Health Promo Exam 4

Which car safety device should be used for a child who is 8 years old and 4 feet tall? A. Seat belt B. Booster seat C. Rear-facing seat D. Front-facing seat

Answer B Rationale: All children who's weight or height is above the forward-facing limit for their car deat should use a belt-positioning booster seat until the seat belt fits tehm properly usually around 4 ft 9 inches and between the ages of 8-12

The nurse notes that the client brought to the ER after an episode of fainting is recieving Olanzapine. Which disorder or condition would the nurse suspect the client is experiencing? A. Schizophrenia B. Dementia Disorder C. Personality Disorder D. Major Depressive Disorder

Answer A Rationale: Olanzapine is an atypical antipsychotic medication used to treat the manifestations of schizophrenia

A nurse is caring for a depressed, withdrwan client who was responsible for an automobile accident that recently resulted in the death of a child. What should the nurse's intial acton be? A. Allow the client to have some time alone to grieve over the loss B. Reinforce to the client that the child's death was a result of the client's actons C. Communicate in a manner that acknowledges and respects the client's depressed state D. Inform the primary car giver of the client's depressive state and get an order for medication

Answer C Rationale: The nurses initial intervention should be to encourage the client to discuss feeling and establish that client-nurse relationship based upon respect

A mother calls a neighbor who is a nurse and tells the nurse that her 3-year child has just ingested liquid furniture polish. The nurse should direct the mother to take what action? A. Induce vomiting B. Call an ambulance C. Call Poison Control Center D. Bring the child to the closest ER

Answer C Rationale: When a poisonig occurs, the Poison Contro Center should be notified

A client diagnosed with delirium anxiously states "Look at those spiders on the wall." Which response by the nurse addresses the client's concerns therapeutically? A. Would you like me to kill the spiders for you? B. While there may be spiders on the wall, they are not going to hurt you. C. I know that you are frightened but I do not see any spiders D. You are having hallucinations I am sure there are no spiders on the wall

Answer C Rationale: When clients are hallucinating, nurses should reinforce reality with the client while acknowledging the client's feelings

A nurse prepares to administer an intramuscular injection to a 4-month old infant. The nurse should select which best site to administer the injection? A. Ventrogluteal B. Lateral Deltoid C. Rectus fermoris D. Vastus lateralis

Answer D Rationale: Vastus lateralis is the only safe muscle group to use for injection in a 4-month old infant

Which nursing interventions are appropriate when caring for an infant? Select all that apply A. Provide swaddling B. Talk in a loud voice C. Provide infant with a bottle of juice at nap time D. Hang mobiles with black and white contrast designs E. Caress the infant when bathing or during diaper changing F. Allow infant to cry for at least 10 minutes before responding

Answers A, D and E Rationale: Holding, caressing and swaddling provide warmth and tactile stimulation to the infant. Hanging mobiles with contrasting colors like black and white provide visual stimulation

A nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply A. Discourage reminiscing B. Make decisions for the family C. Encourage expression of feeling, concerns and fears D. Explain everything that is happening to all family members E.Touch and hold the client's or family member's hand if appropriate F. Be honesst and let the family know they will not be abandoned by the nurse

Answers C,E,F Rationales: The nurse must determine if there is a spokeperson for the family and how much the client and family want to know. The nurse should encourage expressionof feelings and only assist with decision making if asked.

A nurse is caring for a client who is at risk for suicide. Which client behavior BEST indicates that the client may be contemplating suicide? A. Sharing that he or she is finally happy B. Sitting and crying for long periods of time C. Preferring to spend long periods of time alone D. Reporting a variety of sleep disturbances

Answer A Rationale: Expressing happiness shows contentment that is often a sign that a suicide plan has been created.

The nurse is caring for a client with anorexia nervosa. Which behavior is a characteristic of this disorder and reflects anxiety management? A. Engaging in immoral acts B. Always reinforcing self approval C. Observing rigid rules and regulations D. Having the need to always make the right decision

Answer C Rationale: Clients with anorexia nervosa have a desire to please others. They need to be correct or perfect interfered with rational decision making

A nurse in the well-baby clinic is collecting data regarding the motor development of a 15-month old child. Whis is the highest level of development that the nurse should expect to see? A. The child turns a doorknob B. The child unzips a large zipper C. The child builds a tower of two blocks D. The child puts on simple clothes independently

Answer 3 Rationale: A child this age would only be able to build a tower of 2 blocks. A 24-month old would be able to turn a doorknob and unzip a zipper. A 30 month old would be able to put on simple clothes

