality. Some experiment, but this play is usually transitory.

6.The nurse is reviewing laboratory results. Which cation will the nurse observe is the mostabundant in the blood? a. Sodium b. Chloride c. Potassium d. Magnesium

ANS: A Sodium is the most abundant cation in the blood. Potassium is the predominant intracellular cation. Chloride is an anion (negatively charged) rather than a cation (positively charged). Magnesium is found predominantly inside cells and in bone.

A first-time father is changing the diaper of his 1-day-old daughter. He asks the nurse, What is this black, sticky stuff in her diaper? The nurses best response is: a. Thats meconium, which is your babys first stool. Its normal. b. Thats transitional stool. c. That means your baby is bleeding internally. d. Oh, dont worry about that. Its okay.

ANS: A Thats meconium, which is your babys first stool. Its normal is an accurate statement and the most appropriate response. Transitional stool is greenish brown to yellowish brown and usually appears by the third day after initiation of feeding. That means your baby is bleeding internally is not accurate. Oh, dont worry about that. Its okay is not an appropriate statement. It is belittling to the father and does not educate him about the normal stool patterns of his daughter.

Which newborn reflex is elicited by stroking the lateral sole of the infants foot from the heel to the ball of the foot? a. Babinski c. Stepping b. Tonic neck d. Plantar grasp

ANS: A The Babinski reflex causes the toes to flare outward and the big toe to dorsiflex. The tonic neck reflex (also called the fencing reflex) refers to the posture assumed by newborns when in a supine position. The stepping reflex occurs when infants are held upright with their heel touching a solid surface and the infant appears to be walking. Plantar grasp reflex is similar to the palmar grasp reflex: when the area below the toes is touched, the infants toes curl over the nurses finger.

The nurse manager of a pediatric clinic could confirm that the new nurse recognized the purpose of the HEADSS Adolescent Risk Profile when the new nurse responds that it is used to assess for needs related to a. anticipatory guidance. b. low-risk adolescents. c. physical development. d. sexual development.

ANS: A The HEADSS Adolescent Risk Profile is a psychosocial assessment screening tool which assesses home, education, activities, drugs, sex, and suicide for the purpose of identifying high-risk adolescents and the need for anticipatory guidance. It is used to identify high-risk, not low-risk, adolescents. Physical development is assessed with anthropometric data. Sexual development is assessed using physical examination.

14. The parents of a 2 year old tell the nurse that they are concerned because the toddler has started to use "baby talk" since the arrival of their new baby. The nurse should recommend which intervention for the parents? a. Ignore the "baby talk." b. Explain to the toddler that "baby talk" is for babies. c. Tell the toddler frequently, "You are a big kid now." d. Encourage the toddler to practice more advanced patterns of speech.

ANS: A The baby talk is a sign of regression in the toddler. It should be ignored, while praising the child for developmentally appropriate behaviors. Regression is children's way of saying that they are expressing stress. The parents should not introduce new expectations and should allow the child to master the developmental tasks without criticism.

With regard to umbilical cord care, nurses should be aware that: a. The stump can easily become infected. b. A nurse noting bleeding from the vessels of the cord should immediately call for assistance. c. The cord clamp is removed at cord separation. d. The average cord separation time is 5 to 7 days

ANS: A The cord stump is an excellent medium for bacterial growth. The nurse should first check the clamp (or tie) and apply a second one. If the bleeding does not stop, the nurse calls for assistance. The cord clamp is removed after 24 hours when it is dry. The average cord separation time is 10 to 14 days

Which breastfeeding patient is most likely to have severe afterbirth pains and request a narcotic analgesic? a. Gravida 5, para 5 b. Woman who is bottle-feeding her first child c. Primipara who delivered a 7-lb boy d. Woman who wishes to breastfeed as soon as her baby is out of the neonatal intensive care unit

ANS: A The discomfort of afterpains is more acute for multiparas because repeated stretching of muscle fibers leads to loss of uterine muscle tone. Afterpains are particularly severe during breastfeeding, not bottle-feeding. The uterus of a primipara tends to remain contracted. The nonnursing mother may have engorgement problems. The patient whose infant is in the NICU should pump regularly to stimulate milk production and ensure that she will have an adequate milk supply when the baby is strong enough to nurse.

With regard to the respiratory development of the newborn, nurses should be aware that: a. The first gasping breath is an exaggerated respiratory reaction within 1 minute of birth. b. Newborns must expel the fluid from the respiratory system within a few minutes of birth. c. Newborns are instinctive mouth breathers. d. Seesaw respirations are no cause for concern in the first hour after birth.

ANS: A The first breath produces a cry. Newborns continue to expel fluid for the first hour of life. Newborns are natural nose breathers; they may not have the mouth-breathing response to nasal blockage for 3 weeks. Seesaw respirations instead of normal abdominal respirations are not normal and should be reported.

Which finding 12 hours after birth requires further assessment? a. The fundus is palpable two fingerbreadths above the umbilicus. b. The fundus is palpable at the level of the umbilicus. c. The fundus is palpable one fingerbreadth below the umbilicus. d. The fundus is palpable two fingerbreadths below the umbilicus.

ANS: A The fundus rises to the umbilicus after delivery and remains there for about 24 hours. A fundus that is above the umbilicus may indicate uterine atony or urinary retention. A fundus that is palpable at or below the level of the umbilicus is a normal finding for a patient who is 12 hours postpartum. Palpation of the fundus 2 fingerbreadths below the umbilicus is an unusual finding for 12 hours postpartum; however, it is still appropriate

When preparing to administer a hepatitis B vaccine to a newborn, the nurse should: a. Obtain a syringe with a 25-gauge, 5/8-inch needle. b. Confirm that the newborns mother has been infected with the hepatitis B virus. c. Assess the dorsogluteal muscle as the preferred site for injection. d. Confirm that the newborn is at least 24 hours old

ANS: A The hepatitis B vaccine should be administered with a 25-gauge, 5/8-inch needle. Hepatitis B vaccination is recommended for all infants. If the infant is born to an infected mother who is a chronic carrier, hepatitis vaccine and hepatitis B immune globulin should be administered within 12 hours of birth. Hepatitis B vaccine should be given in the vastus lateralis muscle. Hepatitis B vaccine can be given at birth.

Nursing follow-up care often includes home visits for the new mother and her infant. Which information related to home visits is correct? a. Ideally, the visit is scheduled within 72 hours after discharge. b. Home visits are available in all areas. c. Visits are completed within a 30-minute time frame. d. Blood draws are not a part of the home visit.

ANS: A The home visit is ideally scheduled within 72 hours after discharge. This timing allows early assessment and intervention for problems with feedings, jaundice, newborn adaptation, and maternal-infant interaction. Because home visits are expensive, they are not available in all geographic areas. Visits are usually 60 to 90 minutes in length to allow enough time for assessment and teaching. When jaundice is found, the nurse can discuss the implications and check the transcutaneous bilirubin level or draw blood for testing

9.Four patients arrive at the emergency department at the same time. Which patient will the nurse see first? a. An infant with temperature of 102.2° F and diarrhea for 3 days b. A teenager with a sprained ankle and excessive edema c. A middle-aged adult with abdominal pain who is moaning and holding her stomach d. An older adult with nausea and vomiting for 3 days with blood pressure 112/60

ANS: A The infant should be seen first. An infant's proportion of total body water (70% to 80% total body weight) is greater than that of children or adults. Infants and young children have greater water needs and immature kidneys. They are at greater risk for extracellular volume deficit and hypernatremia because body water loss is proportionately greater per kilogram of weight. A teenager with excessive edema from a sprained ankle can wait. A middle-aged adult moaning in pain can wait as can an older adult with a blood pressure of 112/60.

16.A patient is experiencing respiratory acidosis. Which organ system is responsible for compensation in this patient? a. Renal b. Endocrine c. Respiratory d. Gastrointestinal

ANS: A The kidneys (renal) are responsible for respiratory acidosis compensation. A problem with the respiratory system causes respiratory acidosis, so another organ system (renal) needs to compensate. Problems with the gastrointestinal and endocrine systems can cause acid-base imbalances, but these systems cannot compensate for an existing imbalance

18.The nurse is caring for a diabetic patient in renal failure who is in metabolic acidosis. Which laboratory findings are consistent with metabolic acidosis? a. pH 7.3, PaCO2 36 mm Hg, HCO3- 19 mEq/L b. pH 7.5, PaCO2 35 mm Hg, HCO3- 35 mEq/L c. pH 7.32, PaCO2 47 mm Hg, HCO3- 23 mEq/L d. pH 7.35, PaCO2 40 mm Hg, HCO3- 25 mEq/L

ANS: A The laboratory values that reflect metabolic acidosis are pH 7.3, PaCO2 36 mm Hg, HCO3- 19 mEq/L. A laboratory finding of pH 7.5, PaCO2 35 mm Hg, HCO3- 35 mEq/L is metabolic alkalosis. pH 7.32, PaCO2 47 mm Hg, HCO3- 23 mEq/L is respiratory acidosis. pH 7.35, PaCO2 40 mm Hg, HCO3- 25 mEq/L values are within normal range.

23. The parent of a 16 month old asks, "What is the best way to keep our toddler from getting into our medicines at home?" The nurse should provide which advice? a. "All medicines should be locked securely away." b. "The medicines should be placed in high cabinets." c. "Chris just needs to be taught not to touch medicines." d. "Medicines should not be kept in the homes of small children."

ANS: A The major reason for poisoning in the home is improper storage. Toddlers can climb, unlatch cabinets, and obtain access to high-security places. For medications, only a locked cabinet is safe. Toddlers can climb by using furniture. High places are not a deterrent to an exploring toddler. Toddlers are not able to generalize as dangerous all of the different forms of medications that may be available in the home. Teaching them not to touch medicines is not feasible. Many parents require medications for chronic illnesses. They must be taught safe storage for their home and when they visit other homes.

Several changes in the integumentary system that appear during pregnancy disappear after birth, although not always completely. What change is almost certain to be completely reversed? a. Nail brittleness b. Darker pigmentation of the areolae and linea nigra c. Striae gravidarum on the breasts, abdomen, and thighs d. Spider nevi

ANS: A The nails return to their prepregnancy consistency and strength. Some women have permanent darker pigmentation of the areolae and linea nigra. Striae gravidarum (stretch marks) usually do not completely disappear. For some women spider nevi persist indefinitely

Nurses providing nutritional instruction should be cognizant of the uniqueness of human milk. Which statement is correct? a. Frequent feedings during predictable growth spurts stimulate increased milk production. b. The milk of preterm mothers is the same as the milk of mothers who gave birth at term. c. The milk at the beginning of the feeding is the same as the milk at the end of the feeding. d. Colostrum is an early, less concentrated, less rich version of mature milk.

ANS: A These growth spurts (10 days, 3 weeks, 6 weeks, 3 months) usually last 24 to 48 hours, after which infants vresume normal feeding. The milk of mothers of preterm infants is different from that of mothers of full-term infants to meet the needs of these newborns. Milk changes composition during feeding. The fat content of the milk increases as the infant feeds. Colostrum precedes mature milk and is more concentrated and richer in proteins and minerals (but not fat).

The nurse notes that a Vietnamese woman does not cuddle or interact with her newborn other than to feed him, change his diapers or soiled clothes, and put him to bed. In evaluating the womans behavior with her infant, the nurse realizes that: a. What appears to be a lack of interest in the newborn is in fact the Vietnamese way of demonstrating intense love by attempting to ward off evil spirits. b. The woman is inexperienced in caring for newborns. c. The woman needs a referral to a social worker for further evaluation of her parenting behaviors once she goes home with the newborn. d. Extra time needs to be planned for assisting the woman in bonding with her newborn

ANS: A The nurse may observe a Vietnamese woman who gives minimal care to her infant and refuses to cuddle or interact with her infant. The apparent lack of interest in the newborn is this cultural groups attempt to ward off evil spirits and actually reflects an intense love and concern for the infant. It is important to educate the woman in infant care, but it is equally important to acknowledge her cultural beliefs and practices

34.The nurse is caring for a group of patients. Which patient will the nurse see first? a. A patient with D5W hanging with the blood b. A patient with type A blood receiving type O blood c. A patient with intravenous potassium chloride that is diluted d. A patient with a right mastectomy and an intravenous site in the left arm

ANS: A The nurse will see the patient with D5W and blood to prevent a medication error. When preparing to administer blood, prime the tubing with 0.9% sodium chloride (normal saline) to prevent hemolysis or breakdown of RBCs. All the rest are normal. A patient with type A blood can receive type O. Type O is considered the universal donor. A patient with a mastectomy should have the IV in the other arm. Potassium chloride should be diluted, and it is never given IV push.

The nurse is reviewing the patient's arterial blood gas results. The PaO2 is 96 mm Hg, pH is 7.20, PaCO2 is 55 mm Hg, and HCO3 is 25 mEq/L. What might the nurse expect to observe on assessment of this patient? a. Disorientation and tremors b. Tachycardia and decreased blood pressure c. Increased anxiety and irritability d. Hyperventilation and lethargy

ANS: A The patient is experiencing respiratory acidosis (pH and PaCO2) which may be manifested by disorientation, tremors, possible seizures, and decreased level of consciousness. Tachycardia and decreased blood pressure are not characteristic of a problem of respiratory acidosis. Increased anxiety and hyperventilation will cause respiratory alkalosis, which is manifested by an increase in pH and a decrease in PaCO2.

2.The nurse is teaching about the process of passively moving water from an area of lower particle concentration to an area of higher particle concentration. Which process is the nurse describing? a. Osmosis b. Filtration c. Diffusion d. Active transport

ANS: A The process of moving water from an area of low particle concentration to an area of higher particle concentration is known as osmosis. Filtration is mediated by fluid pressure from an area of higher pressure to an area of lower pressure. Diffusion is passive movement of electrolytes or other particles down the concentration gradient (from areas of higher concentration to areas of lower concentration). Active transport requires energy in the form of adenosine triphosphate (ATP) to move electrolytes across cell membranes against the concentration gradient (from areas of lower concentration to areas of higher concentration).

38.A nurse is assessing a patient who is receiving a blood transfusion and finds that the patient is anxiously fidgeting in bed. The patient is afebrile and dyspneic. The nurse auscultates crackles in both lung bases and sees jugular vein distention. On which transfusion complication will the nurse focus interventions? a. Fluid volume overload b. Hemolytic reaction c. Anaphylactic shock d. Septicemia

ANS: A The signs and symptoms are concurrent with fluid volume overload. Anaphylactic shock would have presented with urticaria, dyspnea, and hypotension. Septicemia would include a fever. A hemolytic reaction would consist of flank pain, chills, and fever.

31.A nurse is caring for a diabetic patient with a bowel obstruction and has orders to ensure that the volume of intake matches the output. In the past 4 hours, the patient received dextrose 5% with 0.9% sodium chloride through a 22-gauge catheter infusing at 150 mL/hr and has eaten 200 mL of ice chips. The patient also has an NG suction tube set to low continuous suction that had 300-mL output. The patient has voided 400 mL of urine. After reporting these values to the health care provider, which order does the nurse anticipate? a. Add a potassium supplement to replace loss from output. b. Decrease the rate of intravenous fluids to 100 mL/hr. c. Administer a diuretic to prevent fluid volume excess. d. Discontinue the nasogastric suctioning.

ANS: A The total fluid intake and output equals 700 mL, which meets the provider goals. Patients with nasogastric suctioning are at risk for potassium deficit, so the nurse would anticipate a potassium supplement to correct this condition. Remember to record half the volume of ice chips when calculating intake. The other measures would be unnecessary because the net fluid volume is equal.

The nurse caring for the newborn should be aware that the sensory system least mature at the time of birth is: a. Vision. c. Smell. b. Hearing. d. Taste.

ANS: A The visual system continues to develop for the first 6 months. As soon as the amniotic fluid drains from the ear (minutes), the infants hearing is similar to that of an adult. Newborns have a highly developed sense of smell. The newborn can distinguish and react to various tastes.

4. The nurse is admitting a prenatal patient for diagnostic testing. While eliciting the psychosocial history, the nurse learns the patient smokes a pack of cigarettes daily, drinks a cup of cappuccino with breakfast, has smoked marijuana in the remote past, and is a social drinker. Which action should the nurse first take? a. Strongly advise immediate tobacco cessation b. Elimination of all caffeinated beverages c. Serum and urine testing for drug use and alcohol use d. Referral to a 12-step program

ANS: A There are numerous risk factors for women and men affecting reproductive health and pregnancy outcomes. These can be categorized into biophysical, psychosocial, sociodemographic, and environmental factors. Some of the risk factors for human reproduction fit into multiple categories. Psychosocial factors cover smoking, excessive caffeine, alcohol and drug abuse, psychologic status including impaired mental health, addictive lifestyles, spouse abuse, and noncompliance with cultural norms. Drinking a cup of a caffeinated beverage a day is not associated with adverse fetal outcomes usually. Serum and urine testing for drug/alcohol use is not required for stated marijuana use in the remote past. Patient referral to a 12-step program is usually advisable for current alcohol and/or drug use.

osmosis

Water (solvent) moves from areas of lesser solute (electrolytes) concentration to areas of greater solute concentration until a balance is established

The laboratory results for a postpartum woman are as follows: blood type, A; Rh status, positive; rubella titer, 1:8 (EIA 0.8); hematocrit, 30%. How would the nurse best interpret these data? a. Rubella vaccine should be given. b. A blood transfusion is necessary. c. Rh immune globulin is necessary within 72 hours of birth. d. A Kleihauer-Betke test should be performed.

ANS: A This clients rubella titer indicates that she is not immune and that she needs to receive a vaccine. These data do not indicate that the client needs a blood transfusion. Rh immune globulin is indicated only if the client has a negative Rh status and the infant has a positive Rh status. A Kleihauer-Betke test should be performed if a large fetomaternal transfusion is suspected, especially if the mother is Rh negative. The data do not provide any indication for performing this test

The cheeselike, whitish substance that fuses with the epidermis and serves as a protective coating is called: a. Vernix caseosa. c. Caput succedaneum. b. Surfactant. d. Acrocyanosis.

ANS: A This protection, vernix caseosa, is needed because the infants skin is so thin. Surfactant is a protein that lines the alveoli of the infants lungs. Caput succedaneum is the swelling of the tissue over the presenting part of the fetal head. Acrocyanosis is cyanosis of the hands and feet that results in a blue coloring

In the United States the en face position is preferred immediately after birth. Nurses can facilitate this process by all of these actions except: a. Washing both the infants face and the mothers face. b. Placing the infant on the mothers abdomen or breast with their heads on the same plane. c. Dimming the lights. d. Delaying the instillation of prophylactic antibiotic ointment in the infants eyes

ANS: A To facilitate the position in which the parents and infants faces are approximately 8 inches apart on the same plane, allowing them to make eye contact, the nurse can place the infant at the proper height on the mothers body, dim the light so that the infants eyes open, and delay putting ointment in the infants eyes

3. A parent of an 18 month old tells the nurse that the child says "no" to everything and has rapid mood swings. If scolded, the child shows anger and then immediately wants to be held. What is the nurse's best interpretation of this behavior? a. This is normal behavior for the child's age. b. This is unusual behavior for the child's age. c. The child is not effectively coping with stress. d. The child is showing the need for more attention.

ANS: A Toddlers use distinct behaviors in the quest for autonomy. They express their will with continued negativity and the use of the word "no." Children at this age also have rapid mood swings. The nurse should reassure the parents that their child is engaged in expected behavior for an 18 month old.

Decongestant nose drops are recommended for a 10-month-old infant with an upper respiratory tract infection. Instructions for nose drops should include: a. Avoiding use for more than 3 days. Test Bank - Maternal Child Nursing Care by Perry (6th Edition, 2017) 648 b. Keeping drops to use again for nasal congestion. c. Administering drops until nasal congestion subsides. d. Administering drops after feedings and at bedtime.

ANS: A Vasoconstrictive nose drops such as Neo-Synephrine should not be used for more than 3 days to avoid rebound congestion. Drops should be discarded after one illness because they may become contaminated with bacteria. Vasoconstrictive nose drops can have a rebound effect after 3 days of use. Drops administered before feedings are more helpful.

A woman gave birth to an infant boy 10 hours ago. Where would the nurse expect to locate this womans fundus? a. One centimeter above the umbilicus b. Two centimeters below the umbilicus c. Midway between the umbilicus and the symphysis pubis d. Nonpalpable abdominally

ANS: A Within 12 hours after delivery the fundus may be approximately 1 cm above the umbilicus. The fundus descends about 1 to 2 cm every 24 hours. Within 12 hours after delivery the fundus may be approximately 1 cm above the umbilicus. By the sixth postpartum week the fundus normally is halfway between the symphysis pubis and the umbilicus. The fundus should be easily palpated using the maternal umbilicus as a reference point.

A client is warm and asks for a fan in her room for her comfort. The nurse enters the room to assess the mother and her infant and finds the infant unwrapped in his crib with the fan blowing over him on high. The nurse instructs the mother that the fan should not be directed toward the newborn and the newborn should be wrapped in a blanket. The mother asks why. The nurses best response is: a. Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him. b. Your baby may lose heat by conduction, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him. c. Your baby may lose heat by evaporation, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him. d. Your baby will get cold stressed easily and needs to be bundled up at all times

ANS: A Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him is an accurate statement. Conduction is the loss of heat from the body surface to cooler surfaces, not air, in direct contact with the newborn. Evaporation is loss of heat that occurs when a liquid is converted into a vapor. In the newborn heat loss by evaporation occurs as a result of vaporization of moisture from the skin. Cold stress may occur from excessive heat loss, but this does not imply that the infant will become stressed if not bundled at all times. Furthermore, excessive bundling may result in a rise in the infants temperature.

10. A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first? a. Depth of respirations b. Bowel sounds c. Grip strength d. Electrocardiography

ANS: A A client with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac dysrhythmias, and muscle weakness resulting in shallow respirations and decreased handgrips. The nurse should assess the clients respiratory status first to ensure respirations are sufficient. The respiratory assessment should include rate and depth of respirations, respiratory effort, and oxygen saturation. The other assessments are important but are secondary to the clients respiratory status.

12. A nurse is assessing clients on a medical-surgical unit. Which client is at risk for hypokalemia? a. Client with pancreatitis who has continuous nasogastric suctioning b. Client who is prescribed an angiotensin-converting enzyme (ACE) inhibitor c. Client in a motor vehicle crash who is receiving 6 units of packed red blood cells d. Client with uncontrolled diabetes and a serum pH level of 7.33

ANS: A A client with continuous nasogastric suctioning would be at risk for actual potassium loss leading to hypokalemia. The other clients are at risk for potassium excess or hyperkalemia.

4. A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor). For which expected therapeutic effect should the nurse assess? a. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg b. Daily weight increase from 55 kg to 57 kg c. Heart rate decrease from 100 beats/min to 82 beats/min d. Respiratory rate increase from 12 breaths/min to 15 breaths/min

ANS: A ACE inhibitors will disrupt the reninangiotensin II pathway and prevent the kidneys from reabsorbing water and sodium. The kidneys will excrete more water and sodium, decreasing the clients blood pressure.

13. A nurse is assessing a client with hypokalemia, and notes that the clients handgrip strength has diminished since the previous assessment 1 hour ago. Which action should the nurse take first? a. Assess the clients respiratory rate, rhythm, and depth. b. Measure the clients pulse and blood pressure. c. Document findings and monitor the client. d. Call the health care provider.

ANS: A In a client with hypokalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy. Cardiac dysrhythmias are also associated with hypokalemia. The clients pulse and blood pressure should be assessed after assessing respiratory status. Next, the nurse would call the health care provider to obtain orders for potassium replacement. Documenting findings and continuing to monitor the client should occur during and after potassium replacement therapy.

Which demonstrates the school-age childs developing logic in the stage of concrete operations (select all that apply)? a. The school-age child is able to recognize that he can be a son, brother, or nephew at the same time. b. The school-age child understands the principles of adding, subtracting, and reversibility. c. The school-age child understands the principles of adding, subtracting, and reversibility. d. The school-age child has thinking that is characterized by egocentrism and animism.

ANS: A, B, C The school-age child understands that the properties of objects do not change when their order, form, or appearance does. Conservation occurs in the concrete operations stage. Comprehension of class inclusion occurs as the school-age childs logic increases. The child begins to understand that a person can be in more than one class at the same time. This is characteristic of concrete thinking and logical reasoning. The school- age child is able to understand principles of adding, subtracting, and the process of reversibility, which occurs in the stage of concrete operations. Thinking that is characterized by egocentrism and animism occurs in the intuitive thought stage, not the concrete operations stage of development.

Peer victimization is becoming a significant problem for school-age children and adolescents in the United States. Parents should be educated regarding signs that a child is being bullied. These might include (select all that apply): a. The child spends an inordinate amount of time in the nurses office. b. Belongings frequently go missing or are damaged. c. The child wants to be driven to school. d. School performance improves. e. The child freely talks about his or her day.

ANS: A, B, C Signs that may indicate a child is being bullied are similar to signs of other types of stress and include nonspecific illness or complaints, withdrawal, depression, school refusal, and decreased school performance. Children expressed fear of going to school or riding the school bus, and their belongings often are damaged or missing. Very often, children will not talk about what is happening to them.

What are the most common life events that occur during young adulthood? (Select all that apply.) a. Refining self-perception and ability for intimacy b. Achievement and mastery of the surrounding world c. Examination of life goals and relationships d. Rejection of culture-bound definitions of health and illness e. Women surrendering careers to raise families

ANS: A, B, C Between the ages of 23 and 28, the person refines self-perception and ability for intimacy. From 29 to 34, the person directs enormous energy toward achievement and mastery of the surrounding world. The years from 35 to 43 are a time of vigorous examination of life goals and relationships. Often the stresses of this re-examination result in a "midlife crisis." Each person holds culture-bound definitions of health and illness. Knowing too little about the patient's self-perception or beliefs regarding health and illness creates conflict between the nurse and the patient. Women often continue to work during the childrearing years, and many women struggle with the enormity of balancing three careers: wife, mother, and employee.

Examples of appropriate techniques to wake a sleepy infant for breastfeeding include (Select all that apply): a. Unwrapping the infant. b. Changing the diaper. c. Talking to the infant. d. Slapping the infants hands and feet. e. Applying a cold towel to the infants abdomen.

ANS: A, B, C Unwrapping the infant, changing the diaper, and talking to the infant are appropriate techniques to use when trying to wake a sleepy infant. Slapping the infants hand and feet and applying a cold towel to the infants abdomen are not appropriate. The parent can rub the infants hands or feet to wake the infant. Applying a cold towel to the infants abdomen may lead to cold stress in the infant. The parent may want to apply a cool cloth to the infants face to wake the infant.

The nurse should instruct the parents of an adolescent about which of the following health concerns? (Select all that apply.) a. Signs of substance abuse b. Suicide prevention c. Safe sex practices d. Pregnancy e. Gonadotropic hormone stimulation f. Voice changes

ANS: A, B, C, D All adolescents are at risk for experimental or recreational substance use because some believe that substance use makes them more mature. Suicide is the third leading cause of death in adolescents. Sexually transmitted diseases annually affect 3 million sexually active adolescents. Adolescent pregnancy continues to be a major social challenge for our nation. Gonadotropic hormones stimulate ovarian cells to produce estrogen and testicular cells to produce testosterone. These hormones are normally occurring and contribute to the development of secondary sex characteristics, such as hair growth and voice changes, and play an essential role in reproduction.

Pain should be assessed regularly in all newborn infants. If the infant is displaying physiologic or behavioral cues indicating pain, measures should be taken to manage the pain. Examples of nonpharmacologic pain management techniques include (Select all that apply): a. Swaddling. b. Nonnutritive sucking. c. Skin-to-skin contact with the mother. d. Sucrose. e. Acetaminophen.

ANS: A, B, C, D Swaddling, nonnutritive sucking, skin-to-skin contact with the mother, and sucrose are all appropriate nonpharmacologic techniques used to manage pain in neonates. Acetaminophen is a pharmacologic method of treating pain.

A nurse is discussing the signs and symptoms of mastitis with a mother who is breastfeeding. What signs and symptoms should the nurse include in her discussion (Select all that apply)? a. Breast tenderness b. Warmth in the breast c. An area of redness on the breast often resembling the shape of a pie wedge d. A small white blister on the tip of the nipple e. Fever and flulike symptoms

ANS: A, B, C, E Breast tenderness, breast warmth, breast redness, and fever and flulike symptoms are commonly associated with mastitis and should be included in the nurses discussion of mastitis. A small white blister on the tip of the nipple generally is not associated with mastitis. It is commonly seen in women who have a plugged milk duct

Which toys should a nurse provide to promote imaginative play for a 3-year-old hospitalized child (select all that apply)? a. Plastic telephone b. Hand puppets c. Jigsaw puzzle (100 pieces) d. Farm animals and equipment e. Jump rope

ANS: A, B, D To promote imaginative play for a 3-year-old child, the nurse should provide: dress-up clothes, dolls and dollhouses, housekeeping toys, play-store toys, telephones, farm animals and equipment, village sets, trains, trucks, cars, planes, hand puppets, and medical kits. A 100-piece jigsaw puzzle and a jump rope would be appropriate for a young, school-age child but not a 3-year-old child.

The nurse is planning playroom activities for a hospitalized 6-year-old patient. Which of the following age appropriate items that the nurse should ensure are available? (Select all that apply.) a. Crayons and paper b. Children's books c. 500-piece puzzle d. Building blocks e. Magazines and newspapers

ANS: A, B, D A school-aged child thrives on feelings of accomplishment. Drawing pictures, looking at children's books, and building blocks are all ways that a child this age could play while developing a sense of accomplishment. A 500-piece puzzle would be too difficult for a 6-year-old child to complete without the possibility of getting frustrated. Magazines and newspapers would be written at too high a reading level for a 6-year-old child. If play items offered to the child are too difficult, the child may become frustrated and may experience a feeling of inferiority.

3. The nurse is assessing parental knowledge of temper tantrums. Which are true statements regarding temper tantrums? (Select all that apply.) a. Temper tantrums are a common response to anger and frustration in toddlers. b. Temper tantrums often include screaming, kicking, throwing things, and head banging. c. Parents can effectively manage temper tantrums by giving in to the child's demands. d. Children having temper tantrums should be safely isolated and ignored. e. Parents can learn to anticipate times when tantrums are more likely to occur.

ANS: A, B, D, E Temper tantrums are a common response to anger and frustration in toddlers. They occur more often when toddlers are tired, hungry, bored, or excessively stimulated. A nap prior to fatigue or a snack if mealtime is delayed will be helpful in alleviated the times when tantrums are most likely to occur. Tantrums may include screaming, kicking, throwing things, biting themselves, or banging their head. Effective management of tantrums includes safely isolating and ignoring the child. The child should learn that nothing is gained by having a temper tantrum. Giving into the child's demands only increases the behavior.

Asthma in infants is usually triggered by: a. Medications. c. Exposure to cold air. b. A viral infection. d. Allergy to dust or dust mites.

ANS: B Viral illnesses cause inflammation that causes increased airway reactivity in asthma. Medications such as aspirin, nonsteroidal antiinflammatory drugs, and antibiotics may aggravate asthma, but not frequently in infants. Exposure to cold air may exacerbate already existing asthma. Allergy is associated with asthma, but 20% to 40% of children with asthma have no evidence of allergic disease

2. A nurse is assessing clients on a medical-surgical unit. Which clients are at increased risk for hypophosphatemia? (Select all that apply.) a. A 36-year-old who is malnourished b. A 42-year-old with uncontrolled diabetes c. A 50-year-old with hyperparathyroidism d. A 58-year-old with chronic renal failure e. A 76-year-old who is prescribed antacids

ANS: A, B, E Clients at risk for hypophosphatemia include those who are malnourished, those with uncontrolled diabetes mellitus, and those who use aluminum hydroxidebased or magnesium-based antacids. Hyperparathyroidism and chronic renal failure are common causes of hyperphosphatemia.

1. A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (Select all that apply.) a. Increased pulse rate b. Distended neck veins c. Decreased blood pressure d. Warm and pink skin e. Skeletal muscle weakness

ANS: A, B, E Manifestations of fluid overload include increased pulse rate, distended neck veins, increased blood pressure, pale and cool skin, and skeletal muscle weakness.

The patient has recent bilateral, above-the-knee amputations and has developed C. difficile diarrhea. What assessments should the nurse use to detect ECV deficit in this patient? (Select all that apply.) a. Test for skin tenting. b. Measure rate and character of pulse. c. Measure postural blood pressure and heart rate. d. Check Trousseaus sign. e. Observe for flatness of neck veins when upright. f. Observe for flatness of neck veins when supine.

ANS: A, B, F (ECV deficit is characterized by skin tenting; rapid, thready pulse; and flat neck veins when supine, which can be assessed in this patient. Although ECV deficit also causes postural blood pressure drop with tachycardia, this assessment is not appropriate for a patient with recent bilateral, above-the-knee amputations. Trousseaus sign is a test for increased neuromuscular excitability, which is not characteristic of ECV deficit. Flat neck veins when upright is a normal finding.)

5. A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical manifestations are correctly paired with the contributing electrolyte imbalance? (Select all that apply.) a. Hypokalemia Flaccid paralysis with respiratory depression b. Hyperphosphatemia Paresthesia with sensations of tingling and numbness c. Hyponatremia Decreased level of consciousness d. Hypercalcemia Positive Trousseaus and Chvosteks signs e. Hypomagnesemia Bradycardia, peripheral vasodilation, and hypotension

ANS: A, C Flaccid paralysis with respiratory depression is associated with hypokalemia. Decreased level of consciousness is associated with hyponatremia. Paresthesia with sensations of tingling and numbness is associated with hypophosphatemia or hypercalcemia. Positive Trousseaus and Chvosteks signs are associated with hypocalcemia or hyperphosphatemia. Bradycardia, peripheral vasodilation, and hypotension are associated with hypermagnesemia

5. Which gross motor milestones should the nurse assess in an 18-month-old child? (Select all that apply.) a. Jumps in place with both feet b. Takes a few steps on tiptoe c. Throws ball overhand without falling d. Pulls and pushes toys e. Stands on one foot momentarily

ANS: A, C, D An 18-month-old child can jump in place with both feet, throw a ball overhand without falling, and pull and push toys. Taking a few steps on tiptoe and standing on one foot momentarily are not acquired until 30 months of age.

Nurses need to provide competent care to young and middle adult patients. Why must nurses be knowledgeable about developmental theories to care for this group? (Select all that apply.) a. These theories provide nurses with a basis for understanding the life events and developmental tasks of young and middle adults. b. It is important to understand societal structures and roles because they have not changed in the past 20 or 30 years. c. Patients present challenges to nurses, who themselves are often young or middle adults coping with the demands of their respective developmental period. d. Nurses need to recognize the needs of their patients even if they are not experiencing the same challenges and events.

ANS: A, C, D Developmental theories provide nurses with a basis for understanding the life events and developmental tasks of young and middle adults. Patients present challenges to nurses who themselves are often young or middle adults coping with the demands of their respective developmental period. Nurses need to recognize the needs of their patients even if they are not experiencing the same challenges and events. Faced with a societal structure that differs greatly from the norms of 20 or 30 years ago, both men and women are assuming different roles in today's society.

When providing prenatal care, what information does the nurse expect to provide? (Select all that apply.) a. Protecting against urinary infection b. No longer needing condoms c. Exercise patterns d. Proper diet e. Physical assessments only during the last trimester

ANS: A, C, D Prenatal care includes a thorough physical assessment of the pregnant woman during regularly scheduled intervals (not just the last trimester). Information regarding STIs and other vaginal infections and urinary infections that will adversely affect the fetus and counseling about exercise patterns, diet, and child care are important for a pregnant woman.

Research has shown that the most successful smoking cessation programs among teens include (select all that apply): a. Peer-led education and support. b. Information on the long-term effects of smoking. c. Programs including the media. d. School-based programs. e. Information on the immediate effects of smoking.

ANS: A, C, D, E Two areas of antismoking campaigns that have shown success are those that are peer-led and use media in education related to smoking prevention. School-based programs have also shown success and can be strengthened by expansion into the community and youth groups. Teens respond much better to education that focuses on the immediate effects of smoking. For the most part, smoking prevention programs that focus on the negative long-term effects of smoking have been ineffective.

Which statement is the most appropriate advice to give parents of a 16-year-old girl who is rebellious? a. You need to be stricter so that your teen stops trying to test the limits. b. You need to collaborate with your daughter and set limits that are perceived as being reasonable. c. Increasing your teens involvement with her peers will improve her self-esteem. d. Allow your teenager to choose the type of discipline that is used in your home.

ANS: B Allowing teenagers to choose between realistic options and offering consistent and structured discipline typically enhances cooperation and decreases rebelliousness. Structure helps adolescents to feel more secure and assists them in the decision-making process. Setting stricter limits typically does not decrease rebelliousness or decrease testing of parental limits. Increasing peer involvement does not typically increase self-esteem.

Which interventions should the nurse implement when caring for a family of a sudden infant death syndrome (SIDS) infant (select all that apply)? a. Allow parents to say goodbye to their infant. b. Once parents leave the hospital, no further follow-up is required. c. Arrange for someone to take the parents home from the hospital. d. Avoid requesting an autopsy of the deceased infant. e. Conduct a debriefing session with the parents before they leave the hospital.

ANS: A, C, E An important aspect of compassionate care for parents experiencing a SIDS incident is allowing them to say good-bye to their infant. These are the parents last moments with their infant, and they should be as quiet, meaningful, peaceful, and undisturbed as possible. Because the parents leave the hospital without their infant, it is helpful to accompany them to the car or arrange for someone else to take them home. A debriefing session may help health care workers who dealt with the family and deceased infant to cope with emotions that are often engendered when a SIDS victim is brought into the acute care facility. An autopsy may clear up possible misconceptions regarding the death. When the parents return home, a competent, qualified professional should visit them after the death as soon as possible.

44. Which assessments will alert the nurse that a patient's IV has infiltrated? (Select all that apply.) a. Edema of the extremity near the insertion site b. Reddish streak proximal to the insertion site c. Skin discolored or pale in appearance d. Pain and warmth at the insertion site e. Palpable venous cord f. Skin cool to the touch

ANS: A, C, F Infiltration results in skin that is edematous near the IV insertion site. Skin is cool to the touch and may be pale or discolored. Pain, warmth, erythema, a reddish streak, and a palpable venous cord are all symptoms of phlebitis.

43. A nurse is selecting a site to insert an intravenous (IV) catheter on an adult. Which actions will the nurse take? (Select all that apply.) a. Check for contraindications to the extremity. b. Start proximally and move distally on the arm. c. Choose a vein with minimal curvature. d. Choose the patient's dominant arm. e. Select a vein that is rigid. f. Avoid areas of flexion.

ANS: A, C, F The vein should be relatively straight to avoid catheter occlusion. Contraindications to starting an IV catheter are conditions such as mastectomy, AV fistula, and central line in the extremity and should be checked before initiation of IV. Avoid areas of flexion if possible. The nurse should start distally and move proximally, choosing the nondominant arm if possible. The nurse should feel for the best location; a good vein should feel spongy, a rigid vein should be avoided because it might have had previous trauma or damage.

Injuries claim many lives during adolescence. Which factors contribute to early adolescents engaging in risk-taking behaviors (select all that apply)? a. Peer pressure b. A desire to master their environment c. Engagement in the process of separation from their parents d. A belief that they are invulnerable e. Impulsivity

ANS: A, D, E Peer pressure (including impressing peers) is a factor contributing to adolescent injuries. During early to middle adolescence, children feel that they are exempt from the consequences of risk-taking behaviors; they believe that negative consequences only happen to others. Feelings of invulnerability (It cant happen to me) are evident in adolescence. Impulsivity places adolescents in unsafe situations. Mastering the environment is the task of young school-age children. Emancipation is a major issue for the older adolescent. The process is accomplished as the teenager gains an education or vocational training.

Nurses play a critical role in educating parents regarding measures to prevent infant abduction. Which instructions contribute to infant safety and security? a. The mother should check the photo ID of any person who comes to her room. b. The baby should be carried in the parents arms from the room to the nursery. c. Because of infant security systems, the baby can be left unattended in the patients room. d. Parents should use caution when posting photos of their infant on the Internet. e. The mom should request that a second staff member verify the identity of any questionable person

ANS: A, D, E Nurses must discuss infant security precautions with the mother and her family because infant abduction continues to be a concern. The mother should be taught to check the identity of any person who comes to remove the baby from her room. Hospital personnel usually wear picture identification patches. On some units staff members also wear matching scrubs or special badges that are unique to the perinatal unit. As a rule the baby is never carried in arms between the mothers room and the nursery, but rather is always wheeled in a bassinet. The infant should never be left unattended, even if the facility has an infant security system. Parents should be instructed to use caution when posting photos of their new baby on the Internet and other public forums.

A parent who has a hearing impairment is presented with a number of challenges in parenting. Which nursing approaches are appropriate for working with hearing-impaired new parents (Select all that apply)? a. Use devices that transform sound into light. b. Assume that the patient knows sign language. c. Speak quickly and loudly. d. Ascertain whether the patient can read lips before teaching. e. Written messages aid in communication.

ANS: A, D, E Section 504 of the Rehabilitation Act of 1973 requires that hospitals use various communication techniques and resources with the deaf and hard of hearing patient. This includes devices such as door alarms, cry alarms, and amplifiers. Before initiating communication, the nurse needs to be aware of the parents preferences for communication. Not all hearing-impaired patients know sign language. Do they wear a hearing aid? Do they read lips? Do they wish to have a sign language interpreter? If the parent relies on lip reading, the nurse should sit close enough so that the parent can visualize lip movements. The nurse should speak clearly in a regular voice volume, in short, simple sentences. Written messages such as on a black or white erasable board can be useful. Written materials should be reviewed with the parents before discharge

4. A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance should the nurse assess? (Select all that apply.) a. Electrocardiogram changes b. Slow, shallow respirations c. Orthostatic hypotension d. Paralytic ileus e. Skeletal muscle weakness

ANS: A, D, E Electrolyte imbalances associated with acute renal failure include hyperkalemia and hyperphosphatemia. The nurse should assess for electrocardiogram changes, paralytic ileus caused by decrease bowel mobility, and skeletal muscle weakness in clients with hyperkalemia. The other choices are potential complications of hypokalemia.

At change-of-shift report, the nurse learns the medical diagnoses for four patients. Which patient should the nurse assess most carefully for development of hyponatremia? a. Vomiting all day and not replacing any fluid b. Tumor that secretes excessive antidiuretic hormone (ADH) c. Tumor that secretes excessive aldosterone d. Tumor that destroyed the posterior pituitary gland

ANS: B (ADH causes renal reabsorption of water, which dilutes the body fluids. Excessive ADH thus causes hyponatremia. Excessive aldosterone causes ECV excess rather than hyponatremia. The posterior pituitary gland releases ADH; lack of ADH causes hypernatremia. Vomiting without fluid replacement causes ECV deficit and hypernatremia.)

