416 final prractice questions
A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. The nurse plans care based on which mental health condition?
Conversion disorder
A child is hospitalized because of persistent vomiting. The nurse should monitor the child closely for which problem?
Metabolic alkalosis
Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply.
vitals safe environment address hallucinations therapeutically reorient pt
An emergency department nurse is performing an assessment on a child with a suspected diagnosis of intussusception. Which assessment question for the parents will elicit the most specific data related to this disorder?
"Can you describe the type of pain that the child is experiencing?" severe abdominal pain Typical behavior includes screaming and drawing the knees up to the chest
A child with rheumatic fever will be arriving to the nursing unit for admission. On admission assessment, the nurse should ask the parents which question to elicit assessment information specific to the development of rheumatic fever?
"Did the child have a sore throat or fever within the last 2 months?"
The nurse is collecting data on an infant with a diagnosis of suspected Hirschsprung's disease. Which question to the mother will most specifically elicit information regarding this disorder?
"Does your infant have foul-smelling, ribbon-like stools?"
A client is admitted to a long-term care facility with the diagnosis of weight loss secondary to anorexia. The primary health care provider prescribes an enteral tube feeding of a standard formula to run at 40 mL/hr. A nursing student is assigned to care for the client, and the nursing instructor asks the student to describe the nursing considerations related to a tube feeding. Which statement, if made by the student, indicates an understanding of this dietary treatment?
"Enteral feedings require the normal digestive capabilities of the gastrointestinal tract."
The nurse is assessing a child admitted with a diagnosis of rheumatic fever. Which significant question should the nurse ask the child's parent during the assessment?
"Has any family member had a sore throat within the past few weeks?"
The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin. Which statement made by the parent indicates the need for further instruction?
"If my child vomits after medication administration, I will repeat the dose." Don't mix with food, if more than one dose is missed call the HCP, check pulse before giving
A 1-year-old child is diagnosed with intussusception, and the mother of the child asks the student nurse to describe the disorder. Which statement by the student nurse indicates correct understanding of this disorder?
"It is a condition in which a proximal segment of the bowel prolapses into a distal segment of the bowel."
The spouse of an alcoholic client is attending a support group and says to the group members, "It's all very well for everyone to label me an enabler, but if I didn't call him in sick at work, he'd lose his job. Where would we be then?" Which statement by the nurse co-leader would be therapeutic?
"It is a difficult situation, but do you agree that enabling creates codependency?"
A clinic nurse is monitoring a client with anorexia nervosa. Which client statement should indicate to the nurse that treatment has been effective?
"My friends and I went out to lunch today."
A child is diagnosed with Hirschsprung's disease. The nurse is teaching the parents about the cause of the disease. Which statement, if made by the parent, supports that teaching was successful?
"Special cells are not present in the rectum, which caused the disease."
A nurse is caring for a hospitalized child who has hypotonic dehydration. Which serum sodium level would this student expect to observe?
125 mEq/L (125 mmol/L)
A pediatric client with ventricular septal defect repair is placed on a maintenance dosage of digoxin. The dosage is 8 mcg/kg. The child's weight is 7.2 kg. The pediatrician prescribes digoxin to be given twice daily. The nurse prepares how many mcg of digoxin to administer at each dose?
28.8mcg
A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a 2-bed room. A newly admitted client will be assigned to this client's room. Which client would be the best choice as a roommate for the client with anorexia nervosa?
A client undergoing diagnostic tests
Which roommate choice is least appropriate for a client diagnosed with anorexia nervosa who is in a state of starvation?
A client with pneumonia
A child with a diagnosis of tetralogy of Fallot exhibits an increased depth and rate of respirations. On further assessment, the nurse notes increased hypoxemia. The nurse interprets these findings as indicating which situation?
A hypercyanotic episode
The nurse is monitoring an infant with heart failure. Which sign alerts the nurse to suspect fluid accumulation and the need to call the primary health care provider?
A weight gain of 1 lb (0.5 kg) in 1 day
A 1-year-old infant with a diagnosis of heart failure is prescribed digoxin. The nurse takes the apical pulse for 1 minute before administering the medication and obtains a result of 102 beats/minute. What is the nurse's best action?
Administer the medication hold for HR less than 90
A client is preparing to attend a Gamblers Anonymous meeting for the first time. The nurse should tell the client that which is the first step in this 12-step program?
Admitting to having a problem
The nurse reviews the laboratory results for a child with a suspected diagnosis of rheumatic fever, knowing that which laboratory study would assist in confirming the diagnosis?
Anti-streptolysin O titer "recent strep"
The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care?
Ask the client about the amount of drug use and its effect.
The nurse is performing an assessment on a client being admitted to the mental health unit. During the interview, the nurse discovers that the client suffered a severe emotional trauma 1 month earlier and is now experiencing paralysis of the right arm. Which is the initial nursing action?
Assess the client for organic causes of the paralysis.
The nurse is providing a health promotion session to a group of teenagers and is discussing the abuse of barbiturates. The nurse should provide which information to the teenagers?
