NURS366 Exam 3

9. Which client signs and symptoms indicate contact dermatitis to the nurse? 1. Erythema and oozing vesicles. 2. Pustules and nodule formation. 3. Varicosities and edema. 4. Telangiectasia and flushing.

1. Erythema and oozing vesicles.

While performing passive range of motion for a patient, the nurse puts the ankle joint through the movements of (select all that apply): A: flexion and extension B: inversion and eversion C: pronation and supination D: flexion, extension, abduction, and adduction E: pronation, supination, rotation, and circumduction

A: flexion and extension B: inversion and eversion

A 5-month-old infant is seen in the well-child clinic for a complaint of vomiting and failure to grow. His birth weight was 7 lbs, and he now weighs 8 lbs, 10 oz. The infant's mother reports that he is taking 4-7 oz of formula every 4-5 hrs, but he "spits up a lot after eating and then is hungry again". The child is noted to be alert but appears malnourished. The mother reports his stools are brown in color, and he has 1-2 bowel movements every day. Based on these findings, the nurse anticipates the infant has: A: Meckel diverticulum B: Hypertrophic pyloric stenosis (HPS) C: Intussusception D: Hirschsprung disease

B: Hypertrophic pyloric stenosis (HPS)

The primary function of the skin is: A: Insulation B: Protection C: Sensation D: Absorption

B: Protection

A common site for the lesions associated with atopic dermatitis is the A) buttocks B) temporal area C) antecubital space D) plantar surface of the feet

C) antecubital space

A patient with tendonitis asks what the tendon does. The nurse's response is based on the knowledge that tendons: a. connect bone to muscle. b. provide strength to muscle. c. lubricate joints with synovial fluid. d. relieve friction between moving parts.

a. connect bone to muscle.

Persons with dark skin are more likely to develop: a. keloids b. wrinkles c. skin rashes d. skin cancer

a. keloids

16. The client has been diagnosed with OA for the last seven (7) years and has tried multiple medical treatments and alternative treatments but still has significant joint pain. Which psychosocial client problem should the nurse identify? 1. Severe pain. 2. Body image disturbance. 3. Knowledge deficit. 4. Depression.

4. Depression. *The client experiencing chronic pain often experiences depression and hopelessness.

5. The nurse is caring for a client diagnosed with GERD. Which nursing interventions should be implemented? 1. Place the client prone in bed and administer nonsteroidal anti-inflammatory medications. 2. Have the client remain upright at all times and walk for 30 minutes three (3) times a week. 3. Instruct the client to maintain a right lateral side-lying position and take antacids before meals. 4. Elevate the head of the bed 30 degrees and discuss lifestyle modifications with the client.

4. Elevate the head of the bed 30 degrees and discuss lifestyle modifications with the client. *The head of the bed should be elevated to allow gravity to help in preventing reflux. Lifestyle modifications of losing weight, making dietary modifications, attempting smoking cessation, discontinuing the use of alcohol, and not stooping or bending at the waist all help to decrease reflux.

17. Which should the nurse include in the plan of care to decrease symptoms of gastroesophageal reflux (GER) in a 2-month-old? Select all that apply. 1. Place the infant in an infant seat immediately after feedings. 2. Place the infant in the prone position immediately after feeding to decrease the risk of aspiration. 3. Encourage the parents not to worry because most infants outgrow GER within the first year of life. 4. Encourage the parents to hold the infant in an upright position for 30 minutes following a feeding. 5. Suggest that the parents burp the infant after every 1-2 ounces consumed.

4. Encourage the parents to hold the infant in an upright position for 30 minutes following a feeding. 5. Suggest that the parents burp the infant after every 1-2 ounces consumed. *Keeping the infant in an upright position is the best way to decrease the symptoms of GER. The infant can also be placed in the supine position with the head of the crib elevated. A harness can be used to keep the child from sliding down. *Burping the infant frequently may help decrease spitting up by expelling air from the stomach more often.

35. The nurse is developing a plan of care for a child recently diagnosed with cerebral palsy (CP). Which should be the nurse's priority goal? 1. Ensure the ingestion of sufficient calories for growth. 2. Decrease intracranial pressure. 3. Teach appropriate parenting strategies for a special-needs child. 4. Ensure that the child reaches full potential.