The nurse assessed four patients at the beginning of the shift. Which finding should the nurse report most urgently to the physician? a. Swollen ankles in patient with compensated heart failure b. Positive Chvosteks sign in patient with acute pancreatitis c. Dry mucous membranes in patient taking a new diuretic d. Constipation in patient who has advanced breast cancer

ANS: B (Positive Chvosteks sign indicates increased neuromuscular excitability, which can progress to dangerous laryngospasm or seizures and thus needs to be reported first. The other assessment findings are less urgent and need further assessment. Bilateral ankle edema is a sign of ECV excess, and follow-up is needed, but the situation is not immediately life-threatening. Dry mucous membranes in a patient taking a diuretic may be associated with ECV deficit; however, additional assessments of ECV deficit are required before reporting to the physician. Constipation has many causes, including hypercalcemia and opioid analgesics, and it needs action, but not as urgently as a positive Chvosteks sign.)

The nurse is caring for a hospitalized 4-year-old boy, Ryan. His parents tell the nurse that they will be back to visit at 6 PM. When Ryan asks the nurse when his parents are coming, the nurses best response is: a. They will be here soon. b. They will come after dinner. c. Let me show you on the clock where 6 PM is. d. I will tell you every time I see you how much longer it will be.

ANS: B A 4-year-old understands time in relation to events such as meals. Children perceive soon as a very short time. The nurse may lose the childs trust if his parents do not return in the time he perceives as soon. Children cannot read or use a clock for practical purposes until age 7 years. This answer assumes that the child understands the concept of hours and minutes, which is not developed until age 5 or 6 years.

The parent of a 4-year-old son tells the nurse that the child believes monsters and the boogeyman are in his bedroom at night. The nurses best suggestion for coping with this problem is to: a. Insist that the child sleep with his parents until the fearful phase passes. b. Suggest involving the child to find a practical solution such as a night-light. c. Help the child understand that these fears are illogical. d. Tell the child frequently that monsters and the boogeyman do not exist.

ANS: B A night-light shows a child that imaginary creatures do not lurk in the darkness. Letting the child sleep with parents or telling the child that these creatures do not exist will not get rid of the fears. A 4-year-old is in the preconceptual age and cannot understand logical thought.

A school nurse is conducting a class with adolescents on suicide. Which true statement about suicide should the nurse include in the teaching session? a. A sense of hopelessness and despair are a normal part of adolescence. b. Gay and lesbian adolescents are at a particularly high risk for suicide. c. Problem-solving skills are of limited value to the suicidal adolescent. d. Previous suicide attempts are not an indication of risk for completed suicides.

ANS: B A significant number of teenage suicides occur among homosexual youths. Gay and lesbian adolescents who live in families or communities that do not accept homosexuality are likely to suffer low self-esteem, self- loathing, depression, and hopelessness as a result of a lack of acceptance from their family or community. At- risk teenagers include those who are depressed, have poor problem-solving skills, or use drugs and alcohol. History of previous suicide attempt is a serious indicator for possible suicide completion in the future.

Acyclovir (Zovirax) is given to children with chickenpox to: a. Minimize scarring. b. Decrease the number of lesions. c. Prevent aplastic anemia. d. Prevent spread of the disease.

ANS: B Acyclovir decreases the number of lesions, shortens duration of fever, and decreases itching, lethargy, and anorexia; however, it does not prevent scarring. Preventing aplastic anemia is not a function of acyclovir. Only quarantine of the infected child can prevent the spread of disease.

When is a child with chickenpox considered to be no longer contagious? a. When fever is absent b. When lesions are crusted c. 24 hours after lesions erupt d. 8 days after onset of illness

ANS: B When the lesions are crusted, the chickenpox is no longer contagious. This may be a week after onset of disease. The child is still contagious once the fever has subsided and after the lesions erupt, and may or may not be contagious any time after 6 days as long as all lesions are crusted over.

Which statement is most descriptive of central nervous system stimulants? a. They produce strong physical dependence. b. They can result in strong psychologic dependence. c. Withdrawal symptoms are life threatening. d. Acute intoxication can lead to coma.

ANS: B Central nervous system stimulants such as amphetamines and cocaine produce a strong psychologic dependence. This class of drugs does not produce strong physical dependence and can be withdrawn without much danger. Acute intoxication leads to violent, aggressive behavior or psychotic episodes characterized by paranoia, uncontrollable agitation, and restlessness.

In terms of language and cognitive development, a 4-year-old child would be expected to: A sign of stress. Common at this age. Suggestive of maladaptation. Suggestive of excessive discipline at home. a. Think in abstract terms. b. Follow simple commands. c. Understand conservation of matter. d. Comprehend another persons perspective.

ANS: B Children ages 3 to 4 years can give and follow simple commands. Children cannot think abstractly at age 4 years. Conservation of matter is a developmental task of the school-age child. A 4-year-old child cannot comprehend anothers perspective.

The psychologic effects of being obese during adolescence include: a. Sexual promiscuity. b. Poor body image. c. Memory having no effect on eating behavior. d. Accurate body image but self-deprecating attitude.

ANS: B Common emotional consequences of obesity include poor body image, low self-esteem, social isolation, and feelings of depression and isolation. Sexual promiscuity is an unlikely effect of obesity. The obese adolescent often substitutes food for affection. Eating behaviors are closely related to memory. Memory and appetite are closely linked and can be modified over time with treatment. Obese adolescents most often have a very poor self-image

Which behavior suggests appropriate psychosocial development in the adolescent? a. The adolescent seeks validation for socially acceptable behavior from older adults. b. The adolescent is self-absorbed and self-centered and has sudden mood swings. c. Adolescents move from peers and enjoy spending time with family members. d. Conformity with the peer group increases in late adolescence.

ANS: B During adolescence, energy is focused within. Adolescents concentrate on themselves in an effort to determine who they are or who they will be. Adolescents are likely to be impulsive and impatient. Parents often describe their teenager as being self-centered or lazy. The peer group validates acceptable behavior during adolescence. Adolescents move from family and enjoy spending time with peers. Adolescents also spend time alone; they need this time to think and concentrate on themselves. Conformity becomes less important in late adolescence.

Which predisposes the adolescent to feel an increased need for sleep? a. An inadequate diet b. Rapid physical growth c. Decreased activity that contributes to a feeling of fatigue d. The lack of ambition typical of this age group

ANS: B During growth spurts, the need for sleep is increased. Rapid physical growth, the tendency toward overexertion, and the overall increased activity of this age contribute to fatigue.

Which statement best describes fear in school-age children? a. They are increasingly fearful for body safety. b. Most of the new fears that trouble them are related to school and family. c. They should be encouraged to hide their fears to prevent ridicule by peers. d. Those who have numerous fears need continuous protective behavior by parents to eliminate these fears.

ANS: B During the school-age years, children experience a wide variety of fears, but new fears related predominantly to school and family bother children during this time. During the middle-school years, children become less fearful of body safety than they were as preschoolers. Parents and other persons involved with children should discuss their fear with them individually or as a group activity. Sometimes school-age children hide their fears to avoid being teased. Hiding the fears does not end them and may lead to phobias.

What is descriptive of the preschoolers understanding of time? a. Has no understanding of time. b. Associates time with events. c. Can tell time on a clock. d. Uses terms like yesterday appropriately.

ANS: B In a preschoolers understanding, time has a relation with events such as, Well go outside after lunch. Preschoolers develop an abstract sense of time at age 3 years. Children can tell time on a clock at age 7 years. Children do not fully understand use of time-oriented words until age 6 years.

Which statement accurately describes physical development during the school-age years? a. The childs weight almost triples. b. A child grows an average of 2 inches per year. c. Few physical differences are apparent among children at the end of middle childhood. d. Fat gradually increases, which contributes to the childs heavier appearance.

ANS: B In middle childhood, growth in height and weight occur at a slower pace. Between the ages of 6 and 12 years, children grow 2 inches per year. In middle childhood, childrens weight will almost double; they gain 3 kg/year. At the end of middle childhood, girls grow taller and gain more weight than boys. Children take on a slimmer look with longer legs in middle childhood.

The nurse is performing an assessment on a child and notes the presence of Kopliks spots. In which communicable disease are Kopliks spots present? a. Rubella b. Measles (rubeola) c. Chickenpox (varicella) d. Exanthema subitum (roseola)

ANS: B Kopliks spots are small, irregular red spots with a minute, bluish white center found on the buccal mucosa 2 days before systemic rash. Kopliks spots are not present with rubella, varicella, or roseola.

A teen asks a nurse, What is physical dependence in substance abuse? Which is the correct response by the nurse? a. Problem that occurs in conjunction with addiction b. Involuntary physiologic response to drug c. Culturally defined use of drugs for purposes other than accepted medical purposes d. Voluntary behavior based on psychosocial needs

ANS: B Physical dependence is an involuntary response to the pharmacologic characteristics of drugs such as opioids or alcohol. A person can be physically dependent on a narcotic/drug without being addicted; for example, patients who use opioids to control pain need increasing doses to achieve the same effect. Dependence is a physiologic response; it is not culturally determined or subject to voluntary control.

30.A nurse begins infusing a 250-mL bag of IV fluid at 1845 on Monday and programs the pump to infuse at 50 mL/hr. At what time should the infusion be completed? a. 2300 Monday b. 2345 Monday c. 0015 Tuesday d. 0045 Tuesday

ANS: B 250 mL ÷ 50 mL/hr = 5 hr 1845 + 5 hr = 2345, which would be 2345 on Monday.

What is descriptive of the play of school-age children? a. Individuality in play is better tolerated than at earlier ages. b. Knowing the rules of a game gives an important sense of belonging. c. They like to invent games, making up the rules as they go. d. Team play helps children learn the universal importance of competition and winning.

ANS: B Play involves increased physical skill, intellectual ability, and fantasy. Children form groups and cliques and develop a sense of belonging to a team or club. At this age, children begin to see the need for rules. Conformity and ritual permeate their play. Their games have fixed and unvarying rules, which may be bizarre and extraordinarily rigid. With team play, children learn about competition and the importance of winning, an attribute highly valued in the United States.

A 4-year-old boy is hospitalized with a serious bacterial infection. He tells the nurse that he is sick because he was bad. The nurses best interpretation of this comment is that it is: a. A sign of stress. b. Common at this age. c. Suggestive of maladaptation. d. Suggestive of excessive discipline at home.

ANS: B Preschoolers cannot understand the cause and effect of illness. Their egocentrism makes them think that they are directly responsible for events, making them feel guilt for things outside of their control. Children of this age show stress by regressing developmentally or acting out. Maladaptation is unlikely. This comment does not imply excessive discipline at home.

Parents of a 12-year-old child ask the clinic nurse, How many hours of sleep should our child get? The nurse should respond that 12-year-old children need how many hours of sleep at night? a. 8 b. 9 c. 10 d. 11

ANS: B School-age children usually do not require naps, but they do need to sleep approximately 11 hours at age 5 years and 9 hours at age 12 years each night.

The nurse is completing a health history with a 16-year-old male. He informs the nurse that he has started using smokeless tobacco after he plays baseball. Which information regarding smokeless tobacco would be most correct for the nurse to provide to this teen? a. Not addicting. b. Proven to be carcinogenic. c. Easy to stop using. d. A safe alternative to cigarette smoking.

ANS: B Smokeless tobacco is a popular substitute for cigarettes and poses serious health hazards to children and adolescents. Smokeless tobacco is associated with cancer of the mouth and jaw. Smokeless tobacco is just as addictive as cigarettes. Although teens believe that it is easy to stop using smokeless tobacco, this is not the case. A popular belief is that smokeless tobacco is a safe alternative to cigarettes; this has been proven incorrect. Half of all teens who use smokeless tobacco agree that it poses significant health risks.

A normal characteristic of the language development of a preschool-age child is: a. Lisp. b. Stammering. c. Echolalia. d. Repetition without meaning.

ANS: B Stammering and stuttering are normal dysfluencies in preschool-age children. Lisps are not a normal characteristic of language development. Echolalia and repetition are traits of toddlers language.

A nurse is assessing an older school-age child recently admitted to the hospital. Which assessment indicates that the child is in an appropriate stage of cognitive development? a. The childs addition and subtraction ability b. The childs ability to classify c. The childs vocabulary d. The childs play activity

ANS: B The ability to classify things from simple to complex and the ability to identify differences and similarities are cognitive skills of the older school-age child; this demonstrates use of classification and logical thought processes. Subtraction and addition are appropriate cognitive activities for the young school-age child. Vocabulary is not as valid an assessment of cognitive ability as is the childs ability to classify. Play activity is not as valid an assessment of cognitive function as is the ability to classify.

A 17-year-old tells the nurse that he is not having sex because it would make his parents very angry. This response indicates that the adolescent has a developmental lag in which area? a. Cognitive development b. Moral development c. Psychosocial development d. Psychosexual development

ANS: B The appropriate moral development for a 17-year-old would include evidence that the teenager has internalized a value system and does not depend on parents to determine right and wrong behaviors. Adolescents who remain concrete thinkers may never advance beyond conformity to please others and avoid punishment. Cognitive development is related to moral development, but it is not the pivotal point in determining right and wrong behaviors. Identity formation is the psychosocial development task. Energy is focused within the adolescent, who exhibits behavior that is self-absorbed and egocentric. Although a task during adolescence is the development of a sexual identity, the teenagers dependence on the parents sanctioning of right or wrong behavior is more appropriately related to moral development.

The mean age of menarche in the United States is: a. 11.5 years b. 12.5 years c. 13.5 years d. 14 years

ANS: B The average age of menarche is 12 years and 4 months in North American girls, with a normal range of 10.5 to 15 years.

An important consideration for the school nurse who is planning a class on bicycle safety is: a. Most bicycle injuries involve collision with an automobile. b. Head injuries are the major causes of bicycle-related fatalities. c. Children should wear bicycle helmets if they ride on paved streets. d. Children should not ride double unless the bicycle has an extra-large seat.

ANS: B The most important aspect of bicycle safety is to encourage the rider to use a protective helmet. Head injuries are the major cause of bicycle-related fatalities. Although motor vehicle collisions do cause injuries to bicyclists, most injuries result from falls. The child should always wear a properly fitted helmet approved by the U.S. Consumer Product Safety Commission. Children should not ride double.

Which behavior by parents or teachers will best assist the child in negotiating the developmental task of industry? a. Identifying failures immediately and asking the childs peers for feedback b. Structuring the environment so the child can master tasks c. Completing homework for children who are having difficulty in completing assignments d. Decreasing expectations to eliminate potential failures

ANS: B The task of the caring teacher or parent is to identify areas in which a child is competent and to build on successful experiences to foster feelings of mastery and success. Structuring the environment to enhance self- confidence and to provide the opportunity to solve increasingly more complex problems will promote a sense of mastery. Asking peers for feedback reinforces the childs feelings of failure. When teachers or parents complete childrens homework for them, it sends the message that they do not trust the children to do a good job. Providing assistance and suggestions and praising their best efforts are more appropriate. Decreasing expectations to eliminate failures will not promote a sense of achievement or mastery.

Parents tell the nurse that they found their 3-year-old daughter and a male cousin of the same age inspecting each other closely as they used the bathroom. Which is the most appropriate recommendation the nurse should make? a. Punish children so this behavior stops. b. Neither condone nor condemn the curiosity. c. Allow children unrestricted permission to satisfy this curiosity. d. Get counseling for this unusual and dangerous behavior.

ANS: B Three-year-olds become aware of anatomic differences and are concerned about how the other works. Such exploration should not be condoned or condemned. Children should not be punished for this normal exploration. Encouraging the children to ask questions of the parents and redirecting their activity are more appropriate than giving permission. Exploration is age-appropriate and not dangerous behavior.

Which statement, made by a 4-year-old childs father, is true about the care of the preschoolers teeth? a. Because the baby teeth are not permanent, they are not important to the child. b. My son can be encouraged to brush his teeth after I have thoroughly cleaned his teeth. c. My sons permanent teeth will begin to come in at 4 to 5 years of age. d. Fluoride supplements can be discontinued when my sons permanent teeth erupt.

ANS: B Toddlers and preschoolers lack the manual dexterity to remove plaque adequately, so parents must assume this responsibility. Deciduous teeth are important because they maintain spacing and play an important role in the growth and development of the jaws and face and in speech development. Secondary teeth erupt at about 6 years of age. If the family does not live in an area where fluoride is included in the water supply, fluoride supplements should be continued.

According to Erikson, the psychosocial task of adolescence is developing: a. Intimacy. b. Identity. c. Initiative. d. Independence.

ANS: B Traditional psychosocial theory holds that the developmental crises of adolescence lead to the formation of a sense of identity. Intimacy is the developmental stage for early adulthood. Initiative is the developmental stage for early childhood. Independence is not one of Eriksons developmental stages.

When teaching injury prevention during the school-age years, the nurse should include: a. Teaching the need to fear strangers. b. Teaching basic rules of water safety. c. Avoiding letting children cook in microwave ovens. d. Cautioning children against engaging in competitive sports.

ANS: B Water safety instruction is an important source of injury prevention at this age. The child should be taught to swim, select safe and supervised places to swim, swim with a companion, check sufficient water depth for diving, and use an approved flotation device. Teach stranger safety, not fearing strangers. This includes not going with strangers, not having personalized clothing in public places, having children tell parents if anyone makes them uncomfortable, and teaching children to say no in uncomfortable situations. Teach children safe cooking methods. Caution against engaging in hazardous sports, such as those involving trampolines.

According to Piaget's theory of cognitive development, the nurse should allow a hospitalized 4-year-old patient to safely play with a. The pump administering intravenous fluids. b. The blood pressure cuff. c. A baseball bat. d. A book to read alone in a quiet place.

ANS: B A 4-year-old child would be in the preoperational period. Children at this stage are still egocentric. Play is very important to foster cognitive development. Children should be allowed to play with any equipment that is safe and should be allowed to communicate feelings about their health care. The IV pump is not a safe piece of equipment for a 4-year-old child to play with. A baseball bat typically is not found in a hospital setting and is a potentially dangerous toy to play with in the hospital. The blood pressure cuff is a safer option. A 4-year-old child is of preschool age and more than likely is not able to read yet. Also, the book does not allow for any human interaction and communication if read alone.

35.A nurse is administering a blood transfusion. Which assessment finding will the nurse report immediately? a. Blood pressure 110/60 b. Temperature 101.3° F c. Poor skin turgor and pallor d. Heart rate of 100 beats/min

ANS: B A fever should be reported immediately and the blood transfusion stopped. All other assessment findings are expected. Blood is given to elevate blood pressure, improve pallor, and decrease tachycardia.

To prevent the abduction of newborns from the hospital, the nurse should: a. Instruct the mother not to give her infant to anyone except the one nurse assigned to her that day. b. Apply an electronic and identification bracelet to mother and infant. c. Carry the infant when transporting him or her in the halls. d. Restrict the amount of time infants are out of the nursery.

ANS: B A measure taken by many facilities is to band both the mother and the baby with matching identification bracelets and band the infant with an electronic device that will alarm if the infant is removed from the maternity unit. It is impossible for one nurse to be on call for one mother and baby for the entire shift, so parents need to be able to identify the nurses who are working on the unit. Infants should always be transported in their bassinette, for both safety and security reasons. All maternity unit nursing staff should have unique identification bracelets in comparison with the rest of the hospital. Infants should remain with their parents and spend as little time in the nursery as possible

15.In which patient will the nurse expect to see a positive Chvostek sign? a. A 7-year-old child admitted for severe burns b. A 24-year-old adult admitted for chronic alcohol abuse c. A 50-year-old patient admitted for an acute exacerbation of hyperparathyroidism d. A 75-year-old patient admitted for a broken hip related to osteoporosis

ANS: B A positive Chvostek sign is representative of hypocalcemia or hypomagnesemia. Hypomagnesemia is common with alcohol abuse. Hypocalcemia can be brought on by alcohol abuse and pancreatitis (which also can be affected by alcohol consumption). Burn patients frequently experience extracellular fluid volume deficit. Hyperparathyroidism causes hypercalcemia. Immobility is associated with hypercalcemia.

The parents of a 14-year-old boy express concern over their child's rebellious behavior. The nurse should plan to respond to the parents' concern by informing them that their a. Child should be referred to a juvenile correctional facility. b. Child's behavior is normal because the adolescent is trying to adjust to his emerging identity. c. Child's behavior is a matter of concern because he is likely conflicted about establishing companionship with a partner. d. Child's behavior is expected because he is expressing his need to support future generations.

ANS: B According to Erikson, a 14-year-old adolescent is developing his identity versus role confusion. A teenager is very concerned with self and is often preoccupied with body image. Frequently, teenagers express themselves rebelliously as they struggle to discover their own identities. Rebellious behavior is very common and normal at this stage of development. A juvenile correctional facility usually is not necessary. Establishing companionship occurs in the young adult age group. Feeling the need to support future generations is usually experienced by the middle-aged adult.

The parents of a 15-month-old child express concern to the nurse about their child's thumb-sucking habit. Which of these explanations related to the child's age and developmental level would be most appropriate for the nurse to give the parents? a. Thumb sucking at this age indicates a developmental delay and should be further assessed. b. Sucking achieves a pleasing result for infants, and generalizing that action by thumb sucking is normal. c. Thumb sucking at this age demonstrates a transition away from egocentric thinking. d. At this age, thumb sucking will enhance language development.

ANS: B Action patterns are used by infants and toddlers to deal with the environment. For example, the infant who learns that sucking achieves a pleasing result generalizes that action to suck fingers, blankets, or clothing. Children remain egocentric into the preoperational period. Thumb sucking does not indicate transition away from egocentric thinking. No statements have supported thumb sucking as enhancing language development.

When caring for a newly delivered woman, the nurse is aware that the best measure to prevent abdominal distention after a cesarean birth is: a. Rectal suppositories. b. Early and frequent ambulation. c. Tightening and relaxing abdominal muscles. d. Carbonated beverages

ANS: B Activity will aid the movement of accumulated gas in the gastrointestinal tract. Rectal suppositories can be helpful after distention occurs; however, they do not prevent it. Ambulation is the best prevention. Carbonated beverages may increase distention.

With regard to the postpartum uterus, nurses should be aware that: a. At the end of the third stage of labor it weighs approximately 500 g. b. After 2 weeks postpartum it should not be palpable abdominally. c. After 2 weeks postpartum it weighs 100 g. d. It returns to its original (prepregnancy) size by 6 weeks postpartum.

ANS: B After 2 weeks postpartum, the uterus should not be palpable abdominally; however, it has not yet returned to its original size. At the end of the third stage of labor, the uterus weighs approximately 1000 g. It takes 6 full weeks for the uterus to return to its original size. After 2 weeks postpartum the uterus weighs about 350 g, not its original size. The normal self-destruction of excess hypertrophied tissue accounts for the slight increase in uterine size after each pregnancy.

Infants in whom cephalhematomas develop are at increased risk for: a. Infection. c. Caput succedaneum. b. Jaundice. d. Erythema toxicum.

ANS: B Cephalhematomas are characterized by bleeding between the bone and its covering, the periosteum. Because of the breakdown of the red blood cells within a hematoma, the infants are at greater risk for jaundice. Cephalhematomas do not increase the risk for infections. Caput is an edematous area on the head from pressure against the cervix

A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle-feed. During your assessment you notice that both of her breasts are swollen, warm, and tender on palpation. The woman should be advised that this condition can best be treated by: a. Running warm water on her breasts during a shower. b. Applying ice to the breasts for comfort. c. Expressing small amounts of milk from the breasts to relieve pressure. d. Wearing a loose-fitting bra to prevent nipple irritation.

ANS: B Applying ice to the breasts for comfort is appropriate for treating engorgement in a mother who is bottlefeeding. This woman is experiencing engorgement, which can be treated by using ice packs (because she is not breastfeeding) and cabbage leaves. A bottle-feeding mother should avoid any breast stimulation, including pumping or expressing milk. A bottle-feeding mother should wear a well-fitted support bra or breast binder continuously for at least the first 72 hours after giving birth. A loose-fitting bra will not aid lactation suppression. Furthermore, the shifting of the bra against the breasts may stimulate the nipples and thereby stimulate lactation

Plantar creases should be evaluated within a few hours of birth because: a. The newborn has to be footprinted. b. As the skin dries, the creases will become more prominent. c. Heel sticks may be required. d. Creases will be less prominent after 24 hours.

ANS: B As the infants skin begins to dry, the creases will appear more prominent, and the infants gestation could be misinterpreted. Footprinting will not interfere with the creases. Heel sticks will not interfere with the creases. The creases will appear more prominent after 24 hours.

To promote bonding and attachment immediately after delivery, the most important nursing intervention is to: a. Allow the mother quiet time with her infant. b. Assist the mother in assuming an en face position with her newborn. c. Teach the mother about the concepts of bonding and attachment. d. Assist the mother in feeding her baby.

ANS: B Assisting the mother in assuming an en face position with her newborn will support the bonding process. The mother should be given as much privacy as possible; however, nursing assessments must still be continued during this critical time. The mother has just delivered and is more focused on the infant; she will not be receptive to teaching at this time. This is a good time to initiate breastfeeding; however, the mother first needs time to explore the new infant and begin the bonding process.

A mother expresses concern because her 5-year-old child frequently talks about friends who don't exist. What is the nurse's best response to this mother's concern? a. "Have you considered a child psychological evaluation?" b. "It's very normal for a 5-year-old child to have imaginary playmates." c. "You should stop your child from playing electronic games." d. "Pretend play is a sign your child watches too much television."

ANS: B At age 5, some children have imaginary playmates. Imaginary playmates are a sign of health and allow the child to distinguish between reality and fantasy. The child does not need a psychological evaluation based on this information. Television, videos, electronic games, and computer programs help support development and the learning of basic skills. However, these should be only one part of the child's total play activities.

5. Which statement describes a toddler's cognitive development at age 20 months? a. Searches for an object only if he or she sees it being hidden. b. Realizes that "out of sight" is not out of reach. c. Puts objects into a container but cannot take them out. d. Understands the passage of time such as "just a minute" and "in an hour."

ANS: B At this age the child is in the final sensorimotor stage. Children will now search for an object in several potential places, even though they saw only the original hiding place. Children have a more developed sense of objective permanence. They will search for objects even if they have not seen them hidden. Putting an object in a container but being unable to take it out indicates tertiary circular reactions. An embryonic sense of time exists; although toddlers may behave appropriately to time-oriented phrases, their sense of timing is exaggerated.

A man calls the nurses station and states that his wife, who delivered 2 days ago, is happy one minute and crying the next. The man says, She was never like this before the baby was born. The nurses initial response could be to: a. Tell him to ignore the mood swings, as they will go away. b. Reassure him that this behavior is normal. c. Advise him to get immediate psychological help for her. d. Instruct him in the signs, symptoms, and duration of postpartum blues

ANS: B Before providing further instructions, inform family members of the fact that postpartum blues are a normal process. Telling her partner to ignore the mood swings does not encourage further communication and may belittle the husbands concerns. Postpartum blues are usually short-lived; no medical intervention is needed. Client teaching is important; however, the new fathers anxieties need to be allayed before he will be receptive to teaching.

A mother complains to the nurse at the pediatric clinic that her 4-year-old child always talks to her toys and makes up stories. The mother wants her child to have a psychologic evaluation. The nurse's best initial response is to a. refer the child to a psychologist. b. explain that playing make believe with dolls and people is normal at this age. c. complete a developmental screening. d. separate the child from the mother to get more information.

ANS: B By the end of the fourth year, it is expected that a child will engage in fantasy, so this is normal at this age. A referral to a psychologist would be premature based only on the complaint of the mother. Completing a developmental screening would be very appropriate but not the initial response. The nurse would certainly want to get more information, but separating the child from the mother is not necessary at this time.

The transition period between intrauterine and extrauterine existence for the newborn: a. Consists of four phases, two reactive and two of decreased responses. b. Lasts from birth to day 28 of life. c. Applies to full-term births only. d. Varies by socioeconomic status and the mothers age

ANS: B Changes begin right after birth; the cutoff time when the transition is considered over (although the baby keeps changing) is 28 days. The transition period has three phases: first reactivity, decreased response, and second reactivity. All newborns experience this transition regardless of age or type of birth. Although stress can cause variation in the phases, the mothers age and wealth do not disturb the pattern.

Which statement best describes why children have fewer respiratory tract infections as they grow older? a. The amount of lymphoid tissue decreases. b. Repeated exposure to organisms causes increased immunity. c. Viral organisms are less prevalent in the population. d. Secondary infections rarely occur after viral illnesses.

ANS: B Children have increased immunity after exposure to a virus. The amount of lymphoid tissue increases as children grow older. Viral organisms are not less prevalent, but older children have the ability to resist invading organisms. Secondary infections after viral illnesses include Mycoplasma pneumoniae and groups A and B streptococcal infections.

The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is known as: a. Enterohepatic circuit. c. Unconjugation of bilirubin. b. Conjugation of bilirubin. d. Albumin binding

ANS: B Conjugation of bilirubin is the process of changing the bilirubin from a fat-soluble to a water-soluble product. This is the route by which part of the bile produced by the liver enters the intestine, is reabsorbed by the liver, and then is recycled into the intestine. Unconjugated bilirubin is fat soluble. Albumin binding is to attach something to a protein molecule

A 61-year-old obese patient is diagnosed with type 2 diabetes and high blood pressure. The patient states that he is upset about the diet restrictions imposed by the treatment regimen. What is the nurse's best approach? a. Tell the patient that he must do what the doctor tells him. b. Offer counseling on nutrition and exercise. c. Tell the patient about what happened to other patients who did not change their lifestyle. d. Explain that he needs to accept the care provider's advice without question if he wants to get better.

ANS: B Counseling related to physical activity and nutrition is an important component of the plan of care for overweight and obese patients. To help the patients develop positive health habits, the nurse becomes a teacher and a facilitator, providing information and positive reinforcement. Ultimately, however, the patient decides which behaviors will become habits of daily living. Scare tactics do not usually work. By providing information about how the body works and how patients form and change habits, the nurse raises the patient's level of knowledge regarding the potential impact of behavior on health. The nurse should encourage patients to express their feelings to promote problem solving and recognition of risk factors by patients themselves.

31. Which should the nurse expect for a toddler's language development at age 18 months? a. Vocabulary of 25 words b. Increasing level of comprehension c. Use of phrases d. Approximately one third of speech understandable

ANS: B During the second year of life, level of comprehension and understanding of speech increases and is far greater than the child's vocabulary. This is also true for bilingual children, who are able to achieve this linguistic milestone in both languages. The 18-month-old child has a vocabulary of 10 or more words. At this age, the child does not use one-word sentences or phrases. The child has a limited vocabulary of single words that are comprehensible.

A woman gave birth to a 7-pound, 3-ounce infant boy 2 hours ago. The nurse determines that the womans bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious consequence likely to occur from bladder distention is: a. Urinary tract infection. c. A ruptured bladder. b. Excessive uterine bleeding. d. Bladder wall atony.

ANS: B Excessive bleeding can occur immediately after birth if the bladder becomes distended because it pushes the uterus up and to the side and prevents it from contracting firmly. A urinary tract infection may result from overdistention of the bladder, but it is not the most serious consequence. A ruptured bladder may result from a severely overdistended bladder. However, vaginal bleeding most likely would occur before the bladder reaches this level of overdistention. Bladder distention may result from bladder wall atony. The most serious concern associated with bladder distention is excessive uterine bleeding.

18. What is the most effective way to clean a toddler's teeth? a. Child to brush regularly with toothpaste of his or her choice. b. Parent to stabilize the chin with one hand and brush with the other. c. Parent to brush the mandibular occlusive surfaces, leaving the rest for the child. d. Parent to brush the front labial surfaces, leaving the rest for the child.

ANS: B For young children, the most effective cleaning of teeth is done by the parents. Different positions can be used if the child's back is to the adult. The adult should use one hand to stabilize the chin and the other to brush the child's teeth. The child can participate in brushing, but for a thorough cleaning adult intervention is necessary.

Many first-time parents do not plan on their parents help immediately after the newborn arrives. What statement by the nurse is the most appropriate when counseling new parents about the involvement of grandparents? a. You should tell your parents to leave you alone. b. Grandparents can help you with parenting skills and also help preserve family traditions. c. Grandparent involvement can be very disruptive to the family. d. They are getting old. You should let them be involved while they can.

ANS: B Grandparents can help you with parenting skills and also help preserve family traditions is the most appropriate response. Intergenerational help may be perceived as interference; however, a statement of this sort is not therapeutic to the adaptation of the family. Not only is Grandparent involvement can be very disruptive to the family invalid, it also is not an appropriate nursing response. Regardless of age, grandparents can help with parenting skills and preserve family traditions. Talking about the age of the grandparents is not the most appropriate statement, and it does not demonstrate sensitivity on the part of the nurse

29.A patient is to receive 1000 mL of 0.9% sodium chloride intravenously at a rate of 125 mL/hr. The nurse is using microdrip gravity drip tubing. Which rate will the nurse calculate for the minute flow rate (drops/min)? a. 12 drops/min b. 24 drops/min c. 125 drops/min d. 150 drops/min

ANS: C Microdrip tubing delivers 60 drops/mL. Calculation for a rate of 125 mL/hr using microdrip tubing: (125 mL/1 hr)(60 drops/1 mL)(1 hr/60 min) = 125 drop/min.

In follow-up appointments or visits with parents and their new baby, it may be useful if the nurse can identify parental behaviors that can either facilitate or inhibit attachment. Which one is a facilitating behavior? a. The parents have difficulty naming the infant. b. The parents hover around the infant, directing attention to and pointing at the infant. c. The parents make no effort to interpret the actions or needs of the infant. d. The parents do not move from fingertip touch to palmar contact and holding

ANS: B Hovering over the infant and obviously paying attention to the baby are facilitating behaviors. Inhibiting behaviors include difficulty naming the infant, making no effort to interpret the actions or needs of the infant, and not moving from fingertip touch to palmar contact and holding

To prevent nipple trauma, the nurse should instruct the new mother to: a. Limit the feeding time to less than 5 minutes. b. Position the infant so the nipple is far back in the mouth. c. Assess the nipples before each feeding. d. Wash the nipples daily with mild soap and water

ANS: B If the infants mouth does not cover as much of the areola as possible, the pressure during sucking will be applied to the nipple, thus causing trauma to the area. Stimulating the breast for less than 5 minutes will not produce the extra milk the infant may need. This will also limit access to the higher-fat hindmilk. Assessing the nipples for trauma is important; however, this action alone will not prevent sore nipples. Soap can be drying to the nipples and should be avoided during breastfeeding

The parents of a newborn ask the nurse how much the newborn can see. The parents specifically want to know what type of visual stimuli they should provide for their newborn. The nurse responds to the parents by telling them: a. Infants can see very little until about 3 months of age. b. Infants can track their parents eyes and distinguish patterns; they prefer complex patterns. c. The infants eyes must be protected. Infants enjoy looking at brightly colored stripes. d. Its important to shield the newborns eyes. Overhead lights help them see better

ANS: B Infants can track their parents eyes and distinguish patterns; they prefer complex patterns is an accurate statement. Development of the visual system continues for the first 6 months of life. Visual acuity is difficult to determine, but the clearest visual distance for the newborn appears to be 19 cm. Infants prefer to look at complex patterns, regardless of the color. Infants prefer low illumination and withdraw from bright light

Other early sensual contacts between infant and mother involve sound and smell. Nurses should be aware that, despite what folk wisdom may say: a. High-pitched voices irritate newborns. b. Infants can learn to distinguish their mothers voice from others soon after birth. c. All babies in the hospital smell alike. d. A mothers breast milk has no distinctive odor

ANS: B Infants know the sound of their mothers voice early. Infants respond positively to high-pitched voices. Each infant has a unique odor. Infants quickly learn to distinguish the odor of their mothers breast milk

The breastfeeding mother should be taught a safe method to remove the breast from the babys mouth. Which suggestion by the nurse is most appropriate? a. Slowly remove the breast from the babys mouth when the infant has fallen asleep and the jaws are relaxed. b. Break the suction by inserting your finger into the corner of the infants mouth. c. A popping sound occurs when the breast is correctly removed from the infants mouth. d. Elicit the Moro reflex to wake the baby and remove the breast when the baby cries

ANS: B Inserting a finger into the corner of the babys mouth between the gums to break the suction avoids trauma to the breast. The infant who is sleeping may lose grasp on the nipple and areola, resulting in chewing on the nipple that makes it sore. A popping sound indicates improper removal of the breast from the babys mouth and may cause cracks or fissures in the breast. Most mothers prefer the infant to continue to sleep after the feeding. Gentle wake-up techniques are recommended.

A new father is ready to take his wife and newborn son home. He proudly tells the nurse who is discharging them that within the next week he plans to start feeding the infant cereal between breastfeeding sessions. The nurse can explain to him that beginning solid foods before 4 to 6 months may: a. Decrease the infants intake of sufficient calories. b. Lead to early cessation of breastfeeding. c. Help the infant sleep through the night. d. Limit the infants growth.

ANS: B Introduction of solid foods before the infant is 4 to 6 months of age may result in overfeeding and decreased intake of breast milk. It is not true that feeding of solids helps infants sleep through the night. The proper balance of carbohydrate, protein, and fat for an infant to grow properly is in the breast milk or formula

32. Parents have been using a rearward-facing, convertible car seat since their baby was born. The parents should be taught that most car seats can be safely switched to the forward-facing position when the child reaches which age? a. 1 year b. 2 years c. 3 years d. 4 years

ANS: B It is now recommended that all infants and toddlers ride in rear-facing car safety seats until they reach the age of 2 years or the height or weight recommended by the car seat manufacturer. Children 2 years old and older who have outgrown the rear-facing height or weight limit for their car safety seat should use a forward-facing car safety seat with a harness up to the maximum height or weight recommended by the manufacturer. One year is too young to switch to a forward-facing position.

The nurses initial action when caring for an infant with a slightly decreased temperature is to: a. Notify the physician immediately. b. Place a cap on the infants head and have the mother perform kangaroo care. c. Tell the mother that the infant must be kept in the nursery and observed for the next 4 hours. d. Change the formula because this is a sign of formula intolerance.

ANS: B Keeping the head well covered with a cap will prevent further heat loss from the head, and having the mother place the infant skin to skin should increase the infants temperature. Nursing actions are needed first to correct the problem. If the problem persists after interventions, notification may then be necessary. A slightly decreased temperature can be treated in the mothers room. This would be an excellent time for parent teaching on prevention of cold stress. Mild temperature instability is an expected deviation from normal during the first days as the infant adapts to external life.

A newborn is placed under a radiant heat warmer, and the nurse evaluates the infants body temperature every hour. Maintaining the newborns body temperature is important for preventing: a. Respiratory depression. c. Tachycardia. b. Cold stress. d. Vasoconstriction.

ANS: B Loss of heat must be controlled to protect the infant from the metabolic and physiologic effects of cold stress, and that is the primary reason for placing a newborn under a radiant heat warmer. Cold stress results in an increased respiratory rate and vasoconstriction

Which statement by a newly delivered woman indicates that she knows what to expect about her menstrual activity after childbirth? a. My first menstrual cycle will be lighter than normal and then will get heavier every month thereafter. b. My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles. c. I will not have a menstrual cycle for 6 months after childbirth. d. My first menstrual cycle will be heavier than normal and then will be light for several months after.

ANS: B My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles is an accurate statement and indicates her understanding of her expected menstrual activity. She can expect her first menstrual cycle to be heavier than normal (which occurs by 3 months after childbirth), and the volume of her subsequent cycles will return to prepregnant levels within three or four cycles.

7.The nurse receives the patient's most recent blood work results. Which laboratory value is of greatest concern? a. Sodium of 145 mEq/L b. Calcium of 15.5 mg/dL c. Potassium of 3.5 mEq/L d. Chloride of 100 mEq/L

ANS: B Normal calcium range is 8.4 to 10.5 mg/dL; therefore, a value of 15.5 mg/dL is abnormally high and of concern. The rest of the laboratory values are within their normal ranges: sodium 136 to 145 mEq/L; potassium 3.5 to 5.0 mEq/L; and chloride 98 to 106 mEq/L.

When working with parents who have some form of sensory impairment, nurses should understand that ________ is an inaccurate statement. a. One of the major difficulties visually impaired parents experience is the skepticism of health care professionals. b. Visually impaired mothers cannot overcome the infants need for eye-to-eye contact. c. The best approach for the nurse is to assess the parents capabilities rather than focusing on their disabilities. d. Technologic advances, including the Internet, can provide deaf parents with a full range of parenting activities and information.

ANS: B Other sensory output can be provided by the parent, other people can participate, and other coping devices can be used. The skepticism, open or hidden, of health care professionals places an additional and unneeded hurdle for the parents. After the parents capabilities have been assessed (including some the nurse may not have expected), the nurse can help find ways to assist the parents that play to their strengths. The Internet affords an extra teaching tool for the deaf, as do videos with subtitles or nurses signing. A number of electronic devices can turn sound into light flashes to help pick up a childs cry. Sign language is readily acquired by young children.

8.The nurse observes that the patient's calcium is elevated. When checking the phosphate level, what does the nurse expect to see? a. Increased b. Decreased c. Equal to calcium d. No change in phosphate

ANS: B Phosphate will decrease. Serum calcium and phosphate have an inverse relationship. When one is elevated, the other decreases, except in some patients with end-stage renal disease.

28.A nurse is assessing a patient. Which assessment finding should cause a nurse to further assess for extracellular fluid volume deficit? a. Moist mucous membranes b. Postural hypotension c. Supple skin turgor d. Pitting edema

ANS: B Physical examination findings of deficit include postural hypotension, tachycardia, thready pulse, dry mucous membranes, and poor skin turgor. Pitting edema indicates that the patient may be retaining excess extracellular fluid

After comparing appropriate play activities for infants and preschool children, the nurse should appropriately offer which of the following activities to an infant? a. Set of cards to organize and separate into groups b. Set of plastic stacking rings c. Paperback book d. Set of sock puppets with movable eyes

ANS: B Play becomes manipulative as the child learns control of the hands. Adults facilitate infant learning by planning activities that promote the development of milestones, and by providing toys that are safe for the infant to explore with the mouth and manipulate with the hands, such as rattles, wooden blocks, plastic stacking rings, squeezable stuffed animals, and busy boxes. Preschoolers demonstrate their ability to think more complexly by classifying objects according to size or color, making the cards more appropriate for them. Neither group is ready for paperback books. The sock puppet with movable eyes could create a choking hazard if one of the eyes comes off.

7. Two toddlers are playing in a sandbox when one child suddenly grabs a toy from the other child. What is the best interpretation of this behavior? a. This is typical behavior because toddlers are aggressive. b. This is typical behavior because toddlers are egocentric. c. Toddlers should know that sharing toys is expected of them. d. Toddlers should have the cognitive ability to know right from wrong.

ANS: B Play develops from the solitary play of infancy to the parallel play of toddlers. The toddler plays alongside other children, not with them. This typical behavior of the toddler is not intentionally aggressive. Shared play is not within their cognitive development. Toddlers do not conceptualize shared play. Because the toddler cannot view the situation from the perspective of the other child, it is okay to take the toy. Therefore, no right or wrong is associated with taking a toy.