Barbiturate abuse is the cause of many drug overdose deaths
The nurse is caring for a child with a diagnosis of a right-to-left cardiac shunt. On review of the child's record, the nurse should expect to note documentation of which most common assessment finding?
Bluish discoloration of the skin
The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented?
Bright red blood and mucus in the stools
A child has fluid volume deficit. The nurse performs an assessment and determines that the child is improving and the deficit is resolving if which finding is noted?
Capillary refill is less than 2 seconds
A pediatrician prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription?
Checks the amount of urine output
The nurse is caring for an infant with a diagnosis of congenital heart disease. Which finding, on physical assessment, does the nurse attribute to chronic hypoxia?
Clubbing of the fingers
On assessment of a child admitted with a diagnosis of acute-stage Kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease?
Conjunctival hyperemia fever, conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of the cervical lymph nodes
A 2-year-old child with acute diarrhea has been diagnosed with mild dehydration. Which rehydration methods would the nurse expect the primary health care provider to prescribe?
Consume oral rehydration fluid, advancing to a regular diet
The nurse is preparing an infant for surgery to treat Hirschsprung's disease. Which assessment finding is priority to identify and treat?
Decreased blood pressure and tachycardia "shock"
The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings should the nurse expect to note? Select all that apply.
Dental decay Loss of tooth enamel Electrolyte imbalances
The nurse is caring for an infant with congenital heart disease. Which, if noted in the infant, should alert the nurse to the early development of heart failure?
Diaphoresis during feeding
During a home visit, the nurse suspects that a young daughter of the client is bulimic. The nurse bases this suspicion on which primary characteristics of bulimia?
Eating a lot of food in a short period of time and misuse of laxatives
Which assessments should the nurse closely monitor when caring for a hospitalized client diagnosed with bulimia nervosa? Select all that apply.
Electrolyte levels Intake and output Elimination patterns
The nurse reviews the laboratory results for a child with rheumatic fever and would expect to note which findings?
Elevated C-reactive protein Elevated antistreptolysin O titer Presence of group A beta-hemolytic strep
A 12-year-old is admitted to the hospital with a low-grade fever and joint pain. Which diagnostic test finding will assist to determine a diagnosis of rheumatic fever?
Elevated erythrocyte sedimentation rate
A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes are much too tight and has reduced her calorie intake to 800 calories daily. How should the nurse evaluate this behavior?
Evidence of the client's disturbed body image
The clinic nurse reviews the record of an infant and notes that the primary health care provider (PHCP) has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek health care for the infant?
Foul-smelling ribbon-like stools
The nurse is creating a plan of care for a child admitted with a diagnosis of Kawasaki disease. In developing the initial plan of care, the nurse should include monitoring the child for signs of which condition?
Heart failure
When a client is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa, a cognitive behavioral approach is used as part of the treatment plan. The nurse plans care based on which purpose of this approach?
Helping the client to examine dysfunctional thoughts and beliefs
The nurse is assessing a client who was admitted 24 hours ago for a fractured humerus. Which findings should alert the nurse to the potential for alcohol withdrawal delirium?
Hypertension, changes in level of consciousness, hallucinations
The nurse should monitor a client with a history of opioid abuse for which signs and symptoms associated with opioid withdrawal?
Increased pulse and blood pressure, low-grade fever, yawning, restlessness, anxiety, diarrhea, and mydriasis
The nurse is caring for a female client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate?
Interrupt the client and offer to take her for a walk
The nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic, and the nurse recognizes that the infant is experiencing a hypercyanotic spell (blue or tet spell). The nurse immediately places the infant in what position?
Knee-chest position
Prostaglandin E1 is prescribed for a child with transposition of the great arteries. The mother of the child is a registered nurse and asks the nurse why the child needs the medication. What is the most appropriate response to the mother about the action of the medication?
Maintains adequate cardiac output
A child admitted to the hospital with a diagnosis of gastroenteritis and dehydration weighs 17 lb 2 oz (7.8 kg). The parents state that his preadmission weight was 18 lb 4 oz (8.3 kg). Based on weight alone, what type of dehydration does the nurse expect?
Moderate dehydration Mild dehydration is a weight loss less than 5%; Moderate dehydration is 5% to 10%; Severe dehydration is greater than 10% weight loss
The nurse has developed a plan of care for a client diagnosed with anorexia nervosa. Which client problem would the nurse select as the priority in the plan of care?
Nutritional imbalance because of lack of intake
The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management?
Observing rigid rules and regulations
The clinic nurse is assessing a child for dehydration. The nurse determines that the child is moderately dehydrated if which finding is noted on assessment?
Oliguria
The nurse is caring for an infant with gastroenteritis who is being treated for dehydration. The nurse reviews the health record and notes that the primary health care provider has documented that the infant is mildly dehydrated. Which assessment finding should the nurse expect to note in mild dehydration?
Pale skin color
After hydrostatic reduction for intussusception, the nurse should expect to observe which client response?
