Exam 6
24. A nurse knows that which exercise is best for a child with juvenile arthritis? a. Jogging b. Tennis c. Gymnastics d. Swimming
D
24. A patient with schizophrenia says, "Contagious bacteria are everywhere. When they get in your body, you will be locked up with other infected people." Which problem is evident? a. Poverty of content b. Concrete thinking c. Neologisms d. Paranoia
D
13. A patient with delusions of persecution about being poisoned has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the patient? a. Allowing the patient to have supervised access to food vending machines b. Allowing the patient to telephone a local restaurant to deliver meals c. Offering to taste each portion on the tray for the patient d. Providing tube feedings or total parenteral nutrition
A
4. A mother whose 7-year-old child has been placed in a cast for a fractured right arm reports that the child will not stop crying even after taking acetaminophen with codeine. The child also will not straighten the fingers on the right arm. What advice by the nurse is best? a. Take the child to the emergency department. b. Put ice on the injury. c. Avoid letting the child get so tired. d. Wait another hour; if the child is still crying, call back.
A
10. A child is upset because, when the cast is removed from her leg, the skin surface is caked with desquamated skin and sebaceous secretions. What should the nurse suggest to remove this material? a. Wash the area with warm water and soap. b. Vigorously scrub the leg. c. Apply powder to absorb the material. d. Carefully pick the material off the leg.
A
12. The correct position for the postoperative child who has had a cataract removed from the right eye is the ________ position. a. supine b. prone c. knee-chest d. right lateral Sims
A
12. What is the major concern guiding treatment for the child with Legg-Calvé-Perthes disease? a. Avoid permanent deformity. b. Minimize pain. c. Maintain normal activities. d. Encourage new hobbies.
A
14. A community mental health nurse wants to establish a relationship with a very withdrawn patient diagnosed with schizophrenia. The patient lives at home with a supportive family. Select the nurse's best plan. a. Visit daily for 4 days, then visit every other day for 1 week; stay with the patient for 20 minutes; accept silence; state when the nurse will return. b. Arrange to spend 1 hour each day with the patient; focus on asking questions about what the patient is thinking or experiencing; avoid silences. c. Visit twice daily; sit beside the patient with a hand on the patient's arm; leave if the patient does not respond within 10 minutes. d. Visit every other day; remind the patient of the nurse's identity; encourage the patient to talk while the nurse works on the nurse will return.
A
14. Discharge planning for the child with juvenile arthritis includes the need for a. routine ophthalmologic examinations to assess for visual problems. b. a low-calorie diet to decrease or control weight in the less mobile child. c. avoiding the use of NSAIDs to decrease gastric irritation. d. immobilizing the painful joints, which is the result of the inflammatory process.
A
14. The nurse should know that the results of untreated amblyopia ("lazy eye") in the child may include which of the following? a. Impaired depth perception b. Strabismus c. Color deficiency d. Ptosis
A
17. In caring for a child with an open fracture, the nurse should carefully assess for a. infection. b. osteoarthritis. c. epiphyseal disruption. d. periosteum thickening.
A
18. A nurse is teaching parents the difference between pediatric fractures and adult fractures. Which observation is true about pediatric fractures? a. They seldom are complete breaks. b. They are often open fractures. c. They are often at the epiphyseal plate. d. They are often the result of decreased mobility of the bones.
A
18. A patient with schizophrenia is acutely disturbed and violent. After several doses of haloperidol (Haldol), the patient is calm. Two hours later the nurse sees the patient's head rotated to one side in a stiff position; the lower jaw is thrust forward, and the patient is drooling. Which problem is most likely? a. Acute dystonic reaction b. Tardive dyskinesia c. Waxy flexibility d. Akathisia
A
19. A 5-year-old diagnosed with chlamydial conjunctivitis should be carefully assessed for which of the following? a. Sexual abuse b. Immune deficiency c. Congenital cataract d. Secondary glaucoma
A
19. An acutely violent patient with schizophrenia receives several doses of haloperidol (Haldol). Two hours later the nurse notices the patient's head rotated to one side in a stiffly fixed position; the lower jaw is thrust forward, and the patient is drooling. Which intervention by the nurse is indicated? a. Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record. b. Reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient. c. Give trihexyphenidyl (Artane) 5 mg orally at the next regularly scheduled medication administration time. d. Administer atropine sulfate 2 mg subcut from the PRN medication administration record.