The nurse observes that a 15-year-old mother seems to ignore her newborn. A strategy that the nurse can use to facilitate mother-infant attachment in this mother is to: a. Tell the mother she must pay attention to her infant. b. Show the mother how the infant initiates interaction and pays attention to her. c. Demonstrate for the mother different positions for holding her infant while feeding. d. Arrange for the mother to watch a video on parent-infant interaction.

ANS: B Pointing out the responsiveness of the infant is a positive strategy for facilitating parent-infant attachment. Telling the mother that she must pay attention to her infant may be perceived as derogatory and is not appropriate. Educating the young mother in infant care is important; however, pointing out the responsiveness of her baby is a better tool for facilitating mother-infant attachment. Videos are an educational tool that can demonstrate parent-infant attachment, but encouraging the mother to recognize the infants responsiveness is more appropriate

With regard to the adaptation of other family members, mainly siblings and grandparents, to the newborn, nurses should be aware that: a. Sibling rivalry cannot be dismissed as overblown psychobabble; negative feelings and behaviors can take a long time to blow over. b. Participation in preparation classes helps both siblings and grandparents. c. In the United States paternal and maternal grandparents consider themselves of equal importance and status. d. In the past few decades the number of grandparents providing permanent care to their grandchildren has been declining

ANS: B Preparing older siblings and grandparents helps everyone to adapt. Sibling rivalry should be expected initially, but the negative behaviors associated with it have been overemphasized and stop in a comparatively short time. In the United States, in contrast to other cultures, paternal grandparents frequently consider themselves secondary to maternal grandparents. The number of grandparents providing permanent child care has been on the increase.

The nurse knows that the mother of a newborn understands associated health risks to her baby when she states a. "I need to moisten the umbilical cord every hour during the day until the cord falls off." b. "I need to remind anyone who wants to hold the baby to wash their hands." c. "I need to leave the blankets off the baby to prevent smothering." d. "I can throw away the bulb syringe now because my baby is breathing on her own."

ANS: B Prevention of infection is a major concern in the care of the newborn. Good handwashing technique is the most important factor in protecting the newborn from infection. The umbilical stump should be kept clean and dry. Newborns are susceptible to heat loss and cold stress. Place the new born directly on the mother's abdomen, and cover him or her in warm blankets, making sure to keep the head well covered, or placed unclothed in an infant warmer with a temperature probe in place. Removal of nasopharyngeal and oropharyngeal secretions remains a priority of care to maintain a patent airway.

The hormone necessary for milk production is: a. Estrogen. c. Progesterone. b. Prolactin. d. Lactogen.

ANS: B Prolactin, secreted by the anterior pituitary, is a hormone that causes the breasts to produce milk. Estrogen decreases the effectiveness of prolactin and prevents mature breast milk from being produced. Progesterone decreases the effectiveness of prolactin and prevents mature breast milk from being produced. Human placental lactogen decreases the effectiveness of prolactin and prevents mature breast milk from being produced.

The postpartum woman who continually repeats the story of her labor, delivery, and recovery experience is: a. Providing others with her knowledge of events. b. Making the birth experience real. c. Taking hold of the events leading to her labor and delivery. d. Accepting her response to labor and delivery

ANS: B Reliving the birth experience makes the event real and helps the mother realize that the pregnancy is over and that the infant is born and is now a separate individual. The retelling of the story is to satisfy her needs, not the needs of others. This new mother is in the taking-in phase, trying to make the birth experience seem real and separate the infant from herself

With regard to the postpartum changes and developments in a womans cardiovascular system, nurses should be aware that: a. Cardiac output, the pulse rate, and stroke volume all return to prepregnancy normal values within a few hours of childbirth. b. Respiratory function returns to nonpregnant levels by 6 to 8 weeks after birth. c. The lowered white blood cell count after pregnancy can lead to false-positive results on tests for infections. d. A hypercoagulable state protects the new mother from thromboembolism, especially after a cesarean birth.

ANS: B Respirations should decrease to within the womans normal prepregnancy range by 6 to 8 weeks after birth. Stroke volume increases, and cardiac output remains high for a couple of days. However, the heart rate and blood pressure return to normal quickly. Leukocytosis increases 10 to 12 days after childbirth and can obscure the diagnosis of acute infections (false-negative results). The hypercoagulable state increases the risk of thromboembolism, especially after a cesarean birth

13.Which blood gas result will the nurse expect to observe in a patient with respiratory alkalosis? a. pH 7.60, PaCO2 40 mm Hg, HCO3- 30 mEq/L b. pH 7.53, PaCO2 30 mm Hg, HCO3- 24 mEq/L c. pH 7.35, PaCO2 35 mm Hg, HCO3- 26 mEq/L d. pH 7.25, PaCO2 48 mm Hg, HCO3- 23 mEq/L

ANS: B Respiratory alkalosis should show an alkalotic pH and decreased CO2 (respiratory) values, with a normal HCO3-. In this case, pH 7.53 is alkaline (normal = 7.35 to 7.45), PaCO2 is 30 (normal 35 to 45 mm Hg), and HCO3- is 24 (normal = 22 to 26 mEq/L). A result of pH 7.60, PaCO2 40 mm Hg, HCO3- 30 mEq/L is metabolic alkalosis. pH 7.35, PaCO2 35 mm Hg, HCO3- 26 mEq/L is within normal limits. pH 7.25, PaCO2 48 mm Hg, HCO3- 23 mEq/L is respiratory acidosis.

11.A 2-year-old child is brought into the emergency department after ingesting a medication that causes respiratory depression. For which acid-base imbalance will the nurse most closely monitor this child? a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic acidosis d. Metabolic alkalosis

ANS: B Respiratory depression leads to hypoventilation. Hypoventilation results in retention of CO2 and respiratory acidosis. Respiratory alkalosis would result from hyperventilation, causing a decrease in CO2 levels. Metabolic acid-base imbalance would be a result of kidney dysfunction, vomiting, diarrhea, or other conditions that affect metabolic acids.

14.A nurse is caring for a patient whose ECG presents with changes characteristic of hypokalemia. Which assessment finding will the nurse expect? a. Dry mucous membranes b. Abdominal distention c. Distended neck veins d. Flushed skin

ANS: B Signs and symptoms of hypokalemia are muscle weakness, abdominal distention, decreased bowel sounds, and cardiac dysrhythmias. Distended neck veins occur in fluid overload. Thready peripheral pulses indicate hypovolemia. Dry mucous membranes and flushed skin are indicative of dehydration and hypernatremia.

During the complete physical examination 24 hours after birth: a. The parents are excused to reduce their normal anxiety. b. The nurse can gauge the neonates maturity level by assessing the infants general appearance. c. Once often neglected, blood pressure is now routinely checked. d. When the nurse listens to the heart, the S1 and S2 sounds can be heard; the first sound is somewhat higher in pitch and sharper than the second.

ANS: B The nurse will be looking at skin color, alertness, cry, head size, and other features. The parents presence actively involves them in child care and gives the nurse a chance to observe interactions. Blood pressure is not usually taken unless cardiac problems are suspected. The second sound is higher and sharper than the first.

A mother brings her child to the clinic for a 12-month well visit. The child weighed 6 pounds 2 ounces and was 21 inches long at birth. What finding indicates that the child needs further assessment? a. Height of 30 inches b. Weight of 16 pounds c. The infant is not yet potty-trained. d. The infant is not yet walking up stairs.

ANS: B Size increases rapidly during the first year of life. Birth weight doubles in approximately 5 months and triples by 12 months. This infant should weigh at least 18 pounds by this calculation. This child needs further assessment. Height increases an average of 1 inch during each of the first 6 months and about 1/2 inch each month until 12 months: 21 + 6 + 3 = 30 (30 inches is the predicted height). Patterns of body function are just now starting to stabilize. It is quite normal for a 12-month-old child to not be potty-trained or walking up stairs yet. These milestones usually occur in the toddler period of development (12 to 36 months). In the toddler stage, rapid development of motor skills allows the child to participate in self-care activities such as feeding, dressing, and toileting. Soon the child begins to navigate stairs, using a rail or the wall to maintain balance.

A new mother recalls from prenatal class that she should try to feed her newborn daughter when she exhibits feeding readiness cues rather than waiting until her infant is crying frantically. On the basis of this information, this woman should feed her infant about every 2.5 to 3 hours when she: a. Waves her arms in the air. c. Has hiccups. b. Makes sucking motions. d. Stretches her legs out straight

ANS: B Sucking motions, rooting, mouthing, and hand-to-mouth motions are examples of feeding-readiness cues. Waving the arms in the air, hiccupping, and stretching the legs out straight are not typical feeding-readiness cues

20. An appropriate recommendation in preventing tooth decay in young children would include which intervention? a. Substitute raisins for candy. b. Serve sweets after a meal. c. Use honey or molasses instead of refined sugar. d. Serve sweets between meals.

ANS: B Sweets should be consumed with meals so the teeth can be cleaned afterward. This decreases the amount of time that the sugar is in contact with the teeth. Raisins, honey, and molasses are highly cariogenic and should be avoided.

An examiner who discovers unequal movement or uneven gluteal skin folds during the Ortolani maneuver would then: a. Tell the parents that one leg may be longer than the other, but they will equal out by the time the infant is walking. b. Alert the physician that the infant has a dislocated hip. c. Inform the parents and physician that molding has not taken place. d. Suggest that, if the condition does not change, surgery to correct vision problems may be needed.

ANS: B The Ortolani maneuver is a technique for checking hip integrity. Unequal movement suggests that the hip is dislocated. The physician should be notified.

By knowing about variations in infants blood count, nurses can explain to their clients that: a. A somewhat lower than expected red blood cell count could be the result of delay in clamping the umbilical cord. b. The early high white blood cell (WBC) count is normal at birth and should decrease rapidly. c. Platelet counts are higher than in adults for a few months. d. Even a modest vitamin K deficiency means a problem with the ability of the blood to clot properly

ANS: B The WBC count is high the first day of birth and then declines rapidly. Delayed clamping of the cord results in an increase in hemoglobin and the red blood cell count. The platelet count essentially is the same for newborns and adults. Clotting is sufficient to prevent hemorrhage unless the vitamin K deficiency is significant

The nurse is observing his 2-year-old hospitalized patient in the playroom. The nurse is most likely to observe the child a. Participating as the leader of a small group activity. b. Sitting beside another child while playing with blocks. c. Separating building blocks into groups by size and color. d. Seeking out same sex children to play with.

ANS: B The child beside another child and playing is exhibiting parallel play, characteristic of a toddler. Participating as a group leader does not usually occur until around age 5. Preschoolers (ages 3 to 5) demonstrate their ability to think more complexly by classifying objects according to size or color. A 2-year-old child does not have this ability yet. The play of preschool children becomes more social after the third birthday as it shifts from parallel to associative play. However, gender does not become a factor until the child reaches school age, when she prefers same sex peers to opposite sex peers.

5. A female infertility patient is found to be hypoestrogenic at the preconceptual clinic visit. She asks the nurse why she has never been able to get pregnant. Which response is best? a. Circulating estrogen contributes to secondary sex characteristics. b. Estrogen deficiency prevents the ovum from reaching the uterus and may be a factor in infertility. c. Hyperestrogen may be preventing the zona pellucida from forming an ovum protective layer. d. The corona radiata is preventing fertilization of the ovum.

ANS: B The cilia in the tubes are stimulated by high estrogen levels, which propel the ovum toward the uterus. Without estrogen, the ovum won't reach the uterus. The results of a series of events occurring in the ovary cause an expulsion of the oocyte from the ovarian follicle known as ovulation. The ovarian cycle is driven by multiple important hormones: (1) gonadotropic hormone, (2) follicle stimulating hormone (FSH), and (3) luteinizing hormone (LH). The cilia in the tubes are stimulated by high (4) estrogen levels, which propel the ovum toward the uterus. The zona pellucida (inner layer) and corona radiata (outer layer) form protective layers around the ovum. If an ovum is not fertilized within 24 hours of ovulation by a sperm, it is usually reabsorbed into a woman's body. A patient who is hypoestrogenic would not have excess circulating estrogen. A patient with low estrogen would not be classified as hyperestrogenic. Without sufficient estrogen, there can be no fertilization of the ovum.

A woman gave birth to a healthy 7-pound, 13-ounce infant girl. The nurse suggests that the woman place the infant to her breast within 15 minutes after birth. The nurse knows that breastfeeding is effective during the first 30 minutes after birth because this is the: a. Transition period. c. Organizational stage. b. First period of reactivity. d. Second period of reactivity.

ANS: B The first period of reactivity is the first phase of transition and lasts up to 30 minutes after birth. The infant is highly alert during this phase. The transition period is the phase between intrauterine and extrauterine existence. There is no such phase as the organizational stage. The second period of reactivity occurs roughly between 4 and 8 hours after birth, after a period of prolonged sleep.

The process whereby parents awaken the infant to feed every 3 hours during the day and at least every 4 hours at night is: a. Known as demand feeding. b. Necessary during the first 24 to 48 hours after birth. c. Used to set up the supply-meets-demand system. d. A way to control cluster feeding.

ANS: B The parents do this to make sure that the infant has at least eight feedings in 24 hours. Demand feeding is when the infant determines the frequency of feedings; this is appropriate once the infant is feeding well and gaining weight. The supply-meets-demand system is a milk production system that occurs naturally. Cluster feeding is not a problem if the baby has eight feedings in 24 hours.

12.A patient is admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. Which arterial blood gas values will the nurse expect to observe? a. Respiratory alkalosis b. Metabolic alkalosis c. Metabolic acidosis d. Respiratory acidosis

ANS: B The patient is losing acid from the nasogastric tube so the patient will have metabolic alkalosis. Lung problems will produce respiratory alkalosis or acidosis. Metabolic acidosis will occur when too much acid is in the body like kidney failure.

A new father wants to know what medication was put into his infants eyes and why it is needed. The nurse explains to the father that the purpose of the Ilotycin ophthalmic ointment is to: a. Destroy an infectious exudate caused by Staphylococcus that could make the infant blind. b. Prevent gonorrheal and chlamydial infection of the infants eyes potentially acquired from the birth canal. c. Prevent potentially harmful exudate from invading the tear ducts of the infants eyes, leading to dry eyes. d. Prevent the infants eyelids from sticking together and help the infant see

ANS: B The purpose of the Ilotycin ophthalmic ointment is to prevent gonorrheal and chlamydial infection of the infants eyes potentially acquired from the birth canal. Prophylactic ophthalmic ointment is instilled in the eyes of all neonates to prevent gonorrheal or chlamydial infection. Prophylactic ophthalmic ointment is not instilled to prevent dry eyes. Prophylactic ophthalmic ointment has no bearing on vision other than to protect against infection that may lead to vision problems

The nurse observes several interactions between a postpartum woman and her new son. What behavior, if exhibited by this woman, would the nurse identify as a possible maladaptive behavior regarding parent-infant attachment? a. Talks and coos to her son b. Seldom makes eye contact with her son c. Cuddles her son close to her d. Tells visitors how well her son is feeding

ANS: B The woman should be encouraged to hold her infant in the en face position and make eye contact with the infant. Normal infant-parent interactions include talking and cooing to her son, cuddling her son close to her, and telling visitors how well her son is feeding

b-Adrenergic agonists and methylxanthines are often prescribed for a child with an asthma attack. What is their action? a. Liquefy secretions c. Reduce inflammation of the lungs b. Dilate the bronchioles d. Reduce infection

ANS: B These medications work to dilate the bronchioles in acute exacerbations. These medications do not liquefy secretions or reduce infection. Corticosteroids and mast cell stabilizers reduce inflammation in the lungs.

25. The mother of an 18-month-old child is concerned because the child's appetite has decreased. Which is the best response for the nurse to make to the mother? a. "It is important for your toddler to eat three meals a day and nothing in between." b. "It is not unusual for toddlers to eat less during this developmental stage." c. "Be sure to increase your child's milk consumption, which will improve nutrition." d. "Giving your child a multivitamin supplement daily will increase your toddler's appetite."

ANS: B Toddlers need small, frequent meals. Nutritious selection throughout the day, rather than quantity, is more important with this age-group. Physiologically, growth slows and appetite decreases during the toddler period. Milk consumption should not exceed 16 to 24 ounces daily. Juice should be limited to 4 to 6 ounces per day. Increasing the amount of milk will only further decrease solid food intake. Supplemental vitamins are important for all children, but they do not increase appetite.

Which description of postpartum restoration or healing times is accurate? a. The cervix shortens, becomes firm, and returns to form within a month postpartum. b. Vaginal rugae reappear by 3 weeks postpartum. c. Most episiotomies heal within a week. d. Hemorrhoids usually decrease in size within 2 weeks of childbirth

ANS: B Vaginal rugae reappear by 3 weeks postpartum; however, they are never as prominent as in nulliparous women. The cervix regains its form within days; the cervical os may take longer. Most episiotomies take 2 to 3 weeks to heal. Hemorrhoids can take 6 weeks to decrease in size.

8. Which statement about toilet training is correct? a. Bladder training is usually accomplished before bowel training. b. Wanting to please the parent helps motivate the child to use the toilet. c. Watching older siblings use the toilet confuses the child. d. Children must be forced to sit on the toilet when first learning.

ANS: B Voluntary control of the anal and urethral sphincters is achieved sometime after the child is walking. The child must be able to recognize the urge to let go and to hold on. The child must want to please the parent by holding on rather than pleasing self by letting go. Bowel training precedes bladder training. Watching older siblings provides role modeling and facilitates imitation for the toddler. The child should be introduced to the potty chair or toilet in a nonthreatening manner.

Cardiovascular changes that cause the foramen ovale to close at birth are a direct result of: a. Increased pressure in the right atrium. b. Increased pressure in the left atrium. c. Decreased blood flow to the left ventricle. d. Changes in the hepatic blood flow.

ANS: B With the increase in the blood flow to the left atrium from the lungs, the pressure is increased, and the foramen ovale is functionally closed. The pressure in the right atrium decreases at birth. It is higher during fetal life. Blood flow increases to the left ventricle after birth. The hepatic blood flow changes, but that is not the reason for the closure of the foramen ovale.

As relates to rubella and Rh issues, nurses should be aware that: a. Breastfeeding mothers cannot be vaccinated with the live attenuated rubella virus. b. Women should be warned that the rubella vaccination is teratogenic, and that they must avoid pregnancy for 1 month after vaccination. c. Rh immune globulin is safely administered intravenously because it cannot harm a nursing infant. d. Rh immune globulin boosts the immune system and thereby enhances the effectiveness of vaccinations.

ANS: B Women should understand they must practice contraception for 1 month after being vaccinated. Because the live attenuated rubella virus is not communicable in breast milk, breastfeeding mothers can be vaccinated. Rh immune globulin is administered intramuscularly; it should never be given to an infant. Rh immune globulin suppresses the immune system and therefore could thwart the rubella vaccination

The nurse is explaining the benefits associated with breastfeeding to a new mother. Which statement by the nurse would be inaccurate and provide conflicting information to the patient? a. Women who breastfeed have a decreased risk of breast cancer. b. Breastfeeding is an effective method of birth control. c. Breastfeeding increases bone density. d. Breastfeeding may enhance postpartum weight loss.

ANS: B Women who breastfeed have a decreased risk of breast cancer, an increase in bone density, and a possibility of quicker postpartum weight loss. Breastfeeding delays the return of fertility; however, it is not an effective birth control method.

2. A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first? a. Measure intake and output every 4 hours. b. Apply oxygen by mask or nasal cannula. c. Increase the IV flow rate to 250 mL/hr. d. Place the client in a high-Fowlers position

ANS: B Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimal. Increasing the IV flow rate would increase perfusion. However, depending on the degree of dehydration, rehydrating the client too rapidly with IV fluids can lead to cerebral edema. Measuring intake and output and placing the client in a high-Fowlers position will not address the clients problem.

5. A nurse is assessing clients on a medical-surgical unit. Which adult client should the nurse identify as being at greatest risk for insensible water loss? a. Client taking furosemide (Lasix) b. Anxious client who has tachypnea c. Client who is on fluid restrictions d. Client who is constipated with abdominal pain

ANS: B Insensible water loss is water loss through the skin, lungs, and stool. Clients at risk for insensible water loss include those being mechanically ventilated, those with rapid respirations, and those undergoing continuous GI suctioning. Clients who have thyroid crisis, trauma, burns, states of extreme stress, and fever are also at increased risk. The client taking furosemide will have increased fluid loss, but not insensible water loss. The other two clients on a fluid restriction and with constipation are not at risk for fluid loss.

3. After teaching a client who is being treated for dehydration, a nurse assesses the clients understanding. Which statement indicates the client correctly understood the teaching? a. I must drink a quart of water or other liquid each day. b. I will weigh myself each morning before I eat or drink. c. I will use a salt substitute when making and eating my meals. d. I will not drink liquids after 6 PM so I wont have to get up at night.

ANS: B One liter of water weighs 1 kg; therefore, a change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb daily is indicative of excessive fluid loss. The other statements are not indicative of practices that will prevent dehydration.

16. A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first? a. Encourage oral fluid intake. b. Connect the client to a cardiac monitor. c. Assess urinary output. d. Administer oral calcitonin (Calcimar).

ANS: B This client has hypercalcemia. Elevated serum calcium levels can decrease cardiac output and cause cardiac dysrhythmias. Connecting the client to a cardiac monitor is a priority to assess for lethal cardiac changes. Encouraging oral fluids, assessing urine output, and administering calcitonin are treatments for hypercalcemia, but are not the highest priority.

1. Which are characteristics of the physical development of a 30-month-old child? (Select all that apply.) a. Birth weight has doubled. b. Primary dentition is complete. c. Sphincter control is achieved. d. Anterior fontanel is open. e. Length from birth is doubled.

ANS: B, C Usually by age 30 months, the primary dentition of 20 teeth is completed, and the child has sphincter control in preparation for bowel and bladder control. A doubling of birth weight, opening of the anterior fontanel, and doubling of length are not characteristic of the physical development of a 30-month-old child.

The home health nurse has an acute immunodeficiency syndrome (AIDS) patient who has chronic diarrhea. Which assessments should the nurse use to detect the fluid and electrolyte imbalances for which the patient has high risk? (Select all that apply.) a. Bilateral ankle edema b. Weaker leg muscles than usual c. Postural blood pressure and heart rate d. Positive Trousseaus sign e. Flat neck veins when upright f. Decreased patellar reflexes

ANS: B, C, D (Chronic diarrhea has high risk of causing ECV deficit, hypokalemia, hypocalcemia, and hypomagnesemia because it increases fecal excretion of sodium-containing fluid, potassium, calcium, and magnesium. Appropriate assessments include postural blood pressure and heart rate for ECV deficit; weaker leg muscles than usual for hypokalemia; and positive Trousseaus sign for hypocalcemia and hypomagnesemia. Bilateral ankle edema is a sign of ECV excess, which is not likely with chronic diarrhea. Flat neck veins when upright is a normal finding. Decreased patellar reflexes is associated with hypermagnesemia, which is not likely with chronic diarrhea.)

A nurse teaches parents that team play is important for school-age children. Which can children develop by experiencing team play (select all that apply)? a. Achieve personal goals over group goals. b. Learn complex rules. c. Experience competition. d. Learn about division of labor.

ANS: B, C, D Team play helps stimulate cognitive growth because children are called on to learn many complex rules, make judgments about those rules, plan strategies, and assess the strengths and weaknesses of members of their own team and members of the opposing team. Team play can also contribute to childrens social, intellectual, and skill growth. Children work hard to develop the skills needed to become team members, to improve their contribution to the group, and to anticipate the consequences of their behavior for the group. Team play teaches children to modify or exchange personal goals for goals of the group; it also teaches them that division of labor is an effective strategy for attaining a goal.

Late in pregnancy, the womans breasts should be assessed by the nurse to identify any potential concerns related to breastfeeding. Some nipple conditions make it necessary to provide intervention before birth. These include(Select all that apply): a. Everted nipples b. Flat nipples c. Inverted nipples d. Nipples that contract when compressed e. Cracked nipples

ANS: B, C, D Flat nipples appear soft, like the areola, and do not stand erect unless stimulated by rolling them between the fingers. Inverted nipples are retracted into the breast tissue. These nipples appear normal; however, they will draw inward when the areola is compressed by the infants mouth. Dome-shaped devices known as breast shells can be worn during the last weeks of pregnancy and between feedings after birth. The shells are placed inside the bra with the opening over the nipple. The shells exert slight pressure against the areola to help the nipples protrude. The helpfulness of breast shells is debated. A breast pump can be used to draw the nipples out before feedings after delivery.

When developing a plan of care concerning growth and development for a hospitalized adolescent, what should the nurse do? (Select all that apply.) a. Stick with one developmental theory for consistency. b. Apply developmental theories when making observations of the individual's patterns of growth and development. c. Compare the individual's assessment findings versus established normal findings. d. Recognize his/her own moral developmental level. e. Apply a unidimensional life span perspective.

ANS: B, C, D No one theory successfully describes all the intricacies of human growth and development. Today's nurses need to be knowledgeable about several theoretical perspectives when working with patients. These theories form the basis for meaningful observation of an individual's pattern of growth and development. They provide important guidelines for an understanding of important human processes that allows the nurse to begin to predict human responses, not medical diagnoses, and to recognize deviations from the norm. Recognizing your own moral developmental level is essential in separating your own beliefs from those of others when helping patients with their moral decision-making process. Growth and development, as supported by a life span perspective, is multidimensional.

4. A nurse is planning care for a hospitalized toddler in the preoperational thinking stage. Which characteristics should the nurse expect in this stage? (Select all that apply.) a. Concrete thinking b. Egocentrism c. Animism d. Magical thinking e. Ability to reason

ANS: B, C, D The characteristics of preoperational thinking that occur for the toddler include egocentrism (views everything in relation to self), animism (believes that inert objects are alive), and magical thinking (believes that thinking something causes that event). Concrete thinking is seen in school-age children and ability to reason is seen with adolescents.

Which screening tests should the school nurse perform for the adolescent (select all that apply)? a. Glucose b. Vision c. Hearing d. Cholesterol e. Scoliosis

ANS: B, C, E The school nurse should perform vision, hearing, and scoliosis screening tests according to the school districts required schedule. Glucose and cholesterol screening would be performed in the medical clinic setting.

A nurse is conducting education classes for parents of infants. The nurse plans to discuss sudden infant death syndrome (SIDS). Which risk factors should the nurse include as increasing an infants risk of a SIDS incident(select all that apply)? a. Breastfeeding b. Low Apgar scores c. Male sex d. Birth weight in the 50th or higher percentile e. Recent viral illness

ANS: B, C, E Certain groups of infants are at increased risk for SIDS: those with low birth weight, low Apgar scores, or recent viral illness, and those of male sex. Breastfed infants and infants of average or above-average weight are not at higher risk for SIDS.

7. A nurse develops a plan of care for a client who has a history of hypocalcemia. What interventions should the nurse include in this clients care plan? (Select all that apply.) a. Encourage oral fluid intake of at least 2 L/day. b. Use a draw sheet to reposition the client in bed. c. Strain all urine output and assess for urinary stones. d. Provide nonslip footwear for the client to use when out of bed. e. Rotate the client from side to side every 2 hours.

ANS: B, D Clients with long-standing hypocalcemia have brittle bones that may fracture easily. Safety needs are a priority. Nursing staff should use a draw sheet when repositioning the client in bed and have the client wear nonslip footwear when out of bed to prevent fractures and falls. The other interventions would not provide safety for this client.

In terms of language and cognitive development, a 4-year-old child would be expected to have which traits (select all that apply)? a. Think in abstract terms. b. Follow directional commands. c. Understand conservation of matter. d. Use sentences of eight words. e. Tell exaggerated stories.

ANS: B, E Children ages 3 to 4 years can give and follow simple commands and tell exaggerated stories. Children cannot think abstractly at age 4 years. Conservation of matter is a developmental task of the school-age child. Five- year-old children use sentences with eight words with all parts of speech.

3. A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications should the nurse assess? (Select all that apply.) a. Urine output of 25 mL/hr b. Serum potassium level of 5.4 mEq/L c. Urine specific gravity of 1.02 g/mL d. Serum sodium level of 128 mEq/L e. Blood osmolality of 250 mOsm/L

ANS: B, E Aldosterone is a naturally occurring hormone of the mineralocorticoid type that increases the reabsorption of water and sodium in the kidney at the same time that it promotes excretion of potassium. Any drug or condition that disrupts aldosterone secretion or release increases the clients risk for excessive water loss (increased urine output), increased potassium reabsorption, decreased blood osmolality, and increased urine specific gravity. The client would not be at risk for sodium imbalance

The nurse is assessing a patient for the adequacy of ventilation. What assessment findings would indicate the patient has good ventilation? (Select all that apply.) a. Respiratory rate is 24 breaths/min. b. Oxygen saturation level is 98%. c. The right side of the thorax expands slightly more than the left. d. Trachea is just to the left of the sternal notch. e. Nail beds are pink with good capillary refill. f. There is presence of quiet, effortless breath sounds at lung base bilaterally.

ANS: B, E, F Oxygen saturation level should be between 95 and 100%; nail beds should be pink with capillary refill of about 3 seconds; and breath sounds should be present at base of both lungs. Normal respiratory rate is between 12 and 20 breaths/min. The trachea should be in midline with the sternal notch. The thorax should expand equally on both sides.

45. A nurse is discontinuing a patient's peripheral IV access. Which actions should the nurse take? (Select all that apply.) a. Wear sterile gloves and a mask. b. Stop the infusion before removing the IV catheter. c. Use scissors to remove the IV site dressing and tape. d. Apply firm pressure with sterile gauze during removal. e. Keep the catheter parallel to the skin while removing it. f. Apply pressure to the site for 2 to 3 minutes after removal.

ANS: B, E, F The nurse should stop the infusion before removing the IV catheter, so the fluid does not drip on the patient's skin; keep the catheter parallel to the skin while removing it to reduce trauma to the vein; and apply pressure to the site for 2 to 3 minutes after removal to decrease bleeding from the site. Scissors should not be used because they may accidentally cut the catheter or tubing or may injure the patient. During removal of the IV catheter, light pressure, not firm pressure, is indicated to prevent trauma. Clean gloves are used for discontinuing a peripheral IV access because gloved hands will handle the external dressing, tubing, and tape, which are not sterile.

The nurse is assessing a patient before hanging an IV solution of 0.9% NaCl with KCl in it. Which assessment finding should cause the nurse to hold the IV solution and contact the physician? a. Weight gain of 2 pounds since last week b. Dry mucous membranes and skin tenting c. Urine output 8 mL/hr d. Blood pressure 98/58

ANS: C (Administering IV potassium to a patient who has oliguria is not safe, because potassium intake faster than potassium output can cause hyperkalemia with dangerous cardiac dysrhythmias. Dry mucous membranes, skin tenting, and blood pressure 98/58 are consistent with the need for IV 0.9% NaCl. Weight gain of 2 pounds in a week does not necessarily indicate fluid overload, because it can be from increased nutritional intake. Only an overnight weight gain indicates a fluid gain.)

The patient with which diagnosis should have the highest priority for teaching regarding foods that are high in magnesium? a. Severe hemorrhage b. Diabetes insipidus c. Oliguric renal disease d. Adrenal insufficiency

ANS: C (When renal excretion is decreased, magnesium intake must be decreased also, to prevent hypermagnesemia. The other conditions are not likely to require adjustment of magnesium intake.)

A nurse is caring for an adolescent hospitalized for cellulitis. The nurse notes that the adolescent experiences many mood swings throughout the day. The nurse interprets this behavior as: a. Requiring a referral to a mental health counselor. b. Requiring some further lab testing. c. Normal behavior. d. Related to feelings of depression.

ANS: C Adolescents vacillate in their emotional states between considerable maturity and childlike behavior. One minute they are exuberant and enthusiastic; the next minute they are depressed and withdrawn. Because of these mood swings, adolescents are frequently labeled as unstable, inconsistent, and unpredictable, but the behavior is normal. The behavior would not require a referral to a mental health counselor or further lab testing. The mood swings do not indicate depression.

Which type of play is most typical of the preschool period? a. Solitary b. Parallel c. Associative d. Team

ANS: C Associative play is group play in similar or identical activities but without rigid organization or rules. Solitary play is that of infants. Parallel play is that of toddlers. School-age children play in teams.

A nurse is reviewing hormone changes that occur during adolescence. The hormone that is responsible for the growth of beard, mustache, and body hair in the male is: a. Estrogen. b. Pituitary hormone. c. Androgen. d. Progesterone.

ANS: C Beard, mustache, and body hair on the chest, upward along the linea alba, and sometimes on other areas (e.g., back and shoulders) appears in males and is androgen dependent. Estrogen and progesterone are produced by the ovaries in the female and do not contribute to body hair appearance in the male. The pituitary hormone does not have any relationship to body hair appearance in the male.

What describes moral development in younger school-age children? a. The standards of behavior now come from within themselves. b. They do not yet experience a sense of guilt when they misbehave. c. They know the rules and behaviors expected of them but do not understand the reasons behind them. d. They no longer interpret accidents and misfortunes as punishment for misdeeds.

ANS: C Children who are ages 6 and 7 years know the rules and behaviors expected of them but do not understand the reasons for them. Young children do not believe that standards of behavior come from within themselves but that rules are established and set down by others. Younger school-age children learn standards for acceptable behavior, act according to these standards, and feel guilty when they violate them. Misfortunes and accidents are viewed as punishment for bad acts.

During the preschool period, the emphasis of injury prevention should be placed on: a. Constant vigilance and protection. b. Punishment for unsafe behaviors. c. Education for safety and potential hazards. d. Limitation of physical activities.

ANS: C Education for safety and potential hazards is appropriate for preschoolers because they can begin to understand dangers. Constant vigilance and protection is not practical at this age since preschoolers are becoming more independent. Punishment may make children scared of trying new things. Limitation of physical activities is not appropriate.

The parents of a 15-year-old girl are concerned that their adolescent spends too much time looking in the mirror. Which statement is the most appropriate for the nurse to make? a. Your teenager needs clearer and stricter limits about her behavior. b. Your teenager needs more responsibility at home. c. During adolescence this behavior is not unusual. d. The behavior is abnormal and needs further investigation.

ANS: C Egocentric and narcissistic behavior is normal during this period of development. The teenager is seeking a personal identity. Stricter limits are not an appropriate response for a behavior that is part of normal development. More responsibility at home is not an appropriate response for this situation. The behavior is normal and needs no further investigation.

A nurse is teaching parents of first-grade children general guidelines to assist their children in adapting to school. Which statement by the parents indicates they understand the teaching? a. We will only meet with the teacher if problems occur. b. We will discourage hobbies so our child focuses on schoolwork. c. We will plan a trip to the library as often as possible. d. We will expect our child to make all As in school.

ANS: C General guidelines for parents to help their child in school include sharing an interest in reading. The library should be used frequently and books the child is reading should be discussed. Hobbies should be encouraged. The parents should not expect all As. They should focus on growth more than grades.

The school nurse tells adolescents in the clinic that confidentiality and privacy will be maintained unless a life-threatening situation arises. This practice is: a. Not appropriate in a school setting. b. Never appropriate because adolescents are minors. c. Important in establishing trusting relationships. d. Suggestive that the nurse is meeting his or her own needs.

ANS: C Health professionals who work with adolescents should consider the adolescents increasing independence and responsibility while maintaining privacy and ensuring confidentiality. However, circumstances may occur in which they are not able to maintain confidentiality, such as self-destructive behavior or maltreatment by others. Confidentiality and privacy are necessary to facilitate trust with this age group. The nurse must be aware of the limits placed on confidentiality by local jurisdiction.

Young people with anorexia nervosa are often described as being: a. Independent. b. Disruptive. c. Conforming. d. Low achieving.

ANS: C Individuals with anorexia nervosa are described as perfectionist, academically high achievers, conforming, and conscientious. Independent, disruptive, and low achieving are not part of the behavioral characteristics of anorexia nervosa.

In providing anticipatory guidance to parents whose child will soon be entering kindergarten, which is a critical factor in preparing a child for kindergarten entry? a. The childs ability to sit still b. The childs sense of learned helplessness c. The parents interactions and responsiveness to the child d. Attending a preschool program

ANS: C Interactions between the parent and child are an important factor in the development of academic competence. Parental encouragement and support maximize a childs potential. The childs ability to sit still is important to learning; however, parental responsiveness and involvement are more important factors. Learned helplessness is the result of a child feeling that he or she has no effect on the environment and that his or her actions do not matter. Parents who are actively involved in a supportive learning environment will demonstrate a more positive approach to learning. Preschool and day care programs can supplement the developmental opportunities provided by parents at home, but they are not critical in preparing a child for entering kindergarten.

A nurse planning care for a school-age child should take into account that which thought process is seen at this age? a. Animism b. Magical thinking c. Ability to conserve d. Thoughts are all-powerful

ANS: C One cognitive task of school-age children is mastering the concept of conservation. At an early age (5 to 7 years), children grasp the concept of reversibility of numbers as a basis for simple mathematics problems (e.g., 2 + 4 = 6 and 6 4 = 2). They learn that simply altering their arrangement in space does not change certain properties of the environment, and they are able to resist perceptual cues that suggest alterations in the physical state of an object. Animism, magical thinking, and believing that thoughts are all-powerful are thought processes seen in preschool children.

A group of boys ages 9 and 10 years have formed a boys-only club that is open to neighborhood and school friends who have skateboards. This should be interpreted as: a. Behavior that encourages bullying and sexism. b. Behavior that reinforces poor peer relationships. c. Characteristic of social development of this age. d. Characteristic of children who later are at risk for membership in gangs.

ANS: C One of the outstanding characteristics of middle childhood is the creation of formalized groups or clubs. Peer- group identification and association are essential to a childs socialization. Poor relationships with peers and a lack of group identification can contribute to bullying. A boys-only club does not have a direct correlation with later gang activity.

A 4-year-old child tells the nurse that she does not want another blood sample drawn because I need all my insides, and I dont want anyone taking them out. Which is the nurses best interpretation of this? a. Child is being overly dramatic. b. Child has a disturbed body image. c. Preschoolers have poorly defined body boundaries. d. Preschoolers normally have a good understanding of their bodies.

ANS: C Preschoolers have little understanding of body boundaries, which leads to fears of mutilation. The child is not capable of being dramatic at 4 years of age. She truly has fear. Body image is just developing in the school-age child. Preschoolers do not have good understanding of their bodies.

Generally the earliest age at which puberty begins is: a. 13 years in girls, 13 years in boys. b. 11 years in girls, 11 years in boys. c. 10 years in girls, 12 years in boys. d. 12 years in girls, 10 years in boys.

ANS: C Puberty signals the beginning of the development of secondary sex characteristics. This begins in girls earlier than in boys. Usually a 2-year difference occurs in the age at onset. Girls and boys do not usually begin puberty at the same age; girls usually begin earlier than boys do.

Which statement by the nurse is most appropriate to a 15-year-old whose friend has mentioned suicide? a. Tell your friend to come to the clinic immediately. b. You need to gather details about your friends suicide plan. c. Your friends threat needs to be taken seriously and immediate help for your friend is important. d. If your friend mentions suicide a second time, you will want to get your friend some help.

ANS: C Suicide is the third most common cause of death among American adolescents. A suicide threat from an adolescent serves as a dramatic message to others and should be taken seriously. Adolescents at risk should be targeted for supportive guidance and counseling before a crisis occurs. Instructing a 15-year-old to tell a friend to come to the clinic immediately provides the teen with limited information and does not address the concern. It is important to determine whether a person threatening suicide has a plan of action; however, the best information for the 15-year-old to have is that all threats of suicide should be taken seriously and immediate help is important. Taking time to gather details or waiting until the teen discusses it a second time may be too late.

The nurse is explaining Tanner staging to an adolescent and her mother. Which statement best describes Tanner staging? a. Predictable stages of puberty that are based on chronologic age b. Staging of puberty based on the initiation of menarche and nocturnal emissions c. Predictable stages of puberty that are based on primary and secondary sexual characteristics d. Staging of puberty based on the initiation of primary sexual characteristics

ANS: C Tanner sexual-maturing ratings are based on the development of stages of primary and secondary sexual characteristics. Tanner stages are not based on chronologic age. The age at which an adolescent enters puberty is variable. The puberty stage in girls begins with breast development. The puberty stage in boys begins with genital enlargement. Primary sexual characteristics are not the sole basis of Tanner staging.

Identify the statement that is the most accurate about moral development in the 9-year-old school-age child. a. Right and wrong are based on physical consequences of behavior. b. The child obeys parents because of fear of punishment. c. The school-age child conforms to rules to please others. d. Parents are the determiners of right and wrong for the school-age child.

ANS: C The 7- to 12-year-old child bases right and wrong on a good-boy or good-girl orientation in which the child conforms to rules to please others and avoid disapproval. Children 4 to 7 years of age base right and wrong on consequences, the most important consideration for this age-group. Parents determine right and wrong for the child younger than 4 years of age.

The parents of a 14-year-old girl express concerns about the number of hours their daughter spends with her friends. The nurse explains that peer relationships become more important during adolescence because: a. Adolescents dislike their parents. b. Adolescents no longer need parental control. c. They provide adolescents with a feeling of belonging. d. They promote a sense of individuality in adolescents.

ANS: C The peer group serves as a strong support to teenagers, providing them with a sense of belonging and strength and power. During adolescence, the parent-child relationship changes from one of protection-dependency to one of mutual affection and quality. Parents continue to play an important role in personal and health-related decisions. The peer group forms the transitional world between dependence and autonomy.

The school nurse is discussing testicular self-examination with adolescent boys. Why is this important? a. Epididymitis is common during adolescence. b. Asymptomatic sexually transmitted diseases may be present. c. Testicular tumors during adolescence are generally malignant. d. Testicular tumors, although usually benign, are common during adolescence.

ANS: C Tumors of the testes are not common, but when manifested in adolescence, they are generally malignant and demand immediate evaluation. Epididymitis is not common in adolescence. Asymptomatic sexually transmitted disease would not be evident during testicular self-examination. The focus of this examination is on testicular cancer. Testicular tumors are most commonly malignant.

With regard to afterbirth pains, nurses should be aware that these pains are: a. Caused by mild, continuous contractions for the duration of the postpartum period. b. More common in first-time mothers. c. More noticeable in births in which the uterus was overdistended. d. Alleviated somewhat when the mother breastfeeds.

ANS: C A large baby or multiple babies overdistend the uterus. The cramping that causes afterbirth pains arises from periodic, vigorous contractions and relaxations, which persist through the first part of the postpartum period. Afterbirth pains are more common in multiparous women because first-time mothers have better uterine tone. Breastfeeding intensifies afterbirth pain because it stimulates contractions.