Passage of barium or water-soluble contrast with stools
Assessment findings of an infant admitted to the hospital reveal a machinery-like murmur on auscultation of the heart and signs of heart failure. The nurse reviews congenital cardiac anomalies and identifies the infant's condition as which disorder?
Patent ductus arteriosus
The nurse is assigned to care for an infant with tetralogy of Fallot. The mother of the infant calls the nurse to the room because the infant suddenly seems to be having difficulty breathing. The nurse enters the room and notes that the infant is experiencing a hypercyanotic episode. What is the priority action by the nurse?
Place the infant in a knee-chest position
The nurse in the mental health unit is performing an assessment on a client who has a history of multiple physical complaints involving several organ systems. Diagnostic studies revealed no organic pathology. The care plan developed for this client will reflect that the client is experiencing which disorder?
Somatization disorder
A newly admitted client is exhibiting signs and symptoms associated with a loss of physical functioning, although no such loss can be confirmed medically. This situation supports which mental health diagnosis?
Somatization disorder
The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure (HF). The nurse should assess the infant for which early sign of HF?
Tachycardia
A child is suspected of suffering from intussusception. The nurse should be alert to which clinical manifestation of this condition?
Tender, distended abdomen
A client with suspected opioid overdose has received a dose of naloxone hydrochloride. The client subsequently becomes restless, starts to vomit, and complains of abdominal cramping. The blood pressure increases from 110/72 mm Hg to 160/86 mm Hg. The nurse provides emotional support and reassurance while administering care to the client, knowing which piece of information?
These are signs of opioid withdrawal.
The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess the urine output?
Weighing the diapers
Thiamine supplementation and other nutritional vitamin support measures are prescribed for clients who have been using alcohol to prevent or decrease the risk of which complication?
Wernicke-Korsakoff syndrome
A pediatrician has prescribed oxygen as needed for an infant with heart failure. In which situation should the nurse administer the oxygen to the infant?
When drawing blood for electrolyte level testing
Before giving the client the initial dose of disulfiram (antabuse), what should the psychiatric home health nurse determine?
When the last alcoholic drink was consumed **cant be taken within 12 hrs of drink**
The nurse is preparing to administer digoxin to an infant with heart failure. Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 80 beats/minute. Based on this finding, which is the appropriate nursing action?
Withhold the medication
The nurse is assessing a newborn with heart failure before administering the prescribed digoxin. In reviewing the laboratory data, the nurse notes that the newborn has a digoxin blood level of 1.6 ng/mL (2.05 mmol/L) and an apical heart rate of 90 beats/min. The mother also tells the nurse that the newborn just vomited her formula. Which intervention should the nurse take?
Withhold the medication and notify the primary health care provider.
The nurse is reviewing the primary health care provider's prescriptions for a child with rheumatic fever who is suspected of having a viral infection. The nurse notes that aspirin is prescribed for the child. Which nursing action is most appropriate?
call HCP aspirin shouldn't be given to children with viral infections
On assessment of a child admitted with a diagnosis of acute-stage Kawasaki disease, the nurse expects to note which clinical manifestation of the convalescent stage of the disease?
child appears normal, but signs of inflammation may be present.
The client diagnosed with alcoholism has been prescribed medication therapy to assist in the maintenance of sobriety. The nurse will provide the client with education focused on which medication that will most likely be prescribed?
disulfiram (antabuse
The nurse is performing an assessment on a 16-year-old female client who has been diagnosed with anorexia nervosa. Which statement, made by the client, would the nurse identify as necessitating further assessment on a priority basis?
"I exercise 3 to 4 hours every day to keep my slim figure."
The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement?
"I no longer feel that I deserve the beatings my husband inflicts on me."
The nurse is reviewing the primary health care provider's documentation in the record of a child admitted with a diagnosis of intussusception. The nurse expects to note that the primary health care provider has documented which manifestation?
Currant jelly-like stools
The nurse has provided home care instructions to the parents of a child who is being discharged after cardiac surgery. Which statement made by the parents indicates a need for further instruction?
"I can apply lotion or powder to the incision if it is itchy." post op surgery- balance/rest, Activities in which my child could fall need to be avoided for 2 to 4 weeks, avoid large crowds for 2 weeks
The nurse explains to a group of clients that methamphetamine abuse results in which vascular system dysfunction?
impaired wound healing
Which are the most likely characteristics of a client who abuses alcohol? Select all that apply.
male drugs/alcohol Hx of suicide
A child is admitted to the pediatric unit with a diagnosis of acute stage Kawasaki disease. Which assessment findings by the nurse are characteristic of this disorder? Select all that apply.
red throat conjuntivitis swollen lymph nodes
A nurse is caring for an infant with a respiratory infection and is monitoring the infant for signs of dehydration. What is the nurse's best action to determine fluid loss in the infant?
Monitor body weight
The nurse should monitor the client with a history of heroin addiction for which signs/symptoms of heroin withdrawal?
Nausea, vomiting, diarrhea, muscle aches, and diaphoresis
On assessment of a child admitted with a diagnosis of acute-stage Kawasaki disease, the nurse expects to note which clinical manifestation of the subacute stage of the disease?
cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis
