Maternity and Women's Health Nursing - Newborn, Nur 106- Module G2, Pediatric Growth & Development EAQ, Nursing Sciences EAQ, Theory Communication, Nursing SBU

A nurse conducting a research study is obtaining informed consent from a research subject. Which statement made by the nurse to the client needs correction?

"Let me explain all the details about the research and why it is the best available method of treatment."

A client with schizophrenia who has auditory hallucinations is withdrawn and apathetic. What should the nurse say to involve this client in an activity? "You'll get a reward if you go to the gym." "Would you like to participate in the group walk today?" "Those voices you hear would like it if you did a little exercise." "There's a positive relationship between exercise and good mental health."

"Would you like to participate in the group walk today?" is a declarative statement that invites the client to walk, and the client can comply without making a verbal decision. A client with schizophrenia is often ambivalent, rendering decision-making difficult. A withdrawn, apathetic client probably will not internalize or appreciate rationales for interventions. Saying that the voices want the client to exercise supports the client's hallucinations

Which theory explains psychosexual development through infancy to adolescence? 1 Freud's theory 2 Piaget's theory 3 Erikson's theory 4 Kohlberg's theory

1 Freud's theory Psychosexual development through the five developmental stages is explained by Freud's theory. Piaget's theory explains cognitive and moral development from infancy to adolescence. Erikson's theory explains psychosocial development. Kohlberg's theory demonstrates the development of moral reasoning.

A client is to receive an intravenous (IV) antibiotic in 50 mL of 0.9% sodium chloride to be administered over 20 minutes. At what rate should the nurse set the infusion pump? Record your answer using a whole number. __________ mL/hr

150 ml/hr

Which is observed in the preoperational stage of Piaget's cognitive development? 1 Inductive reasoning 2 Transductive reasoning 3 Sense of cause and effect 4 Deductive and abstract reasoning

2 Transductive reasoning Transductive reasoning is observed in the preoperational stage, in which the individual thinks that because two events occur together, they cause each other. Inductive reasoning occurs in the stage of concrete operations. Sense of cause and effect is observed in the sensorimotor stage of cognitive development. Deductive and abstract reasoning is the characteristic of formal operations.

The nurse is reviewing blood screening tests of the immune system of a client with acquired immunodeficiency syndrome (AIDS). The nurse expects to find:

A decrease in CD4 T cells

Bulging fontanels

An infant has surgery for repair of a myelomeningocele. For which early sign of impending hydrocephalus should the nurse monitor the infant?

What is the order of evidence-based practice that a nurse should follow while caring for a client?

Ask a question Collect evidence Appraise the evidence Make a decision Evaluate changes Share outcomes

4 Agonal breaths

Gasping

Testing heel blood with the use of a glucose-oxidase strip

How should a nurse screen the newborn of a diabetic mother for hypoglycemia?

What makes a crisis access hospital (CAH) different from an intensive care unit (ICU)?

It provides temporary care for 96 hours or less.

Which would the nurse discuss with new parents to assist them in preparing for infant care?

Learning specific behaviors involving states of wakefulness to promote positive interactions

While caring for a group of clients from different ethnicities, the nurse observes that a client from Ireland is stoic and not complaining about pain. Which theory should the nurse follow in this situation?

Leininger's Theory

A registered nurse is teaching a nursing student about Nightingale's theory of nursing. Which statements have been correctly stated by the nursing student as a result of the teaching? Select all that apply.

Nightingale's theory states that the focus of nursing is caring through the environment. Nightingale's theory is oriented towards providing fresh air, light, warmth, cleanliness, quiet, and adequate nutrition. Nightingale's theory focuses on helping the client deal with the symptoms and changes in function related to an illness.

A reasonable short-term outcome for clients who are functioning below the optimal level of mental health is to help them become better able to do what? Understand the dynamics behind their inadequate interpersonal relations. Confront their inadequacies in interpersonal relations and be more sociable. Discuss feelings regarding their life experiences and their significant others. Take actions that will increase their satisfaction with their relationships with others.

The ability to discuss feelings about others and life situations is necessary for positive mental health. Understanding interpersonal dynamics, confronting inadequacies, and taking actions to increase satisfaction in relationships are all long-term, not short-term, outcomes.

dysphagia

condition in which swallowing is difficult or painful

After teaching from the nurse about common infant injuries, the parent says, "I will not allow my child to go near the plants in our house." Which risk to the infant can be prevented by this action? 1 Falls 2 Asphyxia 3 Poisonings 4 Allergic reactions

3 Poisonings Household plants may be a source of accidental poisonings because a curious infant may put the leaves in the mouth. Therefore, plants should be kept out of the child's reach to avoid poisonings and ingestions. Stairs, diaper changing table, and infant walkers are the risk factors for falls in the infant. Asphyxia can be prevented by keeping the small objects out of reach of an infant and avoid giving hard candies to the infants and toddlers. Allergic reactions can be prevented by preventing exposure to the allergens.

The parent of a child says, "My child is repeatedly banging the table to make loud sounds." Which sensorimotor stage of cognitive development best explains this behavior of the child? 1 Reflexes 2 Primary circular reactions 3 Secondary circular reactions 4 Coordination of secondary schemas

3 Secondary circular reactions The third stage of Piaget's sensorimotor phase involves secondary circular reactions, in which the child intentionally repeats an action in order to trigger a response. The first stage of sensorimotor phase comprises of reflexes, in which the infant will exhibit involuntary responses to stimuli, such as sucking, rooting, grasping, and crying. Replacement of reflexive behavior with voluntary acts is seen in primary circular reactions, which is the second stage of sensorimotor phase. The fourth stage is coordination of secondary schemas, in which the child starts showing intentional actions and uses previous behavioral achievements, primarily as the foundation for new intellectual skills.

Which stage of psychosocial development is observed in a 5-year-old child according to Erikson's theory? 1 Initiative vs. guilt 2 Trust vs. mistrust 3 Industry vs. inferiority 4 Autonomy vs. shame and doubt

1 Initiative vs. guilt Children between 3 and 6 years of age like to pretend and try out new things. Conflicts may often occur between the child's desire to explore and the limits placed on his or her behavior, which may lead to frustration and guilt. Therefore, the initiative vs. guilt stage is seen in 3- to 5-year-old children. The trust vs. mistrust stage is observed in infancy (birth to 18 months). The industry vs. inferiority stage is seen in children between 6 and 12 years of age. The autonomy vs. shame and doubt stage is seen in children between 18 months and 3 years of age.

mucositis

painful inflammation of oral mucous membranes

Which education would the nurse provide the parents of an infant with pyloric stenosis?

1 It is unlikely that surgery will be necessary. Correct 2 This is a condition with an excellent prognosis. 3 This condition results from an error of metabolism. Incorrect 4 Special feedings will be needed for a few weeks after surgery. answer is 2

What should the nurse teach parents about their newborn's diagnosis of phenylketonuria (PKU)? 1.A low-phenylalanine diet is required. 2.Phenylalanine is not necessary for growth. 3.Phenylalanine can be administered to correct the deficiency. 4.A substitute for phenylalanine is an increased amount of other amino acids.

1.A low-phenylalanine diet is required Reducing dietary phenylalanine helps prevent brain damage. The PKU diet is planned to maintain the serum phenylalanine level at 2 to 8 mg/100 mL. Phenylalanine is essential for growth and development of the brain. Administering phenylalanine is contraindicated. There are no substitute for phenylalanine, which is one of the essential amino acids.

A 12-year-old child with Down syndrome is admitted to the hospital for intravenous antibiotics for pneumonia. Which clinical findings associated with Down syndrome should the nurse expect when performing a physical assessment? Select all that apply. 1. Saddle nose 2. Thin fingers 3. Inner epicanthic folds 4. Hypertonic musculature 5. Transverse palmar crease

1.Saddle Nose 2.Inner epicanthic folds 3.Transverse palmar crease Children with Down syndrome have a broad nose with a depressed bridge (saddle nose), as well as inner epicanthic folds, and oblique palpebral fissures; they also have speckling of the iris (Brushfield spots). Children with Down syndrome have a transverse palmar crease (simian crease) formed by fusion of the proximal and distal palmar creases. These children also have broad, short, stubby hands and feet. Children with Down syndrome have hypotonic, not hypertonic, musculature.

A client presents with chief complaints of unexplained weight gain and back pain from a compression fracture of the vertebrae. On assessment, there is truncal obesity with excessively thin extremities, a moon-shaped face, a buffalo hump, thin hair, and adult acne. The symptoms described are suggestive of which disease? Addison disease Cushing disease Multiple sclerosis Kaposi sarcoma

2

When providing postoperative teaching, which rationale would the nurse give to explain the purpose of administering an opioid analgesic via epidural catheter? 1 Facilitates oxygen use 21Relieves abdominal pain 3Decreases anxiety and restlessness 4 Dilates coronary and peripheral blood vessels

2

Which condition would the nurse document to describe a client presenting with the loss of the ability to taste after cancer treatment has affected the client's ability to eat food? 1 Mucositis 2 Dysgeusia 3 Dysphagia 4 Xerostomia

2

Which technique would the nurse suggest to a laboring woman's partner that involves gently stroking the woman's abdomen in rhythm with her breathing during a contraction? 1 Massage 2 Effleurage 3 Acupressure 4 Counterpressure

2

What clinical indicators should a nurse expect when assessing a client with hyperthyroidism? Select all that apply. 1. Dry Skin 2. Weight loss 3.Tachycardia 4.Restlessness 5.Constipation 6.Exophthalmos

2, 3, 4 & 6 Weight loss is associated with hyperthyroidism because of the increase in the metabolic rate. Muscle weakness and wasting also occur. Tachycardia, palpitations, increased systolic blood pressure, and dysrhythmias occur with hyperthyroidism because of the increased metabolic rate. Restlessness and insomnia are also associated with hyperthyroidism because of the increased metabolic rate. Protrusion of the eyeballs occurs with hyperthyroidism because of peribulbar edema. Dry, coarse, scaly skin occurs with hypothyroidism, not hyperthyroidism, because of decreased glandular function. Smooth, warm, moist skin occurs with hyperthyroidism. Constipation is associated with hypothyroidism. Increased stools and diarrhea are associated with hyperthyroidism.

The nurse in the pediatric clinic is reviewing the health history of a 10-year-old girl with a diagnosis of juvenile idiopathic arthritis (JIA). Currently the child is experiencing recurrent pain and swelling of the joints, particularly her knees and ankles. What organ is commonly affected in children with this disorder? 1.Ears 2.Eyes 3.Liver 4.Brain

2. Eyes Juvenile idiopathic arthritis can cause inflammation of the iris and ciliary body of the eyes, which may lead to blindness. The ears are not affected. The liver may become enlarged, but this does not occur as frequently as visual problems do. The brain is not affected.

A nurse is recollecting Sigmund Freud's psychoanalytical model of personality development. What are the characteristics of the phallic stage, as per this model? Select all that apply.

"In this stage, a child may develop an oedipal complex." "In this stage, a girl may experience 'penis envy' feelings." "In this stage, the genital organs are the focus of pleasure.

A registered nurse is teaching a student nurse about a rapid-improvement event (RIE), a quality improvement model. Which statement by the student nurse indicates effective learning?

"It is a very intense, usually week-long, event."

A nursing student is listing the steps that need to be followed for applying developmental theory when caring for chronically ill older adults with depression. Which step listed by the nursing student needs correction?

"The nurse should recognize the need to identify depression so that heart failure can be prevented."

A client with schizophrenia reports having ongoing auditory hallucinations and describes them as "voices telling me that I'm a bad person" to the nurse. What is the best response by the nurse? "Try to ignore the voices." "What are the voices saying to you?" "Do you believe what the voices are saying?" "They're only voices, so just try not to be afraid."

"Try to ignore the voices." Clients can sometimes learn to push auditory hallucinations aside, particularly within the framework of a trusting relationship; it may provide the client with a sense of power to manage the voices. Once it has been established by the nurse that the voices are not commanding the client to self-harm or harm others, focusing on the content of the hallucinations is not therapeutic. Asking whether the client believes what the voices are saying or encouraging the client not to be afraid of them is irrelevant to the situation; clients believe in and are frightened by hallucinations.

A client with tuberculosis asks the nurse about the communicability of the disease. Which is the best response by the nurse?

"Untreated active tuberculosis is communicable."

A nurse is planning to provide discharge teaching to the family of a client with acquired immunodeficiency syndrome (AIDS). Which statement should the nurse include in the teaching plan?

"Wash used dishes in hot, soapy water."

Which pain scale would the nurse use to measure the intensity of pain in toddlers? 1 FACES scale 2 Visual analog scale 3 Numerical rating scale 4 Verbal descriptor scale

1

Which content type of play allows a child to experience pleasure by swinging? 1 Skill play 2 Pretend play 3 Social-affective play 4 Sense-pleasure play

4 Sense-pleasure play Sense-pleasure play is a nonsocial stimulating experience in which the pleasurable experiences are derived from the environment, handling of raw materials, and body motion such as swinging, bouncing, and rocking. In skill play, infants persistently demonstrate and exercise their newly acquired abilities. The simple, imitative, dramatic play of toddlers, such as using a telephone, driving a car, or rocking a doll is called pretend play or dramatic play. In social-affective play, the infant takes pleasure in relationships with people. As adults talk, touch, nuzzle, and in various ways elicit responses from an infant, the infant soon learns to provoke parental emotions and responses.

Cracked and peeling skin Long scalp hair and fingernails Creases covering the neonate's full soles and palms

A client at 43 weeks' gestation has just given birth to an infant with typical postmaturity characteristics. Which postmature signs does the nurse identify? (Select all that apply.)

A nurse is examining different situations that represent the superego component of human personality, as per Sigmund Freud. Which situations accurately represent superego? Select all that apply.

A client controls the urge to eat candy because he or she knows that it will affect the blood sugar levels. A client having a craving for fruits does not steal them from the next client because that client needs it more. A client experiencing a stomachache refrains from stealing medications from a friend because it is illegal.

A nurse is evaluating different situations related to Maslow's hierarchy of needs. Which situations come under the second level of needs? Select all that apply.

A client tells the nurse that he or she is taunted by his or her boss every day. A client tells the nurse that his or her spouse belongs to a criminal gang. A client tells the nurse that he or she lives beside a factory that manufactures harmful chemicals.

Staying with her after bringing the infant to help her verbalize her feelings.

A health care provider tells a mother that her newborn has multiple visible birth defects. The mother seems composed and asks to see her baby. What nursing action will be most helpful in easing the mother's stress when she sees her child for the first time?

Documenting the heart rate

A nurse determines that a 1-day-old newborn has a heart rate of 138 beats/min. What is the best nursing action at this time?

Cyanosis Tachypnea Retractions

A nurse determines that a newborn is in respiratory distress. Which signs confirm respiratory distress in the newborn? (Select all that apply.)

Has type 1 diabetes

A nurse expects signs of respiratory distress syndrome (RDS) in a neonate whose mother:

Sneezing Hyperactivity High-pitched cry

A nurse is observing the newborn of a known opioid user for signs of withdrawal. What clinical manifestations does the nurse expect to identify? (Select all that apply.)

An audible click on abduction

A nurse is performing the Ortolani test on a newborn. Which finding indicates a positive result?

A newborn's intestinal tract does not synthesize it for several days after birth.

A nurse prepares to administer vitamin K to a newborn. Why is vitamin K given specifically to newborns?

"We'll have to have the baby fitted with prosthetic devices before he'll be able to walk."

A nurse reviews the prescribed treatment with the parents of an infant born with bilateral clubfeet. Which parental statement indicates to the nurse that further education is required?

Deafness Cardiac anomalies

A nurse suspects that a newborn's mother had rubella during the first trimester of pregnancy. Which newborn problems support this assumption? (Select all that apply.)

Adherence to a corrective diet instituted early

A nurse takes into consideration that the effect PKU has on the infant's development will depend on:

Infection

A nurse who is admitting a newborn to the nursery observes a fetal scalp monitor site on the scalp. For what complication should the nurse monitor this newborn?

A nursing student is taking down notes about paradigm. Which point noted down by the nursing student needs correction?

A paradigm is the perspective of a profession.

Which patients are at risk of developing health care-associated infections (HAIs)? Select all that apply.

A patient with laryngeal cancer A patient with diabetes mellitus A patient with an indwelling urinary catheter

Which program is an example of a continuing education program?

A program on caring for the elderly with dementia offered by a university

antivenin

A serum that counteracts the effect of venom from an animal or insect.

The health care provider prescribes peak and trough levels of an antibiotic for a client who is receiving the medication intravenous piggyback (IVPB). For peak levels the nurse should have the laboratory obtain a blood sample from the client:

Between 30 and 60 minutes after the IVPB

Protecting the sac with moist sterile gauze

After an uneventful pregnancy a client gives birth to an infant with a meningocele. The neonate has 1-minute and 5-minute Apgar scores of 9 and 10, respectively. What is the priority nursing care for this newborn?

"Newborns are deficient in vitamin K. This treatment will protect your baby from bleeding."

After the birth of her daughter, a mother tells the nurse, "I was told that my baby has to have an injection of vitamin K. She's so small to be getting a shot. Why does she have to have it?" How should the nurse respond?

A client presents to the emergency department with a fever, headache, loss of appetite, and malaise. The nurse identifies raised red bumps on the client's arms and legs. A diagnosis of chickenpox is made. The client should be placed in a private room with what kind of precautions?

Airborne precautions

3 examples of objective data

Blood pressure Heart rate Respirations

What are the similarities between Medicare and Medicaid? Select all that apply.

Both programs assist older clients. Both programs pay for home care services

How does a nurse prepare a "factual" record when performing a client documentation?

By recording descriptive and objective information of what the nurse sees, hears, feels, and smells

How does a nurse incorporate the quality of accuracy into client documentation?

By using exact measurements for each client's activity

Which physical findings can be observed in a 2-month-old infant? Select all that apply. A The doll's eye reflex is fading. B The rooting reflex disappears. C The crawling reflex disappears. D The posterior fontanel is closed. E The primitive reflexes are fading.

C The crawling reflex disappears. D The posterior fontanel is closed. The crawling reflex disappears and the posterior fontanel is closed by 2 months of age. The doll's eye reflex disappears at 1 month of age. The primitive reflexes fade during the third month. The rooting reflex disappears at 4 months of age.

A client developed acute herpes zoster and was treated with antiviral medication within 72 hours of the appearance of the rash. The client is reporting persistent pain one week later. What does the nurse identify as the cause of the post therapeutic neuralgia?

Damage to the nerves

Three vessels: one vein and two arteries

During a newborn assessment the nurse counts the infant's cord vessels. What does the nurse expect to observe in a healthy newborn?

Suctioning the airway

During a vertex vaginal birth the nurse notes meconium-stained amniotic fluid. What is the priority nursing intervention for the newborn?

A nurse is heading a performance improvement team. The nurse collects records of needlestick injuries due to improper needle recapping techniques used during medicine administration. What is the next step to be followed by the nurse, if he or she is using the "plan, do, study, act model

Facilitate a training program for all nurses to teach the proper technique of recapping needles

5

Five minutes after being born, a newborn is pale; has irregular, slow respirations; has a heart rate of 120 beats/min; displays minimal flexion of the extremities; and has minimal reflex responses. What is this newborn's Apgar score?

"What is the baby's daily schedule?"

Four weeks after giving birth, a client is agitated and tells the clinic nurse, "The baby cries all the time, and I don't know what to do." What question should the nurse ask before planning nursing care?

A nurse is caring for a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). The IV infiltrates and needs to be restarted. What is necessary to protect the nurse when restarting the IV? (Select all that apply.)

Gloves Hand hygiene

A nurse is caring for a client with a diagnosis of acute salpingitis. Which condition most commonly causing inflammation of the fallopian tubes should the nurse include when planning a teaching program for this client?

Gonorrhea

A nurse is reviewing the physical examination and laboratory tests of a client with malaria. For which important clinical indicators should the nurse be alert when reviewing data about this client? (Select all that apply.)

Hyperthermia Splenomegaly

Before the nurse can be an advocate for a client who is homosexual who has acquired immunodeficiency syndrome (AIDS), the nurse needs to do what?

Identify personal attitudes and feelings about homosexuality

A mother with the diagnosis of acquired immunodeficiency disease (AIDS) states that she has been caring for her baby even though she has not been feeling well. What important information should the nurse determine?

If the baby is breastfeeding

During an acquired immunodeficiency syndrome (AIDS) education class a client states, "Vaseline works great when I use condoms." Which conclusion about the client's knowledge of condom use can the nurse draw from this statement?

Ignorance related to correct condom use

How is a SOAP progress note different from a PIE progress note? Select all that apply.

In a SOAP progress note, the P stands for plan; in a PIE progress note, the P stands for problem. SOAP progress notes originate from medical records; PIE progress notes have a nursing origin. SOAP progress notes include assessment information; PIE progress notes do not include assessment information

Which internal variable influences health beliefs and practices?

Intellectual background

A nurse finds that there is an inaccurate match between clinical cues and the nursing diagnosis. What is the category of the diagnostic error?

Interpreting

The nurse uses evidence-based practice while providing nursing care to clients. What distinguishes research-based practice different from evidence-based practice?

It uses knowledge based only on research studies.

The physiological destruction of fetal red blood cells

Jaundice develops in a newborn 72 hours after birth. What should the nurse tell the parents is the probable cause of the jaundice?

What clinical manifestations does a nurse expect a client with systemic lupus erythematosus (SLE) most likely to exhibit? (Select all that apply.)

Joint pain Facial rash Pericarditis

A nurse is developing a teaching plan for a client with scleroderma. What should the nurse include about skin care?

Keep skin lubricated with lotion

A nurse is completing the Resident Assessment Instrument (RAI) for a resident at the nursing center. What should the nurse consider while completing the RAI? Select all that apply.

Minimum Data Set (MDS) Resident Assessment Protocols Utilization guidelines of the state

A client is concerned about contracting malaria while visiting relatives in Southeast Asia. What should the nurse teach the client to avoid to best prevent malaria?

Mosquito bites

A pregnant woman complains, "I have had morning sickness for one week, which caused me to eat less. I am experiencing irritability because of weakness." The nurse taught the client relaxation and distraction techniques to overcome this problem. During a follow-up visit, the nurse evaluates the client's response and determines if the condition is resolved. Which model is the nurse using in this situation?

Neuman systems model

Which are the core roles for an advanced practice registered nurse (APRN)? Select all that apply.

Nurse practitioner Clinical nurse specialist (CNS) Certified nurse midwife (CNM) Certified registered nurse anesthetist (CRNA)

What kind of health service does the nurse offer in a health promotion or primary care program?

Nutrition counseling

A client scheduled for surgery has a history of methicillin-resistant Staphylococcus aureus (MRSA) since developing an infection in a surgical site nine months ago. The site is healed and the client reports having received antibiotics for the infection. What should the nurse do to determine if the infecting organism is still present?

Obtain a prescription to culture the client's blood

The cause is an increased intravascular pressure during birth.

The parents of a newborn are concerned about red pinpoint dots on their infant's face and neck. How should the nurse explain the finding?

Buccal smear

The parents of a newborn are told that their neonate may have Down syndrome and that additional diagnostic studies will be done to confirm this diagnosis. What procedure does the nurse expect to be performed?

Most important is the institution of a corrective formula soon after birth.

The parents of a newborn with phenylketonuria (PKU) ask a nurse how to prevent future problems. What must the nurse consider before responding?

The nurse leader is giving a speech on leadership skills to followers. Which questions enable the nurse leader to evaluate the understanding level of the followers? Select all that apply. "Are you getting my points?" "Would you all like a break?" "Can I change the topic in a little while?" "How can you solve a conflict at the workplace?" "What did you 'hear' in the process of this communication?"

The question such as "what did you 'hear' in the process of this communication?" cannot be answered by a "yes" or "no" and requires a detailed explanation of the things that are taught. The questions starting with "how" are usually open-ended and require the person to answer in detail. Therefore these questions can help the nurse leader evaluate the understanding level of the followers. The questions such as "are you getting my points?", "would you all like a break?", and "can I change the topic in a little while?" can be answered by a "yes" and "no." Therefore these questions do not help the nurse leader to evaluate the understanding level of the followers.

A client who has sustained an accident says, "I have a dream of conquering the world's highest mountain range." To which level of need does the given scenario refer to, according to Maslow's hierarchy of needs?

Toddler Preschool

A client cannot understand how syphilis was contracted because there has been no sexual activity for several days. Which length of time associated with the incubation of syphilis should the nurse include in the teaching plan?

Two to six weeks

The nurse teaches a group of clients that nutritional support of natural defense mechanisms indicates the need for a diet high in:

Vitamins A, C, E, and selenium

A nurse is planning to provide discharge teaching to the family of a client with acquired immunodeficiency syndrome (AIDS). Which statement should the nurse include in the teaching plan?

Wash used dishes in hot, soapy water."

Which statement is applicable to Watson's theory of transpersonal caring?

Watson's theory defines the outcome of nursing activity in relation to the humanistic aspects of life.

Clinical judgment

a judgment based on experience in observing and treating patients

ABCS

airway, breathing, circulation

Which actions contribute to the transmission of human immunodeficiency virus (HIV) infection from an infected to a healthy person? Select all that apply.

Receiving blood transfusions Having sexual intercourse

A client arrives for a vaccination at an influenza prevention clinic. A nursing assessment identifies a current febrile illness with a cough. The nurse should:

Reschedule administration of the vaccine for the next month

RACE -

Rescue, Activate alarm, Confine the fire, Evacuate/Extinguish

A client is admitted with the diagnosis of tetanus. For which clinical indicators should the nurse assess the client? (Select all that apply.

Restlessness Muscular rigidity Respiratory tract spasms Spastic voluntary muscle contractions

Client A is recovering from heart surgery and needs to adapt to his or her environment. Client B is at the last stage of cancer. Which of these theories may the nurse use for better health maintenance of both the clients?

Roy's theory for client A and Henderson's theory for client B

"This is the time when the baby is likely to be most responsive to you."

The nurse is caring for a couple after the birth of their first child. What should the nurse tell the family to do when their infant is exhibiting the behavior demonstrated in the picture?

A nurse is working in a health care organization that has Magnet status. What specific responsibility does the nurse have in this organization?

The nurse must collect data for comparison against a national level.

What is the duty of a nurse while caring for a client?

The nurse should determine the client's care preferences.

A nurse needs to provide preventive and primary care to adults during a health camp. Which of these actions should the nurse perform? Select all that apply.

The nurse should discuss vaccinations. The nurse should discuss family planning The nurse should instruct the health camp about road safety measures.

According to Piaget's theory, what are the cognitive or moral developmental changes in children aged 6 to 12 years? Select all that apply.

The child develops logical thinking. The child is in the concrete operations period

SOP

Standard Operating Procedure (defined in Queensland mining legislation)

Which activity of the registered nurse is included in supervision? Performing the given task Allocating a portion of the work Providing information to the delegator Providing guidance and oversight in delegating a task

Supervision is defined as "provision of guidance and oversight of a delegated nursing task." It includes open lines of communication between the delegator and the delegatee to provide guidance. Responsibility is the activity of performing a given task. Delegation is the activity of allocating a portion of work. Authority is the activity of providing information to the delegator.

Verifying oxygen saturation frequently to adjust flow on the basis of need

Supplemental oxygen is ordered for a preterm neonate with respiratory distress syndrome (RDS). What action does the nurse take to reduce the possibility of retinopathy of prematurity?

Dyspnea

difficult or labored breathing

dysgeusia

distortion of the sense of taste

antihypertensive

drug that lowers blood pressure

Warm the environment

While observing a newborn, the nurse notes that the skin is mottled. What should the nurse do first?

It contains exposed tissue and blood

While showing a new mother how to care for her infant's umbilical cord stump, the nurse explains that the stump is a potential source of infection because:

glomerulonephritis

inflammation of the glomeruli of the kidney

pyloric stenosis.

narrowing of the opening of the stomach to the duodenum

hematuria

presence of blood in the urine

Use tactile stimuli on the chest or extremities

What should the nurse do when an apnea monitor sounds an alarm 10 seconds after cessation of respirations?

A nurse is concerned about the public health implications of gonorrhea diagnosed in a 16-year-old adolescent. Which should be of most concern to the nurse?

Finding the client's contacts

Etiology

the study of the causes of diseases

Subjective data

things a person tells you about that you cannot observe through your senses; symptoms

xerostomia

dryness of the mouth

2 Tachycardia

Heart rate over a 100

Debillitated

weakened

A nursing student is listing various stages of Lawrence Kohlberg's Theory of Moral Development. Which situation indicates that the individual has reached the Instrumental Relativist Orientation stage?

"An individual identifies that there is more than one right view."

A nurse is recalling Piaget's theory of cognitive development. What is the characteristic of the preoperational stage?

"An infant may learn to think with the use of symbols and mental images."

A nursing instructor asks a student to describe Betty Neuman's theory. Which statement by the student indicates the need for further education?

"Betty Neuman's theory outlines that the external environmental factors act as stressor."

After interacting with a preschooler, the nurse concludes that the child has normal development according to Fowler's spiritual development. Which behavior of the child supports the nurse's conclusion? 1 The child imitates the adults as they pray. 2 The child does not exhibit any spiritual behavior. 3 The child accepts the existence of a supreme power. 4 The child questions the religious practice and its benefits.

1 The child imitates the adults as they pray. A preschooler is in the intuitive-projective stage of Fowler's spiritual development, and would imitate the others as they pray and perform other religious activities. An infant is in the undifferential stage of Fowler's development and will not have any spiritual behavior. The school-age child is in mythical-literal stage of Fowler's spiritual development, and may accept the existence of a supreme power. An adolescent is in the synthetic-convention stage of Fowler's spiritual development, and may question religious practice and its benefits.