A
22. A patient who has a hyphema is at risk for developing which condition? a. Glaucoma b. Strabismus c. Diplopia d. Astigmatism
A
23. What assessment findings mark the prodromal stage of schizophrenia? a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion b. Auditory hallucinations, ideas of reference, thought insertion, and broadcasting c. Stereotyped behavior, echopraxia, echolalia, and waxy flexibility d. Loose associations, concrete thinking, and echolalia neologisms
A
23. When assessing the child with osteogenesis imperfecta, the nurse should expect to observe a. discolored teeth. b. below-normal intelligence. c. increased muscle tone. d. above-average stature.
A
24. The most common type of hearing loss, which results from interference of transmission of sound to the middle ear, is called a. conductive. b. sensorineural. c. mixed conductive-sensorineural. d. central auditory imperceptive.
A
26. A nurse suspects possible visual impairment in a child who displays which problem? a. Excessive tearing of the eyes b. Rapid lateral movement of the eyes c. Delay in speech development d. Lack of interest in casual conversation with peers
A
27. The nurse knows that treatment of Osgood-Schlatter disease includes a. limitation of knee bending or kneeling. b. increasing range of motion (ROM) of the knee. c. encouraging flexion of the hip. d. limitation of adduction of the hip.
A
28. The family of a patient with undifferentiated schizophrenia is unfamiliar with the illness and the family's role in recovery. Which type of therapy should the nurse recommend? a. Psychoeducational b. Psychoanalytic c. Transactional d. Family
A
28. What is the most appropriate intervention for an adolescent with a mild scoliosis? a. Long-term monitoring b. Surgical intervention c. Bracing d. No follow-up
A
29. Which statement by the mother of an adolescent being discharged after spinal fusion for severe scoliosis indicates the need for further teaching? a. "I am glad we chose surgery. Now it is all over and done." b. "I'll see you in a month; we'll be back fairly regularly." c. "I have to pick up some more T-shirts on the way home." d. "Those exercises the physical therapist showed us were not too hard."
A
30. A patient with schizophrenia begins to talks about "volmers" hiding in the warehouse at work. The term "volmers" should be documented as: a. neologism b. concrete thinking c. thought insertion d. idea of reference
A
31. A priority nursing intervention when caring for a child in a Pavlik harness is a. skin care. b. bowel function. c. feeding patterns. d. respiratory function.
A
33. A nurse is assessing cranial nerve VII. How does the nurse perform this assessment? a. Ask the child to smile or "show your teeth." b. Have the child shrug shoulders against resistance. c. Tell the child to squeeze your hands hard. d. Instruct the child to stick out the tongue.
A
4. When a patient with paranoid schizophrenia was discharged 6 months ago, haloperidol (Haldol) was prescribed. The patient now says, "I stopped taking those pills. They made me feel like a robot." What common side effects should the nurse validate with the patient? a. Sedation and muscle stiffness b. Sweating, nausea, and diarrhea c. Mild fever, sore throat, and skin rash d. Headache, watery eyes, and runny nose
A
5. A nurse works with a patient with paranoid schizophrenia regarding the importance of medication management. The patient repeatedly says, "I don't like taking pills." Family members say they feel helpless to foster compliance. Which treatment strategy should the nurse discuss with the health care provider? a. Use of a long-acting antipsychotic preparation b. Addition of a benzodiazepine, such as lorazepam (Ativan) c. Adjunctive use of an antidepressant, such as amitriptyline (Elavil) d. Prolonged hospitalization; this patient is not ready for discharge
A
6. Initial care of the child with a chemical burn to the eye(s) is focused on which of the following? a. Irrigation of the affected eye(s) b. Application of topical steroids c. Administration of an analgesic d. Administration of medication to constrict the pupils
A
7. A child with osteomyelitis asks the nurse, "What is a 'sed' rate?" What is the best response for the nurse? a. "It tells us how you are responding to the treatment." b. "It tells us what type of antibiotic you need." c. "It tells us whether we need to immobilize your extremity." d. "It tells us how your nerves and muscles are doing."