While discussing the societal impacts of breastfeeding, the nurse should be cognizant of the benefits and educate the patient accordingly. Which statement as part of this discussion would be incorrect? a. Breastfeeding requires fewer supplies and less cumbersome equipment. b. Breastfeeding saves families money. c. Breastfeeding costs employers in terms of time lost from work. d. Breastfeeding benefits the environment

ANS: C Actually less time is lost to work by breastfeeding mothers, in part because infants are healthier. Breastfeeding is convenient because it does not require cleaning or transporting bottles and other equipment. It saves families money because the cost of formula far exceeds the cost of extra food for the lactating mother. Breastfeeding uses a renewable resource; it does not need fossil fuels, advertising, shipping, or disposal

Of the many factors that influence parental responses, nurses should be conscious of negative stereotypes that apply to specific patient populations. Which response could be an inappropriate stereotype of adolescent mothers? a. An adolescent mothers egocentricity and unmet developmental needs interfere with her ability to parent effectively. b. An adolescent mother is likely to use less verbal instruction, be less responsive, and interact less positively than other mothers. c. Adolescent mothers have a higher documented incidence of child abuse. d. Mothers older than 35 often deal with more stress related to work and career issues and decreasing libido.

ANS: C Adolescent mothers are more inclined to have a number of parenting difficulties that benefit from counseling; however, a higher incidence of child abuse is not one of them. Midlife mothers have many competencies, but they are more likely to have to deal with career issues and the accompanying stress

22.The health care provider asks the nurse to monitor the fluid volume status of a heart failure patient and a patient at risk for clinical dehydration. Which is the most effective nursing intervention for monitoring both of these patients? a. Assess the patients for edema in extremities. b. Ask the patients to record their intake and output. c. Weigh the patients every morning before breakfast. d. Measure the patients' blood pressures every 4 hours.

ANS: C An effective measure of fluid retention or loss is daily weights; each kilogram (2.2 pounds) change is equivalent to 1 liter of fluid gained or lost. This measurement should be performed at the same time every day using the same scale and the same amount of clothing. Although intake and output records are important assessment measures, some patients are not able to keep their own records themselves. Blood pressure can decrease with extracellular volume (ECV) deficit but will not necessarily increase with recent ECV excess (heart failure patient). Edema occurs with ECV excess but not with clinical dehydration.

An infant boy was born just a few minutes ago. The nurse is conducting the initial assessment. Part of the assessment includes the Apgar score. The Apgar assessment is performed: a. Only if the newborn is in obvious distress. b. Once by the obstetrician, just after the birth. c. At least twice, 1 minute and 5 minutes after birth. d. Every 15 minutes during the newborns first hour after birth

ANS: C Apgar scoring is performed at 1 minute and 5 minutes after birth. Scoring may continue at 5-minute intervals if the infant is in distress and requires resuscitation efforts.

An 18-month-old patient is brought into the clinic for evaluation because the mother is concerned. The 18-month-old child hits her siblings and says only "No" when communicating verbally. According to Piaget's theory, what recommendation should the nurse make a priority? a. Consult the social worker because the child is hitting other children. b. Reassure the mother that the child is developmentally within specified norms. c. Encourage the mother to seek psychological counseling for the child. d. Remove all toys from the child's room until this behavior ceases.

ANS: C At 18 months, the child is in the sensorimotor period of development. Piaget describes hitting, looking, grasping, and kicking as normal schemas to deal with the environment. The social worker does not need to be consulted in this case, nor is psychological counseling warranted, because the child is exhibiting normal behaviors. Play is an important part of all children's development. Removing the toys is not necessary because this child is exhibiting normal behaviors. Removing toys and the opportunity to play with them may actually hinder the child's development.

With regard to the gastrointestinal (GI) system of the newborn, nurses should be aware that: a. The newborns cheeks are full because of normal fluid retention. b. The nipple of the bottle or breast must be placed well inside the babys mouth because teeth have been developing in utero, and one or more may even be through. c. Regurgitation during the first day or two can be reduced by burping the infant and slightly elevating the babys head. d. Bacteria are already present in the infants GI tract at birth because they traveled through the placenta.

ANS: C Avoiding overfeeding can also reduce regurgitation. The newborns cheeks are full because of well-developed sucking pads. Teeth do develop in utero, but the nipple is placed deep because the baby cannot move food from the lips to the pharynx. Bacteria are not present at birth, but they soon enter through various orifices

The nurse administers vitamin K to the newborn for which reason? a. Most mothers have a diet deficient in vitamin K, which results in the infants being deficient. b. Vitamin K prevents the synthesis of prothrombin in the liver and must be given by injection. c. Bacteria that synthesize vitamin K are not present in the newborns intestinal tract. d. The supply of vitamin K is inadequate for at least 3 to 4 months, and the newborn must be supplemented

ANS: C Bacteria that synthesize vitamin K are not present in the newborns intestinal tract. Vitamin K is provided because the newborn does not have the intestinal flora to produce this vitamin for the first week. The maternal diet has no bearing on the amount of vitamin K found in the newborn. Vitamin K promotes the formation of clotting factors in the liver and is used for the prevention and treatment of hemorrhagic disease in the newborn. Vitamin K is not produced in the intestinal tract of the newborn until after microorganisms are introduced. By day 8, normal newborns are able to produce their own vitamin K.

As the nurse assists a new mother with breastfeeding, the client asks, If formula is prepared to meet the nutritional needs of the newborn, what is in breast milk that makes it better? The nurses best response is that it contains: a. More calories. c. Important immunoglobulins. b. Essential amino acids. d. More calcium

ANS: C Breast milk contains immunoglobulins that protect the newborn against infection. The calorie count of formula and breast milk is about the same. All the essential amino acids are in both formula and breast milk; however, the concentrations may differ. Calcium levels are higher in formula than in breast milk. This higher level can cause an excessively high renal solute load if the formula is not diluted properly

The nurse who is teaching a parent about developmental needs of the infant knows that the parent has verbalized understanding of a infant's developmental needs when he states a. "My child is too young to understand words." b. "My child will begin to speak in sentences by 1 year of age." c. "My child will probably enjoy playing peek-a-boo." d. "While my child is in the hospital, I should let the nurses provide most of the care."

ANS: C By 9 months, infants play simple social games such as patty-cake and peek-a-boo. By 1 year, infants not only recognize their own names but are able to say three to five words and understand almost 100 words. Extended separations from parents complicate the attachment process and increase the number of caregivers with whom they must interact. Ideally, the parents provide most of the care during hospitalizations.

17. Developmentally, most children at age 12 months demonstrate what behavior? a. Use a spoon adeptly. b. Relinquish the bottle voluntarily. c. Eat the same food as the rest of the family. d. Reject all solid foods in preference to the bottle.

ANS: C By age 12 months, most children are eating the same food that is prepared for the rest of the family. Using a spoon usually is not mastered until age 18 months. The parents should be engaged in weaning a child from a bottle if that is the source of liquid. Toddlers should be encouraged to drink from a cup at the first birthday and weaned totally by 14 months. The child should be weaned from a milk/formula-based diet to a balanced diet that includes iron-rich sources of food.

28. Which comment indicates that the mother of a toddler needs further teaching about dental care? a. "We use well water so I give my toddler fluoride supplements." b. "My toddler brushes his teeth with my help." c. "My child will not need a dental checkup until his permanent teeth come in." d. "I use a small nylon bristle brush for my toddler's teeth."

ANS: C Children should first see the dentist 6 months after the first primary tooth erupts and no later than age 30 months. Toddlers need fluoride supplements when they use a water supply that is not fluorinated. Toddlers also require supervision with dental care. The parent should finish brushing areas not reached by the child. A small nylon bristle brush works best for cleaning toddlers' teeth.

The nurse hears a primiparous woman talking to her son and telling him that his chin is just like his dads chin. This womans statement reflects: a. Mutuality. c. Claiming. b. Synchrony. d. Reciprocity

ANS: C Claiming refers to the process by which the child is identified in terms of likeness to other family members. Mutuality occurs when the infants behaviors and characteristics call forth a corresponding set of maternal behaviors and characteristics. Synchrony refers to the fit between the infants cues and the parents responses. Reciprocity is a type of body movement or behavior that provides the observer with cues.

A mother expresses fear about changing her infants diaper after he is circumcised. What does the woman need to be taught to take care of the infant when she gets home? a. Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours. b. Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding occurs. c. Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change. d. Wash off the yellow exudate that forms on the glans at least once every day to prevent infection

ANS: C Cleansing the penis gently with water and putting petroleum jelly around the glans after each diaper change are appropriate when caring for an infant who has had a circumcision. With each diaper change, the penis should be washed off with warm water to remove any urine or feces. If bleeding occurs, the nurse should apply gentle pressure to the site of the bleeding with a sterile gauze square. Yellow exudates cover the glans penis in 24 hours after the circumcision. This is part of normal healing and not an infective process. The exudates should not be removed.

The best way for the nurse to promote and support the maternal-infant bonding process is to: a. Help the mother identify her positive feelings toward the newborn. b. Encourage the mother to provide all newborn care. c. Assist the family with rooming-in. d. Return the newborn to the nursery during sleep periods

ANS: C Close and frequent interaction between mother and infant, which is facilitated by rooming-in, is important in the bonding process. This is often referred to as the mother-baby care or couplet care. Having the mother express her feelings is important; however, it is not the best way to promote bonding. The mother needs time to rest and recuperate; she should not be expected to do all of the care. The patient needs to observe the infant during all stages so she will be aware of what to anticipate when they go home

27. What is the primary purpose of a transitional object? a. It helps the parents deal with the guilt when leaving the child. b. It keeps the child quiet at bedtime. c. It is effective in decreasing anxiety in the toddler. d. It decreases negativism and tantrums in the toddler.

ANS: C Decreasing anxiety, particularly separation anxiety, is the function of a transitional object; it provides comfort to the toddler in stressful situations and helps make the transition from dependence to autonomy. A decrease in parental guilt (distress) is an indirect benefit of a transitional object. A transitional object may be part of a bedtime ritual, but it may not keep the child quiet at bedtime. A transitional object does not significantly affect negativity and tantrums, but it can comfort a child after tantrums.

A postpartum woman overhears the nurse tell the obstetrics clinician that she has a positive Homans sign and asks what it means. The nurses best response is: a. You have pitting edema in your ankles. b. You have deep tendon reflexes rated 2+. c. You have calf pain when the nurse flexes your foot. d. You have a fleshy odor to your vaginal drainage

ANS: C Discomfort in the calf with sharp dorsiflexion of the foot may indicate deep vein thrombosis. Edema is within normal limits for the first few days until the excess interstitial fluid is remobilized and excreted. Deep tendon reflexes should be 1+ to 2+. A fleshy odor, not a foul odor, is within normal limits.

An infant has been pronounced dead from sudden infant death syndrome (SIDS) in the emergency department. Which is an appropriate question to ask the parents? a. Did you hear the infant cry out? b. Why didnt you check on the infant earlier? c. What time did you find the infant? d. Was the head buried in a blanket?

ANS: C During a SIDS incident, if the infant is not pronounced dead at the scene, he or she may be transported to the emergency department to be pronounced dead by a physician. While they are in the emergency department, the parents are asked only factual questions, such as when they found the infant, how he or she looked, and whom they called for help. The nurse avoids any remarks that may suggest responsibility, such as Why didnt you go in earlier? Didnt you hear the infant cry out? or Was the head buried in a blanket?

During a phone follow-up conversation with a woman who is 4 days postpartum, the woman tells the nurse, I dont know whats wrong. I love my son, but I feel so let down. I seem to cry for no reason! The nurse would recognize that the woman is experiencing: a. Taking-in. c. Postpartum (PP) blues. b. Postpartum depression (PPD). d. Attachment difficulty.

ANS: C During the PP blues women are emotionally labile, often crying easily and for no apparent reason. This lability seems to peak around the fifth PP day. The taking-in phase is the period after birth when the mother focuses on her own psychologic needs. Typically this period lasts 24 hours. PPD is an intense, pervasive sadness marked by severe, labile mood swings; it is more serious and persistent than the PP blues. Crying is not a maladaptive attachment response; it indicates PP blues.

If the patients white blood cell (WBC) count is 25,000/mm on her second postpartum day, the nurse should: a. Tell the physician immediately. b. Have the laboratory draw blood for reanalysis. c. Recognize that this is an acceptable range at this point postpartum. d. Begin antibiotic therapy immediately.

ANS: C During the first 10 to 12 days after childbirth, values between 20,000 and 25,000/mm are common.Because this is a normal finding there is no reason to alert the physician. There is no need for reassessment or antibiotics because it is expected for the WBCs to be elevated.

It is now recommended that children with asthma who are taking long-term inhaled steroids should be assessed frequently because they may develop: a. Cough. c. Slowed growth. b. Osteoporosis. d. Cushings syndrome.

ANS: C The growth of children on long-term inhaled steroids should be assessed frequently to assess for systemic effects of these drugs. Cough is prevented by inhaled steroids. No evidence exists that inhaled steroids cause osteoporosis. Cushings syndrome is caused by long-term systemic steroids.

On observing a woman on her first postpartum day sitting in bed while her newborn lies awake in the bassinet, the nurse should: a. Realize that this situation is perfectly acceptable. b. Offer to hand the baby to the woman. c. Hand the baby to the woman. d. Explain taking in to the woman

ANS: C During the taking-in phase of maternal adaptation (the mother may be passive and dependent), the nurse should encourage bonding when the infant is in the quiet alert stage. This is done best by simply giving the baby to the mother. The patient is exhibiting expected behavior during the taking-in phase; however, interventions by the nurse can facilitate infant bonding. The patient will learn best during the taking-hold phase

6. Although a 14 month old received a shock from an electrical outlet recently, the parents find the child about to place a paper clip in another outlet. What is the best interpretation of this behavior? a. Her cognitive development is delayed. b. This is typical behavior because toddlers are not very developed. c. This is typical behavior because of inability to transfer knowledge to new situations. d. This is not typical behavior because toddlers should know better than to repeat an act that caused pain.

ANS: C During the tertiary circular reactions stage, children have only a rudimentary sense of the classification of objects. The appearance of an object denotes its function for these children. The slot of an outlet is for putting things into. Her cognitive development is appropriate for her age and represents typical behavior for a toddler. Only some awareness exists of a causal relation between events.

While assessing the integument of a 24-hour-old newborn, the nurse notes a pink, papular rash with vesicles superimposed on the thorax, back, and abdomen. The nurse should: a. Notify the physician immediately. b. Move the newborn to an isolation nursery. c. Document the finding as erythema toxicum. d. Take the newborns temperature and obtain a culture of one of the vesicles

ANS: C Erythema toxicum (or erythema neonatorum) is a newborn rash that resembles flea bites. This is a normal finding that does not require notification of the physician, isolation of the newborn, or any additional interventions.

As relates to the condition and reconditioning of the urinary system after childbirth, nurses should be aware that: a. Kidney function returns to normal a few days after birth. b. Diastasis recti abdominis is a common condition that alters the voiding reflex. c. Fluid loss through perspiration and increased urinary output accounts for a weight loss of more than 2 kg during the puerperium. d. With adequate emptying of the bladder, bladder tone usually is restored 2 to 3 weeks after childbirth.

ANS: C Excess fluid loss through other means occurs as well. Kidney function usually returns to normal in about a month. Diastasis recti abdominis is the separation of muscles in the abdominal wall; it has no effect on the voiding reflex. Bladder tone usually is restored 5 to 7 days after childbirth

How many kilocalories per kilogram (kcal/kg) of body weight does a breastfed term infant require each day? a. 50 to 65 c. 95 to 110 b. 75 to 90 d. 150 to 200

ANS: C For the first 3 months the infant needs 110 kcal/kg/day. At ages 3 to 6 months the requirement is 100 kcal/kg/day. This level decreases slightly to 95 kcal/kg/day from 6 to 9 months and increases again to 100 kcal/kg/day until the baby reaches 12 months

The nursing instructor will need to provide further instruction to the student who states, "Development proceeds a. In a proximal-distal pattern." b. In a cephalocaudal pattern." c. At a slower rate during the embryonic stage." d. At a predictive rate from the moment of conception."

ANS: C From the moment of conception, human development proceeds at a predictive and rapid rate. During gestation or the prenatal period, the embryo grows from a single cell to a complex physiologic being. Development proceeds in a cephalocaudal and proximal-distal pattern

To plan early intervention and care for a child with a developmental delay, the nurse would consider knowledge of the concepts most significantly impacted by development, including a. culture. b. environment. c. functional status. d. nutrition.

ANS: C Function is one of the concepts most significantly impacted by development. Others include sensory-perceptual, cognition, mobility, reproduction, and sexuality. Knowledge of these concepts can help the nurse anticipate areas that need to be addressed. Culture is a concept that is considered to significantly affect development; the difference is the concepts that affect development are those that represent major influencing factors (causes), hence determination of development and would be the focus of preventive interventions. Environment is considered to significantly affect development. Nutrition is considered to significantly affect development.

As part of Standard Precautions, nurses wear gloves when handling the newborn. The chief reason is: a. To protect the baby from infection. b. That it is part of the Apgar protocol. c. To protect the nurse from contamination by the newborn. d. the nurse has primary responsibility for the baby during the first 2 hours.

ANS: C Gloves are worn to protect the nurse from infection until the blood and amniotic fluid are cleaned off the newborn

When comparing physical growth patterns between school-aged children and adolescents, the nurse notes that a. Physical growth usually slows during the adolescent period. b. Boys usually exceed girls in height and weight by the end of the school years. c. Secondary sex characteristics usually develop during the adolescent years. d. The distribution of muscle and fat remains constant during the adolescent years.

ANS: C Hormonal changes during adolescence contribute to the development of secondary sex characteristics such as hair growth and voice changes. Physical growth usually slows during the school-aged period, and then a growth spurt occurs during adolescence. Girls usually exceed boys in height and weight by the end of the school years. As height and weight increase during adolescence, the distribution of muscle and fat changes.

With regard to the nutrient needs of breastfed and formula-fed infants, nurses should be understand that: a. Breastfed infants need extra water in hot climates. b. During the first 3 months breastfed infants consume more energy than do formula-fed infants. c. Breastfeeding infants should receive oral vitamin D drops daily at least during the first 2 months. d. Vitamin K injections at birth are not needed for infants fed on specially enriched formula.

ANS: C Human milk contains only small amounts of vitamin D. Neither breastfed nor formula-fed infants need to be given water, even in very hot climates. During the first 3 months formula-fed infants consume more energy than do breastfed infants and therefore tend to grow more rapidly. Vitamin K shots are required for all infants because the bacteria that produce it are absent from the babys stomach at birth

26.The nurse is evaluating the effectiveness of the intravenous fluid therapy in a patient with hypernatremia. Which finding indicates goal achievement? a. Urine output increases to 150 mL/hr. b. Systolic and diastolic blood pressure decreases. c. Serum sodium concentration returns to normal. d. Large amounts of emesis and diarrhea decrease.

ANS: C Hypernatremia is diagnosed by elevated serum sodium concentration. Blood pressure is not an accurate indicator of hypernatremia. Emesis and diarrhea will not stop because of intravenous therapy. Urine output is influenced by many factors, including extracellular fluid volume. A large dilute urine output can cause further hypernatremia.

36.A nurse has just received a bag of packed red blood cells (RBCs) for a patient. What is the longest time the nurse can let the blood infuse? a. 30 minutes b. 2 hours c. 4 hours d. 6 hours

ANS: C Ideally a unit of whole blood or packed RBCs is transfused in 2 hours. This time can be lengthened to 4 hours if the patient is at risk for extracellular volume excess. Beyond 4 hours there is a risk for bacterial contamination of the blood.

As related to laboratory tests and diagnostic tests in the hospital after birth, nurses should be aware that: a. All states test for phenylketonuria (PKU), hypothyroidism, cystic fibrosis, and sickle cell diseases. b. Federal law prohibits newborn genetic testing without parental consent. c. If genetic screening is done before the infant is 24 hours old, it should be repeated at age 1 to 2 weeks. d. Hearing screening is now mandated by federal law.

ANS: C If done very early, genetic screening should be repeated. States all test for PKU and hypothyroidism, but other genetic defects are not universally covered. Federal law mandates newborn genetic screening, but not screening for hearing problems (although more than half the states do mandate hearing screening)

A recently delivered mother and her baby are at the clinic for a 6-week postpartum checkup. The nurse should be concerned that psychosocial outcomes are not being met if the woman: a. Discusses her labor and birth experience excessively. b. Believes that her baby is more attractive and clever than any others. c. Has not given the baby a name. d. Has a partner or family members who react very positively about the baby

ANS: C If the mother is having difficulty naming her new infant, it may be a signal that she is not adapting well to parenthood. Other red flags include refusal to hold or feed the baby, lack of interaction with the infant, and becoming upset when the baby vomits or needs a diaper change. A new mother who is having difficulty would be unwilling to discuss her labor and birth experience. An appropriate nursing diagnosis could be Impaired parenting related to a long, dif icult labor or unmet expectations of birth. A mother who is willing to discuss her birth experience is making a healthy personal adjustment. The mother who is not coping well would find her baby unattractive and messy. She may also be overly disappointed in the babys sex. The client may voice concern that the baby reminds her of a family member whom she does not like. Having a partner and/or other family members react positively is an indication that this new mother has a good support system in place. This support system will help reduce anxiety related to her new role as a mother.

A nurse should instruct the parents of a 10-year-old child to keep which of the following theoretical principles in mind when dealing with a behavioral problem at home? a. Strategies that worked well with the first child will be equally as effective for the second child. b. Encourage the child to volunteer some time at a local hospital to instill a sense of fulfillment. c. Bargaining about chores in exchange for privileges may be an effective method of encouraging helpful activities. d. Do not offer praise for accomplishments and punishment for behavioral issues.

ANS: C In the concrete operations period, children begin to cooperate and share new information about the acts they perform. Parents will be able to adjust their approaches to guide the child into helpful activities within the home, such as bargaining about chores in exchange for privileges. With the birth of a second child, most parents find that the strategies that worked well with the first child no longer work at all. After birth, children grow according to their genetic blueprint and gain skills in an orderly fashion, but at each individual's own pace. The need for a sense of fulfillment is usually experienced by middle-aged adults, not children. School-aged children need praise to discourage a sense of inferiority; providing praise is the best choice for encouraging positive behaviors while nurturing growth and development.

According to Piaget's formal operations level, a 13-year-old adolescent will likely a. Hit other students to deal with environmental change. b. Use play to understand her surroundings. c. Question her parents about an upcoming presidential election. d. Question where the ice is hiding when ice has melted in her drink.

ANS: C In the formal operations period, adolescents and young adults begin to think about such subjects as achieving world peace, finding justice, and seeking meaning in life. Asking about a presidential election demonstrates that the adolescent is concerned about political issues that affect others besides her. Hitting would be a common schema during the sensorimotor stage of development. Using play to learn about the environment is indicative of the preoperational stage. During the concrete operations stage (ages 6 to 12 years), children are able to coordinate two concrete perspectives in social and scientific thinking, such as understanding the difference between "hiding" and "melting."

Postpartal overdistention of the bladder and urinary retention can lead to which complications? a. Postpartum hemorrhage and eclampsia b. Fever and increased blood pressure c. Postpartum hemorrhage and urinary tract infection d. Urinary tract infection and uterine rupture

ANS: C Incomplete emptying and overdistention of the bladder can lead to urinary tract infection. Overdistention of the bladder displaces the uterus and prevents contraction of the uterine muscle, thus leading to postpartum hemorrhage. There is no correlation between bladder distention and high blood pressure or eclampsia. The risk of uterine rupture decreases after the birth of the infant.

With regard to basic care of the breastfeeding mother, nurses should be able to advise her that she: a. Will need an extra 1000 calories a day to maintain energy and produce milk. b. Can go back to prepregnancy consumption patterns of any drinks, as long as she ingests enough calcium. c. Should avoid trying to lose large amounts of weight. d. Must avoid exercising because it is too fatiguing

ANS: C Large weight loss would release fat-stored contaminants into her breast milk. It would also likely involve eating too little and/or exercising too much. A breastfeeding mother need add only 200 to 500 extra calories to her diet to provide extra nutrients for the infant. The mother can go back to her consumption patterns of any drinks as long as she ingests enough calcium, only if she does not drink alcohol, limits coffee to no more than two cups (caffeine in chocolate, tea, and some sodas), and reads the herbal tea ingredients carefully. The mother needs her rest, but moderate exercise is healthy

3. The emergency department nursing assessment of a pregnant female at 35 weeks gestation reveals back pain, blood pressure 150/92, and leaking of clear fluid from the vagina. Which complication of pregnancy does the nurse suspect? a. Ectopic pregnancy b. Spontaneous abortion c. Premature rupture of membranes d. Supine hypotension

ANS: C Leaking of clear fluid from the vagina with back pain and elevated BP is associated with premature rupture of membranes, a complication of pregnancy. An ectopic pregnancy usually manifests as unilateral pain early in the pregnancy. Vaginal bleeding is a classic sign of miscarriage, or spontaneous abortion, not leaking of clear fluid. This patient's blood pressure is elevated. Supine hypotension occurs when the woman is lying supine; then low blood pressure occurs due to the decrease in venous return from the gravid uterus placing pressure on the vena cava.

A meconium stool can be differentiated from a transitional stool in the newborn because the meconium stool is: a. Seen at age 3 days. b. The residue of a milk curd. c. Passed in the first 12 hours of life. d. Lighter in color and looser in consistency

ANS: C Meconium stool is usually passed in the first 12 hours of life, and 99% of newborns have their first stool within 48 hours. If meconium is not passed by 48 hours, obstruction is suspected. Meconium stool is the first stool of the newborn and is made up of matter remaining in the intestines during intrauterine life. Meconium is dark and sticky.

A new mother wants to be sure that she is meeting her daughters needs while feeding her commercially prepared infant formula. The nurse should evaluate the mothers knowledge about appropriate infant care. The mother meets her childs needs when she: a. Adds rice cereal to her formula at 2 weeks of age to ensure adequate nutrition. b. Warms the bottles using a microwave oven. c. Burps her infant during and after the feeding as needed. d. Refrigerates any leftover formula for the next feeding.

ANS: C Most infants swallow air when fed from a bottle and should be given a chance to burp several times during a feeding and after the feeding. Solid food should not be introduced to the infant for at least 4 to 6 months after birth. A microwave should never be used to warm any food to be given to an infant. The heat is not distributed evenly, and this may pose a risk of burning the infant. Any formula left in the bottle after the feeding should be discarded because the infants saliva has mixed with it.

Immediate intervention is needed when the newborn exhibits a. A soft, protuberant abdomen. b. Molding. c. Lack of reflexes. d. Cyanotic hands and feet.

ANS: C Normal reflexes include blinking in response to bright lights, startling in response to sudden loud noises, and sucking, rooting, grasping, yawning, coughing, sneezing, and hiccoughing. Assessment of these reflexes is vital because the newborn depends largely on reflexes for survival and in response to its environment. Normal physical characteristics include the continued presence of lanugo on the skin of the back; cyanosis of the hands and feet for the first 24 hours; and a soft, protuberant abdomen. Molding, or overlapping of the soft skull bones, allows the fetal head to adjust to various diameters of the maternal pelvis and is a common occurrence with vaginal births.

With regard to parents early and extended contact with their infant and the relationships built, nurses should be aware that: a. Immediate contact is essential for the parent-child relationship. b. Skin-to-skin contact is preferable to contact with the body totally wrapped in a blanket. c. Extended contact is especially important for adolescents and low-income women because they are at risk for parenting inadequacies. d. Mothers need to take precedence over their partners and other family matters.

ANS: C Nurses should encourage any activity that optimizes family extended contact. Immediate contact facilitates the attachment process but is not essential; otherwise, adopted infants would not establish the affectionate ties they do. The mode of infant-mother contact does not appear to have any important effect. Mothers and their partners are considered equally important.

To initiate the milk ejection reflex (MER), the mother should be advised to: a. Wear a firm-fitting bra. c. Place the infant to the breast. b. Drink plenty of fluids. d. Apply cool packs to her breast.

ANS: C Oxytocin, which causes the MER reflex, increases in response to nipple stimulation. A firm bra is important to support the breast; however, will not initiate the MER reflex. Drinking plenty of fluids is necessary for adequate milk production, but this alone will not initiate the MER reflex. Cool packs to the breast will decrease the MER reflex.

The early postpartum period is a time of emotional and physical vulnerability. Many mothers can easily become psychologically overwhelmed by the reality of their new parental responsibilities. Fatigue compounds these issues. Although the baby blues are a common occurrence in the postpartum period, about one-half million women in America experience a more severe syndrome known as postpartum depression (PPD). Which statement regarding PPD is essential for the nurse to be aware of when attempting to formulate a nursing diagnosis? a. PPD symptoms are consistently severe. b. This syndrome affects only new mothers. c. PPD can easily go undetected. d. Only mental health professionals should teach new parents about this condition.

ANS: C PPD can go undetected because parents do not voluntarily admit to this type of emotional distress out of embarrassment, fear, or guilt. PPD symptoms range from mild to severe, with women having both good and bad days. Both mothers and fathers should be screened. PPD may also affect new fathers. The nurse should include information on PPD and how to differentiate this from the baby blues for all clients on discharge. Nurses also can urge new parents to report symptoms and seek follow-up care promptly if symptoms occur.

24.A patient presents to the emergency department with reports of vomiting and diarrhea for the past 48 hours. The health care provider orders isotonic intravenous (IV) therapy. Which IV will the nurse prepare? a. 0.225% sodium chloride (1/4 NS) b. 0.45% sodium chloride (1/2 NS) c. 0.9% sodium chloride (NS) d. 3% sodium chloride (3% NaCl)

ANS: C Patients with prolonged vomiting and diarrhea become hypovolemic. A solution to replace extracellular volume is 0.9% sodium chloride, which is an isotonic solution. 0.225% and 0.45% sodium chloride are hypotonic. 3% sodium chloride is hypertonic.

What marks on a babys skin may indicate an underlying problem that requires notification of a physician? a. Mongolian spots on the back b. Telangiectatic nevi on the nose or nape of the neck c. Petechiae scattered over the infants body d. Erythema toxicum anywhere on the body

ANS: C Petechiae (bruises) scattered over the infants body should be reported to the pediatrician because they may indicate underlying problems. Mongolian spots are bluish-black spots that resemble bruises but fade gradually over months and have no clinical significance. Telangiectatic nevi (stork bites, angel kisses) fade by the second year and have no clinical significance. Erythema toxicum is an appalling-looking rash, but it has no clinical significance and requires no treatment

A first-time dad is concerned that his 3-day-old daughters skin looks yellow. In the nurses explanation of physiologic jaundice, what fact should be included? a. Physiologic jaundice occurs during the first 24 hours of life. b. Physiologic jaundice is caused by blood incompatibilities between the mother and infant blood types. c. The bilirubin levels of physiologic jaundice peak between the second and fourth days of life. d. This condition is also known as breast milk jaundice.

ANS: C Physiologic jaundice becomes visible when the serum bilirubin reaches a level of 5 mg/dL or greater, which occurs when the baby is approximately 3 days old. This finding is within normal limits for the newborn. Pathologic jaundice occurs during the first 24 hours of life. Pathologic jaundice is caused by blood incompatibilities, causing excessive destruction of erythrocytes, and must be investigated. Breast milk jaundice occurs in one third of breastfed infants at 2 weeks and is caused by an insufficient intake of fluids

Which statement by the nurse best explains the importance of play during the toddler stage of development? a. "Exploration can suppress the toddler's curiosity to promote safety." b. "Parental control during play will eliminate the frustration of learning self-control." c. "Play can enhance cognitive and psychosocial development." d. "Play will enhance the toddler's ability to explore the environment safely without supervision."

ANS: C Play can enhance cognitive and psychosocial development. The toddler's curiosity is evident in his or her exploration of the environment. Children strive for independence. Their strong wills are frequently exhibited in negative behavior when caregivers attempt to direct their actions. Temper tantrums result when parental restrictions frustrate toddlers. Parents need to provide toddlers with graded independence, allowing them to do things that do not result in harm to themselves or others.

Which hormone remains elevated in the immediate postpartum period of the breastfeeding woman? a. Estrogen c. Prolactin b. Progesterone d. Human placental lactogen

ANS: C Prolactin levels in the blood increase progressively throughout pregnancy. In women who breastfeed, prolactin levels remain elevated into the sixth week after birth. Estrogen and progesterone levels decrease markedly after expulsion of the placenta and reach their lowest levels 1 week into the postpartum period. Human placental lactogen levels decrease dramatically after expulsion of the placenta.

Which type of formula is not diluted before being administered to an infant? a. Powdered c. Ready-to-use b. Concentrated d. Modified cows milk

ANS: C Ready-to-use formula can be poured directly from the can into babys bottle and is good (but expensive) when a proper water supply is not available. Formula should be well mixed to dissolve the powder and make it uniform in consistency. Improper dilution of concentrated formula may cause malnutrition or sodium imbalances. Cows milk is more difficult for the infant to digest and is not recommended, even if it is diluted.

A 17-year-old girl is hospitalized for appendicitis, and her mother asks the nurse why she is so needy and acting like a child. The best response of the nurse is that in the hospital, adolescents a. have separation anxiety. b. rebel against rules. c. regress because of stress. d. want to know everything.

ANS: C Regression to an earlier stage of development is a common response to stress. Separation anxiety is most common in infants and toddlers. Rebellion against hospital rules is usually not an issue if the adolescent understands the rules and would not create childlike behaviors. An adolescent may want to "know everything" with their logical thinking and deductive reasoning, but that would not explain why they would act like a child.

Which of these statements, if made by a parent, would require further instruction? a. "I should not be surprised that my teenager has so many friends." b. "I get worried because my teenager thinks he's indestructible. He takes a lot of risks." c. "I should cover for my school-aged child when he makes a mistake until he learns the ropes." d. "My 10-year-old child is always hungry right after school, so I usually fix him a nutritious snack."

ANS: C School and home influence growth and development, requiring adjustment by parents and by the child. The child learns to cope with rules and expectations presented by the school and by peers. Parents have to learn to allow their child to make decisions, accept responsibility, and learn from life's experiences. Teenagers typically are very social and have many friends. Adolescents seek a group identity because they need esteem and acceptance. By midadolescence, adolescents believe that they are unique and the exception, giving rise to their risk-taking behaviors. Obesity occurs because children often rush into the home after school or play and eat the most easily obtainable and appealing foods. Providing nutritious snacks is often the best way to ensure good nutritional intake.

If a woman is at risk for thrombus and is not ready to ambulate, nurses may intervene by performing a number of interventions. Which intervention should the nurse avoid? a. Putting the patient in antiembolic stockings (TED hose) and/or sequential compression device (SCD) boots. b. Having the patient flex, extend, and rotate her feet, ankles, and legs. c. Having the patient sit in a chair. d. Notifying the physician immediately if a positive Homans sign occurs.

ANS: C Sitting immobile in a chair will not help. Bed exercise and prophylactic footwear may. TED hose and SCD boots are recommended. Bed exercises, such as flexing, extending, and rotating her feet, ankles, and legs, are useful. A positive Homans sign (calf muscle pain or warmth, redness, or tenderness) requires the physicians immediate attention

7. A female patient comes to the clinic after missing one menstrual period. She lives in a house beneath electrical power lines which is located near an oil field. She drinks two caffeinated beverages a day, is a daily beer drinker, and has not stopped eating sweets. She takes a multivitamin and exercises daily. She denies drug use. Which finding in the history has the greatest implication for this patient's plan of care? a. Electrical power lines are a potential hazard to the woman and her fetus. b. Living near an oil field may mean the water supply is polluted. c. Alcohol exposure should be avoided during pregnancy due to teratogenicity. d. Eating sweets may cause gestational diabetes or miscarriage.

ANS: C Stages of development include ovum, embryonic, and fetal. The beginning of the fourth week to the end of the eighth week comprise the embryonic period. Teratogenicity is a major concern because all external and internal structures are developing in the embryonic period. A pregnant woman should avoid exposure to all potential toxins during pregnancy, especially alcohol, tobacco, radiation, and infections during embryonic development. Living in a house beneath power lines is not the greatest implication in this patient's plan of care as there are no definite risks to the developing fetus. Living near an oil field has no definite risks to the fetus. Eating sweets may contribute to maternal obesity, large for gestational age fetus, and maternal gestational diabetes but does not have the immediate implication of a daily beer drinker which can cause fetal alcohol syndrome.

In the classification of newborns by gestational age and birth weight, the appropriate for gestational age (AGA) weight would: a. Fall between the 25th and 75th percentiles for the infants age. b. Depend on the infants length and the size of the head. c. Fall between the 10th and 90th percentiles for the infants age. d. Be modified to consider intrauterine growth restriction (IUGR)

ANS: C The AGA range is large: between the 10th and the 90th percentiles for the infants age. The infants length and size of the head are measured, but they do not affect the normal weight designation. IUGR applies to the fetus, not the newborns weight.

The most appropriate response of the nurse when a mother asks what the Denver II does is that it a. can diagnose developmental disabilities. b. identifies a need for physical therapy. c. is a developmental screening tool. d. provides a framework for health teaching.

ANS: C The Denver II is the most commonly used measure of developmental status used by health care professionals; it is a screening tool. Screening tools do not provide a diagnosis. Diagnosis requires a thorough neurodevelopment history and physical examination. Developmental delay, which is suggested by screening, is a symptom, not a diagnosis. The need for any therapy would be identified with a comprehensive evaluation, not a screening tool. Some providers use the Denver II as a framework for teaching about expected development, but this is not the primary purpose of the tool.

While examining a newborn, the nurse notes uneven skin folds on the buttocks and a click when performing the Ortolani maneuver. The nurse recognizes these findings as a sign that the newborn probably has: a. Polydactyly. c. Hip dysplasia. b. Clubfoot. d. Webbing

ANS: C The Ortolani maneuver is used to detect the presence of hip dysplasia. Polydactyly is the presence of extra digits. Clubfoot (talipes equinovarus) is a deformity in which the foot turns inward and is fixed in a plantarflexion position. Webbing, or syndactyly, is a fusing of the fingers or toes

While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is: a. 80 to 100 beats/min. c. 120 to 160 beats/min. b. 100 to 120 beats/min. d. 150 to 180 beats/min.

ANS: C The average infant heart rate while awake is 120 to 160 beats/min. The newborns heart rate may be about 85 to 100 beats/min while sleeping. The infants heart rate typically is a bit higher when alert but quiet. A heart rate of 150 to 180 beats/min is typical when the infant cries

In administering vitamin K to the infant shortly after birth, the nurse understands that vitamin K is: a. Important in the production of red blood cells. b. Necessary in the production of platelets. c. Not initially synthesized because of a sterile bowel at birth. d. Responsible for the breakdown of bilirubin and prevention of jaundice.

ANS: C The bowel is initially sterile in the newborn, and vitamin K cannot be synthesized until food is introduced into the bowel. Vitamin K is necessary to activate blood clotting factors. The platelet count in term newborns is near adult levels. Vitamin K is necessary to activate prothrombin and other clotting factors

The nursing instructor will need to provide further instruction to the student who uses which of these statements when describing the differences between cognitive and psychosocial development in children? a. "The preschooler develops the ability to play in small groups." b. "The toddler may participate in parallel play." c. "The school-aged child still requires total assistance in all activities for safety." d. "The toddler period is a time of potential frustration manifested by temper tantrums."

ANS: C The care provider should promote independence within safe limits for the school-aged child. The school-aged child, according to Erikson, is in the industry versus inferiority stage of development. The school-aged child likes to perform tasks by himself when possible and needs to be praised for those tasks. The child continues to engage in solitary play during toddlerhood but also begins to participate in parallel play, which is playing beside rather than with another child. The toddler's strong will is frequently exhibited in negative behavior when caregivers attempt to direct his actions. Temper tantrums result when parental restrictions frustrate toddlers.

The nurse preparing a teaching plan for a preschooler knows that, according to Piaget, the expected stage of development for a preschooler is a. concrete operational. b. formal operational. c. preoperational. d. sensorimotor.

ANS: C The expected stage of development for a preschooler (3 to 4 years old) is preoperational. Concrete operational describes the thinking of a school-age child (7 to 11 years old). Formal operational describes the thinking of an individual after about 11 years of age. Sensorimotor describes the earliest pattern of thinking from birth to 2 years old.

Which documentation on a womans chart on postpartum day 14 indicates a normal involution process? a. Moderate bright red lochial flow b. Breasts firm and tender c. Fundus below the symphysis and not palpable d. Episiotomy slightly red and puffy

ANS: C The fundus descends 1 cm/day, so by postpartum day 14 it is no longer palpable. The lochia should be changed by this day to serosa. Breasts are not part of the involution process. The episiotomy should not be red or puffy at this stage

The nurse is assigned a group of patients. Which patient finding would the nurse identify as a factor leading to increased risk for impaired gas exchange? a. Blood glucose of 350 mg/dL b. Anticoagulant therapy for 10 days c. Hemoglobin of 8.5 g/dL d. Heart rate of 100 beats/min and blood pressure of 100/60

ANS: C The hemoglobin is low (anemia), therefore the ability of the blood to carry oxygen is decreased. High blood glucose and/or anticoagulants do not alter the oxygen carrying capacity of the blood. A heart rate of 100 beats/min and blood pressure of 100/60 are not indicative of oxygen carrying capacity of the blood.

In assisting the breastfeeding mother position the baby, nurses should keep in mind that: a. The cradle position usually is preferred by mothers who had a cesarean birth. b. Women with perineal pain and swelling prefer the modified cradle position. c. Whatever the position used, the infant is belly to belly with the mother. d. While supporting the head, the mother should push gently on the occiput

ANS: C The infant inevitably faces the mother, belly to belly. The football position usually is preferred after cesarean birth. Women with perineal pain and swelling prefer the side-lying position because they can rest while breastfeeding. The mother should never push on the back of the head. It may cause the baby to bite, hyperextend the neck, or develop an aversion to being brought near the breast

A newborn is jaundiced and receiving phototherapy via ultraviolet bank lights. An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method would be to: a. Apply an oil-based lotion to the newborns skin to prevent dying and cracking. b. Limit the newborns intake of milk to prevent nausea, vomiting, and diarrhea. c. Place eye shields over the newborns closed eyes. d. Change the newborns position every 4 hours.

ANS: C The infants eyes must be protected by an opaque mask to prevent overexposure to the light. Eye shields should cover the eyes completely but not occlude the nares. Lotions and ointments should not be applied to the infant because they absorb heat, and this can cause burns. The lights increase insensible water loss, placing the infant at risk for fluid loss and dehydration. Therefore, it is important that the infant be adequately hydrated. The infant should be turned every 2 hours to expose all body surfaces to the light.

The priority assessment immediately after birth is to a. Assess infant-parent interactions. b. Promote parent-newborn physical contact. c. Open the airway. d. Assess gestational age.

ANS: C The most extreme physiologic change occurs when the newborn leaves the in utero circulation and develops independent respiratory functioning. Direct nursing care includes maintaining an open airway, stabilizing and maintaining body temperature, and protecting the newborn from infection. After immediate physical evaluation and application of identification bracelets, the nurse promotes the parents' and newborn's need for close physical contact. Following a comprehensive physical assessment, the nurse assesses gestational age and interactions between infant and parents.

A breastfeeding woman develops engorged breasts at 3 days postpartum. What action would help this woman achieve her goal of reducing the engorgement? The woman: a. Skips feedings to let her sore breasts rest. b. Avoids using a breast pump. c. Breastfeeds her infant every 2 hours. d. Reduces her fluid intake for 24 hours.