4. Ensure that the child reaches full potential.

50. The nurse is teaching the client diagnosed with diverticulosis. Which instruction should the nurse include in the teaching session? 1. Discuss the importance of drinking 1,000 mL of water daily. 2. Instruct the client to exercise at least three (3) times a week. 3. Teach the client about a eating a low-residue diet. 4. Explain the need to have daily bowel movements.

4. Explain the need to have daily bowel movements.

52. The nurse is teaching the parent of a child newly diagnosed with juvenile idiopathic arthritis (JIA). The nurse would evaluate the teaching as successful when the parent is able to say that the disorder is caused by the: 1. Breakdown of osteoclasts in the joint space causing bone loss. 2. Loss of cartilage in the joints. 3. Build-up of calcium crystals in joint spaces. 4. Immune-stimulated inflammatory response in the joint.

4. Immune-stimulated inflammatory response in the joint.

8. Which discharge instruction should the nurse discuss with the client to prevent recurrent episodes of cellulitis? 1. Soak your feet daily in Epsom salts for 20 minutes. 2. Wear thick white socks when working in the yard. 3. Use a mosquito repellant when going outside. 4. Inspect the feet between the toes for cracks in the skin.

4. Inspect the feet between the toes for cracks in the skin.

Which statement most accurately describes child abuse? 1. Intentional physical abuse and neglect. 2. Intentional and unintentional physical and emotional abuse and neglect. 3. Sexual abuse of children, usually by an adult. 4. Intentional physical, emotional, and sexual abuse and neglect.

4. Intentional physical, emotional, and sexual abuse and neglect.

21. The client diagnosed with IBD is prescribed sulfasalazine (Asulfidine), a sulfonamide antibiotic. Which statement best describes the rationale for administering this medication? 1. It is administered rectally to help decrease colon inflammation. 2. This medication slows gastrointestinal motility and reduces diarrhea. 3. This medication kills the bacteria causing the exacerbation. 4. It acts topically on the colon mucosa to decrease inflammation.

4. It acts topically on the colon mucosa to decrease inflammation. *Asulfidine is poorly absorbed from the gastrointestinal tract and acts topically on the colonic mucosa to inhibit the inflammatory process.

64. Which is the nurse's best explanation to the parent of a toddler who asks what a greenstick fracture is? 1. It is a fracture located in the growth plate of the bone. 2. Because children's bones are not fully developed, any fracture in a young child is called a greenstick fracture. 3. It is a fracture in which a complete break occurs in the bone, and small pieces of bone are broken off. 4. It is a fracture that does not go all the way through the bone.

4. It is a fracture that does not go all the way through the bone.

68. Which outcome should the nurse identify for the client scheduled to have a cholecystectomy? 1. Decreased pain management. 2. Ambulate first day postoperative. 3. No break in skin integrity. 4. Knowledge of postoperative care.

4. Knowledge of postoperative care.

7. Which foods would be best for a child with Duchenne muscular dystrophy? 1. High-carbohydrate, high-protein foods. 2. No special food combinations. 3. Extra protein to help strengthen muscles. 4. Low-calorie foods to prevent weight gain.

4. Low-calorie foods to prevent weight gain. *As the child becomes less ambulatory, moving the child will become more of a problem. It is not good for the child to become overweight for several health rea- sons in addition to decreased ambulation.

33. Which should the nurse prepare the parents of an infant for following surgical repair and closure of a myelomeningocele shortly after birth? The infant will: 1. Not need any long-term management and should be considered cured. 2. Not be at risk for urinary tract infections or movement problems. 3. Have continual drainage of cerebrospinal fluid, needing frequent dressing changes. 4. Need lifelong management of urinary, orthopedic, and neurological problems.

4. Need lifelong management of urinary, orthopedic, and neurological problems. *Although immediate surgical repair decreases infection, morbidity, and mortality rates, these children will require lifelong management of neurological, orthopedic, and elimination problems.

17. The client diagnosed with OA is prescribed a nonsteroidal anti-inflammatory drug (NSAID). Which instruction should the nurse teach the client? 1. Take the medication on an empty stomach. 2. Make sure to taper the medication when discontinuing. 3. Apply the medication topically over the affected joints. 4. Notify the health-care provider if vomiting blood.

4. Notify the health-care provider if vomiting blood. *NSAIDs are well known for causing gastric upset and increasing the risk for peptic ulcer disease, which could cause the client to vomit blood.