A
3. A patient with paranoid schizophrenia is hospitalized after arguing with co-workers and threatening to harm them. The patient is aloof and suspicious and says, "Two staff members I saw talking were plotting to kill me." Based on data gathered at this point, which nursing diagnoses relate? Select all that apply. a. Risk for other-directed violence b. Disturbed thought processes c. Risk for loneliness d. Spiritual distress e. Social isolation
A B
1. A child has a cast applied to the left forearm. Which interventions should the nurse include in the home care instructions for the parents? (Select all that apply.) a. Keep small toys away from the cast. b. Use a padded ruler to scratch the skin under the cast if it itches. c. Assess the cast daily for unusual odors. d. Elevate the extremity on pillows for the first 24 to 48 hours. e. Numbness and tingling in the extremity are expected.
A C D
1. The family members of a patient newly diagnosed with paranoid schizophrenia state that they do not understand what has caused the illness. The nurse's response should be based on which models? Select all that apply. a. Neurobiological b. Developmental c. Family theory d. Genetic e. Stress
A D
2. A child is in skeletal traction. Which interventions should the nurse implement to prevent complications of immobility? (Select all that apply.) a. Reposition the child every 2 hours. b. Avoid use of an egg-crate or sheepskin mattress. c. Limit fluid intake. d. Administer stool softeners as prescribed. e. Encourage coughing and deep breathing.
A D E
22. Which symptoms are expected for a patient with disorganized schizophrenia? a. Extremes of motor activity, from excitement to stupor b. Social withdrawal and ineffective communication c. Severe anxiety with ritualistic behavior d. Highly suspicious, delusional behavior
B
1. A person has had difficulty keeping a job because of arguing with coworkers and accusing them of conspiracy. Today the person shouts, "They're all plotting to destroy me. Isn't that true?" Select the nurse's most therapeutic response. a. "Everyone here is trying to help you. No one wants to harm you." b. "Feeling that people want to destroy you must be very frightening." c. "No, that is not true. People here are trying to help you if you will let them." d. "Staff members are health care professionals who are qualified to help you."
B
10. A patient with catatonic schizophrenia is semistuporous, demonstrates little spontaneous movement, and has waxy flexibility. The patient's activities of daily living are severely compromised. An appropriate outcome is that the patient will: a. demonstrate increased interest in the environment by the end of week 1. b. perform self-care activities with coaching by the end of day 3. c. gradually take the initiative for self-care by the end of week 2. d. accept tube feeding without objection by day 2.
B
11. A nurse observes a patient who is in a catatonic state and standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon? a. Echolalia b. Waxy flexibility c. Depersonalization d. Thought withdrawal
B
11. Teaching parents about the use and application of an eye patch to treat strabismus should include which instruction? a. Check under the patch four times a day. b. Apply the patch directly to the face. c. Sometimes patching alone will straighten the eye. d. Negotiate the number of hours per day that the patch is to be worn.
B
15. During painful episodes of juvenile arthritis, a plan of care should include what nursing intervention? a. A weight-control diet to decrease stress on the joints b. Proper positioning of the affected joints to prevent musculoskeletal complications c. Complete bed rest to decrease stress to joints d. High-resistance exercises to maintain muscular tone in the affected joints
B
16. When assessing a child for an upper extremity fracture, the nurse should know that these fractures most often result from a. automobile crashes. b. falls. c. physical abuse. d. sports injuries.
B
18. A child just returned from cataract eye surgery. What is the most significant nursing intervention to prevent increasing intraocular pressure in this child? a. Monitor for hypertension. b. Prevent coughing and vomiting. c. Lower the head of the bed slightly. d. Avoid use of steroids after the surgery.
B
2. A newly admitted patient diagnosed with paranoid schizophrenia is hypervigilant and constantly scans the environment. The patient states, "I saw two doctors talking in the hall. They were plotting to kill me." The nurse may correctly assess this behavior as: a. echolalia b. idea of reference c. delusion of infidelity d. auditory hallucination
B
20. A patient has taken trifluoperazine (Stelazine) 30 mg/day orally for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patient's neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect? a. Agranulocytosis b. Tardive dyskinesia c. Tourette syndrome d. Anticholinergic effects
B
21. A boy who has fractured his forearm is unable to extend his fingers. The nurse knows that this a. is normal following this type of injury. b. may indicate compartment syndrome. c. may indicate fat embolism. d. may indicate damage to the epiphyseal plate.