The nurse is evaluating the dietary plan of a 6-month-old infant. Which action by the infant's mother needs correction? 1 The mother gives low-fat milk to the infant in a bottle. 2 The mother gives teething crackers to the infant for pain relief. 3 The mother refrains from giving iron supplements to the infant. 4 The mother refrains from giving chopped table food to the infant.

1 The mother gives low-fat milk to the infant in a bottle. Cholesterol is required for proper neurological development in infants. Therefore, low-fat milk should not be given to infants and toddlers. Finger foods, such as teething crackers, should be introduced at the age of 6 months, as it helps provide complete nutrition to the infant. The nurse should encourage the mother to give whole cereals instead of iron supplements to the child. Chopped table food can be given to the child at the age of 9 months.

An 8-year-old child is admitted to the pediatric unit with nephrotic syndrome. What measures should the nurse expect to include in the plan of care for this child? Select all that apply 1.Providing symptomatic care 2.Maintaining bedrest 3.Administering antibiotics 4.Eliminating high-sodium foods 5.Monitoring response to steroids

1, 4 & 5 Bedrest for children with nephrotic syndrome is generally no longer ordered. When there is gross edema, children usually prefer to remain in bed to conserve energy, but there are no ill effects of ambulating if they wish to do so. Nephrotic syndrome is a noninfectious disorder; however, these children are prone to infection, and if they contract an infection it is treated accordingly. Examples of symptomatic care are treating azotemia with a low-protein diet; encouraging bedrest if there is gross edema; restricting fluids if there is oliguria; and treating infection if it should occur. Foods that are high in sodium are restricted when there is gross edema; although restricting foods that are high in sodium does not lessen the edema, it seems to prevent it from worsening. A steroid is given to children with nephrotic syndrome because of its antiinflammatory properties. It is essential that the nurse monitor the child's response to steroids to determine the medication's effectiveness.

A healthcare facility is using the "plan, do, study, act (PDSA)" cycle model for performing a quality improvement. Arrange the order in which quality improvement takes place based on this model.

1. Review available data. 2. Choose the appropriate intervention. 3. Evaluate the outcomes. 4. Incorporate new practices in daily performance

Which intervention, if followed by the parent, may help manage encopresis in a 9-year-old child? 1 Limiting fluids in the child's diet 2 Including cereals in the child's diet 3 Giving milk and milk-based products 4 Encouraging the child to delay defecation when the urge is felt

2 Including cereals in the child's diet A child with encopresis may pass feces voluntarily or involuntarily at inappropriate settings. Encopresis is usually associated with constipation. Therefore, cereals should be included in the diet to prevent constipation. Limiting fluids may increase the risk of dehydration and constipation. Increasing the fluid intake may help prevent constipation and encopresis. Milk and milk-based products may increase the risk of encopresis and should be avoided. Delaying defecation may result in constipation, and should not be encouraged.

While caring for a newborn in a neonatal intensive care unit, the nurse notices that the neonate is not moving his legs simultaneously. Which condition might the nurse suspect to be the reason for this? 1 Rickets 2 Spinal cord injury 3 Caput succedaneum 4 Neonatal abstinence syndrome

2 Spinal cord injury The spinal cord controls the movements of the legs. Therefore, failure to move the legs indicates a spinal cord lesion or injury. Rickets is suspected if physiologic craniotabes is present in an infant. Caput succedaneum refers to swelling of the infant's head that is sustained during its passage through the birth canal. Neonatal abstinence syndrome is suspected if the infant has sustained rhythmic tremors, twitches, and myoclonic jerks.

A client with a coronary occlusion is experiencing chest pain and distress. Which is the primary reason that the nurse administers oxygen? 1 To prevent dyspnea 2 To prevent cyanosis 3 To increase oxygen concentration to heart cells 4 To increase oxygen tension in the circulating blood

3

How many levels of critical thinking exist for nursing judgment?

3

After collecting data on a 2-month-old infant, the nurse reinforces proper safety measures to the infant's mother to reduce the risk of injury in the infant. Which statements made by the infant's mother need correction? Select all that apply. 1 "I should use cool mist vaporizers if my baby has a cold." 2 "I should provide a one-piece pacifier to soothe my baby." 3 "I should protect my child's crib mattress with a plastic covering." 4 "I should place a firm mattress and loose blankets in my baby's bed." 5 "I should ensure that my child's car seat is rear-facing in a seat with an airbag."

3 "I should protect my child's crib mattress with a plastic covering." 5 "I should ensure that my child's car seat is rear-facing in a seat with an airbag." Covering a crib mattress with plastic should be avoided, as it can expose the child to toxins. The nurse should instruct the mother to refrain from placing the infant in a seat with an air bag, as it can cause suffocation and trauma. The nurse should inform the mother to use cool mist vaporizers, as they prevent burns. The mother should provide a one-piece pacifier to the infant, as it prevents accidental swallowing of any small objects and aspiration. Placing the infant in a crib with a firm mattress and loose blankets helps to prevent suffocation.

Which age is considered the phallic stage according to Sigmund Freud's developmental theory?

3 to 6 years old

After surgery a client is to receive an antibiotic by intravenous (IV) piggyback in 50 mL of a diluent. The piggyback is to infuse in 20 minutes. The drop factor of the IV set is 15 gtts/mL. The nurse should set the piggyback to flow at how many gtts/min? Record your answer using a whole number. __________ gtts/min

38

After abdominal surgery, a client reports pain. Which action would the nurse take first? 1 Reposition the client. 2 Obtain the client's vital signs. 3 Administer the prescribed analgesic. 4 Determine the characteristics of the pain.

4

An anxious parent of a 6-year-old child expresses that the child looks slimmer than a year ago, although the nurse finds the child's height and weight to be age-appropriate. What is the nurse's response to the parent? 1 "The child's condition may need further investigation." 2 "It seems like the child has not been eating well lately." 3 "You need to include more carbohydrates in the child's diet." 4 "The fat has diminished, and the fat distribution pattern has changed."

4 "The fat has diminished, and the fat distribution pattern has changed." As the preschooler develops into a school-age child, the fat in the body diminishes and the distribution pattern of the fat changes, making the child appear slim. Looking slimmer during school age is a normal part of growth and development. It does not need further investigation and does not indicate that the child has not been eating well. The child may become obese if the parent includes more carbohydrates in the child's diet.

When does the Babinski reflex disappear? 1 By 6 months 2 By 4 months 3 By 3 months 4 After 12 months

4 After 12 months The Babinski reflex disappears after 1 year or 12 months. The Perez reflex disappears by 6 months. The extrusion reflex and the Moro reflex may disappear by 4 months. The rooting reflex may disappear by 3 months.

The nurse teaches a parent about managing nocturnal enuresis for a 7-year-old child. Which action by the parent would be helpful in managing the child? 1 Making the child wear a diaper 2 Limiting fiber in the child's diet 3 Giving the child cranberry juice in the evening 4 Waking up the child at night to use the bathroom

4 Waking up the child at night to use the bathroom Wetting the bed at night, called nocturnal enuresis, may be managed by waking up the child at night to use the bathroom, relieving the bladder. The child should wear regular sleepwear, and parents should avoid use of diapers or pull-ups. Constipation may contribute to enuresis, so dietary fiber should be increased. Fruit juices and beverages are high in water content, and therefore result in an urge to urinate.

A nurse is assessing clients who are to be given the smallpox vaccination. Which client should the nurse remove from the immunization line for medical counseling?

45-year-old woman with breast cancer

Which behaviors are observed in individuals at a conventional level of moral development? Select all that apply. A Obeying the rules B Respecting authority C Maintaining social order D Changing law in terms of societal needs E Orienting culturally to the labels of good or bad

A Obeying the rules B Respecting authority C Maintaining social order At the conventional stage, individuals are concerned with conformity and loyalty. Obeying the rules, doing one's duty, showing respect for authority, and maintaining the social order are the behaviors demonstrated during the conventional stage. Changing law in terms of societal needs is observed at the postconventional level. In the preconventional level, individuals are culturally oriented to the labels of good or bad and right or wrong. These labels of good and bad are then integrated into their concept of physical or pleasurable consequences of their actions.

Getting an informed consent signed by the mother of the baby

A 15-year-old emancipated minor gave birth to a boy 36 hours ago and has requested a circumcision. What is the nurse's priority?

A client with a recent history of sinusitis develops meningitis and demonstrates a positive Brudzinski sign. The priority nursing care is:

Administering prescribed antibiotics

Which intervention by the nurse is an important aspect of client-centered care according to the survey conducted by the Picker Institute?

Asking the client if the family should be involved in his or her care

Nursing Process

Assessment Diagnosis Planning Implementation Evaluation

Which medication is used in the treatment of a client with intervertebral disc disease?

Cyclobenzaprine

Which theory describes the phenomenon of grief or caring?

Descriptive theories

A registered nurse is educating a nursing student about descriptive theories. Which point stated by the nursing student needs correction?

Descriptive theories help direct specific nursing activities.

Which degree does The American Association of Colleges of Nursing (AACN) recommend as terminal practice degree for all advanced practice registered nurses (APRNs)?

Doctor of Nursing Practice (DNP)

A client is diagnosed with gastroenteritis. What does the nurse determine is the basic intention underlying the unique dietary management for this client?

Eliminate chemical, mechanical, and thermal irritation.

Which nursing interventions are examples of the nurse as a caregiver? Select all that apply.

Encouraging the client to exercise daily Setting goals for the client to reduce weight Arranging for the client to meet a spiritual advisor

A client who abused intravenous drugs was diagnosed with the human immunodeficiency virus (HIV) several years ago. The nurse explains that the diagnostic criterion for acquired immunodeficiency syndrome (AIDS) has been met when the client:

Has a CD4+ T lymphocyte level of less than 200 cells/µL

An older client with a history of congestive heart failure expresses concern about potential exposure to tuberculosis. The client states that a roommate at the extended care facility where the client resides sleeps a lot, coughs a great deal, and sometimes spits up blood. The primary reason that the nurse pursues more information about the roommate is because:

Older adults with chronic illness are affected adversely by tuberculosis

Which nursing theory focuses on the client's self-care needs?

Orem's theory

A nursing student is listing the goals of theoretical nursing models. Which goal listed by the nursing student needs correction?

Provide knowledge to validate nursing interventions

SMART goals

Specific, Measurable, Attainable, Realistic, Timely

What is the incubation period for an infectious disease?

The interval between entrance of pathogen into body and appearance of first symptoms

Which intervention by the home health care nurse conforms to the use of safety competency while providing health care?

The nurse ensures the furniture does not obstruct the client's movement.

Evidence-informed nursing uses a variety of sources to support nursing practice. Which are sources of evidence-informed practice? Select all that apply.

Theory Research Clinical expertise

A nurse working in the health services center of a college is reviewing the vaccination records of a young adult who plans to enroll. Which immunizations are required to meet admission criteria according to the American Academy of Pediatrics?

Three doses of diphtheria toxoid and oral poliomyelitis vaccine, and one dose of live measles, live rubella, and mumps vaccine

A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). What precautions should the nurse take when caring for this client?

Use standard precautions.

The ribcage is not compressed, then released during birth.

A client has a cesarean birth. The nurse monitors the newborn's respiration because infants subjected to cesarean birth are more prone to atelectasis. Why does this occur?

ABO incompatibility

A client who has type O Rh-positive blood gives birth. The neonate has type B Rh-negative blood. Eleven hours after birth, the infant's skin appears yellow. What is the most likely cause?

6 months

A mother is breastfeeding her newborn. She asks when she may switch the baby to a cup. The nurse concludes that the mother understands the teaching about feeding when she says she will start to introduce a cup after the baby reaches:

Decrease the rate slowly

A newborn whose mother has type 1 diabetes is receiving a continuous infusion of fluids with glucose. What should the nurse do when preparing to discontinue the IV?

Lack the subcutaneous fat that usually provides insulation

A parent of a preterm infant in the neonatal intensive care unit, asks a nurse why the baby is in a bed with a radiant warmer. The nurse explains that preterm infants are at increased risk for hypothermia because they:

Metabolic acidosis

After a newborn has skin-to-skin contact with the mother, a nurse places the newborn under a radiant warmer. What complication is the nurse attempting to prevent?

Wrinkled skin Long nails

At 42 weeks' gestation a client gives birth to an 8-lb 5-oz newborn. On examining the infant, what does the nurse expect to observe? (Select all that apply.)

These findings indicate that the infant may have a pneumothorax, and the health care provider should be contacted immediately.

Continuous positive-pressure ventilation therapy by way of an endotracheal tube is started in a newborn with respiratory distress syndrome (RDS). The nurse determines that the infant's breath sounds on the right side are diminished and that the point of maximum impulse (PMI) of the heartbeat is in the left axillary line. How should the nurse interpret these data?

Cephalhematoma

During the discharge examination of a 2-day-old newborn, the nurse observes an edematous area confined to the right side of the scalp. How should the nurse document this condition?

"The test won't be done until your baby has had enough milk for the results to be accurate."

On her first postpartum day, a client asks the nurse whether her baby has had a test for phenylketonuria (PKU) yet. How should the nurse reply?

A perfect score is 10; 1 point is deducted for lessened muscle tone (the baby's arms do not flex) and 1 point for acrocyanosis, which is manifested by bluish hands and feet.

One minute after birth a nurse notes that a newborn is crying, has a heart rate of 140 beats/min, is acrocyanotic, resists the suction catheter, and keeps the arms extended. What Apgar score should the nurse assign to the newborn? Record your answer using a whole number. ___

An increased Paco 2 of 55 mm Hg

Respiratory acidosis is confirmed in a neonate with respiratory distress syndrome when the laboratory report reveals:

Voids six or more times a day

The nurse assures a breastfeeding mother that one way she will know that her infant is getting an adequate supply of breast milk is if the infant gains weight. What behavior does the infant exhibit if an adequate amount of milk is being ingested?

Protruding tongue Epicanthal eye folds One transverse palmar crease

What characteristics cause the nurse to suspect that a newborn has Down syndrome? (Select all that apply.)

A registered nurse is teaching a nursing student about Nightingale's theory, which is an initial model for nursing. Which statements of a nursing student indicate an understanding of the theory? Select all that apply.

"Nightingale's theory deals with visionary principles that include areas of practice, research, and education." "Nightingale's theory deals with descriptive theories that provides nurses with a way to think about clients and their environment." "Nightingale's theory focuses on the fact that nursing is caring through the environment and helping the client deal with symptoms related to illness."

A registered nurse is teaching a student nurse about Gesell's theory of biophysical development. Which statement by the student nurse indicates the need for further teaching? Select all that apply.

"Proximodistal growth describes the sequence in which growth is fastest from the head down." "In the cephalocaudal pattern, growth starts at the center of the body and moves toward the extremities."