135. The client has been experiencing difficulty and straining when expelling feces. Which intervention should the nurse discuss with the client? 1. Explain some blood in the stool will be normal for the client. 2. Instruct the client in manual removal of feces. 3. Encourage the client to use a cathartic laxative on a daily basis. 4. Place the client on a high-fiber diet.

4. Place the client on a high-fiber diet. *A high-fiber (residue) diet provides bulk for the colon to use in removing the waste products of metabolism. Bulk laxatives and fiber from vegetables and bran assist the colon to work more effectively.

59. The nurse is instructing the parent of a child with HIV about immunizations. Which of the following should the nurse tell the parent? 1. Hepatitis B vaccine will not be given to this child. 2. Members of the family should be cautioned not to receive the varicella vaccine. 3. The child will need to have a Western blot test done prior to all immunizations. 4. Pneumococcal and influenza vaccines are recommended.

4. Pneumococcal and influenza vaccines are recommended.

31. A 15-year-old with spina bifida is seen in the clinic for a well-child checkup. The teen uses leg braces and crutches to ambulate. Which nursing diagnosis takes priority? 1. Potential for infection. 2. Alteration in mobility. 3. Alteration in elimination. 4. Potential body image disturbance.

4. Potential body image disturbance.

29. Which problems should the nurse include in the plan of care for the client diagnosed with peptic ulcer disease to observe for physiological complications? 1. Alteration in bowel elimination patterns. 2. Knowledge deficit in the causes of ulcers. 3. Inability to cope with changing family roles. 4. Potential for alteration in gastric emptying.

4. Potential for alteration in gastric emptying. *Potential for alteration in gastric emptying is caused by edema or scarring associated with an ulcer, which may cause a feeling of "fullness," vomiting of undigested food, or abdominal distention.

49. The nurse will soon receive a 4-month-old who has been diagnosed with intussuscep- tion. The infant is described as very lethargic with the following vital signs: T 101.8°F (38.7°C), HR 181, BP 68/38. The reporting nurse states the infant's abdomen is very rigid. Which is the most appropriate action for the receiving nurse? 1. Prepare to accompany the infant to a computed tomography scan to confirm the diagnosis. 2. Prepare to accompany the infant to the radiology department for a reducing enema. 3. Prepare to start a second intravenous line to administer fluids and antibiotics. 4. Prepare to get the infant ready for immediate surgical correction.

4. Prepare to get the infant ready for immediate surgical correction. *Intussusception with peritonitis is a surgical emergency, so preparing the infant for surgery is the nurse's top priority.

34. The 84-year-old client is a resident in a long-term care facility. Which intervention should be implemented to help prevent complications secondary to osteoporosis? 1. Keep the bed in the high position. 2. Perform passive range-of-motion exercises. 3. Turn the client every two (2) hours. 4. Provide nighttime lights in the room.

4. Provide nighttime lights in the room. *Nighttime lights will help prevent the client from falling; fractures are the number-one complication of osteoporosis.

75. The client diagnosed with end-stage liver failure is admitted with hepatic encephalopathy. Which dietary restriction should be implemented by the nurse to address this complication? 1. Restrict sodium intake to 2 g/day. 2. Limit oral fluids to 1,500 mL/day. 3. Decrease the daily fat intake. 4. Reduce protein intake to 60 to 80 g/day.

4. Reduce protein intake to 60 to 80 g/day. *Ammonia is a by-product of protein metabolism and contributes to hepatic encephalopathy. Reducing protein intake should decrease ammonia levels.

61. The client is four (4) hours postoperative open cholecystectomy. Which data warrant immediate intervention by the nurse? 1. Absent bowel sounds in all four (4) quadrants. 2. The T-tube has 60 mL of green drainage. 3. Urine output of 100 mL in the past three (3) hours. 4. Refusal to turn, deep breathe, and cough.

4. Refusal to turn, deep breathe, and cough. *Refusing to turn, deep breathe, and cough places the client at risk for pneumonia. This client needs immediate intervention to prevent complications.

50. The nurse is preparing the plan of care for the client with a closed fracture of the right arm. Which problem is most appropriate for the nurse to identify? 1. Risk for ineffective coping related to the inability to perform ADLs. 2. Risk for compartment syndrome-related injured muscle tissue. 3. Risk for infection related to exposed bone and tissue. 4. Risk for complications related to compromised neurovascular status.