ANS: C The mother should be instructed to attempt feeding her infant every 2 hours while massaging the breasts as the infant is feeding. Skipping feedings may cause further swelling and discomfort. If the infant does not feed adequately and empty the breast, the mother may pump to extract the milk and relieve some of the discomfort. Dehydration further irritates swollen breast tissue.

The normal term infant has little difficulty clearing the airway after birth. Most secretions are brought up to the oropharynx by the cough reflex. However, if the infant has excess secretions, the mouth and nasal passages can be cleared easily with a bulb syringe. When instructing parents on the correct use of this piece of equipment, it is important that the nurse teach them to: a. Avoid suctioning the nares. b. Insert the compressed bulb into the center of the mouth. c. Suction the mouth first. d. Remove the bulb syringe from the crib when finished.

ANS: C The mouth should be suctioned first to prevent the infant from inhaling pharyngeal secretions by gasping as the nares are suctioned. The nasal passages should be suctioned one nostril at a time. After compression of the bulb it should be inserted into one side of the mouth. If the bulb is inserted into the center of the mouth, the gag reflex is likely to be initiated. When the infants cry no longer sounds as though it is through mucus or a bubble, suctioning can be stopped. The bulb syringe should remain in the crib so that it is easily accessible if needed again

With regard to the newborns developing cardiovascular system, nurses should be aware that: a. The heart rate of a crying infant may rise to 120 beats/min. b. Heart murmurs heard after the first few hours are cause for concern. c. The point of maximal impulse (PMI) often is visible on the chest wall. d. Persistent bradycardia may indicate respiratory distress syndrome (RDS)

ANS: C The newborns thin chest wall often allows the PMI to be seen. The normal heart rate for infants who are not sleeping is 120 to 160 beats/min. However, a crying infant temporarily could have a heart rate of 180 beats/min. Heart murmurs during the first few days of life have no pathologic significance; an irregular heart rate past the first few hours should be evaluated further. Persistent tachycardia may indicate RDS; bradycardia may be a sign of congenital heart blockage

A formerly independent and active older adult becomes severely withdrawn upon admission to a nursing home. When approaching this patient, which intervention should the nurse plan first? a. Offer a reward for participation in all events. b. Encourage the patient to attend all social events scheduled for the patients. c. Allow the patient to incorporate personal belongings into her room. d. Advise the patient of the importance of attending mandatory activities.

ANS: C The older adult is in the mature thinking stages of development according to Piaget and Kohlberg. According to Gould, the older adult needs help in realistically appreciating his/her accomplishments and in fostering continued development. Erikson's theory proposes that the older adult faces integrity versus despair. To avoid despair, the nurse should allow the patient to actively participate in an independent activity, such as preparing his/her own room with personal belongings. Offering a reward does not address the need for continued independence. Encouraging participation in social events again does not address independence, and the question is asking for the best first intervention. Advising the patient to attend all mandatory activities as the first intervention does not allow for the patient's independence. Some activities may be mandatory, but by first allowing the patient to decorate her room, the nurse is fostering independence and is helping the patient feel welcome and more at home.

12. A toddler's parent asks the nurse for suggestions on dealing with temper tantrums. What intervention is the most appropriate recommendation? a. Punish the child with an age appropriate punishment. b. Leave the child alone until the tantrum is over. c. Ignore the behavior, provided that it is not injurious. d. Explain to child that this is wrong.

ANS: C The parent should be told that the best way to deal with temper tantrums is to ignore the behaviors, provided that the actions are not dangerous to the child. Tantrums are common during this age-group as the child becomes more independent and increasingly complex tasks overwhelm him or her. The parents and caregivers need to have consistent and developmentally appropriate expectations. Punishment and explanations will not be beneficial.

42.While the nurse is taking a patient history, the nurse discovers the patient has a type of diabetes that results from a head injury and does not require insulin. Which dietary change should the nurse share with the patient? a. Reduce the quantity of carbohydrates ingested to lower blood sugar. b. Include a serving of dairy in each meal to elevate calcium levels. c. Drink plenty of fluids throughout the day to stay hydrated. d. Avoid food high in acid to avoid metabolic acidosis.

ANS: C The patient has diabetes insipidus, which places the patient at risk for dehydration and hypernatremia. Dehydration should be prevented by drinking plenty of fluids to replace the extra water excreted in the urine. Foods high in acid are not what causes metabolic acidosis. A reduction in carbohydrates to lower blood sugar will not help a patient with diabetes insipidus but it may help a patient with diabetes mellitus. Calcium-rich dairy products would be recommended for a hypocalcemic patient.

19.The nurse is assessing a patient and finds crackles in the lung bases and neck vein distention. Which action will the nurse take first? a. Offer calcium-rich foods. b. Administer diuretic. c. Raise head of bed. d. Increase fluids.

ANS: C The patient is in fluid overload. Raising the head of the bed to ease breathing is the first action. Offering calcium-rich foods is for hypocalcemia, not fluid overload. Administering a diuretic is the second action. Increasing fluids is contraindicated and would make the situation worse.

Under the Newborns and Mothers Health Protection Act, all health plans are required to allow new mothers and newborns to remain in the hospital for a minimum of _____ hours after a normal vaginal birth and for _____ hours after a cesarean birth. a. 24, 73 c. 48, 96 b. 24, 96 d. 48, 120

ANS: C The specified stays are 48 hours (2 days) for a vaginal birth and 96 hours (4 days) for a cesarean birth. The attending provider and the mother together can decide on an earlier discharge.

Which of these manifestations, if identified in a 6-year-old patient, should the nurse associate with a possible developmental delay based on Piaget's theory? a. The child speaks in complete sentences but often talks only about himself. b. The child still plays with a favorite doll that he has had since he was a toddler. c. The child continues to suck his thumb. d. The child describes an event from his own perspective, even though the entire family was present.

ANS: C This is a characteristic of the sensorimotor stage (birth to 2 years), where schemas become self-initiated activities. For example, the infant who learns that sucking achieves a pleasing result generalizes the action to suck fingers, blanket, or clothing. Successful achievement leads to greater exploration. By age 6, the child is in the preoperational stage of development. The child is expected to be egocentric, even though language ability is progressing. Play becomes a primary means by which children foster their cognitive development; therefore playing with a doll is considered normal at this age. Children see objects and persons from only one point of view—their own—at this stage.

10. In the clinic waiting room, a nurse observes a parent showing an 18-month-old child how to make a tower out of blocks. In this situation the nurse should recognize that fact about this task. a. Blocks at this age are used primarily for throwing. b. Toddlers are too young to imitate the behavior of others. c. Toddlers are capable of building a tower of blocks. d. Toddlers are too young to build a tower of blocks.

ANS: C This is a good parent-child interaction. The 18 month old is capable of building a tower of 3 or 4 blocks. The ability to build towers of blocks usually begins at age 15 months. With ongoing development, the child is able to build taller towers. At this age, children imitate others around them and no longer throw blocks.

A 25-year-old gravida 2, para 2-0-0-2 gave birth 4 hours ago to a 9-pound, 7-ounce boy after augmentation of labor with Pitocin. She puts on her call light and asks for her nurse right away, stating, Im bleeding a lot. The most likely cause of postpartum hemorrhage in this woman is: a. Retained placental fragments. c. Uterine atony. b. Unrepaired vaginal lacerations. d. Puerperal infection

ANS: C This woman gave birth to a macrosomic boy after Pitocin augmentation. The most likely cause of bleeding 4 hours after delivery, combined with these risk factors, is uterine atony. Although retained placental fragments may cause postpartum hemorrhage, this typically would be detected in the first hour after delivery of the placenta and is not the most likely cause of hemorrhage in this woman. Although unrepaired vaginal lacerations may cause bleeding, they typically would occur in the period immediately after birth. Puerperal infection can cause subinvolution and subsequent bleeding; however, this typically would be detected 24 hours after delivery

23.A nurse is caring for a cancer patient who presents with anorexia, blood pressure 100/60, and elevated white blood cell count. Which primary purpose for starting total parenteral nutrition (TPN) will the nurse add to the care plan? a. Stimulate the patient's appetite to eat. b. Deliver antibiotics to fight off infection. c. Replace fluid, electrolytes, and nutrients. d. Provide medication to raise blood pressure.

ANS: C Total parenteral nutrition is an intravenous solution composed of nutrients and electrolytes to replace the ones the patient is not eating or losing. TPN does not stimulate the appetite. TPN does not contain blood pressure medication or antibiotics.

Which of these statements would be most appropriate for a nurse to state when assessing an adult patient for growth and developmental delays? a. "How many times per week do you exercise?" b. "Are you able to stand on one foot for 5 seconds?" c. "Would you please describe your usual activities during the day?" d. "How many hours a day do you spend watching television or sitting in front of a computer?"

ANS: C Understanding normal growth and development helps nurses predict, prevent, and detect deviations from patients' own expected patterns. The nurse can then compare expected patterns of activity based on age with the patient's stated activity patterns to determine deviations from the patient's own expected patterns. Asking the patient to describe his/her usual daily activities will provide the nurse with useful information about the patient's own expected patterns. How many hours are spent watching television or in front of a computer and how many times the patient exercises in a week are closed-ended questions. These questions would not provide the nurse with as much information about the patient's expected patterns when his/her stated patterns are compared with expected patterns for the patient's age group to detect delays.

At a 2-month well-baby examination, it was discovered that a breastfed infant had only gained 10 ounces in the past 4 weeks. The mother and the nurse agree that, to gain weight faster, the infant needs to: a. Begin solid foods. b. Have a bottle of formula after every feeding. c. Add at least one extra breastfeeding session every 24 hours. d. Start iron supplements.

ANS: C Usually the solution to slow weight gain is to improve the feeding technique. Position and latch-on are evaluated, and adjustments are made. It may help to add a feeding or two in a 24-hour period. Solid foods should not be introduced to an infant for at least 4 to 6 months. Bottle-feeding may cause nipple confusion and limit the supply of milk. Iron supplements have no bearing on weight gain.

3.The nurse observes edema in a patient who has venous congestion from right heart failure. Which type of pressure facilitated the formation of the patient's edema? a. Osmotic b. Oncotic c. Hydrostatic d. Concentration

ANS: C Venous congestion increases capillary hydrostatic pressure. Increased hydrostatic pressure causes edema by causing increased movement of fluid into the interstitial area. Osmotic and oncotic pressures involve the concentrations of solutes and can contribute to edema in other situations, such as inflammation or malnutrition. Concentration pressure is not a nursing term.

39.A nurse is preparing to start a blood transfusion. Which type of tubing will the nurse obtain? a. Two-way valves to allow the patient's blood to mix and warm the blood transfusing b. An injection port to mix additional electrolytes into the blood c. A filter to ensure that clots do not enter the patient d. An air vent to let bubbles into the blood

ANS: C When administering a transfusion you need an appropriate-size IV catheter and blood administration tubing that has a special in-line filter. The patient's blood should not be mixed with the infusion blood. Air bubbles should not be allowed to enter the blood. The only substance compatible with blood is normal saline; no additives should be mixed with the infusing blood.

Two days ago a woman gave birth to a full-term infant. Last night she awakened several times to urinate and noted that her gown and bedding were wet from profuse diaphoresis. One mechanism for the diaphoresis and diuresis that this woman is experiencing during the early postpartum period is: a. Elevated temperature caused by postpartum infection. b. Increased basal metabolic rate after giving birth. c. Loss of increased blood volume associated with pregnancy. d. Increased venous pressure in the lower extremities.

ANS: C Within 12 hours of birth women begin to lose the excess tissue fluid that has accumulated during pregnancy. One mechanism for reducing these retained fluids is the profuse diaphoresis that often occurs, especially at night, for the first 2 or 3 days after childbirth. Postpartal diuresis is another mechanism by which the body rids itself of excess fluid. An elevated temperature would cause chills and may cause dehydration, not diaphoresis and diuresis. Diaphoresis and diuresis sometimes are referred to as reversal of the water metabolism of pregnancy, not as the basal metabolic rate. Postpartal diuresis may be caused by the removal of increased venous pressure in the lower extremities

According to demographic research, the woman least likely to breastfeed and therefore most likely to need education regarding the benefits and proper techniques of breastfeeding would be: a. A woman who is 30 to 35 years of age, Caucasian, and employed part time outside the home. b. A woman who is younger than 25 years of age, Hispanic, and unemployed. c. A woman who is younger than 25 years of age, African-American, and employed full time outside the home. d. A woman who is 35 years of age or older, Caucasian, and employed full time at home.

ANS: C Women least likely to breastfeed typically are younger than 25 years of age, have a lower income, are less educated, are employed full time outside the home, and are African-American

9. A nurse teaches a client who is at risk for mild hypernatremia. Which statement should the nurse include in this clients teaching? a. Weigh yourself every morning and every night. b. Check your radial pulse twice a day. c. Read food labels to determine sodium content. d. Bake or grill the meat rather than frying it.

ANS: C Most prepackaged foods have a high sodium content. Teaching clients how to read labels and calculate the sodium content of food can help them adhere to prescribed sodium restrictions and can prevent hypernatremia. Daily self-weighing and pulse checking are methods of identifying manifestations of hypernatremia, but they do not prevent it. The addition of substances during cooking, not the method of cooking, increases the sodium content of a meal.

What infant response to cool environmental conditions is either not effective or not available to them? a. Constriction of peripheral blood vessels b. Metabolism of brown fat c. Increased respiratory rates d. Unflexing from the normal position

ANS: D The newborns flexed position guards against heat loss because it reduces the amount of body surface exposed to the environment. The newborns body is able to constrict the peripheral blood vessels to reduce heat loss. Burning brown fat generates heat. The respiratory rate may rise to stimulate muscular activity, which generates heat.

11. A nurse cares for a client who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular changes. Which prescription should the nurse implement first? a. Prepare to administer sodium polystyrene sulfate (Kayexalate) 15 g by mouth. b. Provide a heart healthy, low-potassium diet. c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. d. Prepare the client for hemodialysis treatment.

ANS: C A client with a high serum potassium level and cardiac changes should be treated immediately to reduce the extracellular potassium level. Potassium movement into the cells is enhanced by insulin by increasing the activity of sodium-potassium pumps. Insulin will decrease both serum potassium and glucose levels and therefore should be administered with dextrose to prevent hypoglycemia. Kayexalate may be ordered, but this therapy may take hours to reduce potassium levels. Dialysis may also be needed, but this treatment will take much longer to implement and is not the first prescription the nurse should implement. Decreasing potassium intake may help prevent hyperkalemia in the future but will not decrease the clients current potassium level.

14. After teaching a client to increase dietary potassium intake, a nurse assesses the clients understanding. Which dietary meal selection indicates the client correctly understands the teaching? a. Toasted English muffin with butter and blueberry jam, and tea with sugar b. Two scrambled eggs, a slice of white toast, and a half cup of strawberries c. Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk d. Bowl of oatmeal with brown sugar, a half cup of sliced peaches, and coffee

ANS: C Meat, dairy products, and dried fruit have high concentrations of potassium. Eggs, breads, cereals, sugar, and some fruits (berries, peaches) are low in potassium. The menu selection of sausage, toast, raisins, and milk has the greatest number of items with higher potassium content.

15. A client at risk for developing hyperkalemia states, I love fruit and usually eat it every day, but now I cant because of my high potassium level. How should the nurse respond? a. Potatoes and avocados can be substituted for fruit. b. If you cook the fruit, the amount of potassium will be lower. c. Berries, cherries, apples, and peaches are low in potassium. d. You are correct. Fruit is very high in potassium.

ANS: C Not all fruit is potassium rich. Fruits that are relatively low in potassium and can be included in the diet include apples, apricots, berries, cherries, grapefruit, peaches, and pineapples. Fruits high in potassium include bananas, kiwi, cantaloupe, oranges, and dried fruit. Cooking fruit does not alter its potassium content.

1. A nurse teaches clients at a community center about risks for dehydration. Which client is at greatest risk for dehydration? a. A 36-year-old who is prescribed long-term steroid therapy b. A 55-year-old receiving hypertonic intravenous fluids c. A 76-year-old who is cognitively impaired d. An 83-year-old with congestive heart failure

ANS: C Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration.

Changes in blood volume after childbirth depend on several factors such as blood loss during childbirth and the amount of extravascular water (physiologic edema) mobilized and excreted. A postpartum nurse anticipates blood loss of (Select all that apply): a. 100 mL b. 250 mL or less c. 300 to 500 mL d. 500 to 1000 mL e. 1500 mL or greate

ANS: C, D The average blood loss for a vaginal birth of a single fetus ranges from 300 to 500 mL (10% of blood volume). The typical blood loss for women who gave birth by cesarean is 500 to 1000 mL (15% to 30% of blood volume). During the first few days after birth the plasma volume decreases further as a result diuresis. Pregnancy-induced hypervolemia (an increase in blood volume of at least 35%) allows most women to tolerate considerable blood loss during childbirth.

6. After administering 40 mEq of potassium chloride, a nurse evaluates the clients response. Which manifestations indicate that treatment is improving the clients hypokalemia? (Select all that apply.) a. Respiratory rate of 8 breaths/min b. Absent deep tendon reflexes c. Strong productive cough d. Active bowel sounds e. U waves present on the electrocardiogram (ECG)

ANS: C, D A strong, productive cough indicates an increase in muscle strength and improved potassium imbalance. Active bowel sounds also indicate treatment is working. A respiratory rate of 8 breaths/min, absent deep tendon reflexes, and U waves present on the ECG are all manifestations of hypokalemia and do not demonstrate that treatment is working.

The nurse is caring for a 10-month-old infant with respiratory syncytial virus (RSV) bronchiolitis. Which interventions should be included in the childs care (Select all that apply)? a. Administer antibiotics. b. Administer cough syrup. c. Encourage infant to drink 8 ounces of formula every 4 hours. Test Bank - Maternal Child Nursing Care by Perry (6th Edition, 2017) 664 d. Institute cluster care to encourage adequate rest. e. Place on noninvasive oxygen monitoring

ANS: C, D, E Hydration is important in children with RSV bronchiolitis to loosen secretions and prevent shock. Clustering of care promotes periods of rest. The use of noninvasive oxygen monitoring is recommended.

The patients laboratory report today indicates severe hypokalemia, and the nurse has notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the most important nursing intervention for this patient now? a. Raise bed side rails due to potential decreased level of consciousness and confusion. b. Examine sacral area and patients heels for skin breakdown due to potential edema. c. Establish seizure precautions due to potential muscle twitching, cramps, and seizures. d. Institute fall precautions due to potential postural hypotension and weak leg muscles.

ANS: D (Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in the lower extremities. Both of these increase the risk of falls. Hypokalemia does not cause edema, decreased level of consciousness, or seizures.)

The patient is receiving tube feedings due to a jaw surgery. What change in assessment findings should prompt the nurse to request an order for serum sodium concentration? a. Development of ankle or sacral edema b. Increased skin tenting and dry mouth c. Postural hypotension and tachycardia d. Decreased level of consciousness

ANS: D (Tube feedings pose a risk for hypernatremia unless adequate water is administered between tube feedings. Hypernatremia causes the level of consciousness to decrease. The serum sodium concentration is a laboratory measure for osmolality imbalances, not ECV imbalances. Edema is a sign of ECV excess, not hypernatremia. Skin tenting, dry mouth, postural hypotension, and tachycardia all can be signs of ECV deficit.)

The nurse is guiding parents in selecting a day care facility for their child. When making the selection, it is especially important to consider: a. Structured learning environment. b. Socioeconomic status of children. c. Cultural similarities of children. d. Teachers knowledgeable about development.

ANS: D A teacher knowledgeable about development will structure activities for learning. A structured learning environment is not necessary at this age. Socioeconomic status is not the most important factor in selecting a preschool. Preschool is about expanding experiences with others; cultural similarities are not necessary.

Which characteristic best describes the language of a 3-year-old child? a. Asks meanings of words b. Follows directional commands c. Can describe an object according to its composition d. Talks incessantly, regardless of whether anyone is listening

ANS: D Because of the dramatic vocabulary increase at this age, 3-year-olds are known to talk incessantly, regardless of whether anyone is listening. A 4- to 5-year-old asks lots of questions and can follow simple directional commands. A 6-year-old can describe an object according to its composition.

Which is probably the most important criterion on which to base the decision to report suspected child abuse? a. Inappropriate parental concern for the degree of injury b. Absence of parents for questioning about childs injuries c. Inappropriate response of child d. Incompatibility between the history and injury observed

ANS: D Conflicting stories about the accident are the most indicative red flags of abuse. Inappropriate response of caregiver or child may be present, but is subjective. Parents should be questioned at some point during the investigation.

Which is the causative agent of scarlet fever? a. Enteroviruses b. Corynebacterium organisms c. Scarlet fever virus d. Group A b-hemolytic streptococci (GABHS)

ANS: D GABHS infection causes scarlet fever. Enteroviruses do not cause the same complications. Corynebacterium organisms cause diphtheria. Scarlet fever is not caused by a virus.

What describes the cognitive abilities of school-age children? a. Have developed the ability to reason abstractly b. Become capable of scientific reasoning and formal logic c. Progress from making judgments based on what they reason to making judgments based on what they see d. Have the ability to classify, group and sort, and hold a concept in their minds while making decisions based on that concept

ANS: D In Piagets stage of concrete operations, children have the ability to group and sort and make conceptual decisions. Children cannot reason abstractly until late adolescence. Scientific reasoning and formal logic are skills of adolescents. Making judgments on what the child sees versus what he or she reasons is not a developmental skill.

In girls, the initial indication of puberty is: a. Menarche. b. Growth spurt. c. Growth of pubic hair. d. Breast development.

ANS: D In most girls, the initial indication of puberty is the appearance of breast buds, an event known as the larche. The usual sequence of secondary sexual characteristic development in girls is breast changes, rapid increase in height and weight, growth of pubic hair, appearance of axillary hair, menstruation, and abrupt deceleration of linear growth.

Which statement is most descriptive of bulimia during adolescence? a. Strong sense of control over eating behavior b. Feelings of elation after the binge-purge cycle c. Profound lack of awareness that the eating pattern is abnormal d. Weight that can be normal, slightly above normal, or below normal

ANS: D Individuals with bulimia are of normal weight or more commonly slightly above normal weight. Those who also restrict their intake can become severely underweight. Behavior related to this eating disorder is secretive, frenzied, and out of control. These cycles are followed by self-deprecating thoughts and a depressed mood. These young women are keenly aware that this eating pattern is abnormal.

What is characteristic of dishonest behavior in children ages 8 to 10 years? a. Cheating during games is now more common. b. Lying results from the inability to distinguish between fact and fantasy. c. They may steal because their sense of property rights is limited. d. They may lie to meet expectations set by others that they have been unable to attain.

ANS: D Older school-age children may lie to meet expectations set by others to which they have been unable to measure up. Cheating usually becomes less frequent as the child matures. In this age group, children are able to distinguish between fact and fantasy. Young children may lack a sense of property rights; older children may steal to supplement an inadequate allowance, or it may be an indication of serious problems.

The role of the peer group in the life of school-age children is that it: a. Gives them an opportunity to learn dominance and hostility. b. Allows them to remain dependent on their parents for a longer time. c. Decreases their need to learn appropriate sex roles. d. Provides them with security as they gain independence from their parents.

ANS: D Peer-group identification is an important factor in gaining independence from parents. Through peer relationships, children learn ways to deal with dominance and hostility. They also learn how to relate to people in positions of leadership and authority and explore ideas and the physical environment. Peer-group identification helps in gaining independence rather than remaining dependent. A childs concept of appropriate sex roles is influenced by relationships with peers.

When planning care for adolescents, the nurse should: a. Teach parents first, and they, in turn, will teach the teenager. b. Provide information for their long-term health needs because teenagers respond best to long-range planning. c. Maintain the parents role by providing explanations for treatment and procedures to the parents only. d. Give information privately to adolescents about how they can manage the specific problems that they identify.

ANS: D Problems that teenagers identify and are interested in are typically the problems that they are the most willing to address. Confidentiality is important to adolescents. Adolescents prefer to confer privately (without parents) with the nurse and health care provider. Teenagers are socially and cognitively at the developmental stage where the health care provider can teach them. The nurse must keep in mind that teenagers are more interested in immediate health care needs than in long-term needs.

Which comment is most developmentally typical of a 7-year-old boy? a. I am a Power Ranger, so dont make me angry. b. I dont know whether I like Mary or Joan better. c. My mom is my favorite person in the world. d. Jimmy is my best friend.

ANS: D School-age children form friendships with peers of the same sex, those who live nearby, and other children who have toys that they enjoy sharing. Magical thinking is developmentally appropriate for the preschooler. Opposite-sex friendships are not typical for the 7-year-old child. Seven-year-old children socialize with their peers, not their parents.

A school nurse is teaching dental health practices to a group of sixth-grade children. How often should the nurse recommend the children brush their teeth? a. Twice a day b. Three times a day c. After meals d. After meals and snacks, and at bedtime

ANS: D Teeth should be brushed after meals, after snacks, and at bedtime. Children who brush their teeth frequently and become accustomed to the feel of a clean mouth at an early age usually maintain the habit throughout life. Twice a day, three times a day, or only after meals would not be often enough.

Steve, 14 years old, mentions that he now has to use deodorant but never had to before. The nurses response should be based on knowledge that: a. Eccrine sweat glands in the axillae become fully functional during puberty. b. Sebaceous glands become extremely active during puberty. c. New deposits of fatty tissue insulate the body and cause increased sweat production. d. Apocrine sweat glands reach secretory capacity during puberty.

ANS: D The apocrine sweat glands, nonfunctional in children, reach secretory capacity during puberty. They secrete a thick substance as a result of emotional stimulation that, when acted on by surface bacteria, becomes highly odoriferous. They are limited in distribution and grow in conjunction with hair follicles in the axillae, genital and anal areas, and other areas. Eccrine sweat glands are present almost everywhere on the skin and become fully functional and respond to emotional and thermal stimulation. Sebaceous glands become extremely active at this time, especially those on the genitals and the flush areas of the body, such as face, neck, shoulders, upper back, and chest. This increased activity is important in the development of acne. New deposits of fatty tissue insulate the body and cause increased sweat production, but this is not the etiology of apocrine sweat gland activity.

You are the nurse evaluating a newly admitted patient's laboratory results, which include several values that are outside of reference ranges. Which of the following would cause the release of antidiuretic hormone (ADH)? A) Increased serum sodium B) Decreased serum potassium C) Decreased hemoglobin D) Increased platelets

Ans: A Feedback: Increased serum sodium causes increased thirst and the release of ADH by the posterior pituitary gland. When serum osmolality decreases and thirst and ADH secretions are suppressed, the kidney excretes more water to restore normal osmolality. Levels of potassium, hemoglobin, and platelets do not directly affect ADH release.

Anorexia nervosa may best be described as: a. Occurring most frequently in adolescent males. b. Occurring most frequently in adolescents from lower socioeconomic groups. c. Resulting from a posterior pituitary disorder. d. Resulting in severe weight loss in the absence of obvious physical causes.

ANS: D The etiology of anorexia remains unclear, but a distinct psychologic component is present. The diagnosis is based primarily on psychologic and behavioral criteria. Anorexia nervosa is observed more commonly in adolescent girls and young women. It does not occur most frequently in adolescents from a lower socioeconomic group. In reality, anorexic adolescents are often from families of means who have high parental expectations for achievement. Anorexia is a psychiatric disorder.

An adolescent boy tells the nurse that he has recently had homosexual feelings. The nurses response should be based on knowledge that: Capability to use a future time perspective Ability to place things in a sensible and logical order Ability to see things from the point of view of another Progress from making judgments based on what they see to making judgments based on what they reason a. This indicates that the adolescent is homosexual. b. This indicates that the adolescent will become homosexual as an adult. c. The adolescent should be referred for psychotherapy. d. The adolescent should be encouraged to share his feelings and experiences.

ANS: D These adolescents are at increased risk for health-damaging behaviors, not because of the sexual behavior itself, but because of societys reaction to the behavior. The nurses first priority is to give the young man permission to discuss his feelings about this topic, knowing that the nurse will maintain confidentially, appreciate his feelings, and remain sensitive to his need to talk it. In recent studies among self-identified gay, lesbian, and bisexual adolescents, many of the adolescents report changing their self-labels one or more times during their adolescence.

The father of 12-year-old Ryan tells the nurse that he is concerned about his son getting fat. Ryans body mass index for age is at the 60th percentile. The most appropriate nursing action is to: a. Reassure the father that Ryan is not fat. b. Reassure the father that Ryan is just a growing child. c. Suggest a low-calorie, low-fat diet. d. Explain that this is typical of the growth pattern of boys at this age.

ANS: D This is a characteristic pattern of growth in preadolescent boys, in which the growth in height has slowed in preparation for the pubertal growth spurt but weight is still gained. This should be reviewed with both the father and Ryan, and a plan should be developed to maintain physical exercise and a balanced diet. Saying that Ryan is not fat is false reassurance. His weight is high for his height. Ryan needs to maintain his physical activity. The father is concerned; an explanation is required. A nutritional diet with physical activity should be sufficient to maintain his balance.

Which accomplishment would the nurse expect of a healthy 3-year-old child? a. Jump rope b. Ride a two-wheel bicycle c. Skip on alternate feet d. Balance on one foot for a few seconds

ANS: D Three-year-olds are able to accomplish the gross motor skill of balancing on one foot. Jumping rope, riding a two-wheel bike, and skipping on alternate feet are gross motor skills of 5-year-old children.

Which medication may be given to high risk children after exposure to chickenpox to prevent varicella? a. Acyclovir b. Vitamin A c. Diphenhydramine hydrochloride d. Varicella zoster immune globulin (VZIG)

ANS: D VZIG is given to high risk children to help prevent the development of chickenpox. Immune globulin intravenous may also be recommended. Acyclovir is given to immunocompromised children to reduce the severity of symptoms. Vitamin A reduces morbidity and mortality associated with the measles. The antihistamine diphenhydramine is administered to reduce the itching associated with chickenpox.

The weight loss of anorexia nervosa is often triggered by: a. Sexual abuse. b. School failure. c. Independence from family. d. Traumatic interpersonal conflict.

ANS: D Weight loss may be triggered by a typical adolescent crisis such as the onset of menstruation or a traumatic interpersonal incident; situations of severe family stress such as parental separation or divorce; or circumstances in which the young person lacks personal control, such as being teased, changing schools, or entering college. There may in fact be a history of sexual abuse; however, this is not the trigger. These adolescents are often overachievers who are successful in school, not failures in school. The adolescent is most often enmeshed with his or her family.

The school nurse has been asked to begin teaching sex education in the 5th grade. The nurse should recognize that: a. Children in 5th grade are too young for sex education. b. Children should be discouraged from asking too many questions. c. Correct terminology should be reserved for children who are older. d. Sex can be presented as a normal part of growth and development.

ANS: D When sex information is presented to school-age children, sex should be treated as a normal part of growth and development. Fifth graders are usually 10 to 11 years old. This age is not too young to speak about physiologic changes in their bodies. They should be encouraged to ask questions. Preadolescents need precise and concrete information.

Which statement concerning the benefits or limitations of breastfeeding is inaccurate? a. Breast milk changes over time to meet changing needs as infants grow. b. Long-term studies have shown that the benefits of breast milk continue after the infant is weaned. c. Breast milk/breastfeeding may enhance cognitive development. d. Breastfeeding increases the risk of childhood obesity

ANS: D Breastfeeding actually decreases the risk of childhood obesity. There are multiple benefits of breastfeeding. Breast milk changes over time to meet changing needs as infants grow. Long-term studies have shown that the benefits of breast milk continue after the infant is weaned. Breast milk/breastfeeding may enhance cognitive development.

When caring for a middle-aged adult exhibiting maladaptive coping skills, the nurse is trying to determine the cause of the patient's behavior. From a growth and development perspective, what should the nurse recall? a. Individuals have uniform patterns of growth and development. b. Health is promoted based on how many developmental failures a patient experiences. c. Culture usually has no effect on predictable patterns of growth and development. d. When individuals experience repeated developmental failures, inadequacies sometimes result.

ANS: D "If individuals experience repeated developmental failures, inadequacies sometimes result" is a true statement. Developmental failures could manifest with ineffective coping skills. However, when an individual experiences successes, health is promoted. Patients have unique patterns of growth and development that are not uniform. Nurses must consider the influence of culture and context on growth and development.

An African-American woman noticed some bruises on her newborn girls buttocks. She asks the nurse who spanked her daughter. The nurse explains that these marks are called: a. Lanugo. c. Nevus flammeus. b. Vascular nevi. d. Mongolian spots.

ANS: D A Mongolian spot is a bluish black area of pigmentation that may appear over any part of the exterior surface of the body. It is more commonly noted on the back and buttocks and most frequently is seen on infants whose ethnic origins are Mediterranean, Latin American, Asian, or African. Lanugo is the fine, downy hair seen on a term newborn. A vascular nevus, commonly called a strawberry mark, is a type of capillary hemangioma. A nevus flammeus, commonly called a port-wine stain, is most frequently found on the face.

An important nursing responsibility when dealing with a family experiencing the loss of an infant from sudden infant death syndrome (SIDS) is to: a. Explain how SIDS could have been predicted and prevented. b. Interview parents in depth concerning the circumstances surrounding the infants death. c. Discourage parents from making a last visit with the infant. d. Make a follow-up home visit to parents as soon as possible after the infants death.

ANS: D A competent, qualified professional should visit the family at home as soon as possible after the death and provide the family with printed information about SIDS. An explanation of how SIDS could have been predicted and prevented is inappropriate. SIDS cannot be prevented or predicted. Discussions about the cause will only increase parental guilt. The parents should be asked only factual questions to determine the cause of death. Parents should be allowed and encouraged to make a last visit with their infant.

Encouraging children to play a game of kickball would be best suited for which age group? a. Infant b. Toddler c. Preschool d. School-aged

ANS: D A game of kickball would be best suited for school-aged children because in this age group, play involves peers and the pursuit of group goals. Although solitary activities are not eliminated, group play overshadows them. Younger children typically are not able to participate cooperatively in groups yet. Infants begin to play simple social games such as patty-cake and peek-a-boo. Toddlers engage in solitary play but also begin to participate in parallel play. Preschoolers playing together engage in similar if not identical activities; however, no division of labor nor rigid organization nor rules are observed. By the age of 5, the group has a temporary leader for each activity.

During life in utero, oxygenation of the fetus occurs through transplacental gas exchange. When birth occurs, four factors combine to stimulate the respiratory center in the medulla. The initiation of respiration then follows. Which is not one of these essential factors? a. Chemical c. Thermal b. Mechanical d. Psychologic

ANS: D A psychologic factor is not one of the essential factors in the initiation of breathing; the fourth factor is sensory. The sensory factors include handling by the provider, drying by the nurse, lights, smells, and sounds. Chemical factors are essential for the initiation of breathing. During labor, decreased levels of oxygen and increased levels of carbon dioxide seem to have a cumulative effect that is involved in the initiation of breathing. Clamping of the cord may also contribute to the start of respirations. Prostaglandins are known to inhibit breathing, and clamping of the cord results in a drop in the level of prostaglandins. Mechanical factors also are necessary to initiate respirations. As the infant passes through the birth canal, the chest is compressed. With birth the chest is relaxed, which allows for negative intrathoracic pressure that encourages air to flow into the lungs. The profound change in temperature between intrauterine and extrauterine life stimulates receptors in the skin to communicate with the receptors in the medulla. This also contributes to the initiation of breathing

20.A chemotherapy patient has gained 5 pounds in 2 days. Which assessment question by the nurse is most appropriate? a. "Are you following any weight loss program?" b. "How many calories a day do you consume?" c. "Do you have dry mouth or feel thirsty?" d. "How many times a day do you urinate?"

ANS: D A rapid gain in weight usually indicates extracellular volume (ECV) excess if the person began with normal ECV. Asking the patient about urination habits will help determine whether the body is trying to excrete the excess fluid or if renal dysfunction is contributing to ECV excess. This is too rapid a weight gain to be dietary; it is fluid retention. Asking about following a weight loss program will not help determine the cause of the problem. Caloric intake does not account for rapid weight changes. Dry mouth and thirst accompany ECV deficit, which would be associated with rapid weight loss.

33.A nurse is assisting the health care provider in inserting a central line. Which action indicates the nurse is following the recommended bundle protocol to reduce central line-associated bloodstream infections (CLABSI)? a. Preps skin with povidone-iodine solution. b. Suggests the femoral vein for insertion site. c. Applies double gloving without hand hygiene. d. Uses chlorhexidine skin antisepsis prior to insertion.

ANS: D A recommended bundle at insertion of a central line is hand hygiene prior to catheter insertion; use of maximum sterile barrier precautions upon insertion; chlorhexidine skin antisepsis prior to insertion and during dressing changes; avoidance of the femoral vein for central venous access for adults; and daily evaluation of line necessity, with prompt removal of non-essential lines. Povidone-iodine is not recommended.

Which of these toys, if selected by the parent of a 10-month-old child, would indicate that the parent has a correct understanding of infant growth and development? a. A game requiring two to four players b. Electronic games c. Small, plastic alphabet letters and magnets d. Plastic stacking rings

ANS: D Adults facilitate infant learning by planning activities that promote the development of milestones and by providing toys that are safe for the infant to explore with the mouth and manipulate with the hands, such as rattles, wooden blocks, plastic stacking rings, squeezable stuffed animals, and busy boxes. Infants are not capable of participating in small group activities. By age 4, children play in groups of two or three. For the toddler (not the infant), television, videos, electronic games, and computer programs help support development and learning of basic skills. Adults should provide toys that are safe for the infant to explore with the mouth. Small, plastic letters and magnets could be choking hazards for an infant.

A postpartum woman telephones about her 4-day-old infant. She is not scheduled for a weight check until the infant is 10 days old, and she is worried about whether breastfeeding is going well. Effective breastfeeding is indicated by the newborn who: a. Sleeps for 6 hours at a time between feedings. b. Has at least one breast milk stool every 24 hours. c. Gains 1 to 2 ounces per week. d. Has at least six to eight wet diapers per day

ANS: D After day 4, when the mothers milk comes in, the infant should have six to eight wet diapers every 24 hours. Sleeping for 6 hours between feedings is not an indication of whether the infant is breastfeeding well. Typically infants sleep 2 to 4 hours between feedings, depending on whether they are being fed on a 2- to 3- hour schedule or cluster fed. The infant should have a minimum of three bowel movements in a 24-hour period

6. An obstetric multipara with triplets is placed on bed rest at 24 weeks' gestation. Her perinatologist is managing intrauterine growth restriction with serial ultrasounds. This prescribed treatment is an example of which type of care? a. Antenatal diagnostics b. Primary prevention c. Secondary prevention d. Collaborative intervention

ANS: D An example of collaborative intervention relating to reproductive health would be managing fetal intrauterine growth restriction by serial ultrasounds. This type of diagnostic maternal/fetal monitoring is performed to determine the best time for delivery due to potential fetal nutritional, circulatory, or pulmonary compromise. A cesarean section (operative delivery) may be performed if maternal or fetal conditions indicate that delivery is necessary. Antenatal diagnostics refers to prior to pregnancy. An example of primary prevention is teaching a high school class about reproductive health. An example of secondary prevention is prenatal care in the second trimester of pregnancy to prevent problems for the developing fetus.

An Apgar score of 10 at 1 minute after birth would indicate a(n): a. Infant having no difficulty adjusting to extrauterine life and needing no further testing. b. Infant in severe distress who needs resuscitation. c. Prediction of a future free of neurologic problems. d. Infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth.

ANS: D An initial Apgar score of 10 is a good sign of healthy adaptation; however, it must be repeated at the 5-minute mark

Postbirth uterine/vaginal discharge, called lochia: a. Is similar to a light menstrual period for the first 6 to 12 hours. b. Is usually greater after cesarean births. c. Will usually decrease with ambulation and breastfeeding. d. Should smell like normal menstrual flow unless an infection is present.

ANS: D An offensive odor usually indicates an infection. Lochia flow should approximate a heavy menstrual period for the first 2 hours and then steadily decrease. Less lochia usually is seen after cesarean births and usually increases with ambulation and breastfeeding

The nurse caring for the postpartum woman understands that breast engorgement is caused by: a. Overproduction of colostrum. b. Accumulation of milk in the lactiferous ducts. c. Hyperplasia of mammary tissue. d. Congestion of veins and lymphatics.

ANS: D Breast engorgement is caused by the temporary congestion of veins and lymphatics, not by overproduction of colostrum, overproduction of milk, or hyperplasia of mammary tissue

The nurse caring for the postpartum woman understands that breast engorgement is caused by: a. Overproduction of colostrum. b. Accumulation of milk in the lactiferous ducts and glands. c. Hyperplasia of mammary tissue. d. Congestion of veins and lymphatics

ANS: D Breast engorgement is caused by the temporary congestion of veins and lymphatics. Breast engorgement is not the result of overproduction of colostrum. Accumulation of milk in the lactiferous ducts and glands does not cause breast engorgement. Hyperplasia of mammary tissue does not cause breast engorgement

Which statement describing physiologic jaundice is incorrect? a. Neonatal jaundice is common, but kernicterus is rare. b. The appearance of jaundice during the first 24 hours or beyond day 7 indicates a pathologic process. c. Because jaundice may not appear before discharge, parents need instruction on how to assess it and when to call for medical help. d. Breastfed babies have a lower incidence of jaundice

ANS: D Breastfeeding is associated with an increased incidence of jaundice. Neonatal jaundice occurs in 60% of newborns; the complication called kernicterus is rare. Jaundice in the first 24 hours or that persists past day 7 is cause for medical concern. Parents need to know how to assess for jaundice in their newborn

40.The nurse is caring for a patient with hyperkalemia. Which body system assessment is the priority? a. Gastrointestinal b. Neurological c. Respiratory d. Cardiac

ANS: D Cardiac is the priority. Hyperkalemia places the patient at risk for potentially serious dysrhythmias and cardiac arrest. Potassium balance is necessary for cardiac function. Respiratory is the priority with hypokalemia. Monitoring of gastrointestinal and neurological systems would be indicated for other electrolyte imbalances.

Nursing activities that promote parent-infant attachment are many and varied. One activity that should not be overlooked is management of the environment. While providing routine mother-baby care, the nurse should ensure that: a. The baby is able to return to the nursery at night so that the new mother can sleep. b. Routine times for care are established to reassure the parents. c. The father should be encouraged to go home at night to prepare for mother-baby discharge. d. An environment that fosters as much privacy as possible should be created.