A 4 -year old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention should be implemented to alleviate that child's fears? A. Encourage the child's parents to stay with the child B. Encourage play with other children of the same age C. Advise family to visit only during the scheduled visiting hours D. Provide a private room, allowing the child to bring favorite toys from home

Answer A Rationale: The child may ask repeatedly when parents are coming for a visit or may want to call parents all the time. To alleivate fears, its best parents stay with the child

A nurse is interacting with a family of a client who is unconscious as a result of a head injury. Which approach would the nurse use to help the family cope with their concerns? A. Explain equipment and prodecures on an ongoing basis B. Discuss diplaying their grief only when not in the room with the client C. Discourage them from touching the client in order to minimize stimulation D. Explain that they need to rest so they can adhere to regular visiting hours

Answer A Rationale: Families often need assistance to cope with sudden and severe illnesses of a loved one

A client comes in the ER demonstrating signs indicative of a severe state of anxiety. What is the priority nursing intervention? A. Remaining with the client B. Placing the client in a quiet room C. Teaching the client deep breathing exercises D. Encouraging the expression of feelings and concerns

Answer A Rationale: If the client is left alone, the client may feel abandoned and become overwhelmed. Placing a client in a quiet room is also indicated but the nurse must stay with the client

A client who is experiencing disturbed thought processes believes his food is being poisoned. Which communication technique should the nurse use to enourage the client to eat? A. Using open-ended questions and silence B. Sharing personal preferences regarding food C. Documenting the reasons why the client does not want to eat D. Offering opinions about the necessity of adequate nutrition

Answer A Rationale: Open ended questions and silence are strageties used to encourage clients to discuss their problems

A parent of a 3-year old tells the clinic nurse that the child is rebelling and having temper tantrums. Which instructions should the nurse provide the parent? Select all that apply A. Set limits on the child's behavior B. Ignore the child when this behavior occurs C. Allow the behavior, because this is normal during this period D. Provide a simple explanation of why the behavior is unacceptable E. Punish the child every time the child says "No" to change the behavior

Answer A & B Rationale: During the ages of 1 and 3, the child focuses on gaining some basic control over self and the environment. Gaining independence oftens means that the child has to rebel against the parents' wishes.

The nurse is monitoring a 3-month-old infant for signs of increased cranial pressure. On palpations of the fontanels, the nurse notes that the anterior fontanel is soft and flat. On the basis of this finding, which nursing intervention action is most appropiate? A. Increase fluids B. Document the findings C. Notify the health care provider D. Elevate the head to 90 degrees

Answer B Rationale. The nurse would document this as normal because it usually closes between 12-18 months

A nurse is planning care for a client who was newly admitted to the unit for suicidal ideation. To provide a caring, therapuetic environment, which intervention should the nurse include in the care plan? A. Placing the client in a private room to ensure privacy and confidentiality B. Interacting with the client demonstrating examples of unconditional positive regard C. Maintaining distance of 10 inches in order to ensure the client that personal control will be provided D. Placing the client in charge of a meaningful unit activity, such as morning chess tournament

Answer B Rationale: Establishing a therapeutic relationship with the suicidal client increases feelings of acceptance

The nurse is bathing a client when the client begins to cry. Which action by the nurse is therapeutic at this time? A. Continue bathing the client and ignore it B. Stop the bath, cover the client and sit with then C. Stop the bath cover the clietn and allow then some private time D. Call the primary provider to report signs of depression

Answer B Rationale: If a client begins to cry, the nurse should stay with them and let them know it is okay to cry

A nurse is preparing a plan regarding home care instructions for the parents of a child with generalized tonic-clonic seizures who is being treated with oral phenytoin. Which instructions should the nurse inlcude in the plan? A. Monitor the child's intake and output daily B. Provide oral hygiene, especially care of the gums C. Administer medication 1 hour before food intake D. Check the child's blood pressure before the administration of the medication

Answer B Rationale: Phenytoin is an anticovulsant that causes gum bleeding and hyperplasia

A 9-year old child is newly diagnosed with type 2 diabetes mellitus. The nurse is planning home care with the client and family and determines that which is an age-appropriate activity for health maintenance? A. Administering insulin drawn up by an adult B. Self-administering insulin with adult supervision C. Making independent decisons with regard to the sliding scale coverage of insulin D. Having an adult to assist in self-administering insulin and glucose monitoring

Answer B Rationale: School-aged children have the cognitive and motor skills to draw up and administer insulin with adult supervision.