4. Risk for complications related to compromised neurovascular status. *Assessing and preventing complica- tions related to the neurovascular compromise is the most appropriate intervention because, if there are no complications, a closed fracture should heal without problems.

61. The nurse is preparing the preoperative client for a total hip replacement (THR). Which intervention should the nursing implement postoperatively? 1. Keep an abduction pillow in place between the legs at all times. 2. Cough and deep breathe at least every four (4) to five (5) hours. 3. Turn to both sides every two (2) hours to prevent pressure ulcers. 4. Sit in a high-seated chair for a flexion of less than 90 degrees.

4. Sit in a high-seated chair for a flexion of less than 90 degrees. *Using a high-seated toilet and chair will help prevent dislocation by limiting the flexion to less than 90 degrees.

39. Which should be the nurse's immediate action when a newborn begins to cough and choke and becomes cyanotic while feeding? 1. Inform the physician of the situation. 2. Have the mother stop feeding the infant, and observe to see if the choking episode resolves on its own. 3. Immediately determine the infant's oxygen saturation, and have the mother stop feeding the infant. 4. Take the infant from the mother, and administer blow-by oxygen while obtaining the infant's oxygen saturation.

4. Take the infant from the mother, and administer blow-by oxygen while obtaining the infant's oxygen saturation.

Which approach should the nurse use to gather information from a child brought to the ED for suspected child abuse? 1. Promise the child that her parents will not know what she tells the nurse. 2. Promise the child that she will not have to see the suspected abuser again. 3. Use correct anatomical terms to discuss body parts. 4. Tell the child that the abuse is not her fault and that she is a good person.

4. Tell the child that the abuse is not her fault and that she is a good person.

24. The nurse and an unlicensed assistive personnel (UAP) are caring for a client with a stage IV pressure ulcer. Which action by the UAP warrants intervention by the nurse? 1. The UAP turns the client every two (2) hours. 2. The UAP keeps the sheets wrinkle free. 3. The UAP encourages the client to drink high-protein drinks. 4. The UAP places multiple diapers on the client.

4. The UAP places multiple diapers on the client.

66. The nurse is caring for the client who has had a total hip replacement. Which data indicate the surgical treatment is effective? 1. The client states the pain is at a "3" on a 1-to-10 scale. 2. The client has a limited ability to ambulate. 3. The client's left leg is shorter than the right leg. 4. The client ambulates to the bathroom.

4. The client ambulates to the bathroom. *The hip should have functional motion and client should be able to ambulate to the bathroom. This indicates surgical treatment has been effective.

141. The client is placed on percutaneous endoscopic gastrostomy (PEG) tube feedings. Which occurrence warrants immediate intervention by the nurse? 1. The client tolerates the feedings being infused at 50 mL/hr. 2. The client pulls the nasogastric feeding tube out. 3. The client complains of being thirsty. 4. The client has green, watery stool.

4. The client has green, watery stool. *This client needs to be cleaned immediately, the abdomen must be assessed, and a determination must be made regarding the type of feeding and the additives and medications being administered and skin damage occurring. This occurrence is priority.

32. The client newly diagnosed with osteoporosis is prescribed calcitonin by nasal spray. Which assessment data indicate to the nurse an adverse effect of the medication? 1. The client complains of nausea and vomiting. 2. The client is drinking two (2) glasses of milk a day. 3. The client has a runny nose and nasal itching. 4. The client has had numerous episodes of nosebleeds.

4. The client has had numerous episodes of nosebleeds.

40. The client is admitted to the medical floor diagnosed with cellulitis of the left arm. Which assessment data would warrant immediate intervention by the nurse? 1. The client has bilaterally weak radial pulses. 2. The client is able to move the left fingers. 3. The client has a CRT less than 3 seconds. 4. The client is unable to remove the wedding ring.

4. The client is unable to remove the wedding ring.

55. The client with viral skin lesions is experiencing pruritus. Which statement would be an appropriate long-term goal? 1. The client will refrain from scratching the skin. 2. The client will maintain intact skin integrity. 3. The client will have relief from itching. 4. The client will not develop a secondary bacterial infection.