Ampicillin 250 mg by mouth every six hours is prescribed for a client who is to be discharged. Which statement indicates to the nurse that the client understands the teaching about ampicillin?

"The medicine should be taken one hour before or two hours after meals."

On her first visit to the neonatal intensive care unit to see her preterm newborn, the mother's only comment to the nurse is, "My baby looks so fragile. Do you think my child will make it?" Which is the most appropriate response by the nurse? 1 "Many infants born as small as yours have done just fine." 2 "The staff is confident in your child's prognosis because preterm babies do look like this at first." 3 "Understandably, your baby looks fragile to you. What have you learned about the condition?" 4 "Your baby is not as fragile as it appears. Do you find it so frightening that you cannot touch your child?"

3 "It's understandable that your baby looks fragile to you. What have you learned about the condition?"

Which condition results from an abnormal organization of cells into a particular tissue type? 1 Dysplasia 2 Disruption 3 Deformation 4 Malformation

1 Dysplasia Dysplasias result from abnormal organizations of cells into a particular tissue. Disruptions result from the breakdown of normal tissue. Extrinsic mechanical forces on previously normal tissue cause deformations. A malformation results when developmental processes lead to an abnormally formed body part or organ.

A client asks the nurse, "Should I tell my partner that I just found out I'm human immunodeficiency virus (HIV) positive?" Which is the nurse's most appropriate response? 1 "Do not tell your partner unless asked." 2 "This is a decision you alone can make." 3 "You are having difficulty deciding what to say." 4 "Tell your partner that you don't know how you became sick."

3 "You are having difficulty deciding what to say."

During a routine checkup, the nurse learns that an adolescent patient is planning to get a navel piercing. What should the nurse assess in the adolescent to ensure safety? 1 Thyroxin levels 2 Hemoglobin levels 3 Blood glucose levels 4 Serum potassium levels

3 Blood glucose levels Skin piercing can cause bleeding, dermatitis, and metal allergy. A patient with diabetes mellitus has an increased risk of skin infection due to high blood glucose levels. Therefore, the nurse should monitor the adolescent's blood glucose levels to ensure safety. A change in thyroxin levels does not indicate that the client has a risk of bleeding, so the nurse does not assess thyroid levels. The nurse assesses hemoglobin levels when the patient has risk of anemia. The nurse will assess serum potassium levels if the adolescent has risk of dehydration, but not before skin piercing.

An infant who has been found to have developmental dysplasia of the hip (DDH) is being examined in the pediatric clinic. What clinical finding does the nurse expect to identify during the physical assessment? 1.Limited abduction of the affected hip 2.Downward and inward rotation of the affected hip 3.Inability to flex and extend the hip on the affected side 4.Free abduction of the affected hip when placed in the frog position

1. Limited abduction of the affected hip Abduction of the hip is limited because the head of the femur slips out of the acetabulum and is unable to rotate. Rotation of the affected hip is unaffected in an infant with DDH. The hip can be flexed on the affected side. Free abduction of the affected hip is impossible; the frog position may be used in the treatment of DDH.

A 4-year-old child is admitted to the pediatric neurological service with a seizure disorder. Shortly after admission, while in bed, the child has a generalized seizure. What nursing actions are most appropriate? Select all that apply. 1. Assessing the seizure 2.Taking the child's vital signs 3.Turning the child on the side 4.Pulling the padded side rails up 5.Initiating oxygen administration

1, 3 & 4 Therapeutic management is based on an accurate description of the seizure. Turning the child on one side or the other allows drainage of secretions that cannot be swallowed during the seizure. The first safety precaution is to prevent injury by raising the padded side rails. It is impossible to take vital signs during a seizure. Administering oxygen is useless because the child does not breathe during a seizure.

A 9-year-old child has a fractured tibia, and a full leg cast is applied. Which assessment findings should the nurse immediately report to the health care provider? Select all that apply. 1. Inability to move the toes 2.Increased urine output 3.Pedal pulse of 90 beats/min 4.Tingling sensation in the foot 5.Fiberglass cast that is damp after 4 hours

1, 4 & 5 A cast is not flexible and can inhibit circulation. Cold toes, loss of sensation in toes, pain, and inability to move the toes should be reported immediately. A tingling sensation in the foot may indicate excessive pressure on the nerves and circulatory system in the casted extremity. A fiberglass cast dries within minutes; if it remains damp, it should be reported before 4 hours have elapsed. Increased urine output is not significant; it may be related to increased fluid intake. The expected pulse rate for a 9-year-old child ranges from 70 to 110 beats/min.

A child is being treated with oral ampicillin (Omnipen) for otitis media. What should be included in the discharge instructions that the nurse provides to the parents of the client? 1. Complete the entire course of antibiotic therapy. 2. Herbal fever remedies are highly discouraged. 3.Administer the medication with meals. 4.Stop the antibiotic therapy when the child no longer has a fever.

1. Complete the entire course of antibiotic therapy Once antibiotics therapy is initiated, the antibiotics start to destroy specific bacterial infections that the health care provider is trying to treat. Antibiotic therapy takes a specific dose and number of days to completely eliminate the bacteria. If the caregivers start a dose and stop it before the course is complete, the remaining bacteria has a chance to grow again, become resistant to antibiotic treatment, and multiply. The nurse should not discourage use of herbal fever remedies; however the herbal treatment should be reviewed to see if it is contraindicated. Ampicillin should be taken 1 to 2 hours after meals. Antibiotic therapy should be completed as prescribed. View Topics

A child with recently diagnosed idiopathic scoliosis has a mild structural curve. The child's mother asks whether the problem can be corrected with exercise. What should the nurse tell the mother concerning an exercise program? 1.Exercise is used in conjunction with a brace. 2.Exercise can be used if the child appears highly motivated. 3.Exercise might exaggerate the curvature if the curve is severe. 4.Exercise is needed to correct the curvature without the need for a brace.

1. Exercise is used in conjunction with a brace. An exercise program and a brace are the treatments of choice for mild structural scoliosis. Although compliance will affect the ultimate outcome of treatment, exercises alone are not helpful in this type of scoliosis. Exercises are to be encouraged, regardless of the type or extent of scoliosis. Exercises alone are used only with postural-related, not structural-related, scoliosis.

The parents of a 14-month-old boy with bilateral cryptorchidism ask the nurse in the pediatric clinic why it is important for him to have surgery before he is 2 years old. Before responding, the nurse takes into consideration the fact that uncorrected cryptorchidism can result in: 1.Infertility 2.Hydrocele 3.Varicocele 4.Epididymitis

1. Infertility Undescended testes (cryptorchidism) is the failure of the testes to move down the inguinal canal into the scrotum; this migration begins around the 25th to 30th week of gestation. Undescended testes are exposed to body heat that can destroy the sperm-producing ability of the testes, resulting in sterility. A hydrocele is an enlargement of the scrotum with fluid; it is not related to cryptorchidism. A varicocele is a dilation and tortuosity of the scrotal veins; it is not caused by undescended testicles. Inflammation of the epididymis may occur whether or not cryptorchidism is corrected.

A nurse plans to discuss childhood nutrition with a group of parents whose children have Down syndrome in an attempt to minimize a common nutritional problem. What problem should be addressed? 1.Rickets 2.Obesity 3.Anemia 4.Rumination

2. Obesity Obesity is a common nutritional problem of children with Down syndrome. It is thought to be related to excessive caloric intake and impaired growth. Rickets is a nutritional disorder related to vitamin D deficiency; it is usually not encountered in these children. Anemia is the most common nutritional problem in children with iron deficiency. Rumination is an eating disorder of infancy characterized by repeated regurgitation without a gastrointestinal illness.

The parents of an 18-month-old toddler are anxious to know why their child has experienced several episodes of acute otitis media. What should the nurse explain to the parents about why toddlers are prone to middle ear infections? 1.Immunological differences between adults and young children 2.Structural differences between eustachian tubes of younger and older children 3.Functional differences between eustachian tubes of younger and older children 4.Circumference differences between middle ear cavity size of adults and young children

2. Structural differences b/w Eustachian tubes of younger and older children. The eustachian tube in young children is shorter and wider, allowing a reflux of nasopharyngeal secretions. Immunological differences are not a factor in the development of otitis media. There is no difference in the function of the eustachian tube among age groups. The size of the middle ear does not play a role in the occurrence of otitis media in young children.

In which type of play do children play together, share toys, and communicate with each other? 1 Parallel play 2 Solitary play 3 Onlooker play 4 Associative play

4 Associative play Children from 2 years of age are mostly involved in associative play, in which they play together, share toys, and communicate with other children. In parallel play, children play next to each other but have little interaction. In solitary play, the child plays alone, which is usually seen in infants. In onlooker play, a child watches others playing, but does not interact.

While assessing a newborn, the nurse strokes the newborn's cheek and observes for a response. What reflex does the newborn produce in response to the nurse's stimulation? 1 Red reflex 2 Startle reflex 3 Sucking reflex 4 Rooting reflex

4 Rooting reflex When the infant's cheek is stroked, the infant will respond by turning toward the stimulated side, which is called the rooting reflex. The red reflex is elicited by placing the infant in a dark room. In an alert state, many infants open their eyes in a supported sitting position. The sucking reflex is elicited by placing a nipple or gloved finger in the infant's mouth. The startle reflex can be elicited by making a loud noise near the infant.

The nurse finds that an adolescent male's trunk is short when compared to the legs. What should the nurse infer from these findings? 1 The adolescent needs further evaluation. 2 The adolescent needs a lot of physical activity. 3 The adolescent may need hormone pills for growth. 4 The adolescent has normal growth and development.

4 The adolescent has normal growth and development. Adolescents have a characteristic growth pattern. In male adolescents, the extremities grow first, followed by the trunk, which can make them appear awkward, with a short trunk and long limbs. Physical activity will not be beneficial because the long extremities reflect normal growth and development. The adolescent does not need hormone pills or further evaluation because these findings are normal for his age.

A nurse is teaching a client how to use the call bell/call light system. Which level of Maslow's hierarchy of needs does this nursing action address? Safety Self-esteem Physiological Interpersonal

A call bell system enables the client to communicate with the staff and supports safety and security, which is a second-level need. Self-esteem involves intrapersonal needs, the fourth level of basic needs. Physiological needs include air, food, and water and represent the first level of needs. Interpersonal needs involve love and belonging, which are third-level needs.

Continue to monitor the blood glucose level per policy.

A nurse who is monitoring the blood glucose level of the term infant of a diabetic mother (IDM) identifies a blood glucose level of 48 mg/dL. What should the nurse do?

Gastric acidity is low and does not provide bacteriostatic protection.

A parent of a newborn asks, "Why do I have to scrub my baby's formula bottles?" What information about a newborn should the nurse consider before replying in language that the parent will understand?

Decreased blood pH

A preterm infant with respiratory distress syndrome (RDS) has blood drawn for an arterial blood gas analysis. What test result should the nurse anticipate for this infant?

A client has a Mantoux test as part of a yearly physical examination. The area of induration is 10 mm within 48 hours after having the test. The nurse concludes that this response indicates that the client has:

Been exposed to the tubercle bacillus

A client in the emergency department states, "I was bitten by a raccoon while I was fixing a water pipe in the crawl space of my basement." Which is the most effective first-aid treatment for the nurse to use for this client?

Cleansing the wound with soap and water

A hospital needs to hire a nursing staff for the intensive care of cancer clients. Which of these positions is most likely to be filled by the nurse?

Clinical nurse specialist

The school nurse conducts a class in nutrition planning for parents. What is the goal of school health nursing programs?

Health promotion

A nurse is counseling a client who has gonorrhea. What additional fact about gonorrhea, besides the fact that it is highly infectious, should the nurse teach this client?

It can produce sterility.

PPE -

Personal Protective Equipment

A client arrives at the clinic after being bitten by a raccoon in an area in the woods where rabies is endemic. When considering the client's needs, the nurse recalls that rabies is a:

Viral infection characterized by convulsions and difficulty swallowing

Isoniazid (INH) is prescribed as a prophylactic measure for a client whose spouse has active tuberculosis (TB). What statements by the client indicate that there is a need for further teaching? (Select all that apply.)

"I sometimes allow our children to sleep in our bed at night." "I know I also have tuberculosis because the skin test was positive." "I'll be skipping the wine but enjoying the cheese at my neighbor's party.

Isoniazid (INH) is prescribed as a prophylactic measure for a client whose spouse has active tuberculosis (TB). What statements by the client indicate that there is a need for further teaching? (Select all that apply.)

"I sometimes allow our children to sleep in our bed at night." "I know I also have tuberculosis because the skin test was positive." "I'll be skipping the wine but enjoying the cheese at my neighbor's party.

A young client with schizophrenia says, "I'm starting to hear voices." What is the nurse's most therapeutic response? "How do you feel about the voices, and what do they mean to you?" "You're the only one hearing the voices. Are you sure you hear them?" "The health team members will observe your behavior. We won't leave you alone." "I understand that you're hearing voices talking to you and that the voices are very real to you. What are the voices saying to you?"

"I understand that you're hearing voices talking to you and that the voices are very real to you. What are the voices saying to you? Acknowledging that client is hearing voices and that the voices are very real to the client validates the presence of the client's hallucinations without agreeing with them, which communicates acceptance and can form a foundation for trust; it may help the client return to reality. The nurse also needs to assess the content of the voices to determine the risk of self-injury or violence against others. The client's contact with reality is too tenuous to explore what the voices mean. Saying that the client is the only one hearing the voices and asking whether the client is sure the voices are being heard demeans the client, which blocks the development of a trusting relationship and future communication. Telling the client that the health team members will observe the behavior and that the client won't be left alone is condescending and may impair future communication

A school-aged child is brought to the clinic by the mother, who states, "Something is very wrong. My child never seems happy and refuses to play." When assessing this child for depressed behavior, what statement should the nurse initially begin with? "Tell me about yourself." "Let's talk about what you do after school." "Can you tell me what's making you so unhappy?" "Why does your mother think that you're unhappy?"

"Let's talk about what you do after school." A structured but nonthreatening question such as asking what the child does after school avoids beginning with the problem and may put the child at some ease, producing information that may be useful. The statement "Tell me about yourself" is too open and global; the child will probably not know how to answer this question or know where to begin. The child may not know the answer to the question "Can you tell me what's making you so unhappy?" Asking "Why does your mother think that you're unhappy?" will probably produce an "I don't know" response; the focus should be on the child, not the mother.

A nurse is evaluating situations based on the responses of several clients. Which client's statement confirms that he or she has reached the Integrity versus Despair stage according to Erikson's theory of psychosocial development? Select all that apply.

"Looking back at my entire life, I find that I have actually achieved nothing." "In the twilight of my life, I regret not fulfilling the promises I made to my wife." "Now that I am at the end of the road, I think I am the luckiest person on the earth because God has given me everything that I had asked for."