ANS: D Care providers need to knock before gaining entry. Nursing care activities should be grouped. Once the baby has demonstrated adjustment to extrauterine life (either in the mothers room or the transitional nursery), all care should be provided in one location. This important principle of family-centered maternity care fosters attachment by giving parents the opportunity to learn about their infant 24 hours a day. One nurse should provide care to both mother and baby in this couplet care or rooming-in model. It is not necessary for the baby to return to the nursery at night. In fact, the mother will sleep better with the infant close by. Care should be individualized to meet the parents needs, not the routines of the staff. Teaching goals should be developed in collaboration with the parents. The father or other significant other should be permitted to sleep in the room with the mother. The maternity unit should develop policies that allow for the presence of significant others as much as the new mother desires

7. After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the clients understanding. Which food choice for lunch indicates the client correctly understood the teaching? a. Slices of smoked ham with potato salad b. Bowl of tomato soup with a grilled cheese sandwich c. Salami and cheese on whole wheat crackers d. Grilled chicken breast with glazed carrots

ANS: D Clients on restricted sodium diets generally should avoid processed, smoked, and pickled foods and those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh produce. The ham, tomato soup, salami, and crackers are often high in sodium.

When teaching parents about mandatory newborn screening, it is important for the nurse to explain that the main purpose is to: a. Keep the state records updated. b. Allow accurate statistical information. c. Document the number of births. d. Recognize and treat newborn disorders early

ANS: D Early treatment of disorders will prevent morbidity associated with inborn errors of metabolism or other genetic conditions. Keeping records and reporting for statistical purposes are not the primary reason for the screening test. The number of births recorded is not reported from the newborn screening test

A 3-month-old infant is at increased risk for developing anemia. The nurse would identify which principle contributing to this risk? a. The infant is becoming more active. b. There is an increase in intake of breast milk or formula. c. The infant is unable to maintain an adequate iron intake. d. A depletion of fetal hemoglobin occurs.

ANS: D Fetal hemoglobin is present for about 5 months. The fetal hemoglobin begins deteriorating, and around 2 to 3 months the infant is at increased risk of developing an anemia due to decreasing levels of hemoglobin. Breast milk or formula is the primary food intake up to around 6 months. Often iron supplemented formula is offered, and/or an iron supplement is given if the infant is breastfed.

Which maternal event is abnormal in the early postpartum period? a. Diuresis and diaphoresis b. Flatulence and constipation c. Extreme hunger and thirst d. Lochial color changes from rubra to alba

ANS: D For the first 3 days after childbirth, lochia is termed rubra. Lochia serosa follows, and then at about 11 days, the discharge becomes clear, colorless, or white. Diuresis and diaphoresis are the methods by which the body rids itself of increased plasma volume. Urine output of 3000 mL/day is common for the first few days after delivery and is facilitated by hormonal changes in the mother. Bowel tone remains sluggish for days. Many women anticipate pain during defecation and are unwilling to exert pressure on the perineum. The new mother is hungry because of energy used in labor and thirsty because of fluid restrictions during labor

22. What is the rationale for the nurse recommends to parents that peanuts are not a good snack food for toddlers? a. They are low in nutritive value. b. They are very high in sodium. c. They cannot be entirely digested. d. They can be easily aspirated.

ANS: D Foreign-body aspiration is common during the second year of life. Although they chew well, children at this age may have difficulty with large pieces of food such as meat and whole hot dogs and with hard foods such as nuts or dried beans. Peanuts have many beneficial nutrients but should be avoided because of the risk of aspiration in this age-group. The sodium level may be a concern, but the risk of aspiration is more important. Many foods pass through the gastrointestinal tract incompletely digested. This is not necessarily detrimental to the child.

2. What are the psychosocial developmental tasks of toddlerhood? a. Development of a conscience. b. Recognition of sex differences. c. Ability to get along with age mates. d. Ability to withstand delayed gratification.

ANS: D If the need for basic trust has been satisfied, toddlers can give up dependence for control, independence, and autonomy. One of the tasks that the toddler is concerned with is the ability to withstand delayed gratification. Development of a conscience occurs during the preschool years. The recognition of sex differences occurs during the preschool years. The ability to get along with age mates develops during the preschool and school-age years.

While assessing an 18-month-old toddler, the nurse distinguishes normal from abnormal findings by remembering that Gesell's theory of development states a. "The developmental stage of the toddler is affected solely by environmental influence." b. "Developmental patterns are not affected by gene activity." c. "Skill development should be identical to that of other toddlers in the playroom." d. "Environmental influence does not affect the sequence of development."

ANS: D Gesell's theory of development states that environment plays a part in child development, but it does not have any part in the sequence of development. Other factors influencing growth and development include biological, cognitive, and socioemotional processes. Environmental factors support, change, and modify the pattern of development, but they do not generate progressions of development. Each child's pattern of growth and development is unique and is directed by gene activity. Not every child develops certain skills at the same time. Children grow according to their own genetic blueprint.

When communicating with a newly admitted teenaged patient, the nurse should a. Avoid questioning the patient about cigarette use when she observes a cigarette lighter lying on the bedside table. b. Complete the admission database as quickly as possible by asking yes and no questions. c. Ignore the patient's withdrawn behavior. d. Observe for congruency between the patient's facial expressions and verbal responses.

ANS: D Good communication skills are critical for adolescents. Following are some hints for communicating with adolescents: Do not avoid discussing sensitive issues. Asking questions about sex, drugs, and school opens the channels for further discussion. Ask open-ended questions. Yes and no questions are closed-ended questions. Look for meaning behind their words and actions. The nurse should inquire about a patient's withdrawn behavior to seek out the meaning of such behaviors. Be alert to clues to their emotional state. The nurse should observe that the patient's statements are congruent with his/her facial expressions of emotion.

The school nurse talking with a high school class about the difference between growth and development would best describe growth as a. processes by which early cells specialize. b. psychosocial and cognitive changes. c. qualitative changes associated with aging. d. quantitative changes in size or weight.

ANS: D Growth is a quantitative change in which an increase in cell number and size results in an increase in overall size or weight of the body or any of its parts. The processes by which early cells specialize are referred to as differentiation. Psychosocial and cognitive changes are referred to as development. Qualitative changes associated with aging are referred to as maturation.

After giving birth to a healthy infant boy, a primiparous woman, 16 years old, is admitted to the postpartum unit. An appropriate nursing diagnosis for her at this time is Risk for impaired parenting related to deficient knowledge of newborn care. In planning for the womans discharge, what should the nurse be certain to include in the plan of care? a. Instruct the patient how to feed and bathe her infant. b. Give the patient written information on bathing her infant. c. Advise the patient that all mothers instinctively know how to care for their infants. d. Provide time for the patient to bathe her infant after she views an infant bath demonstration.

ANS: D Having the mother demonstrate infant care is a valuable method of assessing the clients understanding of her newly acquired knowledge, especially in this age group, because she may inadvertently neglect her child. Although verbalizing how to care for the infant is a form of patient education, it is not the most developmentally appropriate teaching for a teenage mother. Advising the patient that all mothers instinctively know how to care for their infants is an inappropriate statement; it is belittling and false.

Which condition, not uncommon in pregnancy, is likely to require careful medical assessment during the puerperium? a. Varicosities of the legs b. Carpal tunnel syndrome c. Periodic numbness and tingling of the fingers d. Headaches

ANS: D Headaches in the postpartum period can have a number of causes, some of which deserve medical attention. Total or nearly total regression of varicosities is expected after childbirth. Carpal tunnel syndrome is relieved in childbirth when the compression on the median nerve is lessened. Periodic numbness of the fingers usually disappears after birth unless carrying the baby aggravates the condition

The nursing instructor will need to provide further instruction to the student who states a. "Intellectual development is affected by cognitive processes." b. "Socioemotional processes can influence an individual's growth and development." c. "Breast development is an example of a change resulting from biological processes." d. "An individual's biological processes determine physical characteristics and do not affect growth and development."

ANS: D Human growth and development is a complex pattern of movement that involves changes in biological, cognitive, and socioemotional processes. Cognitive processes comprise changes in intelligence, use of language, and development of thinking. Socioemotional processes consist of variations in personality, emotions, and relationships with others. Height and weight, development of gross and fine motor skills, and sexual maturation resulting from hormonal changes during puberty are examples of changes resulting from biological processes.

A 25-year-old multiparous woman gave birth to an infant boy 1 day ago. Today her husband brings a large container of brown seaweed soup to the hospital. When the nurse enters the room, the husband asks for help with warming the soup so that his wife can eat it. The nurses most appropriate response is to ask the woman: a. Didnt you like your lunch? b. Does your doctor know that you are planning to eat that? c. What is that anyway? d. Ill warm the soup in the microwave for you

ANS: D Ill warm the soup in the microwave for you shows cultural sensitivity to the dietary preferences of the woman and is the most appropriate response. Cultural dietary preferences must be respected. Women may request that family members bring favorite or culturally appropriate foods to the hospital. What is that anyway? does not show cultural sensitivity

In a variation of rooming-in, called couplet care, the mother and infant share a room, and the mother shares the care of the infant with: a. The father of the infant. b. Her mother (the infants grandmother). c. Her eldest daughter (the infants sister). d. The nurse.

ANS: D In couplet care the mother shares a room with the newborn and shares infant care with a nurse educated in maternity and infant care.

The nursing student is preparing a teaching project for parents of school-aged children. Which statement correctly identifies health risks in this age group? a. "School-aged children are more likely to suffer from unintentional injury." b. "The risk for infection is not a major concern of this age group as immunity develops." c. "Mental retardation, learning disorders, and malnutrition are prevalent across all socioeconomic categories." d. "Poor nutrition and lack of immunizations continue to be health concerns for children of the poor."

ANS: D Infant mortality, dental problems, poor nutrition, and lack of immunizations continue to be major health concerns for uninsured or impoverished families. Accidents and injuries are major health problems affecting school-aged children. They now have more exposure to various environments and less supervision, but their developed cognitive and motor skills make them less likely to suffer from unintentional injury. Infections account for most childhood illnesses. Mental retardation, learning disorders, and malnutrition are far more prevalent among children living in poverty.

Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman empty her bladder spontaneously as soon as possible. If all else fails, the last thing the nurse could try is: a. Pouring water from a squeeze bottle over the womans perineum. b. Placing oil of peppermint in a bedpan under the woman. c. Asking the physician to prescribe analgesics. d. Inserting a sterile catheter.

ANS: D Invasive procedures usually are the last to be tried, especially with so many other simple and easy methods available (e.g., water, peppermint vapors, pain medication). Pouring water over the perineum may stimulate voiding. It is easy, noninvasive, and should be tried early. The oil of peppermint releases vapors that may relax the necessary muscles. If the woman is anticipating pain from voiding, pain medications may be helpful. Other nonmedical means and pain medication should be tried before insertion of a catheter.

A woman gave birth to a healthy infant boy 5 days ago. What type of lochia would the nurse expect to find when assessing this woman? a. Lochia rubra c. Lochia alba b. Lochia sangra d. Lochia serosa

ANS: D Lochia serosa, which consists of blood, serum, leukocytes, and tissue debris, generally occurs around day 3 or 4 after childbirth. Lochia rubra consists of blood and decidual and trophoblastic debris. The flow generally lasts 3 to 4 days and pales, becoming pink or brown. There is no such term as lochia sangra. Lochia alba occurs in most women after day 10 and can continue up to 6 weeks after childbirth

Nursing care in the fourth trimester includes an important intervention sometimes referred to as taking the time to mother the mother. Specifically this expression refers to: a. Formally initializing individualized care by confirming the womans and infants identification (ID) numbers on their respective wrist bands. (This is your baby.) b. Teaching the mother to check the identity of any person who comes to remove the baby from the room. (Its a dangerous world out there.) c. Including other family members in the teaching of self-care and child care. (Were all in this together.) d. Nurturing the woman by providing encouragement and support as she takes on the many tasks of motherhood.

ANS: D Many professionals believe that the nurses nurturing and support function is more important than providing physical care and teaching. Matching ID wrist bands is more of a formality, but it is also a get-acquainted procedure. Mothering the mother is more a process of encouraging and supporting the woman in her new role. Having the mother check IDs is a security measure for protecting the baby from abduction. Teaching the whole family is just good nursing practice.

Which information should the nurse teach workers at a day care center about respiratory syncytial virus (RSV)? a. RSV is transmitted through particles in the air. b. RSV can live on skin or paper for up to a few seconds after contact. c. RSV can survive on nonporous surfaces for about 60 minutes. d. Frequent hand washing can decrease the spread of the virus.

ANS: D Meticulous hand washing can decrease the spread of organisms. RSV infection is not airborne. It is acquired mainly through contact with contaminated surfaces. RSV can live on skin or paper for up to 1 hour and on cribs and other nonporous surfaces for up to 6 hours.

All parents are entitled to a birthing environment in which breastfeeding is promoted and supported. The Baby Friendly Hospital Initiative endorsed by WHO and UNICEF was founded to encourage institutions to offer optimal levels of care for lactating mothers. Which instruction is not included in the Ten Steps to Successful Breastfeeding for Hospitals? a. Give newborns no food or drink other than breast milk. b. Have a written breastfeeding policy that is communicated to all staff. c. Help mothers initiate breastfeeding within one half hour of birth. d. Give artificial teats or pacifiers as necessary

ANS: D No artificial teats or pacifiers (also called dummies or soothers) should be given to breastfeeding infants. No other food or drink should be given to the newborn unless medically indicated. The breastfeeding policy should be routinely communicated to all health care staff. All staff should be trained in the skills necessary to maintain this policy.

32.A nurse is caring for a patient who is receiving peripheral intravenous (IV) therapy. When the nurse is flushing the patient's peripheral IV, the patient reports pain. Upon assessment, the nurse notices a red streak that is warm to the touch. What is the nurse's initial action? a. Record a phlebitis grade of 4. b. Assign an infiltration grade. c. Apply moist compress. d. Discontinue the IV.

ANS: D The IV site has phlebitis. The nurse should discontinue the IV. The phlebitis score is 3. The site has phlebitis, not infiltration. A moist compress may be needed after the IV is discontinued.

Which of these approaches would be most appropriate for the nurse to use when teaching a 4-year-old patient about a scheduled surgery? a. Give the parents a book to read about the procedure and do not discuss the procedure with the child to decrease anxiety. b. Set boundaries before teaching by telling the child that she can ask only three questions because time is limited. c. Insist that the parents wait outside the room to ensure privacy of the child. d. Allow the child to touch and hold medical equipment such as thermometers and syringes.

ANS: D Nursing interventions during the preoperational period (age 2 to 7 years) should recognize the use of play (such as handling equipment) to help the child understand the events taking place. Giving the parents a book and not involving the child is not the best option, because the nurse should explain all procedures to children and their parents. Children tend to ask a lot of questions; therefore limiting questions may increase anxiety. Parents and the child all should be involved in preoperative teaching because the parents will be the primary caregivers upon discharge.

1. A female college student is planning to become sexually active. She is considering birth control options and desires a method in which ovulation will be prevented. To prevent ovulation while reaching 99% effectiveness in preventing pregnancy, which option should be given the strongest consideration? a. Intrauterine device b. Coitus interruptus c. Natural family planning d. Oral contraceptive pills

ANS: D Oral contraceptive pills prevent ovulation and are 99% effective in preventing pregnancy when taken as directed. Intrauterine devices, coitus interruptus, and natural family planning will not prevent ovulation while reaching 99% effectiveness in preventing pregnancy, so they are not recommended for this college student.

Which of the following is characteristic of the cognitive changes in a preschooler? a. The ability to think in a logical manner about the here and now b. The ability to think abstractly and deal effectively with hypothetical problems c. The inability to assume the view of another person and to use symbols to represent others d. The ability to classify objects by size or color

ANS: D Preschoolers demonstrate their ability to think more complexly by classifying objects according to size or color. Cognitive changes that provide the ability to think in a logical manner about the here and now and to understand the relationships between things and ideas occur during the school-aged years. It is during the teenaged years when the individual thinks abstractly and deals effectively with hypothetical problems. The toddler is unable to assume the view of another. Toddlers also use symbols to represent objects, places, and persons.

When caring for an infant with an upper respiratory tract infection and elevated temperature, an appropriate nursing intervention is to: a. Give tepid water baths to reduce fever. b. Encourage food intake to maintain caloric needs. c. Have child wear heavy clothing to prevent chilling. d. Give small amounts of favorite fluids frequently to prevent dehydration.

ANS: D Preventing dehydration by small frequent feedings is an important intervention in the febrile child. Tepid water baths may induce shivering, which raises temperature. Food should not be forced; it may result in the child vomiting. The febrile child should be dressed in light, loose clothing.

Which clinical management prevention concept would the nurse identify as representative of secondary prevention? a. Decreasing venous stasis and risk for pulmonary emboli b. Implementation of strict hand washing routines c. Maintaining current vaccination schedules d. Prevention of pneumonia in patients with chronic lung disease

ANS: D Prevention of and treatment of existing health problems to avoid further complications is an example of secondary prevention. Primary prevention includes infection control (hand washing), smoking cessation, immunizations, and prevention of postoperative complications.

A postpartum patient asks, Will these stretch marks go away? The nurses best response is: a. They will continue to fade and should be gone by your 6-week checkup. b. No, never. c. Yes, eventually. d. They will fade to silvery lines but won`t disappear completely

ANS: D Stretch marks never disappear altogether; however, they gradually fade to silvery lines.

Which symptoms should the nurse expect to observe during the physical assessment of an adolescent girl with severe weight loss and disrupted metabolism associated with anorexia nervosa? a. Dysmenorrhea and oliguria b. Tachycardia and tachypnea c. Heat intolerance and increased blood pressure d. Lowered body temperature and brittle nails

ANS: D Symptoms of anorexia nervosa include lower body temperature, severe weight loss, decreased blood pressure, dry skin, brittle nails, altered metabolic activity, and presence of lanugo hair. Amenorrhea, rather than dysmenorrhea, and cold intolerance are manifestations of anorexia nervosa. Bradycardia, rather than tachycardia, may be present.

4. The nurse is planning care for a 17-month-old child. According to Piaget, in what stage would the nurse expect the child to be? a. Trust b. Preoperations c. Secondary circular reaction d. Tertiary circular reaction

ANS: D The 17 month old is in the fifth stage of the sensorimotor phase: tertiary circular reactions. The child uses active experimentation to achieve previously unattainable goals. Trust is Erikson's first stage. Preoperation is the stage of cognitive development, usually present in older toddlers and preschoolers. Secondary circular reactions last from about ages 4 to 8 months.

When responding to the question Will I produce enough milk for my baby as she grows and needs more milk at each feeding? the nurse should explain that: a. The breast milk will gradually become richer to supply additional calories. b. As the infant requires more milk, feedings can be supplemented with cows milk. c. Early addition of baby food will meet the infants needs. d. The mothers milk supply will increase as the infant demands more at each feeding

ANS: D The amount of milk produced depends on the amount of stimulation of the breast. Increased demand with more frequent and longer breastfeeding sessions results in more milk available for the infant. Mature breast milk will stay the same. The amounts will increase as the infant feeds for longer times. Supplementation will decrease the amount of stimulation of the breast and decrease the milk production. Solids should not be added until about 4 to 6 months, when the infants immune system is more mature. This will decrease the chance of allergy formations.

11. The parents of a newborn say that their toddler "hates the baby and suggested that we put the baby in the trash can so the trash truck could take him away." What is the nurse's best response to the parent's concern? a. "Let's see if we can figure out why your toddler hates the new baby." b. "That's a strong statement to come from such a small child." c. "Let's refer your child to counseling to work this hatred out. It's not a normal response." d. "That is a normal response to the birth of a sibling. Let's look at ways to deal with this."

ANS: D The arrival of a new infant represents a crisis for even the best-prepared toddler. Toddlers have their entire schedule and routines disrupted because of the new family member. The nurse should work with parents on ways to involve the toddler in the newborn's care and help focus attention on the toddler. The toddler does not hate the infant. This is an expected response to the changes in routines and attention that affect the toddler. This is a normal response. The toddler can be provided with a doll to tend to its needs when the parent is performing similar care for the newborn.

While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms, his fingers fan out and form a C with the thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a positive: a. Tonic neck reflex. c. Babinski reflex. b. Glabellar (Myerson) reflex. d. Moro reflex.

ANS: D The characteristics displayed by the infant are associated with a positive Moro reflex. The tonic neck reflex occurs when the infant extends the leg on the side to which the infants head simultaneously turns. The glabellar reflex is elicited by tapping on the infants head while the eyes are open. A characteristic response is blinking for the first few taps. The Babinski reflex occurs when the sole of the foot is stroked upward along the lateral aspect of the sole and then across the ball of the foot. A positive response occurs when all the toes hyperextend, with dorsiflexion of the big toe

16. A father tells the nurse that his toddler wants the same plate and cup used at every meal, even if they go to a restaurant. The nurse should explain that this is a result of what factor? a. A sign that the child is spoiled. b. A way to exert unhealthy control. c. Regression, common at this age. d. Ritualism, common at this age.

ANS: D The child is exhibiting the ritualism that is characteristic at this age. Ritualism is the need to maintain sameness and reliability. It provides a sense of comfort to the toddler. It will dictate certain principles in feeding practices, including rejecting a favorite food because it is served in a different container. This does not indicate a child who has unreasonable expectations or a need to exert control, but rather normal development. Toddlers use ritualistic behaviors to maintain necessary structure in their lives. This is not regression, which is a retreat from a present pattern of functioning.

Nurses should be able to teach breastfeeding mothers the signs that the infant has latched on correctly. Which statement indicates a poor latch? a. She feels a firm tugging sensation on her nipples but not pinching or pain. b. The baby sucks with cheeks rounded, not dimpled. c. The babys jaw glides smoothly with sucking. d. She hears a clicking or smacking sound

ANS: D The clicking or smacking sound may indicate that the baby is having difficulty keeping the tongue out over the lower gum ridge. The mother should hope to hear the sound of swallowing. The tugging sensation without pinching is a good sign. Rounded cheeks are a positive indicator of a good latch. A smoothly gliding jaw is a good sign

A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago by cesarean section is found to have moist lung sounds. What is the best interpretation of these data? a. The nurse should notify the pediatrician stat for this emergency situation. b. The neonate must have aspirated surfactant. c. If this baby was born vaginally, it could indicate a pneumothorax. d. The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth.

ANS: D The condition will resolve itself within a few hours. For this common condition of newborns, surfactant acts to keep the expanded alveoli partially open between respirations. In vaginal births, absorption of remaining lung fluid is accelerated by the process of labor and delivery. Remaining lung fluid will move into interstitial spaces and be absorbed by the circulatory and lymphatic systems. This is a particularly common condition for infants delivered by cesarean section. Surfactant is produced by the lungs, so aspiration is not a concern.

After they are born, a crying infant may be soothed by being held in a position in which the newborn can hear the mothers heartbeat. This phenomenon is known as: a. Entrainment. c. Synchrony. b. Reciprocity. d. Biorhythmicity

ANS: D The newborn is in rhythm with the mother. The infant develops a personal biorhythm with the parents help over time. Entrainment is the movement of newborns in time to the structure of adult speech. Reciprocity is body movement or behavior that gives cues to the persons desires. These take several weeks to develop with a new baby. Synchrony is the fit between the infants behavioral cues and the parents responses

19. The nurse is discussing with a parent group the importance of fluoride for healthy teeth. What recommendation should the nurse make to the parents? a. Use fluoridated mouth rinses in children older than 1 year. b. Have children brush teeth with fluoridated toothpaste unless fluoride content of water supply is adequate. c. Give fluoride supplements to breastfed infants beginning at age 1 month. d. Determine whether water supply is fluoridated.

ANS: D The decision about fluoride supplementation cannot be made until it is known whether the water supply contains fluoride and the amount. It is difficult to teach this age-group to spit out the mouthwash. Swallowing fluoridated mouthwashes can contribute to fluorosis. Fluoridated toothpaste is still indicated, but very small amounts are used. Fluoride supplementation is not recommended until after age 6 months.

With regard to postpartum ovarian function, nurses should be aware that: a. Almost 75% of women who do not breastfeed resume menstruating within a month after birth. b. Ovulation occurs slightly earlier for breastfeeding women. c. Because of menstruation/ovulation schedules, contraception considerations can be postponed until after the puerperium. d. The first menstrual flow after childbirth usually is heavier than normal

ANS: D The first flow is heavier, but within three or four cycles, it is back to normal. Ovulation can occur within the first month, but for 70% of nonlactating women, it returns within 12 weeks after birth. Breastfeeding women take longer to resume ovulation. Because many women ovulate before their first postpartum menstrual period, contraceptive options need to be discussed early in the puerperium

As part of their teaching function at discharge, nurses should educate parents regarding safe sleep. Which statement is incorrect? a. Prevent exposure to people with upper respiratory tract infections. b. Keep the infant away from secondhand smoke. c. Avoid loose bedding, water beds, and beanbag chairs. d. Place the infant on his or her abdomen to sleep

ANS: D The infant should be laid down to sleep on his or her back for better breathing and to prevent sudden infant death syndrome. Infants are vulnerable to respiratory infections; infected people must be kept away. Secondhand smoke can damage lungs. Infants can suffocate in loose bedding, and furniture that can trap them. Per AAP guidelines, infants should always be placed back to sleep and allowed tummy time to play, to prevent plagiocephaly

Early this morning, an infant boy was circumcised using the PlastiBell method. The nurse tells the mother that she and the infant can be discharged after: a. The bleeding stops completely. b. Yellow exudate forms over the glans. c. The PlastiBell rim falls off. d. The infant voids

ANS: D The infant should be observed for urination after the circumcision. Bleeding is a common complication after circumcision. The nurse will check the penis for 12 hours after a circumcision to assess and provide appropriate interventions for prevention and treatment of bleeding. Yellow exudates cover the glans penis in 24 hours after the circumcision. This is part of normal healing and not an infective process. The PlastiBell remains in place for about a week and falls off when healing has taken place.

A primiparous woman is delighted with her newborn son and wants to begin breastfeeding as soon as possible. The nurse can facilitate the infants correct latch-on by helping the woman hold the infant: a. With his arms folded together over his chest. b. Curled up in a fetal position. c. With his head cupped in her hand. d. With his head and body in alignment

ANS: D The infants head and body should be in correct alignment with the mother and the breast during latch-on and feeding. Holding the infant with his arms folded together over his chest, curled up in a fetal position, or with his head cupped in her hand are not ideal positions to facilitate latch-on.

The nurse assessing a newborn knows that the most critical physiologic change required of the newborn is: a. Closure of fetal shunts in the circulatory system. b. Full function of the immune defense system at birth. c. Maintenance of a stable temperature. d. Initiation and maintenance of respirations

ANS: D The most critical adjustment of a newborn at birth is the establishment of respirations. The cardiovascular system changes markedly after birth as a result of fetal respiration, which reduces pulmonary vascular resistance to the pulmonary blood flow and initiates a chain of cardiac changes that support the cardiovascular system. The infant relies on passive immunity received from the mother for the first 3 months of life. After the establishment of respirations, heat regulation is critical to newborn survival.

A newly delivered mother who intends to breastfeed tells her nurse, I am so relieved that this pregnancy is over so I can start smoking again. The nurse encourages the client to refrain from smoking. However, this new mother insists that she will resume smoking. The nurse will need to adapt her health teaching to ensure that the client is aware that: a. Smoking has little or no effect on milk production. b. There is no relation between smoking and the time of feedings. c. The effects of secondhand smoke on infants are less significant than for adults. d. The mother should always smoke in another room.

ANS: D The new mother should be encouraged not to smoke. If she continues to smoke, she should be encouraged to always smoke in another room removed from the baby. Smoking may impair milk production. When the products of tobacco are broken down, they cross over into the breast milk. Tobacco also results in a reduction of the immunologic properties of breast milk. Research supports that mothers should not smoke within 2 hours before a feeding. The effects of secondhand smoke on infants include sudden infant death syndrome.

A new father states, I know nothing about babies, but he seems to be interested in learning. This is an ideal opportunity for the nurse to: a. Continue to observe his interaction with the newborn. b. Tell him when he does something wrong. c. Show no concern, as he will learn on his own. d. Include him in teaching sessions.

ANS: D The nurse must be sensitive to the fathers needs and include him whenever possible. As fathers take on their new role, the nurse should praise every attempt, even if his early care is awkward. It is important to note the bonding process of the mother and the father; however, that does not satisfy the expressed needs of the father. The new father should be encouraged in caring for his baby by pointing out the things that he does right. Criticizing him will discourage him

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurses first action is to: a. Begin an intravenous (IV) infusion of Ringers lactate solution. b. Assess the womans vital signs. c. Call the womans primary health care provider. d. Massage the womans fundus.

ANS: D The nurse should assess the uterus for atony. Uterine tone must be established to prevent excessive blood loss. The nurse may begin an IV infusion to restore circulatory volume, but this would not be the first action. Blood pressure is not a reliable indicator of impending shock from impending hemorrhage; assessing vital signs should not be the nurses first action. The physician would be notified after the nurse completes the assessment of the woman

37.A patient has an acute intravascular hemolytic reaction to a blood transfusion. After discontinuing the blood transfusion, which is the nurse's next action? a. Discontinue the IV catheter. b. Return the blood to the blood bank. c. Run normal saline through the existing tubing. d. Start normal saline at TKO rate using new tubing.

ANS: D The nurse should first attach new tubing and begin running in normal saline at a rate to keep the vein open, in case any medications need to be delivered through an IV site. The existing tubing should not be used because that would infuse the blood in the tubing into the patient. It is necessary to preserve the IV catheter in place for IV access to treat the patient. After the patient has been assessed and stabilized, the blood can be returned to the blood bank.

13. A parent asks the nurse about how to respond to negativism in toddlers. What is the most appropriate recommendation? a. Punish the child. b. Provide more attention. c. Ask child not always to say "no." d. Reduce the opportunities for a "no" answer.

ANS: D The nurse should suggest to the parent that questions should be phrased with realistic choices rather than "yes" or "no" answers. This provides a sense of control for the toddler and reduces the opportunity for negativism. Negativism is not an indication of stubbornness or insolence and should not be punished. The negativism is not a function of attention; the child is testing limits to gain an understanding of the world. The toddler is too young to be asked to not always say "no."

A nurse is observing a family. The mother is holding the baby she delivered less than 24 hours ago. Her husband is watching his wife and asking questions about newborn care. The 4-year-old brother is punching his mother on the back. The nurse should: a. Report the incident to the social services department. b. Advise the parents that the toddler needs to be reprimanded. c. Report to oncoming staff that the mother is probably not a good disciplinarian. d. Realize that this is a normal family adjusting to family change.

ANS: D The observed behaviors are normal variations of families adjusting to change. There is no need to report this one incident. Giving advice at this point would make the parents feel inadequate.

29. What information should a nurse provide a mother who is concerned about preventing sleep problems in her 2-year-old child? a. Have the child always sleep in a quiet, darkened room. b. Provide high-carbohydrate snacks before bedtime. c. Communicate with the child's daytime caregiver about eliminating the afternoon nap. d. Use a night-light in the child's room.

ANS: D The preschooler has a great imagination. Sounds and shadows can have a negative effect on sleeping behavior. Night-lights provide the child with the ability to visualize the environment and decrease the fear felt in a dark room. A dark, quiet room may be scary to a preschooler. High-carbohydrate snacks increase energy and do not promote relaxation. Most 2 year olds take one nap each day. Many give up the habit by age 3. Insufficient rest during the day can lead to irritability and difficulty sleeping at night.

When performing a thorough psychosocial assessment on a young adult, what must the nurse realize? a. Having a job is the best way to relieve stress. b. Although psychologically disturbing, stress does not lead to physical illness. c. Change is inevitable and is not a factor in stress-related illness. d. Psychosocial health is often related to job and family stress.

ANS: D The psychosocial health concerns of the young adult are often related to job and family stressors. If stress is prolonged and the patient is unable to adapt to the stressor, health problems will develop. Job assessment also includes conditions and hours, duration of employment, changes in sleep or eating habits, and evidence of increased irritability or nervousness. When a patient seeks health care and presents stress-related symptoms, the nurse needs to assess for the occurrence of a life change event.

The interval between the birth of the newborn and the return of the reproductive organs to their normal nonpregnant state is called the: a. Involutionary period because of what happens to the uterus. b. Lochia period because of the nature of the vaginal discharge. c. Mini-tri period because it lasts only 3 to 6 weeks. d. Puerperium, or fourth trimester of pregnancy

ANS: D The puerperium, also called the fourth trimester or the postpartum period of pregnancy, lasts about 3 to 6 weeks. Involution marks the end of the puerperium, or the fourth trimester of pregnancy. Lochia refers to the various vaginal discharges during the puerperium, or fourth trimester of pregnancy

5.A nurse is preparing to start peripheral intravenous (IV) therapy. In which order will the nurse perform the steps starting with the first one? 1. Clean site. 2. Select vein. 3. Apply tourniquet. 4. Release tourniquet. 5. Reapply tourniquet. 6. Advance and secure. 7. Insert vascular access device. a. 1, 3, 2, 7, 5, 4, 6 b. 1, 3, 2, 5, 7, 6, 4 c. 3, 2, 1, 5, 7, 6, 4 d. 3, 2, 4, 1, 5, 7, 6

ANS: D The steps for inserting an intravenous catheter are as follows: Apply tourniquet; select vein; release tourniquet; clean site; reapply tourniquet; insert vascular access device; and advance and secure.

One reason the brain is vulnerable to nutritional deficiencies and trauma in early infancy is the: a. Incompletely developed neuromuscular system. b. Primitive reflex system. c. Presence of various sleep-wake states. d. Cerebellum growth spurt.

ANS: D The vulnerability of the brain likely is to the result of the cerebellum growth spurt. The neuromuscular system is almost completely developed at birth. The reflex system is not relevant. The various sleep-wake states are not relevant.

Childbirth may result in injuries to the vagina and uterus. Pelvic floor exercises also known asKegel exercises will help to strengthen the perineal muscles and encourage healing. The nurse knows that the client understands the correct process for completing these conditioning exercises when she reports: a. I contract my thighs, buttocks, and abdomen. b. I do 10 of these exercises every day. c. I stand while practicing this new exercise routine. d. I pretend that I am trying to stop the flow of urine midstream.

ANS: D The woman can pretend that she is attempting to stop the passing of gas or the flow of urine midstream. This will replicate the sensation of the muscles drawing upward and inward. Each contraction should be as intense as possible without contracting the abdomen, buttocks, or thighs. Guidelines suggest that these exercises should be done 24 to 100 times per day. Positive results are shown with a minimum of 24 to 45 repetitions per day. The best position to learn Kegel exercises is to lie supine with knees bent. A secondary position is on the hands and knees

A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders? a. The woman is a gravida 2, para 2. b. The woman had a vacuum-assisted birth. c. The woman received epidural anesthesia. d. The woman has an episiotomy

ANS: D These orders are typical interventions for a woman who has had an episiotomy, lacerations, and hemorrhoids. A multiparous classification is not an indication for these orders. A vacuum-assisted birth may be used in conjunction with an episiotomy, which would indicate these interventions. Use of epidural anesthesia has no correlation with these orders

The parents of a 3-month-old infant report that their infant sleeps supine (face up) but is often prone (face down) while awake. The nurses response should be based on knowledge that this is: a. Unacceptable because of the risk of sudden infant death syndrome (SIDS). b. Unacceptable because it does not encourage achievement of developmental milestones. c. Unacceptable to encourage fine motor development. d. Acceptable to encourage head control and turning over.

ANS: D These parents are implementing the guidelines to reduce the risk of SIDS. Infants should sleep on their backs and then be placed on their abdomens when awake to enhance development of milestones such as head control. The face-down position while awake and positioning on the back for sleep are acceptable because they reduce risk of SIDS and allow achievement of developmental milestones. These position changes encourage gross motor, not fine motor, development.

20. How should the nurse describe the fact that a 6 month old has 6 teeth? a. Normal tooth eruption. b. Delayed tooth eruption. c. Unusual and dangerous. d. Earlier-than-normal tooth eruption.

ANS: D This is earlier than expected. Most infants at age 6 months have two teeth, the lower central incisors. Six teeth at 6 months is not delayed; it is early tooth eruption. Although unusual, it is not dangerous.

41.Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL? a. Weak quadriceps muscles b. Decreased deep tendon reflexes c. Light-headedness when standing up d. Tingling of extremities with possible tetany

ANS: D This patient has hypocalcemia because the normal calcium range is 8.4 to 10.5 mg/dL. Hypocalcemia causes muscle tetany, positive Chvostek's sign, and tingling of the extremities. Sodium and potassium values are within their normal ranges: sodium 135 to 145 mEq/L; potassium 3.5 to 5.0 mEq/L. Light-headedness when standing up is a manifestation of ECV deficit or sometimes hypokalemia. Weak quadriceps muscles are associated with potassium imbalances. Decreased deep tendon reflexes are related to hypercalcemia or hypermagnesemia.

1. Which factor is most important in predisposing toddlers to frequent infections such as otitis media, tonsillitis, and upper respiratory tract infections? a. Respirations are abdominal. b. Pulse and respiratory rates are slower than those in infancy. c. Defense mechanisms are less efficient than those during infancy. d. The presence of short, straight internal ear/throat structures and large tonsil/adenoid lymph tissue.

ANS: D Toddlers continue to have the short, straight internal ear canal of infants. The lymphoid tissue of the tonsils and adenoids continues to be relatively large. These two anatomic conditions combine to predispose the toddler to frequent infections. The abdominal respirations and lowered pulse and respiratory rate of toddlers do not affect their susceptibility to infection. The defense mechanisms are more efficient compared with those of infancy.

Which nursing action is most appropriate to correct a boggy uterus that is displaced above and to the right of the umbilicus? a. Notify the physician of an impending hemorrhage. b. Assess the blood pressure and pulse. c. Evaluate the lochia. d. Assist the patient in emptying her bladder.

ANS: D Urinary retention may cause overdistention of the urinary bladder, which lifts and displaces the uterus. Nursing actions need to be implemented before notifying the physician. It is important to evaluate blood pressure, pulse, and lochia if the bleeding continues; however, the focus at this point in time is to assist the patient in emptying her bladder.

A nurse discusses the risks of repeated sun exposure with a young adult patient. Which of these patient responses would be most expected from this patient? a. "I'll make an appointment with my doctor right away for a full skin check." b. "I should consider participating in a health fair about safe sun practices." c. "I have a mole that has been bothering me. I'll call my family doctor for an appointment to get it checked." d. "I've had this mole my whole life. So what if it changed color? My skin is fine."

ANS: D Young adults often ignore physical symptoms and often postpone seeking health care. Making an appointment right away with the doctor and participating in health fairs are not typical behaviors of young adults for the same reason.

17. A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital? a. Ask family members to speak quietly to keep the client calm. b. Assess urine color, amount, and specific gravity each day. c. Encourage the client to drink at least 1 liter of fluids each shift. d. Dangle the client on the bedside before ambulating.

ANS: D An older adult with moderate dehydration may experience orthostatic hypotension. The client should dangle on the bedside before ambulating. Although dehydration in an older adult may cause confusion, speaking quietly will not help the client remain calm or decrease confusion. Assessing the clients urine may assist with the diagnosis of dehydration but would not prevent injury. Clients are encouraged to drink fluids, but 1 liter of fluid each shift for an older adult may cause respiratory distress and symptoms of fluid overload, especially if the client has heart failure or renal insufficiency.

6. A nurse is evaluating a client who is being treated for dehydration. Which assessment result should the nurse correlate with a therapeutic response to the treatment plan? a. Increased respiratory rate from 12 breaths/min to 22 breaths/min b. Decreased skin turgor on the clients posterior hand and forehead c. Increased urine specific gravity from 1.012 to 1.030 g/mL d. Decreased orthostatic light-headedness and dizziness

ANS: D The focus of management for clients with dehydration is to increase fluid volumes to normal. When fluid volumes return to normal, clients should perfuse the brain more effectively, therefore improving confusion and decreasing orthostatic light-headedness or dizziness. Increased respiratory rate, decreased skin turgor, and increased specific gravity are all manifestations of dehydration.

Phosphate Function

Acid-base balance, bone and teeth formation, hormone regulation, muscle and red blood cell function

You are the nurse caring for a patient who is to receive IV daunorubicin, a chemotherapeutic agent. You start the infusion and check the insertion site as per protocol. During your most recent check, you note that the IV has infiltrated so you stop the infusion. What is your main concern with this infiltration? A) Extravasation of the medication B) Discomfort to the patient C) Blanching at the site D) Hypersensitivity reaction to the medication

Ans: A Feedback: Irritating medications, such as chemotherapeutic agents, can cause pain, burning, and redness at the site. Blistering, inflammation, and necrosis of tissues can occur. The extent of tissue damage is determined by the medication concentration, the quantity that extravasated, infusion site location, the tissue response, and the extravasation duration. Extravasation is the priority over the other listed consequences.

The nurse is providing care for a patient with chronic obstructive pulmonary disease. When describing the process of respiration the nurse explains how oxygen and carbon dioxide are exchanged between the pulmonary capillaries and the alveoli. The nurse is describing what process? A) Diffusion B) Osmosis C) Active transport D) Filtration

Ans: A Feedback: Diffusion is the natural tendency of a substance to move from an area of higher concentration to one of lower concentration. It occurs through the random movement of ions and molecules. Examples of diffusion are the exchange of oxygen and carbon dioxide between the pulmonary capillaries and alveoli and the tendency of sodium to move from the ECF compartment, where the sodium concentration is high, to the ICF, where its concentration is low. Osmosis occurs when two different solutions are separated by a membrane that is impermeable to the dissolved substances; fluid shifts through the membrane from the region of low solute concentration to the region of high solute concentration until the solutions are of equal concentration. Active transport implies that energy must be expended for the movement to occur against a concentration gradient. Movement of water and solutes occurring from an area of high hydrostatic pressure to an area of low hydrostatic pressure is filtration.

The nurse is caring for a patient in metabolic alkalosis. The patient has an NG tube to low intermittent suction for a diagnosis of bowel obstruction. What drug would the nurse expect to find on the medication orders? A) Cimetidine B) Maalox C) Potassium chloride elixir D) Furosemide

Ans: A Feedback: H2 receptor antagonists, such as cimetidine (Tagamet), reduce the production of gastric HCl, thereby decreasing the metabolic alkalosis associated with gastric suction. Maalox is an oral simethicone used to break up gas in the GI system and would be of no benefit in treating a patient in metabolic alkalosis. KCl would only be given if the patient were hypokalemic, which is not stated in the scenario. Furosemide (Lasix) would only be given if the patient were fluid overloaded, which is not stated in the scenario.

A patient has questioned the nurse's administration of IV normal saline, asking whether sterile water would be a more appropriate choice than "saltwater." Under what circumstances would the nurse administer electrolyte-free water intravenously? A) Never, because it rapidly enters red blood cells, causing them to rupture. B) When the patient is severely dehydrated resulting in neurologic signs and symptoms C) When the patient is in excess of calcium and/or magnesium ions D) When a patient's fluid volume deficit is due to acute or chronic renal failure

Ans: A Feedback: IV solutions contain dextrose or electrolytes mixed in various proportions with water. Pure, electrolyte-free water can never be administered by IV because it rapidly enters red blood cells and causes them to rupture.

