NURS 220 -EAQ #3

A child sitting on a chair in a playroom starts to have a tonic-clonic seizure with clenched jaw. what is the best initial action by the nurse?

2. Placing the child on the floor.

Identify the nail with Beau's grooves due to acute, severe illness?

2.

The school nurse presents a class on female reproduction to a group of junior high school girls. Which statement by a student after the class indicates a nee for clarification of the teaching?

2. "Women with big breasts have more milk after they have a baby."

While assessing a client, a nurse finds that the ratio of anteroposterior diameter and transverse diameter of the chest is 1:1. What is indicated by this finding? Select all that apply.

2. Client is an older adult. 4. Client has a history of smoking. 5. Client has chronic lung disease.

A client at 42 weeks' gestation is admitted for a nonstress test. the nurse concludes that this test is being done because of what possible complication related to a prolonged pregnancy?

2. Placental insufficiency

A nursing student is learning about the nursing process, which consists of four components. Which scenarios should the nursing student consider as examples of the feedback component? select all that apply.

1. "The nurse notices that the client's pain has decreased after giving a back massage." 2. "The caregiver says that the client's body temperature has decreased after administering the prescribed medication." 5. "The nurse finds that the client has developed breathing issues after the medication is administered through the central venous access device."

The nurse is assess the clinical data of four clients. Which client's tears contain mucus strands?

1. Dry eye syndrome with reduced tear production.

A nurse employed in an outpatient radiology department is reviewing safety precautions with staff members. What explanation does the nurse provide to explain the reason radium is stored in lead containers?

1. Lead functions as a barrier.

A nurse considers that communication links people with their surroundings. What should the nurse identify as the most important communication link?

1. Social

The nurse is caring for a community-dwelling older adult who is suffering from confusion. Which are the best nursing interventions in this situation? Select all that apply.

1. The nurse should provide a protective environment. 2. The nurse should assist with personal hygiene. 4. The nurse should promote activities that reinforce reality.

A client with a known history of opioid addiction is treated for multiple stab wounds to the abdomen. After surgical repair the nurse notes that the client's pain is not relieved by the prescribed morphine injections. the nurse realizes that the failure to achieve pan relief indicates that the client is probably experiencing what phenomenon.

1. Tolerance

What critical thinking skill is applicable when knowledge and experience is used to care for clients?

3. Explantation.

Which type of client eye disorders are caused by staphylococcus aureus? Select all that apply.

3. Hordeolum 4. Conjunctivitis

What does a nurse recognize as the most serious complication of meningitis in young children?

3. Peripheral circulatory collapse

What is the primary purpose of conducting a cystoscopy in a client with decreased and difficult urination?

3. To ascertain the presence of urethral wall abnormality.

A client reports severe itching with redness and wheals on the uncovered parts of the legs after sleeping in am old bed. The primary healthcare provider prescribes antihistamines and topical corticosteroids. Which assessment finding made by the nurse supports the intervention?

3. Utricaria grouped in threes surrounded by vivid flare, transforming into persistent lesion. Rationale: Bedbugs reside in furniture, bedding, and walls and usually feed during night time. Bedbug bites manifest as urticaria grouped in threes surrounded by vivid flare, transforming into persistent lesion. Severe itching due to bedbug bites is treated with antihistamines or topical corticosteroids. Tick bites manifest as spreading, ring-like rash with erythema border after 3 to 4 weeks and are treated with oral and intravenous antibiotics. Scabies manifest with the presence of burrows with erythematous papules with possible vesiculation and interdigital web crusting. It is treated with 5% permethrin topical lotion. Head lice bites manifest as minute, red, noninflammatory points flush with the skin that progress to papular wheal-like lesions with secondary excoriation in intrascapular region. These bites are treated with γ-benzene hexachloride or pyrethrins.

A depressed client is admitted to the mental health unit. What factor should the nurse consider most important when evaluating the client's current risk for suicide?

4. Impending anniversary of the loss of a loved one.

A combination of drugs, including vincristine and prednisone, is prescribed for a child with leukemia. For which adverse effect of vincristine will the nurse assess the child?

4. Neurologic complications

A client is admitted to the hospital for surgical replacement of the mitral valve with a mechanical valve. Which risk factor would be the primary reason that the nurse must frequently check pulses in the client's legs after surgery?

4. Peripheral thromboembolism.

An adolescent child admitted to a pediatric unit with the tentative diagnosis of acute poststreptococcal glomerulonephritis (APSGN). What diagnostic tests does the nurse expect will be performed to confirm his diagnosis?

4. Serum complement (C3) activity level and urinalysis.