A disturbed client says, "The voices are saying that I killed my husband." What is the best response by the nurse? "I just saw your husband, and he's doing fine." "Tell me more about your concerns for your husband." "We'll put you in a private room where you'll be safe." "You seem to be having very frightening thoughts right now."

"You seem to be having very frightening thoughts right now" demonstrates that the nurse understands the client's feelings; reflection opens a channel for communication. The nurse cannot talk the client out of her delusions by pointing out reality. Focusing on delusional content only reinforces false beliefs. "We'll put you in a private room where you'll be safe" does not reflect the content of the client's statement.

While receiving a preoperative enema, a client starts to cry and says, "I'm sorry you have to do this messy thing for me." What is the nurse's best response? "I don't mind it." "You seem upset." "This is part of my job." "Nurses get used to this."

"You seem upset." The nurse should identify clues to a client's anxiety and encourage verbalization of feelings. Saying it is part of the job focuses on the task rather than on the client's feelings. Saying "I don't mind it" or "Nurses get used to this" negates the client's feelings and presents a negative connotation.

Which statement by the parents of an infant with Erb palsy indicates to the nurse that they have an accurate understanding of their infant's prognosis? 1 "Complete recovery takes a few months." 2 "This is a progressive paralysis with no cure." 3 "Physical therapy will be necessary for a year." 4 "Surgery will be needed to correct the problem."

1 "Complete recovery takes a few months." The nerves that have been stretched take about 3 months to recover from the trauma sustained during the birth process. The paralysis is not progressive, and the prognosis is usually excellent. Passive range of motion and intermittent splinting performed by a family member are generally all the interventions that are necessary; only in rare instances, when avulsion of the nerves results in permanent damage, is orthopedic or surgical intervention necessary.

Which statement by the mother of a 5-month-old infant indicates effective learning about proper nutrition for the infant's growth and development? 1 "I will breastfeed my child." 2 "I will give my child whole cow's milk." 3 "I will give my child adequate fruit juice." 4 "I will give my child iron-fortified cereals."

1 "I will breastfeed my child." Breastfeeding is recommended for infant nutrition because breast milk contains essential nutrients of proteins, fats, carbohydrates, and immunoglobulins. Giving cow's milk to an infant may lead to internal bleeding, anemia, and an increased incidence of allergies. Fruit juices should be avoided because they do not provide sufficient calories during this period. Iron-fortified cereals should be given to infants after 6 months of age because infants younger than 6 months of age are not sufficiently mature to digest solid foods.

Which statement by the parent of a 9-month-old supports the nurse's conclusion that the infant displays developmental accomplishments appropriate for this age? 1 "My child can throw a ball." 2 "My child can crawl backwards." 3 "My child can locate small objects." 4 "My child shows jerky movements upon hearing loud sounds."

1 "My child can throw a ball." A child who is 8 to 12 months old is capable of throwing objects. Therefore, this statement made by the parent indicates that the 9-month-old infant has achieved the developmental milestone appropriate for the age. An infant who is 4 to 7 months old is capable of crawling backwards and can locate small objects. These actions can be observed in an infant who is 9 months old, but it does not indicate major developmental accomplishments as per its age. Showing jerky movements upon hearing loud noise indicates that the child is showing startle reflex, which is an involuntary reflex seen from the birth to 4 months of age.

At which age does an infant have a strong grasp reflex? 1 1 month 2 2 months 3 3 months 4 4 months

1 1 month The grasp reflex is strong in 1-month-old infants. Fading of the grasp reflex is observed at 2 months of age. The absence of a grasp reflex is observed in a 3-month-old infant. A 4-month-old infant grasps objects with both hands. However, a grasp reflex is absent in this infant.

Which reading of a newborn's pulse may indicate an abnormality in the function of the cardiovascular system? 1 100 beats/min 2 120 beats/min 3 130 beats/min 4 140 beats/min

1 100 beats/min The normal pulse rate of a newborn ranges from 120 to 160 beats/min. Therefore, a pulse rate of 100 beats/min may indicate an abnormality. Pulse rates of 120 beats/min, 130 beats/min, and 140 beats/min are within normal range.

Which type of cerebral palsy may cause a wide-based gait in children? 1 Ataxic 2 Spastic 3 Dyskinetic 4 Mixed type

1 Ataxic Ataxic cerebral palsy is caused by damage to the cerebellum, which is essential for the coordination of muscle movements and balance. Therefore, a wide-based gait is observed in patients with ataxic cerebral palsy. Spastic cerebral palsy causes hypertonicity with poor control of posture, balance, and coordinated motion. Dyskinetic cerebral palsy is characterized by athetoid and dystonic movements. Mixed cerebral palsy is a combination of spastic and dyskinetic cerebral palsy, and symptoms of both conditions are present.

Which behavior is observed in a newborn in deep sleep? 1 Closed eyes 2 Irregular breathing 3 Occasional smiling 4 Rapid eye movements

1 Closed eyes A newborn in deep sleep will have closed eyes, regular breathing, and no eye movements. A newborn in light sleep would have irregular breathing, rapid eye movements, and may smile.

An infant with a myelomeningocele is scheduled for surgery to close the defect. Which nursing action best facilitates the parent-child relationship in the preoperative period? 1 Encouraging the parents to stroke their infant 2 Allowing the parents to hold their infant in their arms 3 Referring the parents to the Spina Bifida Association of America 4 Teaching the parents to use special techniques when feeding the infant

1 Encouraging the parents to stroke their infant Because the infant cannot be held, tactile stimulation helps meet the infant's needs and fosters bonding with the parents. An infant with an unrepaired myelomeningocele cannot be held in the arms. Referrals will be more appropriate at a later time. Although special feeding techniques are important in the postoperative period, they may not improve the parent-infant relationship.

The parents of a toddler who has been admitted to the pediatric unit for surgery to correct hypospadias ask the nurse when this defect happened. The nurse responds that it usually occurs during fetal development, in the: 1 First 12 weeks 2 Third trimester 3 Second 16 weeks 4 Implantation phase

1 First 12 weeks The critical period of organogenesis occurs during the first trimester, when fetal development is most likely to be adversely affected. The fetus is less vulnerable after the first trimester because organ development is complete. The fetus is less vulnerable to major anomalies during the second 16 weeks because all major organ systems already are formed. At the time of implantation cellular differentiation has not occurred; the genital bud appears in the seventh week.

Which immunoglobulins (Ig) are transferred from a mother to a fetus? 1 IgG 2 IgA 3 IgD 4 IgM

1 IgG Significant amounts of maternal IgG antibodies are passed on to a newborn and confer immunity against antigens. IgA is not present at birth but is found in saliva and tears by 2 to 5 weeks of age. The production of IgD is gradual, and increases progressively during childhood. Significant amounts of IgM are produced at birth, and adult levels are reached by 9 months of age.

n which phase does a child develop the sense of object permanence according to Jean Piaget? 1 Sensorimotor 2 Preoperational 3 Formal operations 4 Concrete operations

1 Sensorimotor During the sensorimotor period, the child understands that objects continue to exist even when they cannot be seen, heard, or touched. This is called object permanence. During the preoperational phase, children learn to think with the use of symbols and mental images. Egocentricity is observed in the formal operations period. Children are able to perform mental operations during the concrete operations period.

Which gross motor skill can be observed in a 7-month-old infant? 1 Sits alone without support 2 Creeps on hands and knees 3 Walks holding onto furniture 4 Sits down from a standing position

1 Sits alone without support Infants between 6 and 8 months of age can sit alone without support. Infants can creep on their hands and knees at the age of 8 to 10 months. Infants who are 10 to 12 months of age can walk while holding onto furniture and can sit down from a standing position due to their well-developed motor skills.

What could be a cause of a stiff, tense appearance of the sutures in a newborn? 1 The neonate is crying. 2 The neonate is sneezing. 3 The skull bones of the neonate are fused. 4 The neonate has irregular breathing pattern.

1 The neonate is crying. Sutures are the layers of connective tissue formed between the bones of the cranium. They facilitate the molding of the cranium during vaginal delivery. Conditions like crying and coughing may cause a temporary bulging in the sutures, which may cause stiffness and tension on palpation. Sneezing and an irregular breathing pattern may not directly influence the stiffness of the sutures. The fusion of skull bones is not generally observed in newborns except in some rare conditions.

Irregular, abdominal, 30 to 60/min

A nurse is observing a newborn's respiratory rate. What clinical findings indicate that the rate is within the expected range?

Preterm infant Small-for-gestational-age infant Large-for-gestational-age infant

A nurse is testing a newborn's heel blood for the level of glucose. Which newborn does the nurse anticipate will experience hypoglycemia? (Select all that apply.)

A nurse is assessing a 3-week-old infant who has been admitted to the pediatric unit with hydrocephalus. What finding denotes a complication requiring immediate attention? 1.Tense anterior fontanel 2.Uncoordinated eye/muscle movement 3.Larger head circumference than chest circumference 4.Inability to support the head while in the prone position

1. Tense anterior fontanel A tense or bulging fontanel is indicative of increased intracranial pressure, which is caused by the fluid accumulation associated with hydrocephalus. Conjugate gaze does not occur until 3 to 4 months of age, once the eye muscles have matured. The head is the largest part of the body at this age; the head circumference should be about 1 inch larger than that of the chest. An infant cannot support the head before 1 to 1½ months of age.

A nurse is helping a 7-year-old child with juvenile idiopathic arthritis (JIA) perform range-of-motion exercises. What outcome indicates that the exercises have been effective? 1.The knees are more mobile. 2.The pedal pulses become stronger. 3.Subcutaneous nodules at the joints recede. 4.The child states that the pain is diminished.

1. The knees are more mobile. The exercises are done to preserve function by mobilizing restricted joints. Circulation is not affected by the arthritic process. Exercises are done to restore joint function; they do not necessarily relieve pain. Exercise does not affect the subcutaneous nodules in the joints.

What should the nurse teach parents about their newborn's diagnosis of phenylketonuria (PKU)? 1. A low-phenylalanine diet is required. 2. Phenylalanine is not necessary for growth. 3. Phenylalanine can be administered to correct the deficiency. 4. A substitute for phenylalanine is an increased amount of other amino acids.

1.A low-phenylalanine diet is requiredReducing dietary phenylalanine helps prevent brain damage. The PKU diet is planned to maintain the serum phenylalanine level at 2 to 8 mg/100 mL. Phenylalanine is essential for growth and development of the brain. Administering phenylalanine is contraindicated. There are no substitute for phenylalanine, which is one of the essential amino acids.

Which statement by a mother indicates the need for additional teaching about safety guidelines for infants and toddlers? 1 "I will use plastic eating and drinking utensils." 2 "I will give my child hard candies for chewing." 3 "I will not allow my child to chew on old furniture." 4 "I will turn pot handles toward the back of the stove."

2 "I will give my child hard candies for chewing." Hard candies should not be given to infants and toddlers because they can be easily aspirated, which will result in choking. Therefore, the nurse should suggest that the mother avoid giving hard candies to young children. The nurse should suggest that the mother use plastic eating and drinking utensils for young children because glass and ceramic utensils may break and lead to injury. Old furniture may contain lead paints, which are toxic. Therefore, children should not be allowed to chew on them. Some children, out of curiosity, may grab pot handles, which can cause burns. Therefore, the nurse should advise the mother to turn pot handles toward the back of the stove for the safety of young children.

The registered nurse is teaching the mother of an infant about the prevention of sudden infant death syndrome (SIDS). Which statement by the mother indicates effective learning? 1 "I will sleep in the bed with my baby." 2 "I will position my baby on the back while sleeping." 3 "I will use warm blankets and sheets to cover my baby." 4 "I will put my baby to sleep on soft bedding with pillows."

2 "I will position my baby on the back while sleeping." Sleeping on the stomach may cause upper airway obstruction and increase the risk of SIDS. Therefore, infants should be placed on their backs to decrease this risk. Sleeping in the same bed as the baby may increase the risk of SIDS. Covering the baby with warm blankets may cause overheating or suffocation and can increase the risk of SIDS. The use of soft bedding and pillows for an infant may lead to suffocation. Therefore, the nurse will teach the mother to use a firm mattress.

During the assessment of a newborn, the nurse pulls the infant from a lying to a sitting position and observes that the infant is unable to control the head in an upright position. Which problem does the nurse suspect? 1 Hydrocephalus 2 Down syndrome 3 Congenital syphilis 4 Thromboembolic condition

2 Down syndrome An infant's inability to control the head in an upright position when pulled to a sitting position indicates head lag. The nurse suspects Down syndrome in this neonate because infants with Down syndrome typically experience delays in certain areas of development, including head lag. Hydrocephalus is suspected if the infant has a head circumference more than 4 cm larger than the chest circumference, or if physiologic craniotabes is found in the infant. The presence of physiologic craniotabes in an infant may indicate congenital syphilis. An underlying thromboembolic condition may be suspected if the infant has hypertension.

How would the nurse incorporate the quality of accuracy into client documentation? 1 By providing a logical order for the communication 2 By using exact measurements for each client's activity 3 By providing complete and appropriate information in each client's record Incorrect 4 By recording descriptive and objective information that he or she sees, hears, feels, and smells

2 By using exact measurements for each client's activity

What common finding can the nurse identify in most children with symptomatic cardiac malformations? 1 Mental retardation 2 Inherited genetic factors 3 Delayed physical growth 4 Clubbing of the fingertips

3 Delayed physical growth Children with cardiac malformations often require more energy to fulfill the activities of daily living; decreased oxygen utilization and increased energy output in the developing child result in a slow growth rate. Mental retardation is not a common finding in children with congenital heart disease. Cardiac anomalies are more often a result of prenatal, rather than genetic, factors. Clubbing is not characteristic of most children with cardiac anomalies, only of those with more severe hypoxia.

Upon interacting with the parent of an infant, the nurse observes that the parent is using an incorrect formula preparation method. Which risk does this pose to the infant? 1 Colic 2 Plagiocephaly 3 Failure to thrive 4 Sudden infant death syndrome

3 Failure to thrive Incorrect formula preparation can lead to inadequate calorie intake and malnutrition, which causes failure to thrive in the infants. Colic in infants may be due to overfeeding, improper feeding techniques, and swallowing excessive air, but not incorrect formula preparation. Positional plagiocephaly and sudden infant death syndrome (SIDS) are avoided by repositioning the infant's sleeping positions, not through formula preparations.

The school health nurse is teaching a group of teachers about promoting the mental health of school-age children. Which action made by the teachers promotes a sense of industry among the children? 1 Separating children during tasks 2 Basing a reward structure on evidence of mastery 3 Giving grades and gifts for satisfactory performances 4 Comparing the performances of children with one another

3 Giving grades and gifts for satisfactory performances During the psychosocial development of school-age children, reinforcement in the form of grades, material rewards, additional privileges, and recognition provides encouragement and stimulation. A sense of accomplishment also involves the ability to cooperate, to compete with others, and to cope effectively with people, so separating children will not promote their mental health. When the reward structure is based on evidence of mastery, children who are incapable of developing these skills are also at risk for feelings of inadequacy and inferiority. Comparison with one another can also cause some children to develop negative feelings towards themselves, and result in a sense of inferiority.