You are the nurse caring for a 77-year-old male patient who has been involved in a motor vehicle accident. You and your colleague note that the patient's labs indicate minimally elevated serum creatinine levels, which your colleague dismisses. What can this increase in creatinine indicate in older adults? A) Substantially reduced renal function B) Acute kidney injury C) Decreased cardiac output D) Alterations in ratio of body fluids to muscle mass

Ans: A Feedback: Normal physiologic changes of aging, including reduced cardiac, renal, and respiratory function, and reserve and alterations in the ratio of body fluids to muscle mass, may alter the responses of elderly people to fluid and electrolyte changes and acid-base disturbances. Renal function declines with age, as do muscle mass and daily exogenous creatinine production. Therefore, high-normal and minimally elevated serum creatinine values may indicate substantially reduced renal function in older adults. Acute kidney injury is likely to cause a more significant increase in serum creatinine.

You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patient's most recent laboratory reports, you note that the patient's magnesium levels are high. You should prioritize assessment for which of the following health problems? A) Diminished deep tendon reflexes B) Tachycardia C) Cool, clammy skin D) Acute flank pain

Ans: A Feedback: To gauge a patient's magnesium status, the nurse should check deep tendon reflexes. If the reflex is absent, this may indicate high serum magnesium. Tachycardia, flank pain, and cool, clammy skin are not typically associated with hypermagnesemia.

You are doing discharge teaching with a patient who has hypophosphatemia during his time in hospital. The patient has a diet ordered that is high in phosphate. What foods would you teach this patient to include in his diet? Select all that apply. A) Milk B) Beef C) Poultry D) Green vegetables E) Liver

Ans: A, C, E Feedback: If the patient experiences mild hypophosphatemia, foods such as milk and milk products, organ meats, nuts, fish, poultry, and whole grains should be encouraged.

A gerontologic nurse is teaching students about the high incidence and prevalence of dehydration in older adults. What factors contribute to this phenomenon? Select all that apply. A) Decreased kidney mass B) Increased conservation of sodium C) Increased total body water D) Decreased renal blood flow E) Decreased excretion of potassium

Ans: A, D, E Feedback: Dehydration in the elderly is common as a result of decreased kidney mass, decreased glomerular filtration rate, decreased renal blood flow, decreased ability to concentrate urine, inability to conserve sodium, decreased excretion of potassium, and a decrease of total body water.

The nurse caring for a patient post colon resection is assessing the patient on the second postoperative day. The nasogastric tube (NG) remains patent and continues at low intermittent wall suction. The IV is patent and infusing at 125 mL/hr. The patient reports pain at the incision site rated at a 3 on a 0-to-10 rating scale. During your initial shift assessment, the patient complains of cramps in her legs and a tingling sensation in her feet. Your assessment indicates decreased deep tendon reflexes (DTRs) and you suspect the patient has hypokalemia. What other sign or symptom would you expect this patient to exhibit? A) Diarrhea B) Dilute urine C) Increased muscle tone D) Joint pain

Ans: B Feedback: Manifestations of hypokalemia include fatigue, anorexia, nausea, vomiting, muscle weakness, leg cramps, decreased bowel motility, paresthesias (numbness and tingling), and dysrhythmias. If prolonged, hypokalemia can lead to an inability of the kidneys to concentrate urine, causing dilute urine (resulting in polyuria, nocturia) and excessive thirst. Potassium depletion suppresses the release of insulin and results in glucose intolerance. Decreased muscle strength and DTRs can be found on physical assessment. You would expect decreased, not increased, muscle strength with hypokalemia. The patient would not have diarrhea following bowel surgery, and increased bowel motility is inconsistent with hypokalemia.

You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should you first suspect? A) Hypophosphatemia B) Hypocalcemia C) Hypermagnesemia D) Hyperkalemia

Ans: B Feedback: Tetany is the most characteristic manifestation of hypocalcemia and hypomagnesemia. Sensations of tingling may occur in the tips of the fingers, around the mouth, and, less commonly, in the feet. Hypophosphatemia creates central nervous dysfunction, resulting in seizures and coma. Hypermagnesemia creates hypoactive reflexes and somnolence. Signs of hyperkalemia include paresthesias and anxiety.

A medical nurse educator is reviewing a patient's recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis? A) The kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance. B) The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. C) The kidneys react rapidly to compensate for imbalances in the body. D) The kidneys regulate the bicarbonate level in the intracellular fluid.

Ans: B Feedback: The kidneys regulate the bicarbonate level in the ECF; they can regenerate bicarbonate ions as well as reabsorb them from the renal tubular cells. In respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. In respiratory and metabolic alkalosis, the kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance. The kidneys obviously cannot compensate for the metabolic acidosis created by renal failure. Renal compensation for imbalances is relatively slow (a matter of hours or days).

A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid-base imbalance? A) Respiratory acidosis B) Respiratory alkalosis C) Increased PaCO2 D) CNS disturbances

Ans: B Feedback: The most common cause of acute respiratory alkalosis is hyperventilation. Extreme anxiety can lead to hyperventilation. Acute respiratory acidosis occurs in emergency situations, such as pulmonary edema, and is exhibited by hypoventilation and decreased PaCO2. CNS disturbances are found in extreme hyponatremia and fluid overload.

You are caring for a patient with a diagnosis of pancreatitis. The patient was admitted from a homeless shelter and is a vague historian. The patient appears malnourished and on day 3 of the patient's admission total parenteral nutrition (TPN) has been started. Why would you know to start the infusion of TPN slowly? A) Patients receiving TPN are at risk for hypercalcemia if calories are started too rapidly. B) Malnourished patients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started too aggressively. C) Malnourished patients who receive fluids too rapidly are at risk for hypernatremia. D) Patients receiving TPN need a slow initiation of treatment in order to allow digestive enzymes to accumulate

Ans: B Feedback: The nurse identifies patients who are at risk for hypophosphatemia and monitors them. Because malnourished patients receiving parenteral nutrition are at risk when calories are introduced too aggressively, preventive measures involve gradually introducing the solution to avoid rapid shifts of phosphorus into the cells. Patients receiving TPN are not at risk for hypercalcemia or hypernatremia if calories or fluids are started to rapidly. Digestive enzymes are not a relevant consideration.

The physician has ordered a peripheral IV to be inserted before the patient goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter? A) Choose a hairless site if available. B) Consider potential effects on the patient's mobility when selecting a site. C) Have the patient briefly hold his arm over his head before insertion. D) Leave the tourniquet on for at least 3 minutes.

Ans: B Feedback: Ideally, both arms and hands are carefully inspected before choosing a specific venipuncture site that does not interfere with mobility. Instruct the patient to hold his arm in a dependent position to increase blood flow. Never leave a tourniquet in place longer than 2 minutes. The site does not necessarily need to be devoid of hair.

The community health nurse is performing a home visit to an 84-year-old woman recovering from hip surgery. The nurse notes that the woman seems uncharacteristically confused and has dry mucous membranes. When asked about her fluid intake, the patient states, "I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom." What would be the nurse's best response? A) "I will need to have your medications adjusted so you will need to be readmitted to the hospital for a complete workup." B) "Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids." C) "It is normal to be a little confused following surgery, and it is safe not to urinate at night." D) "If you build up too much urine in your bladder, it can cause you to get confused, especially when your body is under stress. "

Ans: B Feedback: In elderly patients, the clinical manifestations of fluid and electrolyte disturbances may be subtle or atypical. For example, fluid deficit may cause confusion or cognitive impairment in the elderly person. There is no mention of medications in the stem of the question or any specific evidence given for the need for readmission to the hospital. Confusion is never normal, common, or expected in the elderly. Urinary retention does normally cause confusion.

A nurse in the neurologic ICU has orders to infuse a hypertonic solution into a patient with increased intracranial pressure. This solution will increase the number of dissolved particles in the patient's blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which of the following? A) Hydrostatic pressure B) Osmosis and osmolality C) Diffusion D) Active transport

Ans: B Feedback: Osmosis is the movement of fluid from a region of low solute concentration to a region of high solute concentration across a semipermeable membrane. Hydrostatic pressure refers to changes in water or volume related to water pressure. Diffusion is the movement of solutes from an area of greater concentration to lesser concentration; the solutes in an intact vascular system are unable to move so diffusion normally should not be taking place. Active transport is the movement of molecules against the concentration gradient and requires adenosine triphosphate (ATP) as an energy source; this process typically takes place at the cellular level and is not involved in vascular volume changes.

The nurse is preparing to insert a peripheral IV catheter into a patient who will require fluids and IV antibiotics. How should the nurse always start the process of insertion? A) Leave one hand ungloved to assess the site. B) Cleanse the skin with normal saline. C) Ask the patient about allergies to latex or iodine. D) Remove excessive hair from the selected site.

Ans: C Feedback: Before preparing the skin, the nurse should ask the patient if he or she is allergic to latex or iodine, which are products commonly used in preparing for IV therapy. A local reaction could result in irritation to the IV site, or, in the extreme, it could result in anaphylaxis, which can be life threatening. Both hands should always be gloved when preparing for IV insertion, and latex-free gloves must be used or the patient must report not having latex allergies. The skin is not usually cleansed with normal saline prior to insertion. Removing excessive hair at the selected site is always secondary to allergy inquiry.

One day after a patient is admitted to the medical unit, you note that the patient is oliguric. You notify the acute-care nurse practitioner who orders a fluid challenge of 200 mL of normal saline solution over 15 minutes. This intervention will achieve which of the following? A) Help distinguish hyponatremia from hypernatremia B) Help evaluate pituitary gland function C) Help distinguish reduced renal blood flow from decreased renal function D) Help provide an effective treatment for hypertension-induced oliguria

Ans: C Feedback: If a patient is not excreting enough urine, the health care provider needs to determine whether the depressed renal function is the result of reduced renal blood flow, which is a fluid volume deficit (FVD or prerenal azotemia), or acute tubular necrosis that results in necrosis or cellular death from prolonged FVD. A typical example of a fluid challenge involves administering 100 to 200 mL of normal saline solution over 15 minutes. The response by a patient with FVD but with normal renal function is increased urine output and an increase in blood pressure. Laboratory examinations are needed to distinguish hyponatremia from hypernatremia. A fluid challenge is not used to evaluate pituitary gland function. A fluid challenge may provide information regarding hypertension-induced oliguria, but it is not an effective treatment.

You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease. What principle should guide your assessment of the patient's skin turgor? A) Overhydration is common among healthy older adults. B) Dehydration causes the skin to appear spongy. C) Inelastic skin turgor is a normal part of aging. D) Skin turgor cannot be assessed in patients over 70.

Ans: C Feedback: Inelastic skin is a normal change of aging. However, this does not mean that skin turgor cannot be assessed in older patients. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy.

You are making initial shift assessments on your patients. While assessing one patient's peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy? A) Air emboli B) Phlebitis C) Infiltration D) Fluid overload

Ans: C Feedback: Infiltration is the administration of nonvesicant solution or medication into the surrounding tissue. This can occur when the IV cannula dislodges or perforates the wall of the vein. Infiltration is characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort and coolness in the area of infiltration, and a significant decrease in the flow rate. Air emboli, phlebitis, and fluid overload are not indications of infiltration.

You are caring for a 65-year-old male patient admitted to your medical unit 72 hours ago with pyloric stenosis. A nasogastric tube placed upon admission has been on low intermittent suction ever since. Upon review of the morning's blood work, you notice that the patient's potassium is below reference range. You should recognize that the patient may be at risk for what imbalance? A) Hypercalcemia B) Metabolic acidosis C) Metabolic alkalosis D) Respiratory acidosis

Ans: C Feedback: Probably the most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia. This patient would not be at risk for hypercalcemia; hyperparathyroidism and cancer account for almost all cases of hypercalcemia. The nasogastric tube is removing stomach acid and will likely raise pH. Respiratory acidosis is unlikely since no change was reported in the patient's respiratory status.

The nurse in the medical ICU is caring for a patient who is in respiratory acidosis due to inadequate ventilation. What diagnosis could the patient have that could cause inadequate ventilation? A) Endocarditis B) Multiple myeloma C) Guillain-Barré syndrome D) Overdose of amphetamines

Ans: C Feedback: Respiratory acidosis is always due to inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 concentrations and, consequently, increased levels of carbonic acid. Acute respiratory acidosis occurs in emergency situations, such as acute pulmonary edema, aspiration of a foreign object, atelectasis, pneumothorax, overdose of sedatives, sleep apnea, administration of oxygen to a patient with chronic hypercapnia (excessive CO2 in the blood), severe pneumonia, and acute respiratory distress syndrome. Respiratory acidosis can also occur in diseases that impair respiratory muscles, such as muscular dystrophy, myasthenia gravis, and Guillain-Barré syndrome. The other listed diagnoses are not associated with respiratory acidosis.

You are called to your patient's room by a family member who voices concern about the patient's status. On assessment, you find the patient tachypnic, lethargic, weak, and exhibiting a diminished cognitive ability. You also find 3+ pitting edema. What electrolyte imbalance is the most plausible cause of this patient's signs and symptoms? A) Hypocalcemia B) Hyponatremia C) Hyperchloremia D) Hypophosphatemia

Ans: C Feedback: The signs and symptoms of hyperchloremia are the same as those of metabolic acidosis: hypervolemia and hypernatremia. Tachypnea; weakness; lethargy; deep, rapid respirations; diminished cognitive ability; and hypertension occur. If untreated, hyperchloremia can lead to a decrease in cardiac output, dysrhythmias, and coma. A high chloride level is accompanied by a high sodium level and fluid retention. With hypocalcemia, you would expect tetany. There would not be edema with hyponatremia. Signs or symptoms of hypophosphatemia are mainly neurologic.

The nurse is assessing the patient for the presence of a Chvostek's sign. What electrolyte imbalance would a positive Chvostek's sign indicate? A) Hypermagnesemia B) Hyponatremia C) Hypocalcemia D) Hyperkalemia

Ans: C Feedback: You can induce Chvostek's sign by tapping the patient's facial nerve adjacent to the ear. A brief contraction of the upper lip, nose, or side of the face indicates Chvostek's sign. Both hypomagnesemia and hypocalcemia may be tested using the Chvostek's sign.

A nurse educator is reviewing peripheral IV insertion with a group of novice nurses. How should these nurses be encouraged to deal with excess hair at the intended site? A) Leave the hair intact. B) Shave the area. C) Clip the hair in the area. D) Remove the hair with a depilatory.

Ans: C Feedback: Hair can be a source of infection and should be removed by clipping; it should not be left at the site. Shaving the area can cause skin abrasions, and depilatories can irritate the skin.

A nurse is planning care for a nephrology patient with a new nursing graduate. The nurse states, "A patient in renal failure partially loses the ability to regulate changes in pH." What is the cause of this partial inability? A) The kidneys regulate and reabsorb carbonic acid to change and maintain pH. B) The kidneys buffer acids through electrolyte changes. C) The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH. D) The kidneys combine carbonic acid and bicarbonate to maintain a stable pH.

Ans: C Feedback: The kidneys regulate the bicarbonate level in the ECF; they can regenerate bicarbonate ions as well as reabsorb them from the renal tubular cells. In respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. The lungs regulate and reabsorb carbonic acid to change and maintain pH. The kidneys do not buffer acids through electrolyte changes; buffering occurs in reaction to changes in pH. Carbonic acid works as the chemical medium to exchange O2 and CO2 in the lungs to maintain a stable pH whereas the kidneys use bicarbonate as the chemical medium to maintain a stable pH by moving and eliminating H+.

You are an emergency-room nurse caring for a trauma patient. Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would you interpret these results? A) Respiratory acidosis with no compensation B) Metabolic alkalosis with a compensatory alkalosis C) Metabolic acidosis with no compensation D) Metabolic acidosis with a compensatory respiratory alkalosis

Ans: D Feedback: A low pH indicates acidosis (normal pH is 7.35 to 7.45). The PaCO3 is also low, which causes alkalosis. The bicarbonate is low, which causes acidosis. The pH bicarbonate more closely corresponds with a decrease in pH, making the metabolic component the primary problem.

When planning the care of a patient with a fluid imbalance, the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur? A) Active transport of hydrogen ions across the capillary walls B) Pressure of the blood in the renal capillaries C) Action of the dissolved particles contained in a unit of blood D) Hydrostatic pressure resulting from the pumping action of the heart

Ans: D Feedback: An example of filtration is the passage of water and electrolytes from the arterial capillary bed to the interstitial fluid; in this instance, the hydrostatic pressure results from the pumping action of the heart. Active transport does not move water and electrolytes from the arterial capillary bed to the interstitial fluid, filtration does. The number of dissolved particles in a unit of blood is concerned with osmolality. The pressure in the renal capillaries causes renal filtration.

A patient's most recent laboratory results show a slight decrease in potassium. The physician has opted to forego drug therapy but has suggested increasing the patient's dietary intake of potassium. Which of the following would be a good source of potassium? A) Apples B) Asparagus C) Carrots D) Bananas

Ans: D Feedback: Bananas are high in potassium. Apples, carrots, and asparagus are not high in potassium.

You are caring for a patient with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis? A) Hypertension B) Kussmaul respirations C) Increased DTRs D) Shallow respirations

Ans: D Feedback: If hypermagnesemia is suspected, the nurse monitors the vital signs, noting hypotension and shallow respirations. The nurse also observes for decreased DTRs and changes in the level of consciousness. Kussmaul breathing is a deep and labored breathing pattern associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA), but also renal failure. This type of patient is associated with decreased DTRs, not increased DTRs.

Diagnostic testing has been ordered to differentiate between normal anion gap acidosis and high anion gap acidosis in an acutely ill patient. What health problem typically precedes normal anion gap acidosis? A) Metastases B) Excessive potassium intake C) Water intoxication D) Excessive administration of chloride

Ans: D Feedback: Normal anion gap acidosis results from the direct loss of bicarbonate, as in diarrhea, lower intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate). Based on these facts, the other listed options are incorrect.

The ICU nurse is caring for a patient who experienced trauma in a workplace accident. The patient is complaining of having trouble breathing with abdominal pain. An ABG reveals the following results: pH 7.28, PaCO2 50 mm Hg, HCO3- 23 mEq/L. The nurse should recognize the likelihood of what acid-base disorder? A) Respiratory acidosis B) Metabolic alkalosis C) Respiratory alkalosis D) Mixed acid-base disorder

Ans: D Feedback: Patients can simultaneously experience two or more independent acid-base disorders. A normal pH in the presence of changes in the PaCO2 and plasma HCO3- concentration immediately suggests a mixed disorder, making the other options incorrect.

A 73-year-old man comes into the emergency department (ED) by ambulance after slipping on a small carpet in his home. The patient fell on his hip with a resultant fracture. He is alert and oriented; his pupils are equal and reactive to light and accommodation. His heart rate is elevated, he is anxious and thirsty, a Foley catheter is placed, and 40 mL of urine is present. What is the nurse's most likely explanation for the low urine output? A) The man urinated prior to his arrival to the ED and will probably not need to have the Foley catheter kept in place. B) The man likely has a traumatic brain injury, lacks antidiuretic hormone (ADH), and needs vasopressin. C) The man is experiencing symptoms of heart failure and is releasing atrial natriuretic peptide that results in decreased urine output. D) The man is having a sympathetic reaction, which has stimulated the renin-angiotensin-aldosterone system that results in diminished urine output.

Ans: D Feedback: Renin is released by the juxtaglomerular cells of the kidneys in response to decreased renal perfusion. Angiotensin-converting enzyme converts angiotensin I to angiotensin II. Angiotensin II, with its vasoconstrictor properties, increases arterial perfusion pressure and stimulates thirst. As the sympathetic nervous system is stimulated, aldosterone is released in response to an increased release of renin, which decreases urine production. Based on the nursing assessment and mechanism of injury, this is the most likely causing the lower urine output. The man urinating prior to his arrival to the ED is unlikely; the fall and hip injury would make his ability to urinate difficult. No assessment information indicates he has a head injury or heart failure.

The baroreceptors, located in the left atrium and in the carotid and aortic arches, respond to changes in the circulating blood volume and regulate sympathetic and parasympathetic neural activity as well as endocrine activities. Sympathetic stimulation constricts renal arterioles, causing what effect? A) Decrease in the release of aldosterone B) Increase of filtration in the Loop of Henle C) Decrease in the reabsorption of sodium D) Decrease in glomerular filtration

Ans: D Feedback: Sympathetic stimulation constricts renal arterioles; this decreases glomerular filtration, increases the release of aldosterone, and increases sodium and water reabsorption. None of the other listed options occurs with increased sympathetic stimulation.

A patient has been encouraged to increase her fluid intake. Which measure would be most effective for the nurse to implement? A. Explaining the mechanisms involved in transporting fluids to and from ICF compartments B. Keeping fluids readily available for the patient C. Emphasizing the long-term outcome of increasing fluids when she returns home D. Planning to offer most daily fluids in the evening

B

Which diet selection contains the most potassium and should be removed from the tray of the client with renal failure? A. Peach B. Baked potato C. Marshmallows D. Bread

B

You are caring for a patient who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. During your assessment, you note the patient complains of a new onset of weakness with abdominal pain. Further assessment suggests that the patient likely has a fluid volume deficit. You should recognize that this patient may be experiencing what electrolyte imbalance? A) Hypernatremia B) Hypomagnesemia C) Hypophosphatemia D) Hypercalcemia

Ans: D Feedback: The most common causes of hypercalcemia are malignancies and hyperparathyroidism. Anorexia, nausea, vomiting, and constipation are common symptoms of hypercalcemia. Dehydration occurs with nausea, vomiting, anorexia, and calcium reabsorption at the proximal renal tubule. Abdominal and bone pain may also be present. Primary manifestations of hypernatremia are neurologic and would not include abdominal pain and dehydration. Tetany is the most characteristic manifestation of hypomagnesemia, and this scenario does not mention tetany. The patient's presentation is inconsistent with hypophosphatemia.

You are working on a burns unit and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance? A) Metabolic alkalosis B) Hypermagnesemia C) Hypercalcemia D) Hypovolemia

Ans: D Feedback: Third-spacing fluid shift, which occurs when fluid moves out of the intravascular space but not into the intracellular space, can cause hypovolemia. Increased calcium and magnesium levels are not indicators of third-spacing fluid shift. Burns typically cause acidosis, not alkalosis.

A newly graduated nurse is admitting a patient with a long history of emphysema. The new nurse's preceptor is going over the patient's past lab reports with the new nurse. The nurse takes note that the patient's PaCO2 has been between 56 and 64 mm Hg for several months. The preceptor asks the new nurse why they will be cautious administering oxygen. What is the new nurse's best response? A) The patient's calcium will rise dramatically due to pituitary stimulation. B) Oxygen will increase the patient's intracranial pressure and create confusion. C) Oxygen may cause the patient to hyperventilate and become acidotic. D) Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia.

Ans: D Feedback: When PaCO2 chronically exceeds 50 mm Hg, it creates insensitivity to CO2 in the respiratory medulla, and the use of oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia. No information indicates the patient's calcium will rise dramatically due to pituitary stimulation. No feedback system that oxygen stimulates would create an increase in the patient's intracranial pressure and create confusion. Increasing the oxygen would not stimulate the patient to hyperventilate and become acidotic; rather, it would cause hypoventilation and acidosis.

You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patient's plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the patient's health? A) Nutritional status B) Potassium balance C) Calcium balance D) Fluid volume status

Ans: D Feedback: A specific gravity will detect if the patient has a fluid volume deficit or fluid volume excess. Nutrition, potassium, and calcium levels are not directly indicated.

A patient who is being treated for pneumonia starts complaining of sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect? A) Respiratory acidosis B) Metabolic alkalosis C) Respiratory alkalosis D) Metabolic acidosis

Ans:A Feedback: The pH is below 7.40, PaCO2 is greater than 40, and the HCO3 is normal; therefore, it is a respiratory acidosis, and compensation by the kidneys has not begun, which indicates this was probably an acute event. The HCO3 of 24 is within the normal range so it is not metabolic alkalosis. The pH of 7.21 indicates an acidosis, not alkalosis. The pH of 7.21 indicates it is an acidosis but the HCO3 of 24 is within the normal range, ruling out metabolic acidosis.

FVE assessment findings

Fatigue •Edema •↓ urine output •↑ abd girth •Weight gain •MS changes •↑BP •↑ RR w/ or w/o dyspnea •SOB/Crackles

Source of Potassium

Fruits, veggies, dried peas, whole grains, milk, meats

FVE nursing interventions

Monitor VS, I/O, labs •Fluid Restriction • Sign, swabs, chapstick, no candy/gum, small cups •Daily weight •Auscultate lungs/heart •Encourage cough/deep breath *semi-fowler's •Skin care •Safety precautions •Administer diuretics per MD order

nursing FVD interventions

Monitor VS, I/O, labs •Daily weight •Palpate pedal pulse •Monitor capillary refill •Skin/mouth care •IVF per MD order •Safety precautions •Offer fluid options, clean cups, straws, pitcher at bedside •Promote independence •Tube feeds = free water flush

Source of Magnesium

Green veggies, nuts, seafood, whole grains, cocoa

Hyperchloremia Causes

Head trauma, metabolic acidosis, decreased glomerular filtration, excess adrenocoritacal hormone

Fluid Volume Excess

Hypervolemia

Branches of ECF

Intravascular (plasma) , interstitial (lymph), transcellular (synovial, pericardial, pleural)

Hypophosphatemia Symptoms

Irritability, fatigue, weakness, confusion, seizures, coma

Chloride Function

Regulates fluid balance, works with Na, works with hydrogen ions to form Hydrochloric acid

Hypermagnesemia Causes

Renal failure, antacids, or laxitives

Hypochloremia Causes

Vomiting and diarrhea, gastric drainage, burns, diuretics, metabolic alkalosis

TBW depends on...

age, weight, fat, gender

Hypercalemia Causes

cancer, hyperparathyroidism

Hyperbicarbonatemia Causes

excessive acid losses or increased base ingestion

Hypobicarbonatemia Symptoms

increased rate and depth of respirations

Hypobicarbonatemia Causes

loss of bicarbonate, increased acid ingestion

Water

most important nutrient of life •A medium for transporting nutrients/wastes to/from cells •A medium for transporting WBC/RBCs, PLT's, hormones •Acts as a solvent for electrolytes and nonelectrolytes •Acts as a tissue lubricant •Helps maintain normal body temperature •Facilitates digestion and promotes elimination

hypovolemia

•Results from: •excessive loss of body fluids •decreased PO intake •Systemic infections, fever •Intestinal obstruction or fistulas •Kidney disease, Diabetes Insipidus (DI) •Young children and elderly at greatest risk •May result in rapid weight loss •5% → pronounced •8% → severe •15% → life threatening

Hypervolemia

•Retention of sodium and water in ECF •Related to: •CKD/ARF/CHF •Excess Na+ intake •Excessive IVF •Weight gain •Daily weights • Same time, scale, clothing. • 0600. Zero the bed.

FVD assessment findings

↓ BP, ↑ HR •↑ RR •Rapid/shallow breathing •↓ urine output •Weight loss •Flattened neck veins •Tingling of extremities •Dry mucus membranes

4. A nurse suspects an older-adult patient is experiencing caregiver neglect. Which assessment findings are consistent with the nurse's suspicions? a.Flea bites and lice infestation b.Left at a grocery store c.Refuses to take a bath d.Cuts and bruises

ANS: A Caregiver neglect includes unsafe and unclean living conditions, soiled bedding, and animal or insect infestation. Abandonment includes desertion at a hospital, nursing facility, or public location such as a shopping center. Self-neglect includes refusal or failure to provide oneself with basic necessities such as food, water, clothing, shelter, personal hygiene, medication, and safety. Physical abuse includes hitting, beating, pushing, slapping, kicking, physical restraint, inappropriate use of drugs, fractures, lacerations, rope burns, and untreated injuries.

23. Which assessment finding of an older adult, who has a urinary tract infection, requires an immediate nursing intervention? a.Confusion b.Presbycusis c.Temperature of 97.9° F d.Death of a spouse 2 months ago

ANS: A Confusion is a common manifestation in older adults with urinary tract infection; however, the cause requires further assessment. There may be another reason for the confusion. Confusion is not a normal finding in the older adult, even though it is commonly seen with concurrent infections. Difficulty hearing, presbycusis, is an expected finding in an older adult. Older adults tend to have lower core temperatures. Coping with the death of a spouse is a psychosocial concern to be addressed after the acute physiological concern in this case.

Spastic cerebral palsy is characterized by: a. Hypertonicity and poor control of posture, balance, and coordinated motion. b. Athetosis and dystonic movements. c. Wide-based gait and poor performance of rapid, repetitive movements. d. Tremors and lack of active movement.

ANS: A Hypertonicity and poor control of posture, balance, and coordinated motion are part of the classification of spastic cerebral palsy. Athetosis and dystonic movements are part of the classification of dyskinetic/athetoid cerebral palsy. Wide-based gait and poor performance of rapid, repetitive movements are part of the classification of ataxic cerebral palsy. Tremors and lack of active movement may indicate other neurologic disorders.

3. Which information from a co-worker on a gerontological unit will cause the nurse to intervene? a.Most older people have dependent functioning. b.Most older people have strengths we should focus on. c.Most older people should be involved in care decision. d.Most older people should be encouraged to have independence.

ANS: A Most older people remain functionally independent despite the increasing prevalence of chronic disease; therefore, this misconception should be addressed. It is critical for you to respect older adults and actively involve them in care decisions and activities. You also need to identify an older adult's strengths and abilities during the assessment and encourage independence as an integral part of your plan of care.

16. An older patient with dementia and confusion is admitted to the nursing unit after hip replacement surgery. Which action will the nurse include in the plan of care? a.Keep a routine. b.Continue to reorient. c.Allow several choices. d.Socially isolate patient.

ANS: A Patients with dementia need a routine. Continuing to reorient a patient with dementia is nonproductive and not advised. Patients with dementia need limited choices. Social interaction based on the patient's abilities is to be promoted.

20. An outcome for an older-adult patient living alone is to be free from falls. Which statement indicates the patient correctly understands the teaching on safety concerns? a."I'll take my time getting up from the bed or chair." b."I should dim the lighting outside to decrease the glare in my eyes." c."I'll leave my throw rugs in place so that my feet won't touch the cold tile." d."I should wear my favorite smooth bottom socks to protect my feet when walking around."

ANS: A Postural hypotension is an intrinsic factor that can cause falls. Changing positions slowly indicates a correct understanding of this concept. Environmental hazards outside and within the home such as poor lighting, slippery or wet flooring, and items on floor that are easy to trip over such as throw rugs are other factors that can lead to falls. Impaired vision and poor lighting are other risk factors for falls and should be avoided (dim lighting). Inappropriate footwear such as smooth bottom socks also contributes to falls.

A child with autism spectrum disorder (ASD) is admitted to the hospital with pneumonia. The nurse should plan which priority intervention when caring for the child? a. Maintain a structured routine and keep stimulation to a minimum. b. Place the child in a room with a roommate of the same age. c. Maintain frequent touch and eye contact with the child. d. Take the child frequently to the playroom to play with other children.

ANS: A Providing a structured routine for the child to follow is key in the management of ASD. Decreasing stimulation by using a private room, avoiding extraneous auditory and visual distractions, and encouraging the parents to bring in possessions the child is attached to may lessen the disruptiveness of hospitalization. Because physical contact often upsets these children, minimum holding and eye contact may be necessary to avoid behavioral outbursts. Children with ASD need to be introduced slowly to new situations, with visits with staff caregivers kept short whenever possible. The playroom would be too overwhelming with new people and situations and should not be a priority of care.

The major consideration when selecting toys for a child who is cognitively impaired is: a. Safety. c. Ability to provide exercise. b. Age appropriateness. d. Ability to teach useful skills

ANS: A Safety is the primary concern in selecting recreational and exercise activities for all children. This is especially true for children who are cognitively impaired. Age appropriateness, the ability to provide exercise, and the ability to teach useful skills are all factors to consider in the selection of toys, but safety is of paramount importance.

Parents have learned that their 6-year-old child has autism. The nurse may help the parents to cope by explaining that the child may: a. Have an extremely developed skill in a particular area. b. Outgrow the condition by early adulthood. c. Have average social skills. d. Have age-appropriate language skills.

ANS: A Some children with autism have an extremely developed skill in a particular area, such as mathematics or music. No evidence supports that autism is outgrown. Autistic children have abnormal ways of relating to people (social skills). Speech and language skills are usually delayed in autistic children.

22. An older-adult patient has developed acute confusion. The patient has been on tranquilizers for the past week. The patient's vital signs are normal. What should the nurse do? a.Take into account age-related changes in body systems that affect pharmacokinetic activity. b.Increase the dose of tranquilizer if the cause of the confusion is an infection. c.Note when the confusion occurs and medicate before that time. d.Restrict phone calls to prevent further confusion.

ANS: A Some sedatives and tranquilizers prescribed for acutely confused older adults sometimes cause or exacerbate confusion. Carefully administer drugs used to manage confused behaviors, taking into account age-related changes in body systems that affect pharmacokinetic activity. When confusion has a physiological cause (such as an infection), specifically treat that cause, rather than the confused behavior. When confusion varies by time of day or is related to environmental factors, nonpharmacological measures such as making the environment more meaningful, providing adequate light, etc., should be used. Making phone calls to friends or family members allows older adults to hear reassuring voices, which may be beneficial.

21. A nurse's goal for an older adult is to reduce the risk of adverse medication effects. Which action will the nurse take? a.Review the patient's list of medications at each visit. b.Teach that polypharmacy is to be avoided at all cost. c.Avoid information about adverse effects. d.Focus only on prescribed medications.

ANS: A Strategies for reducing the risk for adverse medication effects include reviewing the medications with older adults at each visit; examining for potential interactions with food or other medications; simplifying and individualizing medication regimens; taking every opportunity to inform older adults and their families about all aspects of medication use; and encouraging older adults to question their health care providers about all prescribed and over-the-counter medications. Although polypharmacy often reflects inappropriate prescribing, the concurrent use of multiple medications is often necessary when an older adult has multiple acute and chronic conditions. Older adults are at risk for adverse drug effects because of age-related changes in the absorption, distribution, metabolism, and excretion of drugs. Work collaboratively with the older adult to ensure safe and appropriate use of all medications—both prescribed medications and over-the-counter medications and herbal options.

When should children with cognitive impairment be referred for stimulation and educational programs? a. As young as possible b. As soon as they have the ability to communicate in some way c. At age 3 years, when schools are required to provide services d. At age 5 or 6 years, when schools are required to provide services

ANS: A The child's education should begin as soon as possible. Considerable evidence exists that early intervention programs for children with disabilities are valuable for cognitively impaired children. The early intervention may facilitate the child's development of communication skills. States are encouraged to provide early intervention programs from birth under Public Law 101-476, the Individuals with Disabilities Act.

17. Which is an appropriate play activity for a 7-month-old infant to encourage visual stimulation? a. Playing peek-a-boo. b. Playing pat-a-cake. c. Imitating animal sounds. d. Showing how to clap hands.

ANS: A Because object permanence is a new achievement, peek-a-boo is an excellent activity to practice this new skill for visual stimulation. Playing pat-a-cake and showing how to clap hands will help with kinesthetic stimulation. Imitating animal sounds will help with auditory stimulation.

3. The nurse is doing a routine assessment on a 14-month-old infant and notes that the anterior fontanel is closed. This should be interpreted as: a. a normal finding. b. a questionable finding—the infant should be rechecked in 1 month. c. an abnormal finding—indicates the need for immediate referral to a practitioner. d. an abnormal finding—indicates the need for developmental assessment.

ANS: A Because the anterior fontanel normally closes between ages 12 and 18 months, this is a normal finding, and no further intervention is required.

14. The nurse is interviewing the father of 10-month-old. When the child, playing on the floor and notices an electrical outlet and reaches up to touch it, the father says "No" firmly and removes the child away from the outlet. The nurse should use this opportunity to teach the father that the child is capable of understanding what association? a. Understand the word "No." b. Father always means "No." c. Electrical outlets are dangerous. d. Spanking as a deterrent.

ANS: A By age 10 months, children are able to associate meaning with words. The child should be old enough to understand the word "No." The 10-month-old is too young to understand the purpose of an electrical outlet and is not likely to always associate her father with the word "No." The father is using both verbal and physical cues to teach safety measures and alert the child to dangerous situations. Physical discipline should be avoided.

7. The nurse determines an infant of 7 months is demonstrating appropriate fine motor development when performing which action? a. Transferring a rattler from one hand to the other. b. Using thumb and index finger to grasp a piece of food. c. Holding a crayon and make a mark on paper. d. Releasing cubes into a cup.

ANS: A By age 7 months, infants can transfer objects from one hand to the other, crossing the midline. The crude pincer grasp is apparent at about age 9 months. The infant can scribble spontaneously at age 15 months. At age 12 months, the infant can release cubes into a cup.

What do changing norms and values about family life in the United States reveal? a. Basic shifts in attitudes in our society b. Greater resistance to cohabitation without marriage c. Decreased numbers of infants born to unmarried women d. Greater support and acceptance from the health care system

ANS: A Changing norms and values about family life in the United States reveal basic shifts in attitudes in our society. The trend toward greater acceptance of cohabitation without marriage is a factor in the greater numbers of infants being born to unmarried women. Many times, parents from alternative family structures feel lack of support and even bias from the health care system.

A patient states that she is pregnant and concerned because she does not know what to expect, and she wants her husband to play an active part in the birthing process. What should the nurse tell the patient? a. Lamaze classes can prepare pregnant women and their partners for what is coming. b. The frequency of sexual intercourse is key to helping the husband feel valued. c. After the birth, the stress of pregnancy will disappear and will be replaced by relief. d. After the baby is born, the wife should accept the extra responsibilities of motherhood.

ANS: A Education such as Lamaze classes can prepare pregnant women, their partners, and other support persons to participate in the birthing process. The psychodynamic aspect of sexual activity is as important as the type or frequency of sexual intercourse to young adults. The stress that many women experience after childbirth has a significant impact on the health of postpartum women. To avoid stress in a two-career family, partners should share all responsibilities.

15. Sara, age 4 months, was born at 35 weeks' gestation. She seems to be developing normally, but her parents are concerned because she is a "more difficult" baby than their other child, who was term. The nurse should explain that: a. infants' temperaments are part of their unique characteristics. b. infants become less difficult if they are not kept on scheduled feedings and structured routines. c. Sara's behavior is suggestive of failure to bond completely with her parents. d. Sara's difficult temperament is the result of painful experiences in the neonatal period.

ANS: A Infant temperament has a strong biologic component. Together with interactions with the environment, primarily the family, the biologic component contributes to the infant's unique temperament. Children perceived as difficult may respond better to scheduled feedings and structured caregiving routines than to demand feedings and frequent changes in routines. Sara's temperament has been created by both biologic and environmental factors. The nurse should provide guidance in parenting techniques that are best suited to Sara's temperament.

23. The parents of a 4-month-old infant tell the nurse that they are getting a microwave oven and will be able to heat the baby's formula faster. What recommendations should the nurse provide the parents? a. Never heat a bottle in a microwave oven. b. Heat only 10 ounces or more. c. Always leave the bottle top uncovered to allow heat to escape. d. Shake the bottle vigorously for at least 30 seconds after heating.

ANS: A Neither infant formula nor breast milk should be warmed in a microwave oven as this may cause oral burns as a result of uneven heating in the container. The bottle may remain cool while hot spots develop in the milk. Warming expressed milk in a microwave decreases the availability of antiinfective properties and causes separation of the fat content. Milk should be warmed in a lukewarm water bath. None of the other options adequately deals with the issue of overheating.

30. Which clinical manifestations should cause the nurse to suspect that a child, diagnosed with a digestive disorder, may be demonstrating signs of failure to thrive? a. Avoidance of eye contact. b. An associated malabsorption defect. c. Weight that falls below the 15th percentile. d. Normal achievement of developmental landmarks.

ANS: A One of the clinical manifestations of nonorganic failure to thrive is the child's avoidance of eye contact with the health professional. A malabsorption defect would result in a physiologic problem, not behavioral. Weight (but not height) below the 5th percentile is indicative of failure to thrive. Developmental delays, including social, motor, adaptive, and language, exist.

8. In terms of gross motor development, what hallmark action should the nurse identify for the parents of a 5-month-old infant to anticipate? a. Roll from abdomen to back. b. Roll from back to abdomen. c. Sit erect without support. d. Move from prone to sitting position.

ANS: A Rolling from abdomen to back is developmentally appropriate for a 5-month-old infant. The ability to roll from back to abdomen usually occurs at 6 months old. Sitting erect without support is a developmental milestone usually achieved by 8 months. The 10-month-old infant can usually move from a prone to a sitting position.

The nurse is caring for a hospitalized young adult male who is uninsured even though he works as a dishwasher at a local restaurant. He states that he would like to get a better job, but he has no education. How can the nurse best assist this patient psychosocially? a. By providing information and referrals b. By telling the patient that he needs to go back to school c. By focusing on the patient's medical diagnoses d. By expecting the patient to be flexible in his decision making

ANS: A Support from the nurse, access to information, and appropriate referrals provide opportunities for achievement of a patient's potential. Many young adults lack the necessary resources or support systems to facilitate further education or development of skills necessary for many positions in the workplace. As a result, some young adults have limited occupational choices. Health is not merely the absence of disease but involves wellness in all human dimensions. Insecure persons tend to be more rigid in making decisions.

16. Which information could be given to the parents of a 12-month-old child regarding appropriate play activities for this age? a. Give large push-pull toys for kinesthetic stimulation. b. Place cradle gym across crib to facilitate fine motor skills. c. Provide child with finger paints to enhance fine motor skills. d. Provide stick horse to develop gross motor coordination.

ANS: A The 12-month-old child is able to pull to a stand and walk holding on or independently. Appropriate toys for a child of this age include large push-pull toys for kinesthetic stimulation. A cradle gym should not be placed across the crib. Finger paints are appropriate for older children. A 12-month-old child does not have the stability to use a stick horse.

4. By what age does the posterior fontanel usually close? a. 6 to 8 weeks b. 10 to 12 weeks c. 4 to 6 months d. 8 to 10 months

ANS: A The bones surrounding the posterior fontanel fuse and close by age 6 to 8 weeks. Ten weeks or longer is too late and indicates a problem.

31. Which consideration should be considered when planning care for an infant diagnosed with failure to thrive? a. Establishing a structured routine and follow it consistently. b. Maintaining a nondistracting environment by not speaking to the infant during feeding. c. Placing the infant in an infant seat during feedings to prevent overstimulation. d. Limiting sensory stimulation and play activities to alleviate fatigue.

ANS: A The infant with failure to thrive should have a structured routine that is followed consistently. Disruptions in other activities of daily living can have a great impact on feeding behaviors. Bathing, sleeping, dressing, playing, and feeding are structured. The nurse should talk to the infant by giving directions about eating. This will help the infant maintain focus. Young children should be held while being fed, and older children can sit at a feeding table. The infant should be fed in the same manner at each meal. The infant can engage in sensory and play activities at times other than mealtime.

6. A 3-month-old infant, born at 38 weeks of gestation, will hold a rattle if it is put in her hands; however, she will not voluntarily grasp it. How should the nurse interpret this behavior? a. Normal development b. Significant developmental lag c. Slightly delayed development caused by prematurity d. Suggestive of a neurologic disorder such as cerebral palsy

ANS: A This indicates normal development. Reflexive grasping occurs during the first 2 to 3 months and then gradually becomes voluntary. No evidence of developmental lag, delayed development, or neurologic dysfunction is present by this behavior.