B
23. A parent brings an 18-month-old to the pediatrician for a routine well-child visit and reports the child has been babbling and cooing since 6 months of age but is not yet saying any words. Which response by the nurse is the most appropriate? a. "Don't worry, your child should catch up soon." b. "The doctor will want to refer your child to an audiologist and speech pathologist." c. "This is normal speech development for an 18-month-old child." d. "Your child has an expressive language disorder and needs further evaluation."
B
25. Juvenile arthritis should be suspected in a child who exhibits a. frequent fractures. b. joint swelling and pain lasting longer than 6 weeks. c. increased joint mobility. d. lurching and abnormal gait with limited abduction.
B
25. The nurse should suspect a hearing impairment in an infant who demonstrates which of the following? a. Absence of intelligible speech by 12 months b. Cessation of babbling at age 7 months c. Lack of eye contact when being spoken to d. Lack of gesturing to indicate wants after age 15 months
B
27. A patient with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive, but the patient continues to have apathy, poverty of thought, and social isolation. The nurse expects a change to which medication? a. haloperidol (Haldol) b. olanzapine (Zyprexa) c. chlorpromazine (Thorazine) d. diphenhydramine (Benadryl)
B
3. A patient diagnosed with paranoid schizophrenia says, "My co-workers are out to get me. I also saw two doctors plotting to kill me." How does this patient perceive the environment? a. Disorganized b. Dangerous c. Supportive d. Bizarre
B
30. Which factor should the nurse include when teaching a parent about the care of a newborn in a Pavlik harness for hip dysplasia? a. The harness may be removed with every diaper change. b. The harness maintains the hips in flexion, abduction, and external rotation. c. The harness is only the first step of treatment. d. The harness is worn for 2 weeks.
B
32. During a well-child visit, the nurse identifies that an 18-month-old infant is bowlegged. What action by the nurse is most appropriate? a. Assess the infant's diet history. b. Document the finding in the chart. c. Facilitate a referral to an orthopedist. d. Perform further assessment of the musculoskeletal system.
B
34. A patient with schizophrenia begins a new prescription for lurasidone HCl (Latuda). The patient is 5', 6" tall and currently weighs 204 pounds. Which topic is most important for the nurse to include in the teaching plan related to this medication? a. How to recognize tardive dyskinesia b. Weight management strategies c. Ways to manage constipation d. Sleep hygiene measures
B
6. A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating? a. Aloofness, haughtiness, suspicion b. Darting eyes, tilted head, mumbling to self c. Elevated mood, hyperactivity, distractibility d. Performing rituals, avoiding open places
B
7. The nurse is caring for a 2-year-old child who has a history of meningitis as an infant. The child is not speaking and does not turn the head to the sound of a rattle. Which type of hearing loss in a child may have resulted from a previous infection with meningitis? a. Conductive b. Sensorineural c. Central d. Mixed
B
8. On the second postoperative day of an eye surgery, the child has puffy eyes, increased tearing, and fever. What is the most applicable nursing diagnosis? a. Risk for Infection related to surgical procedure b. Infection related to surgical procedure c. Disturbed Sensory Perception (Visual) related to surgical procedure d. Acute Pain related to recent surgical intervention
B
8. Which instruction is part of the discharge plan for a school-age child with osteomyelitis who is receiving home antibiotic therapy? a. Instructions for a low-calorie diet b. Arrange for tutoring and school work c. Instructions for a high-fiber diet d. Instructions to return the child to school as soon as possible
B
9. A patient with catatonic schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which patient needs are of priority importance? a. Psychosocial b. Physiologic c. Self-actualization d. Safety and security
B
9. Parents of a 4-year-old child are concerned because the child continues to stutter. What nursing intervention is correct? a. Remind the parents that stuttering is normal in children younger than 10 years. b. Facilitate a speech evaluation performed if the stuttering continues beyond age 5 years. c. Reinforce the fact that this common speech defect requires no treatment. d. Tell the parents that speech problems are most treatable during the child's teen years.