An infant is being admitted with bacterial meningitis. The nurse knows the priority nursing action is: 1 Assessing the infant's neurological status 2 Beginning intravenous fluids and antibiotics 3 Implementing respiratory isolation precautions 4 Teaching the parents the importance of maintaining a quiet environment

3 Implementing respiratory isolation precautions The infant's illness is contagious, and the nurse, as well as other clients, must first be protected with the implementation of respiratory isolation precautions. Assessment of neurological status, implementation of prescribed fluids and antibiotics, and parental teaching may be done after assessment. Also, antibiotics are usually not administered until after all cultures have been obtained.

A 6-week-old infant and his mother arrive in the emergency department in an ambulance. The father arrives several minutes later with two children, 7 and 9 years old. The infant is not breathing, and the eventual diagnosis is sudden infant death syndrome (SIDS). The parents take turns holding the infant in another room. The nurse remains present and provides emotional support to the parents. What is an important short-term goal for this family? 1 Identifying the problems that they will be facing as a result of the loss of the infant 2 Accepting that there was nothing that they could have done to prevent the infant's death. 3 Including the infant's siblings in the events and grieving in the wake of the infant's death 4 Seeking out other families who have lost infants to SIDS and obtaining support from them.

3 Including the infant's siblings in the events and grieving in the wake of the infant's death The other children need to be involved with the grieving process and to work through their own feelings. Identifying the problems that the family will be facing in regard to the loss of the infant is a long-term goal. It is too early to seek out other families who have lost infants to SIDS and receive support from them. It is premature to accept that there was nothing that the family could have done to prevent the infant's death; in fact, they may never achieve this goal.

Which attribute of temperament is related to the energy level of the child's reaction? 1 Attention span 2 Sensory threshold 3 Intensity of reaction 4 Approach-withdrawal

3 Intensity of reaction The energy level of the child's reaction is called intensity of reaction. Sensory threshold is the amount of stimulation, such as sounds or light, required to evoke a response in the child. Approach-withdrawal is the nature of initial responses to a new stimulus. Approach responses are positive expressions, and withdrawal responses are negative expressions. The length of time a child pursues a given activity is called attention span.

What does a nurse recognize as the most serious complication of meningitis in young children? 1 Epilepsy 2 Blindness 3 Peripheral circulatory collapse 4 Communicating hydrocephalus

3 Peripheral circulatory collapse Peripheral circulatory collapse (Waterhouse-Friderichsen syndrome) is a serious complication of meningococcal meningitis caused by bilateral adrenal hemorrhage. The resultant acute adrenocortical insufficiency causes profound shock, petechiae, ecchymotic lesions, vomiting, prostration, and hypotension. Although epilepsy or blindness may occur, neither condition is as serious a complication as peripheral circulatory collapse. Similarly, although hydrocephalus may occur, it is rare and not as serious as peripheral circulatory collapse.

Which internal asset helps young people make positive choices and build relationships? 1 Positive values 2 Positive identity 3 Social competencies 4 Commitment to learning

3 Social competencies Social competencies help young people make positive choices and build relationships. Positive values are a strong sense of values that are needed to direct the choices of young people. Positive identity provides a sense of own power, purpose, worth, and promise in young people. Young people need to develop a commitment to education and lifelong learning.

A newborn who was delivered with the assistance of forceps sustains an injury that results in facial paralysis. What would the nurse state to the mother? 1 The baby will have this condition for life. 2 The newborn may need intensive physiotherapy. 3 The condition usually subsides on its own in a few days. 4 The newborn should not be allowed to cry because it can cause pain.

3 The condition usually subsides on its own in a few days. A difficult delivery performed with forceps may result in facial paralysis, which may manifest as asymmetrical movements of the face, an inability to close the eyelid, and drooping of the corner of the mouth. This condition is self-limiting and may subside in few days. Physiotherapy is not indicated for the treatment of this condition. The parents should be informed that this condition is not painful.

The nurse is reinforcing best parenting practices to the parents of a 13-year-old child. Which statements made by the parent need correction? Select all that apply. 1 "I should apologize to my child when I am wrong." 2 "I should assist my child in selecting appropriate career goals." 3 "I should motivate my child to perform well in exams by comparing her to her siblings." 4 "I should strictly instruct my child to adhere to the house rules even though it hurts her." 5 "I should teach my child to make decisions and understand consequences as an adult would."

3 "I should motivate my child to perform well in exams by comparing her to her siblings." 5 "I should teach my child to make decisions and understand consequences as an adult would." The nurse should suggest that the parents avoid comparing the adolescent to his or her siblings in order to prevent the development of an inferiority complex. The nurse should encourage parents to allow adolescent children to make their own choices and learn from them, even when those choices are not the choices an adult would make. The nurse should suggest that the parents respect their child and apologize to their child if they make a mistake. The nurse should suggest that the parents assist their child in selecting appropriate career goals and preparing for adult roles. The nurse should suggest that the parents make clear house rules and instruct the child to adhere to them, as it helps prevent the development of high-risk behaviors, like alcohol addiction.

The mother of a 2-year-old child tells the nurse that she is concerned about her child's vision. What behavior when the child is tired leads the nurse to suspect strabismus? 1 One eyelid droops. 2Both eyes look cloudy. 3One eye moves inward. 4Both eyes blink excessively

3. One eye moves inward An inward moving eye (tropia) is one form of strabismus. A drooping eyelid is called ptosis; it may be congenital or caused by trauma. Cloudy eyes are associated with congenital cataracts. Blinking may be a tic.

A 2-year-old toddler is admitted to the pediatric unit with a diagnosis of bacterial meningitis. What is the most important safety measure for the nurse to institute immediately after the child has a seizure? 1.Monitoring the child's vital signs 2.Padding the side rails of the toddler's crib 3.Placing the child in the side-lying position 4.Bringing suction equipment to the bedside

3. Placing the child in the side-lying position The side-lying position promotes a patent airway; the tongue can move away from the back of the pharynx and saliva can flow out of the mouth by gravity. Although monitoring of vital signs is important, a patent airway is the priority. Suctioning may be unnecessary; the child should not be left alone while equipment is obtained. The crib sides should have been padded as a part of seizure precautions before the seizure. If the seizure was unexpected and seizure precautions were not previously instituted, they should be instituted after the immediate respiratory and safety needs of the toddler have been met.

A father expresses concern that his 2-year-old daughter has become a "finicky eater" and is eating less. How should the nurse respond? 1 "Your daughter has become manipulative." 2 "She's probably experiencing the stress of a typical 2-year-old." 3 "She may have an eating problem that requires a referral to a specialist." 4 "Your daughter's behavior is expected in response to her slower growth."

4 "Your daughter's behavior is expected in response to her slower growth." Growth slows during the toddler years and these children generally do not eat as much as they do during infancy; this is called physiologic anorexia, which is typical of this age group. Toddlers may try to manipulate as they assert their autonomy, but usually not through eating behaviors unless the parents express anxiety and concern over their food intake. Although toddlers have difficulty withstanding frustration and are prone to temper tantrums, these eating behaviors are within the norm for toddlers. Eating disorders usually do not occur in children this young; these behaviors are typical of healthy toddlers.

An 8-year-old child is being prepared for surgery the next day. How should the nurse present preoperative instructions to this child? 1 By repeating instructions often 2 By providing time for needle play 3 By using several abstract examples 4 By focusing on simple anatomical diagrams

4 By focusing on simple anatomical diagrams According to Piaget, an 8-year-old child's level of development is in the stage of concrete operations; the child will benefit from simple, concrete examples. The preschooler and younger child, not the school-age child, require repetition. Therapeutic needle play is more appropriate if and when the child is to receive an injection. The child who is in the period of concrete operations cannot think in the abstract; the ability to do this develops during adolescence.

A nurse is caring for a 3-month-old infant with congenital hypothyroidism. What should the parents be taught about the probable effect of the condition on the infant's future if treatment is not begun immediately? 1 Myxedema 2 Thyrotoxicosis 3 Spastic paralysis 4 Cognitive impairment

4 Cognitive impairment Congenital hypothyroidism is the result of insufficient secretion by the thyroid gland because of an embryonic defect. A decreased level of thyroid hormone affects the fetus before birth during cerebral development, so it is likely that there will be some cognitive impairments at birth. Treatment before 3 months will prevent further damage. Congenital hypothyroidism does not become myxedema. Thyrotoxicosis is another term for hyperthyroidism. Although it is not expected, it may occur with an overdose of exogenous thyroid hormone, but it is too soon to discuss this possibility with the parents. Spastic paralysis occurs only if the infant has cerebral palsy.

While playing, a child takes a few pebbles and places them in order from smallest to largest. Which stage of cognitive development does the child's behavior demonstrate? 1 Sensorimotor 2 Preoperational 3 Formal operations 4 Concrete operations

4 Concrete operations During the stage of concrete operations, the child's thought becomes more logical and coherent. The child in this stage is able to classify, sort, order, and organize facts about the world to use in problem-solving. Therefore, the child placing the pebbles in order of smallest to largest indicates that the child is in the stage of concrete operations. In the sensorimotor stage, the child develops a sense of cause and effect as they direct behavior towards objects. In the preoperational stage, thinking is concrete and tangible. The child lacks the ability to make deductions or generalizations. In formal operations, thought is characterized by adaptability and flexibility. Abstract thinking and problem-solving skills are observed in this stage.

A middle-aged adult contributes to future generations through parenthood, teaching, and community involvement. To which stage of Erikson's theory does this relate? 1 Ego integrity versus despair 2 Intimacy versus isolation 3 Identity versus role confusion 4 Generativity versus stagnation

4 Generativity versus stagnation In the generativity versus stagnation stage, the adult focuses on supporting future generations. Middle-aged adults achieve success in this stage by contributing to future generations through parenthood, teaching, and community involvement. The ego integrity versus despair stage is seen in older adults. During this stage, some older adults live their lives with a sense of satisfaction and others see themselves as failures marked by despair and regret. The intimacy versus isolation stage is seen in young adults, in which they develop a sense of identity and a capacity to love and care for others. In the identity versus role confusion stage, an individual will have a marked preoccupation with his or her appearance and body image.

What behavior does the nurse expect a healthy 5-month-old infant to exhibit? 1 Using the pincer grasp 2 Sitting without support 3 Crawling across the floor 4 Grasping objects voluntarily

4 Grasping objects voluntarily The 5-month-old infant's neurological development has reached the stage at which objects can be grasped voluntarily; this is considered a developmental milestone. The pincer grasp appears between 9 and 12 months of age. Sitting alone without support is usually accomplished at 6 to 8 months of age. The infant begins to crawl at 8 to 10 months of age.

A nurse is caring for an infant with phenylketonuria. What diet should the nurse anticipate will be prescribed by the health care provider? 1 Fat free 2 Protein-enriched 3 Phenylalanine-free 4 Low-phenylalanine

4 Low-phenylalanine Because phenylalanine is an essential amino acid it must be provided in quantities sufficient for the promotion growth but low enough to maintain a safe blood level. Phenylalanine is derived from protein, not fat. An enriched-protein diet contains increased amount of proteins, including phenylalanine, which should be ingested in limited amounts. Because phenylalanine is an essential amino acid, it cannot be totally removed from the diet.

According to Piaget, which developmental stage is characterized by logical thinking? 1 Preschool 2 Adolescence 3 Early childhood 4 Middle childhood

4 Middle childhood Logical thinking is a characteristic of middle childhood, which is 6 to 12 years of age. The use of symbols and egocentric behavior is seen in preschoolers. Adolescence is characterized by abstract thinking. Early childhood is characterized by a preoperational period during which thinking using symbols and egocentric behavior are observed.

According to Kohlberg's moral judgment theory, which characteristic behavior would the nurse find in the child who is in the naive instrumental orientation stage? 1 The child tries to follow laws and respects order. 2 The child tries to develop good social relationships. 3 The child follows the rules due to fear of punishment. 4 The child is motivated by a selfish desire to obtain rewards and benefits.

4 The child is motivated by a selfish desire to obtain rewards and benefits. According to Kohlberg's moral judgment theory, every child has a gradual development of moral consciousness based on cognitive development. During the naive instrumental orientation stage, the child's behavior is motivated by a selfish desire to obtain rewards and benefits. During the law and order orientation stage, the child tries to follow rules and laws. During the social contract orientation stage, the child tries to develop good social relationships. During the punishment and obedience orientation stage, the child obeys rules without question due to fear of punishment.

Having sex with many partners

A nurse is caring for the newborn of a drug-addicted mother with suspected cytomegalovirus disease. What does the nurse suspect was the cause of the disease?

A 9-year-old child who has had type 1 diabetes for several years is brought to the emergency department of a community hospital. The child is exhibiting deep, rapid respirations; flushed, dry cheeks; abdominal pain with nausea; and increased thirst. What blood pH and glucose level does the nurse expect the laboratory tests to reveal? 1.7.20 and 60 mg/dL 2.7.50 and 60 mg/dL 3.7.50 and 460 mg/dL 4.7.20 and 460 mg/dL

4. 7.20 and 460 mg/dL A pH of 7.20 and blood glucose level of 460 mg/dL are expected values in ketoacidosis; the pH of 7.20 indicates acidosis (metabolic) and the blood glucose level of 460 mg/dL is higher than the expected range of 90 to 110 mg/dL. Although the blood pH of 7.20 indicates acidosis, the blood glucose of 60 mg/dL is less than the expected range of 90 to 110 mg/dL, indicating hypoglycemia rather than hyperglycemia. Neither the pH of 7.50 nor the blood glucose value of 60 mg/dL is expected with ketoacidosis; with ketoacidosis, the pH is decreased and the blood glucose level is increased. Although the blood glucose is increased with ketoacidosis, the pH is decreased, not increased; a pH of 7.50 indicates alkalosis.

A 4-year-old child is admitted to the pediatric unit with a diagnosis of Wilms tumor. Considering the unique needs of a child with this diagnosis, the nurse should place a sign on the child's bed that states: 1.Keep NPO. 2.No IV medications. 3.Record intake and output. 4.Do not palpate the abdomen.

4. Do not palpate the abdomen. Palpation increases the risk of tumor rupture and is contraindicated. There are no data to indicate that surgery is scheduled; therefore there is no reason to maintain nothing-by-mouth (NPO) status. There is no contraindication to intravenous medication. Recording of intake and output may or may not be instituted; it is not specific to children with Wilms tumor.