2. In terms of gross motor development, what would the nurse educate the parents to expect a 5-month-old infant to do? (Select all that apply.) a. Roll from abdomen to back. b. Put feet in mouth when supine. c. Roll from back to abdomen. d. Sit erect without support. e. Move from prone to sitting position.

ANS: A, B Rolling from abdomen to back and placing the feet in the mouth when supine are developmentally appropriate for a 5-month-old infant. Rolling from back to abdomen is developmentally appropriate for a 6-month-old infant. An 8-month-old infant should be able to sit erect without support. A 10-month-old infant can usually move from a prone to a sitting position.

18. At what age should the nurse expect an infant to begin smiling in response to pleasurable stimuli? a. 1 month b. 2 months c. 3 months d. 4 months

ANS: B At age 2 months, the infant has a social, responsive smile. A reflex smile is usually present at age 1 month. The 3-month-old can recognize familiar faces. At age 4 months, the infant can enjoy social interactions.

1. A recently widowed older-adult patient is dehydrated and is admitted to the hospital for intravenous fluid replacement. During the evening shift, the patient becomes acutely confused. Which possible reversible causes will the nurse consider when assessing this patient? (Select all that apply.) a.Electrolyte imbalance b.Sensory deprivation c.Hypoglycemia d.Drug effects e.Dementia

ANS: A, B, C, D Delirium, or acute confusional state, is a potentially reversible cognitive impairment that is often due to a physiological event. Physiological causes include electrolyte imbalances, untreated pain, infection, cerebral anoxia, hypoglycemia, medication effects, tumors, subdural hematomas, and cerebrovascular infarction or hemorrhage. Sometimes it is also caused by environmental factors such as sensory deprivation or overstimulation, unfamiliar surroundings, or sleep deprivation or psychosocial factors such as emotional distress. Dementia is a gradual, progressive, and irreversible cerebral dysfunction.

1. In teaching parents about appropriate pacifier selection, the nurse should explain that a pacifier should have which characteristics? (Select all that apply.) a. Easily grasped handle b. One-piece construction c. Ribbon or string to secure to clothing d. Soft, pliable material e. Sturdy, flexible material

ANS: A, B, E A good pacifier should be easily grasped by the infant. One-piece construction is necessary to avoid having the nipple and guard separate. The material should be sturdy and flexible. An attached ribbon or string and soft, pliable material are not characteristics of a good pacifier.

A child with autism is hospitalized with asthma. The nurse should plan care so that the: a. Parents' expectations are met. b. Child's routine habits and preferences are maintained. c. Child is supported through the autistic crisis. d. Parents need not be at the hospital.

ANS: B Children with autism are often unable to tolerate even slight changes in routine. The child's routine habits and preferences are important to maintain. Focus of care is on the child's needs rather than on the parent's desires. Autism is a lifelong condition. The presence of the parents is almost always required when an autistic child is hospitalized.

4. Which interventions should the nurse implement when caring for a family of a sudden infant death syndrome (SIDS) infant? (Select all that apply.) a. Allow parents to say goodbye to their infant. b. Once parents leave the hospital, no further follow-up is required. c. Arrange for someone to take the parents home from the hospital. d. Avoid requesting an autopsy of the deceased infant. e. Conduct a debriefing session with the parents before they leave the hospital.

ANS: A, C, E An important aspect of compassionate care for parents experiencing a SIDS incident is allowing them to say good-bye to their infant. These are the parents' last moments with their infant, and they should be as quiet, meaningful, peaceful, and undisturbed as possible. Because the parents leave the hospital without their infant, it is helpful to accompany them to the car or arrange for someone else to take them home. A debriefing session may help health care workers who dealt with the family and deceased infant to cope with emotions that are often engendered when a SIDS victim is brought into the acute care facility. An autopsy may clear up possible misconceptions regarding the death. When the parents return home, a competent, qualified professional should visit them after the death as soon as possible.

Autism is a complex developmental disorder. The diagnostic criteria for autism include delayed or abnormal functioning in which area(s) with onset before age 3 years (select all that apply)? a. Language as used in social communication b. Gross motor development c. Growth below the 5th percentile for height and weight d. Symbolic or imaginative play e. Social interaction

ANS: A, D, E Language as used in social communication, symbolic or imaginative play, and social interaction are three of the areas in which autistic children may show delayed or abnormal functioning. Gross motor development and growth below the 5th percentile for height and weight are not areas in which autistic children may show delayed or abnormal functioning.

When a child with mild cognitive impairment reaches the end of adolescence, what characteristic would be expected? a. Achieves a mental age of 5 to 6 years b. Achieves a mental age of 8 to 12 years c. Is unable to progress in functional reading or arithmetic d. Acquires practical skills and useful reading and arithmetic to an eighth-grade level

ANS: B By the end of adolescence, the child with mild cognitive impairment can usually acquire social and vocational skills, may need occasional guidance and support when under unusual social or economic stress, and may be able to adjust to marriage but not childrearing. Achieving a mental age of 5 to 6 years is considered a level of skill development associated with severe cognitive impairment. Being unable to progress in functional reading or math would indicate a level of skill development associated with profound cognitive impairment. Acquiring practical skills and useful reading and math to an eighth-grade level represents a level of skill development associated with moderate cognitive impairment.

Mark, a 9-year-old with Down syndrome, is mainstreamed into a regular third-grade class for part of the school day. His mother asks the school nurse about programs such as Cub Scouts that he might join. The nurse's recommendation should be based on knowing that: a. Programs such as Cub Scouts are inappropriate for children who are cognitively impaired. b. Children with Down syndrome have the same need for socialization as other children. c. Children with Down syndrome socialize better with children who have similar disabilities. d. Parents of children with Down syndrome encourage programs such as scouting because they deny that their children have disabilities.

ANS: B Children of all ages need peer relationships. Children with Down syndrome should have peer experiences similar to those of other children, such as group outings, Cub Scouts, and Special Olympics, which can all help children with cognitive impairment to develop socialization skills. Although all children should have an opportunity to form a close relationship with someone of the same developmental level, it is appropriate for children with disabilities to develop relationships with children who do not have disabilities. The parents are acting as advocates for their child.

A parent asks the nurse why a developmental assessment is being conducted for a child during a routine well-child visit. The nurse answers based on the knowledge that routine developmental assessments during well-child visits are: a. Not necessary unless the parents request them. b. The best method for early detection of cognitive disorders. c. Frightening to parents and children and should be avoided. d. Valuable in measuring intelligence in children.

ANS: B Early detection of cognitive disorders can be facilitated through assessment of development at each well-child examination. Developmental assessment is a component of all well-child examinations; however, they are not intended to measure intelligence. Developmental assessments are not frightening when the parent and child are educated about the purpose of the assessment.

2. A nurse is developing a plan of care for an older adult. Which information will the nurse consider? a.Should be standardized because most geriatric patients have the same needs b.Needs to be individualized to the patient's unique needs c.Focuses on the disabilities that all aging persons face d.Must be based on chronological age alone

ANS: B Every older adult is unique, and the nurse needs to approach each one as a unique individual. The nursing care of older adults poses special challenges because of great variation in their physiological, cognitive, and psychosocial health. Aging does not automatically lead to disability and dependence. Chronological age often has little relation to the reality of aging for an older adult.

24. Which patient statement is the most reliable indicator that an older adult has the correct understanding of health promotion activities? a."I need to increase my fat intake and limit protein." b."I still keep my dentist appointments even though I have partials now." c."I should discontinue my fitness club membership for safety reasons." d."I'm up-to-date on my immunizations, but at my age, I don't need the influenza vaccine."

ANS: B General preventive measures for the nurse to recommend to older adults include keeping regular dental appointments to promote good oral hygiene, eating a low-fat, well-balanced diet, exercising regularly, and maintaining immunizations for seasonal influenza, tetanus, diphtheria and pertussis, shingles, and pneumococcal disease.

12. A nurse is teaching a health promotion class for older adults. In which order will the nurse list the most common to least common conditions that can lead to death in older adults? 1. Chronic obstructive lung disease 2. Cerebrovascular accidents 3. Heart disease 4. Cancer a.4, 1, 2, 3 b.3, 4, 1, 2 c.2, 3, 4, 1 d.1, 2, 3, 4

ANS: B Heart disease is the leading cause of death in older adults followed by cancer, chronic lung disease, and stroke (cerebrovascular accidents).

1. A nurse is obtaining a history on an older adult. Which finding will the nurse most typically find? a.Lives in a nursing home b.Lives with a spouse c.Lives divorced d.Lives alone

ANS: B In 2012, 57% of older adults in non-institutional settings lived with a spouse (45% of older women, 71% of older men); 28% lived alone (35% of older women, 19% of older men); and only 3.5% of all older adults resided in institutions such as nursing homes or centers. Most older adults have lost a spouse due to death rather than divorce.

11. A nurse is discussing sexuality with an older adult. Which action will the nurse take? a.Ask closed-ended questions about specific symptoms the patient may experience. b.Provide information about the prevention of sexually transmitted infections. c.Discuss the issues of sexuality in a group in a private room. d.Explain that sexuality is not necessary as one ages.

ANS: B Include information about the prevention of sexually transmitted infections when appropriate. Open-ended questions inviting an older adult to explain sexual activities or concerns elicit more information than a list of closed-ended questions about specific activities or symptoms. You need to provide privacy for any discussion of sexuality and maintain a nonjudgmental attitude. Sexuality and the need to express sexual feelings remain throughout the human life span.

Which finding should cause the nurse to suspect a diagnosis of spastic cerebral palsy? a. Tremulous movements at rest and with activity b. Sudden jerking movement caused by stimuli c. Writhing, uncontrolled, involuntary movements d. Clumsy, uncoordinated movements

ANS: B Spastic cerebral palsy, the most common type of cerebral palsy, will manifest with hypertonicity and increased deep tendon reflexes. The child's muscles are very tight and any stimuli may cause a sudden jerking movement. Tremulous movements are characteristic of rigid/tremor/atonic cerebral palsy. Slow, writhing, uncontrolled, involuntary movements occur with athetoid or dyskinetic cerebral palsy. Clumsy movements, loss of coordination, equilibrium, and kinesthetic sense occur in ataxic cerebral palsy.

Appropriate interventions to facilitate socialization of the cognitively impaired child include to: a. Provide age-appropriate toys and play activities. b. Provide peer experiences such as Special Olympics when older. c. Avoid exposure to strangers who may not understand cognitive development. d. Emphasize mastery of physical skills because they are delayed more often than verbal skills.

ANS: B The acquisition of social skills is a complex task. Children of all ages need peer relationships. Parents should enroll the child in preschool. When older, the child should have peer experiences similar to other children, such as group outings, Boy or Girl Scouts, and Special Olympics. Providing age-appropriate toys and play activities is important, but peer interactions will facilitate social development. Parents should expose the child to strangers so the child can practice social skills. Verbal skills are delayed more than physical skills.

A nurse is providing a parent information regarding autism. Which statement made by the parent indicates understanding of the teaching? a. "Autism is characterized by periods of remission and exacerbation." b. "The onset of autism usually occurs before 3 years of age." c. "Children with autism have imitation and gesturing skills." d. "Autism can be treated effectively with medication."

ANS: B The onset of autism usually occurs before 3 years of age. Autism does not have periods of remission and exacerbation. Autistic children lack imitative skills. Medications are of limited use in children with autism.

10. A nurse is observing for the universal loss in an older-adult patient. What is the nurse assessing? a.Loss of finances through changes in income b.Loss of relationships through death c.Loss of career through retirement d.Loss of home through relocation

ANS: B The universal loss for older adults usually revolves around the loss of relationships through death. Life transitions, of which loss is a major component, include retirement and the associated financial changes, changes in roles and relationships, alterations in health and functional ability, changes in one's social network, and relocation. However, these are not the universal loss.

A parent whose child has been diagnosed with a cognitive deficit should be counseled that intellectual impairment: a. Is usually due to a genetic defect. b. May be caused by a variety of factors. c. Is rarely due to first-trimester events. d. Is usually caused by parental intellectual impairment.

ANS: B There are a multitude of causes for intellectual impairment. In most cases, a specific cause has not been identified. Only a small percentage of children with intellectual impairment are affected by a genetic defect. One third of children with intellectual impairment are affected by first-trimester events. Intellectual impairment can be transmitted to a child only if the parent has a genetic disorder.

2. The nurse assessing a 6-month-old healthy infant who weighed 7 lbs at birth, shares with the parents that the infant should weigh approximately how many pounds? a. 10 lbs. b. 15 lbs. c. 20 lbs. d. 25 lbs.

ANS: B Birth weight doubles at about age 5 to 6 months. At 6 months, an infant who weighed 7 lbs at birth would weigh approximately 15 lbs. Ten pounds is too little; the infant would have gone from the 50th percentile at birth to below the 5th percentile. Twenty pounds or more is too much; the infant would have tripled the birth weight at 6 months.

22. When is the best age for solid food to be introduced into the infant's diet? a. 2 to 3 months b. 4 to 6 months c. When birth weight has tripled d. When tooth eruption has started

ANS: B Physiologically and developmentally, the 4 to 6 months old is in a transition period. The extrusion reflex has disappeared, and swallowing is a more coordinated process. In addition, the gastrointestinal tract has matured sufficiently to handle more complex nutrients and is less sensitive to potentially allergenic food. Infants of this age will try to help during feeding. Two to three months is too young. The extrusion reflex is strong, and the infant will push food out with the tongue. No research base indicates that the addition of solid food to bottle-feeding has any benefit. Tooth eruption can facilitate biting and chewing; most infant foods do not require this ability.

When choosing an appropriate topic for a young adult health fair, the nurse ranks which topic as least relevant? a. Unplanned pregnancies b. Menopause and climacteric factors c. Smoking cessation d. Alcohol and drug use

ANS: B The onset of menopause and the climacteric affect the sexual health of the middle adult, not the young adult. Unplanned pregnancies are a continued source of stress that can result in adverse health outcomes for the mother (young adult), infant, and family. Smoking is a well-documented risk factor for pulmonary, cardiac, and vascular diseases in smokers and in individuals who receive secondhand smoke and constitutes a health risk for the young adult. Substance abuse directly or indirectly contributes to mortality and morbidity in young adults.

27. The clinic is lending a federally approved car seat to an infant's family. Where in the car should the nurse explain is the safest place to put the car seat? a. Front facing in back seat. b. Rear facing in back seat. c. Front facing in front seat if an air bag is on the passenger side. d. Rear facing in front seat if an air bag is on the passenger side.

ANS: B The rear-facing car seat provides the best protection for an infant's disproportionately heavy head and weak neck. Infants should face the rear from birth to 20 lbs and as close to 1 year of age as possible. The middle of the back seat provides the safest position. Severe injuries and deaths in children have occurred from air bags deploying on impact in the front passenger seat.

28. A nurse is teaching parents about prevention and treatment of colic. Which should the nurse include in the teaching plan? a. Avoid use of pacifiers. b. Eliminate all secondhand smoke contact. c. Lay infant flat after feeding. d. Avoid swaddling the infant.

ANS: B To prevent and treat colic, teach parents that if household members smoke, they should avoid smoking near the infant; smoking activity should preferably be confined to outside of the home. A pacifier can be introduced for added sucking. The infant should be swaddled tightly with a soft, stretchy blanket, and placed in an upright seat after feedings.

What should the nurse recognize when comparing the physical changes in young and middle adulthood? a. Fertility issues do not occur in young adulthood. b. Young adults are quite active but are at risk for illness in later years. c. Young adults tend to suffer more from severe illness. d. Exercise is less important in young adulthood than in middle adulthood.

ANS: B Young adults are generally active and have a minimum of major health problems. However, their lifestyles put them at risk for illnesses or disabilities during their middle or older adult years. An estimated 10% to 15% of reproductive couples are infertile, and many are young adults. Exercise in young adulthood is increasingly important to prevent or decrease the development of chronic health conditions such as high blood pressure, obesity, and diabetes that develop later in life.

3. A nurse is conducting education classes for parents of infants. The nurse plans to discuss sudden infant death syndrome (SIDS). Which risk factors should the nurse include as increasing an infant's risk of a SIDS incident? (Select all that apply.) a. Breastfeeding b. Low Apgar scores c. Male sex d. Birth weight in the 50th or higher percentile e. Recent viral illness

ANS: B, C, E Certain groups of infants are at increased risk for SIDS: those with low birth weight, low Apgar scores, or recent viral illness, and those of male sex. Breastfed infants and infants of average or above-average weight are not at higher risk for SIDS.

9. A nurse is caring for an older adult. Which goal is priority? a.Adjusting to career b.Adjusting to divorce c.Adjusting to retirement d.Adjusting to grandchildren

ANS: C Adjusting to retirement is one of the developmental tasks for an older person. A young or middle-aged adult has to adjust to career and/or divorce. A middle-aged adult has to adjust to grandchildren.

The nurse is discussing sexuality with the parents of an adolescent girl with moderate cognitive impairment. Which should the nurse consider when dealing with this issue? a. Sterilization is recommended for any adolescent with cognitive impairment. b. Sexual drive and interest are limited in individuals with cognitive impairment. c. Individuals with cognitive impairment need a well-defined, concrete code of sexual conduct. d. Sexual intercourse rarely occurs unless the individual with cognitive impairment is sexually abused.

ANS: C Adolescents with moderate cognitive impairment may be easily persuaded and lack judgment. A well-defined, concrete code of conduct with specific instructions for handling certain situations should be laid out for the adolescent. Permanent contraception by sterilization presents moral and ethical issues and may have psychologic effects on the adolescent. It may be prohibited in some states. The adolescent needs to have practical sexual information regarding physical development and contraception. Cognitively impaired individuals may desire to marry and have families. The adolescent needs to be protected from individuals who may make intimate advances.

7. What is the best suggestion a nurse could make to a family requesting help in selecting a local nursing center? a.Have the family members evaluate nursing home staff according to their ability to get tasks done efficiently and safely. b.Make sure that nursing home staff members get patients out of bed and dressed according to staff's preferences. c.Explain that it is important for the family to visit the center and inspect it personally. d.Suggest a nursing center that has standards as close to hospital standards as possible.

ANS: C An important step in the process of selecting a nursing home is to visit the nursing home. The nursing home should not feel like a hospital. It is a home, a place where people live. Members of the nursing home staff should focus on the person, not the task. Residents should be out of bed and dressed according to their preferences, not staff preferences.

A nurse is preparing to perform a dressing change on a 6-year-old child with mild cognitive impairment (CI) who sustained a minor burn. Which strategy should the nurse use to prepare the child for this procedure? a. Verbally explain what will be done. b. Have the child watch a video on dressing changes. c. Demonstrate a dressing change on a doll. d. Explain the importance of keeping the burn area clean.

ANS: C Children with CI have a marked deficit in their ability to discriminate between two or more stimuli because of difficulty in recognizing the relevance of specific cues. However, these children can learn to discriminate if the cues are presented in an exaggerated, concrete form and if all extraneous stimuli are eliminated. Therefore, demonstration is preferable to verbal explanation, and learning should be directed toward mastering a skill rather than understanding the scientific principles underlying a procedure. Watching a video would require the use of both visual and auditory stimulation and might produce overload in the child with mild CI. Explaining the importance of keeping the burn area clean would be too abstract for the child.

What should the nurse keep in mind when planning to communicate with a child who has autism? a. The child has normal verbal communication. b. The child is expected to use sign language. c. The child may exhibit monotone speech and echolalia. d. The child is not listening if she is not looking at the nurse.

ANS: C Children with autism have abnormalities in the production of speech, such as a monotone voice or echolalia, or inappropriate volume, pitch, rate, rhythm, or intonation. The child has impaired verbal communication and abnormalities in the production of speech. Some autistic children may use sign language, but it is not assumed. Children with autism often are reluctant to initiate direct eye contact.

The pediatric nurse understands that fragile X syndrome is: a. A chromosome defect affecting only females. b. A chromosome defect that follows the pattern of X-linked recessive disorders. c. The second most common genetic cause of cognitive impairment. d. The most common cause of noninherited cognitive impairment.

ANS: C Fragile X syndrome is the most common inherited cause of cognitive impairment and the second most common genetic cause of cognitive impairment after Down syndrome. Fragile X primarily affects males and follows the pattern of X-linked dominant disorders with reduced penetrance.

17. A nurse is helping an older-adult patient with instrumental activities of daily living. The nurse will be assisting the patient with which activity? a.Taking a bath b.Getting dressed c.Making a phone call d.Going to the bathroom

ANS: C Instrumental activities of daily living or IADLs (such as the ability to write a check, shop, prepare meals, or make phone calls) and activities of daily living or ADLs (such as bathing, dressing, and toileting) are essential to independent living.

13. A nurse is observing skin integrity of an older adult. Which finding will the nurse document as a normal finding? a.Oily skin b.Faster nail growth c.Decreased elasticity d.Increased facial hair in men

ANS: C Loss of skin elasticity is a common finding in the older adult. Other common findings include pigmentation changes, glandular atrophy (oil, moisture, and sweat glands), thinning hair (facial hair: decreased in men, increased in women), slower nail growth, and atrophy of epidermal arterioles.

A young child who has an intelligence quotient (IQ) of 45 would be described as: a. Within the lower limits of the range of normal intelligence. b. Mildly cognitively impaired but educable. c. Moderately cognitively impaired but trainable. d. Severely cognitively impaired and completely dependent on others for care.

ANS: C Moderately cognitively impaired IQs range from 35 to 55. The lower limit of normal intelligence is approximately 70 to 75. Individuals with IQs of 50 to 70 are considered mildly cognitively impaired but educable. An IQ of 20 to 40 results in severe cognitive impairment.

15. A nurse is assessing an older adult for cognitive changes. Which symptom will the nurse report as normal? a.Disorientation b.Poor judgment c.Slower reaction time d.Loss of language skills

ANS: C Slower reaction time is a common change in the older adult. Symptoms of cognitive impairment, such as disorientation, loss of language skills, loss of the ability to calculate, and poor judgment are not normal aging changes and require further investigation of underlying causes.

8. A 70-year-old patient who suffers from worsening dementia is no longer able to live alone. The nurse is discussing health care services and possible long-term living arrangements with the patient's only son. What will the nurse suggest? a.An apartment setting with neighbors close by b.Having the patient utilize weekly home health visits c.A nursing center because home care is no longer safe d.That placement is irrelevant because the patient is retreating to a place of inactivity

ANS: C Some family caregivers consider nursing center placement when in-home care becomes increasingly difficult or when convalescence from hospitalization requires more assistance than the family is able to provide. An apartment setting and the use of home health visits are not appropriate because living at home is unsafe. Dementia is not a time of inactivity but an impairment of intellectual functioning.

5. A nurse is teaching a group of older-adult patients. Which teaching strategy is best for the nurse to use? a.Provide several topics of discussion at once to promote independence and making choices. b.Avoid uncomfortable silences after questions by helping patients complete their statements. c.Ask patients to recall past experiences that correspond with their interests. d.Speak in a high pitch to help patients hear better.

ANS: C Teaching strategies include the use of past experiences to connect new learning with previous knowledge, focusing on a single topic to help the patient concentrate, giving the patient enough time in which to respond because older adults' reaction times are longer than those of younger persons, and keeping the tone of voice low; older adults are able to hear low sounds better than high-frequency sounds.

During a routine physical assessment, the nurse obtaining a health history notes that a 50-year-old female patient reports pain and redness in the right breast. What is the nurse's best action in response to this finding? a. Explain to the patient that breast tenderness is normal at her age. b. Tell the patient that redness is not a cause for concern and is quite common. c. Assess the patient as thoroughly as possible. d. Inform her that redness is the precursor to normal unilateral breast enlargement.

ANS: C A comprehensive assessment offers direction for health promotion recommendations, as well as for planning and implementing any acutely needed intervention. Redness or painful breasts are abnormal physical assessment findings in the middle adult. Increased size of one breast is an abnormal physical assessment finding in the middle adult.

13. A parent asks the nurse "At what age do most babies begin to fear strangers?" The nurse responds that most infants begin to fear strangers at what age? a. 2 months b. 4 months c. 6 months d. 12 months

ANS: C Between ages 6 and 8 months, fear of strangers and stranger anxiety become prominent and are related to the infant's ability to discriminate between familiar and nonfamiliar people. At age 2 months, the infant is just beginning to respond differentially to the mother. At age 4 months, the infant is beginning the process of separation individuation when the infant begins to recognize self and mother as separate beings. Twelve months is too late and requires referral for evaluation if the infant does not fear strangers at this age.

The nurse is teaching a class to pregnant women about common physiological changes during pregnancy. Which statement by the nurse accurately describes these changes? a. "Pregnancy enhances your ability to cope with stress." b. "Being nauseated and feeling tired will not affect your physical body image." c. "You and your partner may experience feelings of uncertainty about assuming the roles of parents." d. "Returning home after delivery will rejuvenate you and foster independence."

ANS: C Both partners think about and have feelings of uncertainty about impending role changes. Parents need reassurance that childbirth and childrearing are natural and positive experiences but are also stressful. Parents often are unable to cope with particular stressors. Morning sickness and fatigue contribute to poor body image. New mothers often return home from the hospital fatigued and unfamiliar with infant care.

12. Which behavior indicates that an infant has developed object permanence? a. Recognizes familiar face such as the mother b. Recognizes familiar object such as a bottle c. Actively searches for a hidden object d. Secures objects by pulling on a string

ANS: C During the first 6 months of life, infants believe that objects exist only as long as they can see them. When infants search for an object that is out of sight, this signals the attainment of object permanence, whereby an infant knows that an object exists even when it is not visible. Between ages 8 and 12 weeks, infants begin to respond differentially to their mothers. They cry, smile, vocalize, and show distinct preference for their mothers. This preference is one of the stages that influence the attachment process, but it is too early for object permanence. Recognizing familiar objects is an important transition for the infant, but it does not signal object permanence. The ability to understand cause and effect, such as pulling on a string to secure an object, is part of secondary schema development.

35. The nurse should teach parents that at what age it is safe to give infants whole milk instead of commercial infant formula? a. 6 months b. 9 months c. 12 months d. 18 months

ANS: C The American Academy of Pediatrics does not recommend the use of cow's milk for children younger than 12 months. At 6 and 9 months, the infant should be receiving commercial infant formula or breast milk. At age 18 months, milk and formula are supplemented with solid foods, water, and some fruit juices.

24. The parent of a 2 week old asks the nurse if the infant needs fluoride supplements because they plan to exclusively breastfed. What is the nurse's best response? a. "Your infant needs to begin taking them now." b. "They are not needed if you drink fluoridated water." c. "Your infant may need to begin taking them at age 6 months." d. "Your infant can have infant cereal mixed with fluoridated water instead of supplements."

ANS: C Fluoride supplementation is recommended by the American Academy of Pediatrics beginning at age 6 months if the child is not drinking adequate amounts of fluoridated water. The recommendation is to begin supplementation at 6 months, not at 2 weeks. The amount of water that is ingested and the amount of fluoride in the water are evaluated when supplementation is being considered.

1. A mother tells the nurse that she is discontinuing breastfeeding her 5-month-old infant. What should the nurse recommend to be used as substitute for the breastmilk? a. Skim milk b. Whole cow's milk c. Commercial iron-fortified formula d. Commercial formula without iron

ANS: C For children younger than 1 year, the American Academy of Pediatrics recommends the use of breast milk. If breastfeeding has been discontinued, iron-fortified commercial formula should be used. Cow's milk should not be used in children younger than 12 months. Maternal iron stores are almost depleted by this age; the iron-fortified formula will help prevent the development of iron deficiency anemia.

1. Which statement accurately describes an event associated with an infant's physical development? a. Anterior fontanel closes by age 6 to 10 months. b. Binocularity is well established by age 8 months. c. Birth weight doubles by age 5 months and triples by age 1 year. d. Maternal iron stores persist during the first 12 months of life.

ANS: C Growth is very rapid during the first year of life. The birth weight approximately doubles by age 5 to 6 months and triples by age 1 year. The anterior fontanel closes at age 12 to 18 months. Binocularity is not established until age 15 months. Maternal iron stores are usually depleted by age 6 months.

When describing relevant family psychosocial factors in middle adulthood that cause stress, the nurse would not include a. Singlehood and feeling isolated. b. Choices stemming from marital changes. c. Financial security and certainty. d. Planning for the future when children leave home.

ANS: C In the middle adult years, as children depart from the household, the family enters the postparental family stage. Time and financial demands on parents decrease, and the couple faces the task of redefining their own relationship. Psychosocial factors involving the family include the stresses of singlehood, marital changes, transition of the family as children leave home, and the care of aging parents.

11. According to Piaget, the 6-month-old infant would be in what stage of the sensorimotor phase? a. Use of reflexes b. Primary circular reactions c. Secondary circular reactions d. Coordination of secondary schemata

ANS: C Infants are usually in the secondary circular reaction stage from age 4 months to 8 months. This stage is characterized by a continuation of the primary circular reaction for the response that results. For example, shaking of a rattle is performed to hear the noise of the rattle, not just for shaking. The use of reflexes is primarily during the first month of life. The primary circular reaction stage marks the replacement of reflexes with voluntary acts. The infant is in this stage from age 1 month to 4 months. The fourth sensorimotor stage is coordination of secondary schemata. This is a transitional stage in which increasing motor skills enable greater exploration of the environment.

The nurse knows that the young adult patient understands the health risks that affect his/her age group when the patient states a. "It's probably safe for me to start smoking. At my age, there's not enough time for cancer to develop." b. "I am sure that I am going to get emphysema. Both my mother and my aunt had it. It's genetic." c. "Controlling the amount of stress in my life may decrease the risk of illness." d. "I don't do drugs. I do drink coffee, but caffeine is not a drug. It is perfectly safe and has no side effects."

ANS: C Lifestyle habits that activate the stress response increase the risk of illness. Smoking is a well-documented risk factor for pulmonary, cardiac, and vascular disease in smokers and in individuals who receive secondhand smoke. The presence of certain chronic illnesses in the family increases the family member's risk of developing a disease. Family risk is distinct from hereditary disease. Caffeine is a naturally occurring legal stimulant that is readily available. Caffeine stimulates catecholamine release, which, in turn, stimulates the central nervous system; it also increases gastric acid secretion, heart rate, and basal metabolic rate.

10. By what age should the nurse expect that an infant will be able to pull to a standing position? a. 6 months b. 8 months c. 9 months d. 11 to 12 months

ANS: C Most infants can pull themselves to a standing position at age 9 months. Any infant who cannot pull to a standing position by age 11 to 12 months should be referred for further evaluation for developmental dysplasia of the hips (DDH). At 6 months, the infant has just obtained coordination of arms and legs. By age 8 months, infants can bear full weight on their legs.

9. At which age can most infants sit steadily unsupported? a. 4 months b. 6 months c. 8 months d. 10 months

ANS: C Sitting erect without support is a developmental milestone usually achieved by 8 months. At age 4 months, an infant can sit with support. At age 6 months, the infant will maintain a sitting position if propped. By 10 months, the infant can maneuver from a prone to a sitting position.

19. The mother of a breastfed infant being seen in the clinic for the sixth month checkup is concerned that the infant has begun thumb sucking. How should the nurse respond to the mother's concern? a. Recommend that the mother substitute a pacifier for the infant's thumb. b. Assess the infant for other signs of sensory deprivation. c. Reassure the mother that this behavior is very normal at this age. d. Suggest that the mother breastfeed more often to satisfy sucking needs.

ANS: C Sucking is an infant's chief pleasure, and she may not be satisfied by bottle-feeding or breastfeeding alone. During infancy and early childhood, there is no need to restrict nonnutritive sucking. Dental damage does not appear to occur unless the use of the pacifier or finger persists after age 4 to 6 years. The nurse should explore with the mother her feelings about pacifier versus thumb. This is a normal behavior to meet nonnutritive sucking needs. No data support that Latasha has sensory deprivation.

A 55-year-old female presents to the outpatient clinic describing irregular menstrual periods and hot flashes. What should the nurse explain? a. Those symptoms are normal when a woman undergoes the climacteric. b. An assessment is not really needed because these problems are normal for older women. c. The patient's age and symptoms point toward normal menopause. d. The patient should stop regular exercise because that is probably causing her symptoms.

ANS: C The most significant physiological changes during middle age are menopause in women and the climacteric in men. The nurse should continue with the examination because a comprehensive assessment offers direction for health promotion recommendations, as well as for planning and implementing any acutely needed interventions. High self-esteem, a favorable body image, and a positive attitude toward physiological changes occur when adults engage in physical exercise, balanced diets, adequate sleep, and good hygiene practices that promote vigorous, healthy bodies.

18. A male older-adult patient expresses concern and anxiety about decreased penile firmness during an erection. What is the nurse's best response? a.Tell the patient that libido will always decrease, as well as the sexual desires. b.Tell the patient that touching should be avoided unless intercourse is planned. c.Tell the patient that heterosexuality will help maintain stronger libido. d.Tell the patient that this change is expected in aging adults.

ANS: D Aging men typically experience an erection that is less firm and shorter acting and have a less forceful ejaculation. Testosterone lessens with age and sometimes (not always) leads to a loss of libido. However, for both men and women sexual desires, thoughts, and actions continue throughout all decades of life. Sexuality involves love, warmth, sharing, and touching, not just the act of intercourse. Touch complements traditional sexual methods or serves as an alternative sexual expression when physical intercourse is not desired or possible. Clearly not all older adults are heterosexual, and there is emerging research on older adult, lesbian, gay, bisexual, and transgender individuals and their health care needs.

The parents of a child with cerebral palsy ask the nurse if any drugs can decrease their child's spasticity. The nurse's response should be based on knowing that: a. Anticonvulsant medications are sometimes useful for controlling spasticity. b. Medications that would be useful in reducing spasticity are too toxic for use with children. c. Many different medications can be highly effective in controlling spasticity. d. Implantation of a pump to deliver medication into the intrathecal space to decrease spasticity has recently become available.

ANS: D Baclofen given intrathecally is best suited for children with severe spasticity that interferes with activities of daily living and ambulation. Anticonvulsant medications are used when seizures occur in children with cerebral palsy. The intrathecal route decreases the side effects of the drugs that reduce spasticity. Few medications are presently available for the control of spasticity.

14. An older-adult patient in no acute distress reports being less able to taste and smell. What is the nurse's best response to this information? a.Notify the health care provider immediately to rule out cranial nerve damage. b.Schedule the patient for an appointment at a smell and taste disorders clinic. c.Perform testing on the vestibulocochlear nerve and a hearing test. d.Explain to the patient that diminished senses are normal findings.

ANS: D Diminished taste and smell senses are common findings in older adults. Scheduling an appointment at a smell and taste disorders clinic, testing the vestibulocochlear nerve, or an attempt to rule out cranial nerve damage is unnecessary at this time as per the information provided.

6. An older patient has fallen and suffered a hip fracture. As a consequence, the patient's family is concerned about the patient's ability to care for self, especially during this convalescence. What should the nurse do? a.Stress that older patients usually ask for help when needed. b.Inform the family that placement in a nursing center is a permanent solution. c.Tell the family to enroll the patient in a ceramics class to maintain quality of life. d.Provide information and answer questions as family members make choices among care options.

ANS: D Nurses help older adults and their families by providing information and answering questions as they make choices among care options. Some older adults deny functional declines and refuse to ask for assistance with tasks that place their safety at great risk. The decision to enter a nursing center is never final, and a nursing center resident sometimes is discharged to home or to another less-acute residence. What defines quality of life varies and is unique for each person.

19. A patient asks the nurse what the term polypharmacy means. Which information should the nurse share with the patient? a.This is multiple side effects experienced when taking medications. b.This is many adverse drug effects reported to the pharmacy. c.This is the multiple risks of medication effects due to aging. d.This is concurrent use of many medications.

ANS: D Polypharmacy refers to the concurrent use of many medications. It does not have anything to do with side effects, adverse drug effects, or risks of medication use due to aging.

25. A 72-year-old woman was recently widowed. She worked as a teller at a bank for 40 years and has been retired for the past 5 years. She never learned how to drive. She lives in a rural area that does not have public transportation. Which psychosocial change does the nurse focus on as a priority? a.Sexuality b.Retirement c.Environment d.Social isolation

ANS: D The highest priority at this time is the potential for social isolation. This woman does not know how to drive and lives in a rural community that does not have public transportation. All of these factors contribute to her social isolation. Other possible changes she may be going through right now include sexuality related to her advanced age and recent death of her spouse; however, this is not the priority at this time. She has been retired for 5 years, so this is also not an immediate need. She may eventually experience needs related to environment, but the data do not support this as an issue at this time.

32. What is an important nursing responsibility when dealing with a family experiencing the loss of an infant from sudden infant death syndrome (SIDS)? a. Explain how SIDS could have been predicted and prevented. b. Interview parents in depth concerning the circumstances surrounding the infant's death. c. Discourage parents from making a last visit with the infant. d. Make a follow-up home visit to parents as soon as possible after the infant's death.

ANS: D A competent, qualified professional should visit the family at home as soon as possible after the death and provide the family with printed information about SIDS. An explanation of how SIDS could have been predicted and prevented is inappropriate. SIDS cannot be prevented or predicted. Discussions about the cause will only increase parental guilt. The parents should be asked only factual questions to determine the cause of death. Parents should be allowed and encouraged to make a last visit with their infant.

According to some developmental theorists, intellectual development and moral development differ between men and women. What did Gilligan propose? a. As women progress toward adulthood, concepts, morals, and responsibility remain unchanged. b. Providing and protecting remain the sole responsibilities of men in today's society. c. Women continue to play a minor role in the financial well-being of their families. d. Women struggle with issues of care and responsibility.

ANS: D According to Gilligan, women struggle with issues of care and responsibility, and in turn, their relationships progress toward a maturity of interdependence. As women progress toward adulthood, the moral dilemma changes from how to exercise their rights without interfering with the rights of others to "how to lead a moral life," which includes obligations to themselves and their families and people in general. Traditional masculine roles include providing and protecting. Recently, however, men have been moving into greater disequilibrium. Both men and women are assuming different roles in today's society. Today, many women pursue careers and contribute significantly to their family's income.

During middle adulthood, the 50-year-old patient is likely to adapt favorably to a changing body image if he or she a. Decreases the amount of physical exercise. b. Eats a diet composed of 40% fat. c. Gets less than 5 hours of sleep per night. d. Engages in good hygiene practices.

ANS: D High self-esteem, a favorable body image, and a positive attitude toward physiological changes occur when adults engage in physical exercise, balanced diets, adequate sleep, and good hygiene practices that promote vigorous, healthy bodies.

26. The parents of a 12-month-old child ask the nurse if the child can eat hot dogs. The nurse's reply should be based on what understanding? a. The child is too young to digest hot dogs. b. The child is too young to eat hot dogs safely. c. Hot dogs must be sliced into sections to prevent aspiration. d. Hot dogs must be cut into small, irregular pieces to prevent aspiration.

ANS: D Hot dogs are of a consistency, diameter, and round shape that may cause complete obstruction of the child's airway. If given to young children, the hot dog should be cut into small irregular pieces rather than served whole or in slices. The child's digestive system is mature enough to digest hot dogs. To eat the hot dog safely, the child should be sitting down, and the hot dog should be appropriately cut into irregularly shaped pieces.

25. A mother tells the nurse that she does not want her infant immunized because of the discomfort associated with injections. The nurse should explain that: a. this cannot be prevented. b. infants do not feel pain as adults do. c. this is not a good reason for refusing immunizations. d. a topical anesthetic, eutectic mixture of local anesthetic (EMLA), will minimize the discomfort.

ANS: D Several topical anesthetic agents can be used to minimize the discomfort associated with immunization injections. These include EMLA and vapor coolant sprays. Pain associated with many procedures can be prevented or minimized by using the principles of atraumatic care. With preparation, the injection site can be properly anesthetized to decrease the amount of pain felt by the infant. Infants have the neural pathways to sense pain. Numerous research studies have indicated that infants perceive and react to pain in the same manner as do children and adults. The mother should be allowed to discuss her concerns and the alternatives available. This is part of the informed consent process.

36. A parent asks the nurse whether her infant is susceptible to pertussis. The nurse's response should be based on which statement concerning susceptibility to pertussis? a. Neonates will be immune the first few months. b. If the mother has had the disease, the infant will receive passive immunity. c. Children younger than 1 year seldom contract this disease. d. Most children are highly susceptible from birth.

ANS: D The acellular pertussis vaccine is recommended by the American Academy of Pediatrics beginning at age 6 weeks. Infants are at greater risk for complications of pertussis. The vaccine is not given after age 7 years, when the risks of the vaccine become greater than those of pertussis. The infant is highly susceptible to pertussis, which can be a life-threatening illness in this age-group.

5. The parents of a 9-month-old infant tell the nurse that they have noticed foods such as peas and corn are not completely digested and can be seen in their infant's stool. The nurse bases her explanation on what fact? a. Children should not be given fibrous foods until the digestive tract matures at age 4 years. b. The infant should not be given any solid foods until this digestive problem is resolved. c. This is abnormal and requires further investigation. d. This is normal because of the immaturity of digestive processes at this age.

ANS: D The immaturity of the digestive tract is evident in the appearance of the stools. Solid foods are passed incompletely broken down in the feces but it is not necessity to eliminate solid foods. An excess quantity of fiber predisposes the child to large, bulky stools. This is a normal part of the maturational process, and no further investigation is necessary.

A nursing student is asked to compare major life events of young adult, middle adult, and childbearing families. Which statement by the student demonstrates understanding? a. "Young adults have gained sexual experience and do not need sexual education." b. "Once a woman has her baby, stress levels decrease, as does health risk." c. "The social pressure to get married is greater now than it ever was." d. "When married people both work, income is increased, but so is stress."

ANS: D The two-career family has benefits and liabilities. Stressors result from transfer to a new city; increased expenditures of physical, mental, or emotional energy; child care demands; or household needs. To avoid stress, partners should share all responsibilities. Young adults are at risk for sexually transmitted diseases. Consequently, there is an increased need for education regarding mode of transmission, prevention, and symptom recognition and management for sexually transmitted diseases. The stress that many women experience after childbirth has a significant impact on the health of postpartum women. Social pressure to get married is not as great as it once was, and many young adults do not marry until their late 20s or early 30s, or not at all.

34. The parents of a 3-month-old infant report that their infant sleeps supine (face up) but is often prone (face down) while awake. The nurse's response should be based on what knowledge? a. Unacceptable because of the risk of sudden infant death syndrome (SIDS). b. Unacceptable because it does not encourage achievement of developmental milestones. c. Unacceptable to encourage fine motor development. d. Acceptable to encourage head control and turning over.

ANS: D These parents are implementing the guidelines to reduce the risk of SIDS. Infants should sleep on their backs and then be placed on their abdomens when awake to enhance development of milestones such as head control. The face-down position while awake and positioning on the back for sleep are acceptable because they reduce risk of SIDS and allow achievement of developmental milestones. These position changes encourage gross motor, not fine motor development.