A pediatric patient with ventricular septal defect repair is placed on a maintenance dose of digoxin. The dosage is 8mcg/kg/day, and the client's weight is 7.2 kg. The health care provider presctibes digoxin to be be given twice a day. The nurse should prepare to adminster how many mcg of digoxin at each dose? A. 12.6 B. 21.4 C. 28.8 D. 32.2

Answer C

Sulfisoxazole , 1 g orally twice daily is prescribed for an adolescent with a urinary tract infection. The medication label reads, "500-mg tablets." The nurse determines that the dosage prescribed is safe. The nurse should administer how many tablets? A. 1/2 B. 1 C. 2 D.3

Answer C

A client is hospitalized for ingesting an overdose of acetaminophen.The nurse prepares to administer what antidote for this medication overdose? A. Flumazenil B. Phytonadione C. N-acetylcysteine D. Naloxone

Answer C Rationale: Acetylcysteine restores sulfhydryl groups that are depleted by acetaminophen metabolism

The nurse is caring for a client who was involuntary hospitalized to a mental health unit and is scheduled for the electroconvulsive therapy. The nurse notes that an informed consent has not been obtained for the procedure. Based on this information, what is the nurse's best determination for planning care? A. The informed consent does not need to be obtained B. The informed consent should be obtained for the family C. The informed consent needs to be obtained from the client D. The healthcare provider will provide the informed consent

Answer C Rationale: Clients who are involuntary admitted do not loose thier rights to informed consent. Clients must be considered legally competent until they have been determined not to be

A depressed client verbalizes feelings of low self esteem and self worth typified by statements like "I am such a failure. I can't do anything right." How should the nurse plan to respond to the client's statements? A. Reassure the client that things will get better B. Tell the client that this is not true and that we all have purpose in life C. Identify recent behaviors or accomplishements that demonstrate the client's skill D. Remain with the client and sit in silence this with encourage the client to verbalize feelings

Answer C Rationale: Feeling of low self-esteem and worthlessness are common symptoms of depression. To enhance the client's personal self esteem provides experiences that will interrupt the client's negative talk and distorted cognitive view of self

The nurse is providing medication instructions to a parent. Which statement by the parent indicates a need for further instructions? A. I should cuddle my child after giving the medication B. I can give my child frozen juice bar after he swallows the medication C. I should mix the medication in baby foods and give it when feeding the my child D. If my child does not like the taste of the medicine I should encourage my child to pinch his nose and drink it through a straw

Answer C Rationale: Parents should avoid putting medication in food because it may give the food an unpleasant taste and the child may refuse that food in the future

The mother of an 8-year old child tells the nurse that she is concerned about the child because the child seems to be more attentive to friends than anything else. Which response from the nurse is most appropriate? A. You need to be concerned B. You need to monitor the child's behavior closely C. At this age, the child is developing his/her own personality D. You need to provide more praise to the child to stop this behavior

Answer C Rationale: School-aged children begin to move towards peers and friends and away from parents for support.

A nurse in the ER is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action? A. Adhering to the mandatory abuse-reporting laws B. Notifying the caseworker of the family situation C. Removing the client from any immediate danger D. Obtaining treatment for the abusing family member

Answer C Rationale: Whenever an abuse client remains in an abusive environment, priority must be placed on ascerting whethr the client is in any immediate danger

A 16-year old client is admitted to the hospital for acute appendicitis and an appendectomy is performed. Which nursing intervention is MOST appropiate to facilitate normal growth and development postoperatively? A. Encourage client to rest and read B. Encourage parents to room in with the child C. Allow family to bring in the client's favorite computer games D. Allow client to interact with others in his or her age group (adolescent)

Answer D Rationale: Because of the importance of their peer group, seperation from friends is a source of anxiety. Ideally, members of this peer group will support their ill friend

A newborn infant recieves the first dose of Hep B vaccine within 12 hours of birth. The nurse instructs the parent regarding the immunization schedule for this vaccine and tells the parent the second vaccine is adinistered at which time period? A. 3 years of age and then during adolescenct years B. 8 months of age and 1 year after first dose C. 6 months abd the 8 months after the initial dose D. 1 to 2 months of age and then 6 months after the original dose

Answer D Rationale: Hep B vaccination schedule is as follows: It consists of 3 dose, 1 at birth, 2nd dose 1-2 months and then 6 months after the original dose for infants whose mothers test negative for Hep B

A client with a diagnosis of depression who has attempted suicide says to the nurse, I should have died. I've always been a failure. Nothing ever goes right for me." Which response by the nurse demstrates a therapeutic form of communcation? A. You have everything to live for B. Why do you see yourself as a failure C. Feeling like this is all apart of being depressed D. You've been feeling like this for a while

Answer D Rationale: Responding to feelings expressed by a client is an effective therapeutic communication and is restating what the client is feeling