A mother brings her 6-year-old child to the pediatric clinic, stating that the child has not been feeling well, is weak and lethargic, and has a poor appetite, headaches, and smoky-colored urine. What additional information should the nurse obtain that will aid diagnosis? 1.Rash on palms and feet 2.Shoulder and knee pain 3.Recent weight loss of 2 lb 4.Strep throat in the past 2 weeks

4. Strep throat in the past 2 weeks The smoky urine and the stated symptoms should lead the nurse to suspect glomerulonephritis, which usually occurs after a recent streptococcal infection. A rash on the hands and feet is associated with scarlet fever, not glomerulonephritis. Shoulder and knee pain is associated with rheumatic fever, not glomerulonephritis. Weight loss generally occurs in children who have type 1 diabetes, not those with glomerulonephritis

The nurse who is caring for a child with botulism anticipates that the child's growth and development may be hampered due to cranial nerve deficits. Which signs presented by the child support the nurse's conclusion? Select all that apply. A Reduced gag reflex B Loss of head control C Accumulated secretions D Breathlessness in vocalizations E Paroxysmal muscle contractions

A Reduced gag reflex B Loss of head control Cranial nerve deficits are evidenced by diminished or reduced gag reflex or loss of head control. Accumulated secretions are seen due to laryngospasm and tetany of the respiratory muscles. Breathlessness in vocalizations is observed in Guillain-Barré syndrome due to intercostal and phrenic nerve involvement. Paroxysmal muscle contractions are observed in patients with tetanus due to extreme sensitivity to external stimuli.

Promote clotting of the blood

A 7-lb newborn is admitted to the nursery with a prescription for intramuscular phytonadione (vitamin K, Aquamephyton) 1 mg. The nurse explains to the parents that this vitamin is administered to:

Flaring nares

A nurse is observing a newborn of 33 weeks' gestation. Which sign alerts the nurse to notify the health care provider?

"The swelling and discharge are expected. They're a response to your hormones."

A mother is inspecting her newborn girl for the first time. The infant's breasts are edematous, and she has a pink vaginal discharge. How should the nurse respond when the mother asks what is wrong?

Cognitive Impairment

A neonate is tested for phenylketonuria (PKU) after formula feedings are initiated. The nurse explains to the parents that this is done to prevent:

30 to 60 breaths/min

A neonate weighing 5 lb 6 oz (2438 g) is born in a cesarean birth and admitted to the newborn nursery. What range of resting respiratory rate should the nurse anticipate?

"This often happens as the baby's head moves down the birth canal—the bones move for easier passage."

A new mother exclaims to the nurse, "My baby looks like a Conehead!" How should the nurse respond?

By asking her to describe her concerns more fully

A new mother with class II heart disease tells a nurse that she is afraid that her heart condition will prevent her from caring for her baby and her home when she is discharged. How should the nurse respond?

Thin upper lip Small upturned nose Smooth vertical ridge in the upper lip

A new mother's laboratory results indicate the presence of cocaine and alcohol. Which craniofacial characteristic indicates to the nurse that the newborn has fetal alcohol syndrome (FAS)? (Select all that apply.)

Start resuscitation

A newborn has an Apgar score of 3 at 1 minute after birth. What is the immediate nursing action in response to this Apgar score?

Rubella

A newborn has congenital cataracts, microcephaly, deafness, and cardiac anomalies. Which infection does the nurse suspect that the newborn's mother contracted during her pregnancy?

Milia

A newborn has small, whitish, pinpoint spots over the nose that are caused by retained sebaceous secretions. When documenting this observation, a nurse identifies them as:

3

A newborn of 30 weeks' gestation has a heart rate of 86 beats/min and slow, irregular respirations. The infant grimaces in response to suctioning, is cyanotic, and has flaccid muscle tone. What Apgar score should the nurse assign to this neonate?

Notify the practitioner, because circumoral pallor may indicate cardiac problems

A newborn's hands and feet are cyanotic and there is circumoral pallor when the infant cries or feeds. What should the nurse do?

Color

A nurse assesses a healthy 8-lb 8-oz (3860-gm) newborn who was given Apgar scores of 9 at 1 minute and 10 at 5 minutes. Which category of the Apgar score received a 1 rating at one minute?

A demonstration and explanation of infant care

A nurse decides on a teaching plan for a new mother and her infant. What should the plan include?

How to monitor their child for signs of jaundice

A nurse identifies a right cephalhematoma on an otherwise healthy 1-day-old newborn. What should the nurse teach the parents at the time of discharge?

It can be acquired during a vaginal birth.

A nurse in the newborn nursery receives a call from the emergency department saying that a woman with active herpes virus lesions gave birth in a taxicab while coming to the hospital. What does the nurse consider about the transmission of the herpes virus?

Jaundice that develops in the first 12 to 24 hours

A nurse is assessing a newborn for signs of hyperbilirubinemia (pathological jaundice). What clinical finding confirms this complication?

Ductus arteriosus Foramen ovale

A nurse is assessing a newborn with suspected retention of a fetal structure that will result in a congenital heart defect. Which fetal structures should undergo change after birth? (Select all that apply.)

Pneumonia Preterm birth Conjunctivitis

A nurse is caring for a new mother who has a chlamydial infection. Which complications are associated with chlamydial infections in neonates? (Select all that apply.)

Supporting the parents

A nurse is caring for a newborn with a cephalohematoma. What is the priority nursing action?

Breaks down the bilirubin into a conjugated form

A nurse is caring for a preterm neonate with physiological jaundice who requires phototherapy. What is the action of this therapy?

Hypoglycemia

A small-for-gestational-age (SGA) newborn who has just been admitted to the nursery has a high-pitched cry, appears jittery, and exhibits irregular respirations. What complication does the nurse suspect?

A 2.5-year-old child is admitted for treatment of injuries supposedly sustained in a fall down a flight of stairs. Child abuse is suspected. What statements might the nurse expect from a parent who engages in child abuse? Select all that apply. "Kids have to learn to be careful on the stairs." "Every time I turn around the kid is falling over something." "This child tends to be adventurous and doesn't understand about getting hurt on the stairs." "I can't understand it. This child didn't have a problem using the stairs without my help before this." "I try to keep an eye on my child, but little kids are always on the go and I just can't keep running after the kid."

Abusive parents often have a poor understanding of the expected growth and development of children and tend to blame the child. Toddlers generally need supervision and some assistance when climbing stairs, but abusive parents have little understanding of toddlers' abilities. Although "Kids have to learn to be careful on the stairs" is a true statement about toddlers, it is an unlikely response from an abusive parent because these people do not have an understanding of children's needs in relation to growth and development. "This child tends to be adventurous and doesn't understand about getting hurt on the stairs" is an unlikely response from an abusive parent because these people do not have an understanding of children's needs in relation to growth and development. Although "I try to keep an eye on my child, but little kids are always on the go and I just can't keep running after the kid" is a true statement about toddlers, it is an unlikely response from an abusive parent because these people usually do not have an understanding of children's needs in relation to growth and development.

The nurse finds that a client with bilateral oral swelling, pain, and trismus had undergone a surgical extraction of an impacted tooth five days ago. What type of nursing diagnosis does the documentation of acute pain refer to?

Actual nursing diagnosis

A client with multiple myeloma who is receiving chemotherapy has a temperature of 102.2° F. The temperature was 99.2° F when it was taken six hours ago. A priority nursing intervention is to:

Administer the prescribed antipyretic and notify the charge nurse or primary health care provider

Reflex irritability: cry Respiratory rate: good cry Heart rate: 110 beats/min

After a difficult birth, a neonate has an Apgar score of 8 after 5 minutes. Which signs met the criteria of 2 points? (Select all that apply.)

How many deciduous teeth would be present in a 10-month-old infant? Record your answer as a whole number. ________

Age of child in months minus 6 = Number of deciduous teeth. Therefore, the number of deciduous teeth is 10 - 6 = 4.

A client is placed on a restricted diet. What is the best communication technique for the nurse to use when beginning to teach the client about the diet? Asking about what type of foods the client usually eats Telling the client that the diet must be followed exactly as written Telling the client that the intake of foods on the list must be limited Asking about what the client knows about the diet that was prescribed

Asking about what the client knows about the prescribed diet may validate the client's understanding; the response may indicate the need for further teaching or that the client understands; understanding and accepting the need for restrictions will increase adherence to the diet. Assessing the client's food preferences and teaching about diets follow an assessment of the client's understanding about the need for a specific diet; the client must understand the need for and the benefits of the diet before there is a readiness for learning. Telling the client that the diet must be followed exactly as written and telling the client that the intake of foods on the list must be limited are authoritarian and should be avoided.

Suctioning the mouth

At 10 hours of age a newborn has a large amount of mucus in the nasopharynx and becomes cyanotic. What is the nurse's initial action?

A client receiving chemotherapy takes a steroid daily. The client has a white blood cell count of 12,000/mm3 and a red blood cell count of 4.5 million/mm3. What is the priority instruction that the nurse should teach the client?

Avoid large crowds and persons with infections

A client who has participated in caring for her infant in the neonatal intensive care unit for several days in preparation for the infant's discharge comes to the unit on the last hospital day with an alcohol odor on her breath and slurred speech. What is the most appropriate action for the nurse to take at this juncture? Speak with the mother about her condition and assess her willingness to participate in an alternate discharge plan. Request that the mother wait in the hospital lobby and call the primary healthcare provider to cancel the discharge order. Speak to the mother about her condition and have her see a social worker about the infant's discharge to a foster home. Continue with the discharge procedure and alert the home health nurse that the mother needs an immediate follow-up visit.

Confrontation regarding the active substance abuse and the mother's diminished ability to care for the infant safely at this time is necessary to help the mother obtain help and to protect the infant. Decisions should not be made without input from the mother. Continuing with the discharge procedure and alerting the home health nurse that the mother needs an immediate follow-up visit is unsafe; the mother may not be capable of caring for the infant.

The nurse is explaining which developmental milestones a child's parents should expect to see at the age of 18 months. Which statements made by the parents indicate the need for further instruction? Select all that apply. 1 "My child will be able to take a few steps on tiptoe." 2 "My child will be able to pull and push toys." 3 "My child will be able to climb stairs with assistance." 4 "My child will be able to pick up objects without falling." 5 "My child will be able to kick a ball without losing balance."

Correct 1 "My child will be able to take a few steps on tiptoe." Correct 4 "My child will be able to pick up objects without falling." Correct 5 "My child will be able to kick a ball without losing balance." The child starts taking a few steps on tiptoe at the age of 30 months, not 18 months. The child will be able to pick up objects without falling and kick a ball forward at the age of 24 months, not 18 months. The gross motor skills of an 18-month-old child are well developed, so the child can pull or push toys. The child should also be able to climb stairs with one hand held.

A new mother who is unable to breastfeed her newborn expresses breast milk to feed the baby. Which actions of the mother should be corrected by the nurse? Select all that apply. A Adding water to dilute the expressed milk B Storing expressed milk at room temperature C Expressing milk by hand or with breast pump D Storing expressed milk in the refrigerator for 5 days E Adding honey to expressed milk to improve taste

Correct A Adding water to dilute the expressed milk Correct B Storing expressed milk at room temperature Correct E Adding honey to expressed milk to improve taste

Which physiologic changes are observed in pregnant women during the third trimester? Select all that apply. A Fatigue B Morning sickness C Urinary frequency D Breast enlargement E Braxton Hicks contractions

Correct A Fatigue Correct C Urinary frequency Correct E Braxton Hicks contractions Due to the enhanced growth of the fetus and uterus in the third trimester, physiologic changes including fatigue, urinary frequency, and Braxton Hicks contractions are observed in pregnant women. Women in the first trimester may experience morning sickness, breast enlargement and tenderness, and fatigue.

The nurse is about to perform a wound irrigation on a client who had a left hemispheric stroke 1 year ago. Which assessment is most important for the nurse to perform before beginning the irrigation? Tachycardia Hypotension Rigid abdomen Nausea and vomiting Back and shoulder pain

Correct1 Tachycardia Correct2 Hypotension Correct3 Rigid abdomen Correct4 Nausea and vomiting Correct5 Back and shoulder pain

A registered nurse advises parents to assist their child with stretching exercises. The child has impaired physical mobility due to neuromuscular impairment. What is the rationale for performing stretching exercises? 1 To minimize pain 2 To prevent contractures 3 To promote the achievement of developmental milestones 4 To facilitate the mobilization of foods and fluids through the esophagus

Correct2 To prevent contractures A contracture deformity is the result of stiffness or constriction in the muscles. A contracture would adversely affect a child's development, depending upon location and severity. For example, if an infant developed a contracted Achilles tendon, the infant would not be able to physically develop the ability to walk. Administering pain medications helps decrease the pain. To promote the achievement of developmental milestones, the nurse encourages play exercises that involve joint movement and enhance fine and gross motor skill acquisition. The nurse places the child in the semi-upright position during feedings to facilitate the mobilization of food and fluids through the esophagus.

A 13-year-old child states, "I don't know if I want to go to college or start working after high school." Which stage of psychosocial development is indicated by this child's uncertainty? 1 Intimacy vs. isolation 2 Ego integrity vs. despair 3 Identity vs. role confusion 4 Generativity vs. stagnation

Correct3 Identity vs. role confusion This child's statement indicates a struggle to establish a sense of identity, which is characteristic of the identity vs. role confusion stage. The intimacy vs. isolation stage is characterized by establishing intimate bonds of love and friendship. Looking back over one's life and accepting its meaning are observed in the ego integrity vs. despair stage of psychosocial development. The generativity vs. stagnation stage is seen in middle adulthood, where fulfilling life goals that involve family, career, and society plays an important role.

When assessing the cognitive development of a 9-year-old child, which characteristic indicates inadequate cognitive development? 1 The child collects different-colored rocks. 2 The child says that fall is better than spring. 3 The child considers a boy at school to be a better friend than a neighbor. 4 The child believes there are more blocks when spread out on the floor than in the container.

Correct4 The child believes there are more blocks when spread out on the floor than in the container. At ages 5 to 7, children learn that simply altering the arrangement of objects in space does not change certain properties of the objects. A 9-year-old child should able to resist perceptual cues that there are more blocks when on the floor than when in their container. During Piaget's stage of concrete operations, children develop an understanding of relationships between things and ideas. They become occupied with collections of objects, such as rocks, and derive enjoyment from classifying and ordering their environment. They may even begin to order friends and relationships (e.g., best friend, second-best friend).

According to Watson's theory, in which practice is the nurse least likely to engage?

Curing the disease before engaging in care of the client

A primary health care provider prescribes airborne precautions for a client with tuberculosis. After being taught about the details of airborne precautions, the client is seen walking down the hall to get a glass of juice from the kitchen. The most effective nursing intervention is to:

Explore what the precautions mean to the client

A newly immigrated older Chinese adult is brought to a mental health clinic when family members become concerned that their parent is depressed. In an attempt to conduct a culturally competent assessment interview, the nurse asks certain questions. Which questions does the nurse ask? Select all that apply. "What brought you here for treatment today?" "What do you believe is the cause of your depression?" "Does religion have a role in your perception of health and wellness?" "Do you have insurance that includes coverage of mental health issues?" "Have you ever sought treatment for a mental health problem previously?"