B
2. A nurse at the mental health clinic plans a series of psychoeducational groups for persons with schizophrenia. Which two topics would take priority? a. How to complete an application for employment b. The importance of correctly taking your medication c. How to dress when attending community events d. How to give and receive compliments e. Ways to quit smoking
B E
26. When providing education for the parents of a child with Duchenne muscular dystrophy, the nurse plans to include a. testing all female children for the disease. b. testing the father for the presence of the trait on the Y chromosome. c. genetic counseling for all female children. d. testing the parents to determine the carrier.
C
35. A patient with schizophrenia has auditory hallucinations, delusions of grandeur, poor personal hygiene, and motor agitation. Which assessment finding would the nurse regard as a negative symptom of schizophrenia? a. Auditory hallucinations b. Delusions of grandeur c. Poor personal hygiene d. Motor agitation
C
1. Which statement is accurate concerning a child's musculoskeletal system and how it may be different from an adult's? a. Growth occurs in children as a result of an increase in the number of muscle fibers. b. Infants are at greater risk for fractures because their epiphyseal plates are not fused. c. Because soft tissues are resilient in children, dislocations and sprains are less common than in adults. d. Their bones have less blood flow.
C
10. A 13-year-old adolescent is suspected to have a visual deficit and is scheduled for further evaluation. The teen asks the nurse to tell "the truth" about the tests. What is the nurse's best response? a. "Don't worry about anything. We're here to take good care of you." b. "Ask your parents. They have talked with the physicians." c. "Most of the vision tests are painless and noninvasive." d. "Trust the doctors. They know what is best for you."
C
11. Which factor is important to include in the teaching plan for parents of a child with Legg-Calvé-Perthes disease? a. It is an acute illness lasting 1 to 2 weeks. b. It affects primarily adolescents. c. There is a disturbance in the blood supply to the femoral epiphysis. d. It is caused by a virus.
C
13. A neonate is born with mild clubfeet. When the parents ask the nurse how this will be corrected, what response by the nurse is best? a. Traction is tried first. b. Surgical intervention is needed. c. Frequent, serial casting is tried first. d. Children outgrow this condition when they learn to walk.
C
13. What manifestation in a 5-month-old child could indicate visual problems? a. Lack of binocularity b. Visual acuity of 20/50 c. Strabismus d. Hyperopia
C
16. A newly admitted patient with schizophrenia says, "The voices are bothering me. They yell and tell me I'm bad. I have got to get away from them." Select the nurse's most helpful reply. a. "Do you hear the voices often?" b. "Do you have a plan for getting away from the voices?" c. "I'll stay with you. Focus on what we are talking about, not the voices." d. "Forget the voices, and ask some other patients to play cards with you."
C
16. The teaching plan for a 7-year-old boy with color deficiency should include what instruction? a. Buy only one color of clothing to ensure the child's ability to match items himself. b. Patching the weaker eye will improve his color vision. c. Teach him an alternate way to distinguish between the colors of traffic signals. d. Botulism toxin drops must be administered every 2 months to improve color vision.
C
17. A patient with schizophrenia has taken fluphenazine (Prolixin) 5 mg orally twice daily for 3 weeks. The nurse now assesses a shuffling propulsive gait, a masklike face, and drooling. Which term applies to these symptoms? a. Neuroleptic malignant syndrome b. Hepatocellular effects c. Pseudoparkinsonism d. Akathisia
C
2. A 10-year-old patient is talking to the nurse about wanting to try contact lenses instead of wearing glasses. The child states that the other children at school call her "four-eyes." Contact lenses should be prescribed for a child who is a. at least 12 years of age. b. able to read all the written information and instructions. c. able to independently care for the lenses in a responsible manner. d. confident that she really wants contact lenses.
C
2. When infants are seen for fractures, which nursing intervention is a priority? a. No intervention is necessary. It is not uncommon for infants to fracture bones. b. Assess the family's safety practices. Fractures in infants usually result from falls. c. Assess for child abuse. Fractures in infants are often nonaccidental. d. Assess for genetic factors.