Determining the client's perception of the problem is an appropriate question that allows cultural factors to be included. Encouraging the client to discuss the problems will facilitate a clearer understanding of the factors involved. Religion often plays a significant role in a client's view of health, wellness, and recovery. Knowing whether a client has ever undergone treatment for a mental health problem reveals mental health history and how previous issues were addressed. Insurance coverage is not pertinent to the issue and is an inappropriate topic of questioning by the nurse.

When assessing the oral cavity of a newly admitted client with acquired immunodeficiency syndrome (AIDS), the nurse identifies areas of white plaque on the client's tongue and palate. What is the nurse's initial response?

Document the presence of the lesions, describing their size, location, and color

Early parenting behavior

During a male newborn's first encounter with his mother the nurse encourages her to undress him. The mother strokes him with her whole hand and while looking at him intently says, "He feels so velvety, and he is going to be just as good looking as his daddy." The baby is alert and responsive while gazing at his mother. What is the nurse's assessment of this first mother-infant encounter?

Remove secretions from the pharynx

During the second reactive period a newborn becomes more alert and responsive and there is an increase in mucus production and gagging. What should the nurse do first?

While teaching a nursing student, a registered nurse says "This is a study in which the investigator controls the study variable and randomly assigns subjects to different conditions to test the variable." Which type of research is the above statement?

Experimental research

The nurse is caring for a client who is recovering from a stroke. The primary health care provider has referred the client for rehabilitative care. Which interventions by the nurse help to make a successful referral process? Select all that apply.

Explain the need for referral to the client and family. Provide the referral with adequate client information. Determine what the referral recommends for client care.

3 examples of subjective data

Pain, Dizziness, Exhaustion

The parents of a toddler who has been admitted to the pediatric unit for surgery to correct hypospadias ask the nurse when this defect happened. Which fetal development time period would the nurse respond? 1 First 12 weeks 2 Third trimester 3 Second 16 weeks 4 Implantation phase

First 12 Weeks

A client who has been diagnosed with Lyme disease is started on doxycycline (Vibramycin) as part of the therapy. What should the nurse do when administering this drug?

Give the medication an hour before milk products are ingested.

A hospital organization plans to conduct a study on the effect of dried plums for lowering the risk of colon cancer. After selecting the subjects, a nurse researcher provides adequate information about the research and then inquires about the preference of the subjects to associate with the research. What does this procedure indicate?

Informed consent

A client is admitted to the hospital for general paresis as a complication of syphilis. Which therapy should the nurse anticipate will most likely be prescribed for this client?

Penicillin therapy

Which group benefits from Medicare?

People who are 65 years or older

Which of these is a part of health belief model?

Perception of susceptibility to an illness

The parent of a 4-year-old client states, "My child gets so upset when I ask her to stop talking so that I can answer a work phone call. I don't understand why this happens." Which response by the nurse is most appropriate? "School is a source of stress for many children at this age." "Worrying is a source of stress for many children at this age." "Attention is a source of stress for many children at this age." "Belongings are a source of stress for many children at this age."

Lack of attention is often a stressor for the 4-year-old preschool-age client; therefore, the nurse should provide education about this stressor to the parent. The child's reaction is not due to the stressors of school, worrying, or belongings

Which steps are taken by a nurse during the implementation phase of drug research? Select all that apply.

Obtaining necessary approvals Recruiting subjects and collecting data obtained from the study

Which important intervention would be included in the nursing care provided immediately after a sexual assault? 1. Obtaining the assault history from the client 2. Reporting the assault to the police before the client is examined 3 Having the client void a clean-catch urine specimen 4 Testing the client's urine for seminal alkaline phosphatase

Obtaining the assault history from the client

What criteria should the nurse consider when determining if an infection should be categorized as a health care-associated infection?

Occurred in conjunction with treatment for an illness

A chronically ill, older client tells the home care nurse that the daughter with whom the client lives seems run-down and disinterested in her own health, as well as the health of her children, who are 5, 7, and 12 years old. The client tells the nurse that the daughter coughs a good deal and sleeps a lot. Why is it important that the nurse pursue the daughter's condition for potential case finding?

Older adults with chronic illness are more susceptible to tuberculosis

How is public health nursing different from community health nursing?

Public health nursing focuses on population.

What should the nurse do when a client with the diagnosis of schizophrenia talks about being controlled by others? Express disbelief about the client's delusion. Divert the client's attention to unit activities. React to the feeling tone of the client's delusion. Respond to the verbal content of the client's delusion.

Reacting to the feeling tone of the client's delusion helps the client explore underlying feelings and allows the client to see the message that the verbalizations are communicating. Expressing disbelief about the client's delusion denies the client's feelings rather than accepting and working with them. Attempting to divert the client rather than accepting and working with the client denies the client's feelings. Responding to the verbal content of the client's delusion focuses on the delusion itself rather than on the feeling that is causing the delusion.

A client is admitted with the diagnosis of tetanus. For which clinical indicators should the nurse assess the client? (Select all that apply.)

Restlessness Muscular rigidity Respiratory tract spasms Spastic voluntary muscle contractions

A nurse observes that an unlicensed assistive personnel (UAP) did not use a bag impervious to liquid for contaminated linen from a client who is on contact precautions. The nurse's best way to handle this situation is to:

Review transmission-based precautions with the UAP

A new toy is shown to a baby, and after his or her attention is drawn, the parent hides the toy under the bed. Then the baby tries to find the toy, which is hidden. Which stage of cognitive development does the child belong, according to Jean Piaget?

Sensorimotor

The Institute of Medicine (IOM) identified five interrelated competencies for all health care workers in the twenty-first century. What should the nurse do to provide patient-centered care?

Share decision-making and management.

What information should the nurse provide for a client who is discharged from the health care facility with a surgical wound? Select all that apply.

Skill to care for the surgical wound Safe and effective use of medications List of appropriate community resources

The nurse cares for a client who develops pyrexia three days after surgery. The nurse should monitor the client for which signs and symptoms commonly associated with pyrexia? (Select all that apply.)

Tachypnea Increased pulse rate

A middle-aged client says, "I have been unsuccessful in raising my kids." Which stage should the nurse expect the client to have reached, according to Erikson's theory of psychosocial development?

The client has reached the Generativity versus Self-Absorption and Stagnation stage.

A 16-year-old girl has been admitted to the pediatric eating disorders unit with a diagnosis of anorexia and is undergoing behavioral therapy. Unit privileges are based on weight gain and have been explained to the client. What is the most appropriate intervention for the nurse to use when taking the lunch tray to the client's room? Setting the tray down and saying nothing Reminding the client that eating will be rewarded Commenting on the client's thinness and need to gain weight Threatening the client that if she doesn't eat she won't gain any privileges

The client uses eating/weight gain as a means of controlling the environment. The client has been told the rules of the unit and must make the personal decision to try to win privileges. The nurse needs to take the focus away from eating. The client knows that gaining weight will be rewarded and does not need reminders. The client is used to everyone commenting on her weight. Although the client appears thin to others, the client's self-perception is that she needs to lose a little bit of weight. Threats should not be used in any circumstance.

The parents of a 6-year-old boy tell the nurse in the pediatric clinic that their son has recently started to wet the bed at night. What is the most helpful response by the nurse? "How's your son doing in school?" "Have there been any changes in his life recently?" "You should arrange to see the doctor, because there may be a physical problem." "When children are angry at their parents, they may use bed-wetting to punish them."

The collection of more information is essential before the nurse can intervene further. Asking a general question opens the lines of communication. Asking specifically about school might be appropriate later in the discussion. Suggesting a medical consultation is premature; more information is needed. Enuresis is usually not a behavioral response precipitated by anger; this statement may cause the parents to feel guilty or become defensive.

Opiate withdrawal syndrome

The nurse observes that 12 hours after birth the neonate is hyperactive and jittery, sneezes frequently, has a high-pitched cry, and is having difficulty suckling. Further assessment reveals increased deep tendon reflexes and a diminished Moro reflex. What problem does the nurse suspect?

After a week on the mental health unit, a client with the diagnosis of paranoid schizophrenia continues to say, "They're trying to kill me. They all are." What is the best response by the nurse? "We're here to protect you." "No one wants to hurt anyone." "You're having very frightening thoughts." "Tell me more about their wanting to kill you."

The observation that the client is experiencing frightening thoughts is a reflection of the client's feelings; it leaves the line of communication open. Telling the client that the staff is there to protect the client does not provide security, because the client may believe that the nurse is one of the people plotting. Telling the client that no one wants to hurt anyone discounts the client's thoughts and may increase the agitation. Asking the client to detail the plot supports the client's delusion.

A client is admitted to the hospital after having a tonic-clonic seizure. The client has a two-year history of a seizure disorder, but the seizures have been well controlled by phenytoin for the last six months. The client says to the nurse, "I am so upset. I didn't think I was going to have more seizures." Which is the best response by the nurse? "Did you forget to take your medication?" "You are worried about having more seizures?" "You must be under a lot of stress right now." "Don't be too concerned

The response "You are worried about having more seizures?" addresses the client's feelings and encourages communication. The question "Did you forget to take your medication?" sounds accusatory; it ignores the client's feelings and discourages communication. Although the statement "You must be under a lot of stress right now" may be true, it does not encourage further communication concerning the seizure. The statement "Don't be too concerned because your medication needs to be increased" negates the client's feelings and discourages communication.

A nurse stops by the room of a newly admitted depressed client and offers to walk with the tearful client to the evening meal. The client looks intently at the nurse but says nothing. What is the best response by the nurse? "I'll be at the desk if you need me." "You must tell me what you're feeling now." "We'll walk together to dinner when you calm down." "It must be very difficult for you to be on a psychiatric unit."

The statement "It must be very difficult for you to be on a psychiatric unit" lets the client know that the nurse realizes that the client is having difficulty without asking direct questions or focusing on specific behavior. The response "I'll be at the desk if you need me" connotes avoidance. Saying "You must tell me what you're feeling now" sounds more like an order than an opportunity to express feelings. Saying "We'll walk together to dinner when you calm down" negates the client's feelings. The nurse should talk to the client without any expectation that the client will "calm down."

As depression begins to lift, a client is asked to join a small discussion group that meets every evening on the unit. The client is reluctant to join and says, "I have nothing to talk about." What is the best response by the nurse? "Maybe tomorrow you'll feel more like talking." "Could you start off by talking about your family?" "A person like you has a great deal to offer the group." "You feel you won't be accepted unless you have something to say?"

The statement about the client's feelings of acceptance is a reflective statement that allows the client to either validate the statement or correct the nurse. Postponing the conversation delays addressing the problem and avoids exploring feelings. Asking the client to start talking about her or his family is a response that gives advice and does not allow the client to explore feelings. Stating that the client has a lot to offer the group denies the client's statement and does not allow the exploration of feelings.

The nurse as a leader provides feedback to a newly recruited nursing student after checking the student's progress report. Which action of the registered nurse is most closely aligned with the application of two-factor theory during the feedback session? Creating enthusiasm for practice Ignoring negative behaviors of the student nurse Promoting job enrichment by creating job satisfaction Providing specific feedback about positive performance

The two-factor theory of leadership indicates that motivating factors such as promoting job enrichment by creating job satisfaction inspire the work performance of the staff. Creating enthusiasm for staff practice characterizes the transformational theory of leadership. Ignoring the negative behaviors of student nurses indicates an application of the Organizational Behavior Modification theory of leadership. Providing specific feedback about positive performance indicates the application of the Expectancy theory of leadership.

Immature liver function

Three days after birth, a breastfeeding newborn becomes jaundiced. The parents bring the infant to the clinic and blood is drawn for an indirect serum bilirubin determination, which reveals a concentration of 12 mg/dL. The nurse explains that what the infant has is physiological jaundice, a benign condition, caused by:

A nurse working in the health services center of a college is reviewing the vaccination records of a young adult who plans to enroll. Which immunizations are required to meet admission criteria according to the American Academy of Pediatrics?

Three doses of diphtheria toxoid and oral poliomyelitis vaccine, and one dose of live measles, live rubella, and mumps vaccine.

A nurse is caring for a client who has been taking several antibiotic medications for a prolonged time. Because long-term use of antibiotics interferes with the absorption of fat, the nurse anticipates a prescription for:

Water-soluble forms of vitamins A and E

A client's sputum smears for acid-fast bacilli (AFB) are positive, and transmission-based airborne precautions are prescribed. What should the nurse teach visitors to do?

Wear a particulate respirator mask

Barely visible areolae and nipples

What characteristic does the nurse anticipate in an infant born at 32 weeks' gestation?

Protruding tongue Hypotonic muscle tone Broad nose with a depressed bridge

What clinical findings does the nurse expect to observe in a newborn with trisomy 21 (Down syndrome)? (Select all that apply.)

They have a tendency to collapse with each breath.

What does the nurse expect concerning the alveoli in the lungs of a 28-week-gestation neonate?

Keeping the infant in a warm environment

What nursing care is most important for a newborn with respiratory distress syndrome (RDS)?

Protecting the skin surrounding the exposed bladder

What should be included in the teaching plan for the mother of a newborn with exstrophy of the bladder?

Learning specific behaviors involving states of wakefulness to promote positive interactions

What should the nurse discuss with new parents to help them prepare for infant care?

Help the parents stimulate their awake baby through touch, sound, and sight

What should the nurse do to enhance a neonate's behavioral development?

Expected movements and behaviors

What should the nurse's initial discussion include to best help new parents understand the unique characteristics of a newborn?

Avoid squeezing them and don't try to wash them off.

When a nurse brings a newborn to a mother, the mother comments about the milia on her infant's face. What information should the nurse include when responding?

Having the visitor step outside the room

When a nurse who is carrying a newborn to the mother enters the room, a visitor asks to hold the infant. The visitor is sneezing and coughing. What is the most important measure for the nurse to take?

Mucous membranes of the mouth

Where is the best area for the nurse to determine adequate tissue oxygenation in a neonate born of black parents?

Small breast buds Wrinkled thin skin Pinnae that remain flat when folded

Which characteristics should alert the nurse to conclude that a male newborn is a preterm infant? (Select all that apply.)

Face Trunk Buttocks

Which parts of a newborn's body are usually affected by the rash erythema toxicum neonatorum? Select all that apply.

Numerous superficial veins

Which sign indicates to the nurse that a neonate is preterm?

"Infants' feet appear flat because the arch is covered with a fat pad."

While inspecting her newborn a mother asks the nurse whether her baby has flat feet. How should the nurse respond?

Palliative care

hospice care; taking care of the whole person—body, mind, spirit, heart and soul—with the goal of giving patients with life-threatening illnesses the best quality of life they can have through the aggressive management of symptoms

Objective data

information that is seen, heard, felt, or smelled by an observer; signs

A female client is upset with her diagnosis of gonorrhea and asks the nurse, "What can I do to prevent getting another infection in the future?" The nurse evaluates that the teaching is understood when the client states, "My best protection is to:

insist that my partner use a condom."