C
20. A 6-year-old patient who has been placed in skeletal traction has pain, edema, and fever. The nurse should assess which of the following? a. Neurologic status b. Range of motion of all extremities c. Warmth at site of pain d. Blood pressure
C
20. Which statement by a parent indicates understanding of instructions on the care of a child with conjunctivitis? a. "I should treat my other children with these eye drops to prevent spread of the disease." b. "My child must remain home from school until she has received 72 hours of antibiotic drops." c. "I should avoid touching the tip of the ointment tube to my child's eye." d. "My child may go back to wearing her contact lenses 24 hours after treatment has started."
C
21. Discharge planning for an 8-year-old child with a patched eye after a large corneal abrasion should include which instruction? a. Removing the patch after 8 hours for instillation of antibiotic ointment b. Gently massaging the affected eye to prevent edema c. Keeping the patch in place for 24 hours d. Returning after 7 days of patching for reassessment
C
4. Which statement by a parent about conjunctivitis indicates that further teaching is needed? a. "I'll have separate towels and washcloths for each family member." b. "I'll notify my doctor if the eye gets redder or the drainage increases." c. "When the eye drainage improves, we'll stop giving the antibiotic ointment." d. "After taking the antibiotic for 24 hours, my child can return to school."
C
5. A 4-year-old child with a long leg cast complains of "fire" in his cast. Which action by the nurse is most appropriate? a. Notify the provider on his or her next rounds. b. Note the complaint in the nurse's notes. c. Notify the provider immediately. d. Report the complaint to the next nurse on duty.
C
5. Which teaching guideline helps prevent eye injuries during sports and play activities? a. Restrict helmet use to those who wear eye glasses or contact lenses. b. Discourage the use of goggles with helmets so the child can see better. c. Wear eye protection when participating in high-risk sports such as paintball. d. Wear a face mask when playing any sport or playing roughly.
C
1. An adolescent goes to the primary care provider complaining of difficulty with vision. When the nurse asks the adolescent to explain the visual deficits, the adolescent states, "I am having difficulty seeing distant objects; they are less clear than things that are close." What disorder does the nurse suspect the adolescent has? a. Hyphema b. Astigmatism c. Amblyopia d. Myopia
D
12. Which patient with schizophrenia would be expected to have the lowest score in global assessment of functioning? a. 39 years old; paranoid ideation since age 35 years b. 32 years old; diagnosed as catatonic at age 24 years; stable for 3 years c. 19 years old; diagnosed with undifferentiated schizophrenia at age 17 d. 40 years old; disorganized schizophrenia since age 18; frequent relapses
D
15. The teaching plan for the parents of a 3-year-old child with amblyopia ("lazy eye") should include what instruction? a. Apply a patch to the child's eyeglass lenses. b. Apply a patch only during waking hours. c. Apply a patch over the "bad" eye to strengthen it. d. Cover the "good" eye completely with a patch.
D
15. Withdrawn patients with schizophrenia: a. Universally fear sexual involvement with therapists. b. Are socially disabled by the positive symptoms of schizophrenia. c. Exhibit a high degree of hostility as evidenced by rejecting behavior. d. Avoid relationships because they become anxious with emotional closeness.
D
17. A 2-year-old has excessive tearing and corneal haziness. The nurse knows that these symptoms may indicate which of the following? a. Viral conjunctivitis b. Paralytic strabismus c. Congenital cataract d. Infantile glaucoma
D
19. Patient and parent education for the child who has a synthetic cast should include which of the following? a. Applying a heating pad to the cast if the child has swelling in the affected extremity b. Wrapping the outer surface of the cast with an Ace bandage c. Splitting the cast if the child complains of numbness or pain d. Covering the cast with plastic and waterproof tape to keep it dry while bathing or showering
D
21. A nurse sits with a patient diagnosed with disorganized schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurse's best response. a. "Why are you laughing?" b. "Please share the joke with me." c. "I don't think I said anything funny." d. "You're laughing. Tell me what's happening."
D
3. What actions should the nurse perform while caring for a school-age child who sprained his ankle playing football? (Select all that apply.) a. Turn the child every 1 to 2 hours. b. Assist with range-of-motion exercises every 2 hours. c. Apply ice to the affected ankle. d. Wrap the ankle with an ACE bandage. e. Elevate the affected extremity.
C D E
22. Which term is used to describe an abnormally increased convex angulation in the curvature of the thoracic spine? a. Scoliosis b. Ankylosis c. Lordosis d. Kyphosis
D
25. A patient diagnosed with paranoid schizophrenia angrily tells a nurse, "You act like a homosexual. No one trusts you or wants to be around you." Select the most likely analysis. The patient: a. is showing reaction formation in response to feelings of abandonment. b. is unleashing unconscious, hostile feelings toward the nurse. c. is dwelling on others' shortcomings, thus placing them on the defensive. d. may be projecting homosexual urges.
D
26. A patient diagnosed with disorganized schizophrenia says, "It's beat. Time to eat. No room for the cat." What type of verbalization is evident? a. Neologism b. Idea of reference c. Thought broadcasting d. Associative looseness
D
29. A patient with schizophrenia has been stable for a year; however, the family now reports the patient is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The patient says, "Volmers are hiding in the house." The nurse can correctly assess this information as an indication of: a. need for psychoeducation b. medication noncompliance c. chronic deterioration d. relapse
D
3. Which nursing intervention is appropriate to assess for neurovascular competency in a child who fell off the monkey bars at school and hurt his arm? a. The degree of motion and ability to position the extremity b. The length, diameter, and shape of the extremity c. The amount of swelling noted in the extremity and pain intensity d. The skin color, temperature, movement, sensation, and capillary refill of the extremity
D
3. Which statement best describes how a cataract affects a child's vision? a. It increases intraocular pressure. b. It alters the ability to distinguish among colors. c. It causes double vision. d. It prevents a clear image from forming on the retina.
D
31. A patient with schizophrenia anxiously says, "I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror." While listening, the nurse should: a. sit close to the patient. b. place an arm protectively around the patient's shoulders. c. place a hand on the patient's arm and exert light pressure. d. maintain a normal social interaction distance from the patient.
D
32. A patient with schizophrenia and auditory hallucinations anxiously tells the nurse, "The voice is telling me to do things." Select the nurse's priority assessment question. a. "How long has the voice been directing your behavior?" b. "Does what the voice tells you to do frighten you?" c. "Do you recognize the voice speaking to you?" d. "What is the voice telling you to do?"
D
33. A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 10:30 AM. By noon, the patient has difficulty swallowing and is drooling. By 4:00 PM, vital signs are body temperature, 102.8° F; pulse, 110 beats per minute; respirations, 26 breaths per minute; and blood pressure, 150/90 mm Hg. The patient is diaphoretic. Select the nurse's best analysis and action. a. Agranulocytosis. Institute reverse isolation. b. Tardive dyskinesia. Withhold the next dose of medication. c. Cholestatic jaundice. Begin a highprotein, high-cholesterol diet. d. Neuroleptic malignant syndrome. Immediately notify the health care provider.
D
6. When a child with a musculoskeletal injury on the foot is assessed, what is most indicative of a fracture? a. Increased swelling after the injury is iced b. The presence of localized tenderness distal to the site c. The presence of an elevated temperature for 24 hours d. The inability of the child to bear weight
D
7. A health care provider considers which antipsychotic medication to prescribe for a patient with schizophrenia who has auditory hallucinations and poor social functioning. The patient is also overweight and has hypertension. Which drug should the nurse advocate? a. clozapine (Clozaril) b. ziprasidone (Geodon) c. olanzapine (Zyprexa) d. aripiprazole (Abilify)
D
8. A patient with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it?" Select the nurse's best response. a. "Nothing you are saying is clear." b. "Your thoughts are very disconnected." c. "Try to organize your thoughts, and then tell me again." d. "I am having difficulty understanding what you are saying."
D
9. The nurse is assessing a 14-year-old who plays football and complains of knee pain when running and climbing stairs during football practice. The nurse should anticipate which action for this condition? a. Bedrest with range-of-motion exercises b. Prolonged IV antibiotics c. Electromyography d. NSAIDs or knee immobilizer
D