4. The client will not develop a secondary bacterial infection.

28. Which client is at the greatest risk for the development of skin cancer? 1. The African American male who lives in the northeast. 2. The elderly Hispanic female who moved from Mexico as a child. 3. The client who has a family history of basal cell carcinoma. 4. The client with fair complexion who cannot get a tan.

4. The client with fair complexion who cannot get a tan.

18. The wound care nurse documented a client's pressure ulcers on admission as 3.3 cm × 4.0 cm stage II on the coccyx. Which information would alert the nurse that the client's pressure ulcer is getting worse? 1. The skin is not broken and is 2.5 cm × 3.5 cm with erythema that does not blanch. 2. There is a 3.2-cm × 4.1-cm blister that is red and drains occasionally. 3. The skin covering the coccyx is intact but the client complains of pain in the area. 4. The coccyx wound extends to the subcutaneous layer and there is drainage.

4. The coccyx wound extends to the subcutaneous layer and there is drainage.

68. The client who had a total knee replacement is being discharged home. To which multidisciplinary team member should the nurse refer the client? 1. The occupational therapist. 2. The physiatrist. 3. The recreational therapist. 4. The home health nurse.

4. The home health nurse. *The home health care nurse will be able to assess the client in the home and make further referrals if necessary.

67. The nurse is caring for a client six (6) hours postoperative right total knee replacement. Which data should the nurse report to the surgeon? 1. A total of 100 mL of red drainage in the autotransfusion drainage system. 2. Pain relief after using the patient-controlled analgesia (PCA) pump. 3. Cool toes, distal pulses palpable, and pale nailbeds bilaterally. 4. Urinary output of 60 mL of clear yellow urine in three (3) hours.

4. Urinary output of 60 mL of clear yellow urine in three (3) hours. *The urinary output is not adequate; therefore, the surgeon needs to be notified. This is only 20 mL/hr. The minimum should be 30 mL/hr.

5. Which can elicit the Gower sign? Have the patient: 1. Close the eyes and touch the nose with alternating index fingers. 2. Hop on one foot and then the other. 3. Bend from the waist to touch the toes. 4. Walk like a duck and rise from a squatting position.

4. Walk like a duck and rise from a squatting position. *Children with muscular dystrophy display the Gower sign, which is great difficulty rising and standing from a squatting position due to the lack of muscle strength.

Before assisting a patient after a THA with ambulation on POD #1 , which action is most important for the nurse to take? A. Administer the ordered opioid pain medication. B. Instruct the patient about the benefits of stool softeners. C. Ensure that the incisional drain has been discontinued. D. Change the hip dressing and document the wound appearance.

A. Administer the ordered opioid pain medication. *The patient should be adequately medicated for pain before any attempt to ambulate. Instructions about the benefits of ambulation may increase the patient's willingness to ambulate, but decreasing pain with ambulation is more important. The presence of an incisional drain or timing of dressing change will not affect ambulation.

A 32-year-old patient who has had an open reduction and internal fixation (ORIF) of left lower leg fractures continues to complain of severe pain in the leg 15 minutes after receiving the prescribed IV morphine. Pulses are faintly palpable and the foot is cool. Which action should the nurse take next? A. Notify the health care provider. B. Assess the incision for redness. C. Reposition the left leg on pillows. D. Check the patient's blood pressure.

A. Notify the health care provider.

The nurse assess the patient's skin lesions as firm, edematous, irregularly shaped with a variable diameter. They would be called: A: Wheals B: Papules C: Pustules D: Plaques

A: Wheals

A patient with a pelvic fracture should be monitored for: A: changes in urine output B: petechiae on the abdomen C: a palpable lump in the buttock D: sudden increase in BP

A: changes in urine output

A patient with a humeral fracture is returning for a 4-week checkup. The nurse explains that initial evidence of healing on x-ray is indicated by: A: formation of callus B: complete bony union C: hematoma at the fracture site D: presence of granulation tissue

A: formation of callus

Because many children with celiac disease require parenteral nutrition therapy, they are at risk for which of the following nutritional deficiencies when the PN is discontinued? Select all that apply: A: iron deficiency anemia B: folic acid deficiency C: zinc deficiency D: vitamin A, D, E, K deficiency E: vitamin B12 deficiency

A: iron deficiency anemia B: folic acid deficiency D: vitamin A, D, E, K deficiency

The potential physiologic and psychologic effects of prolonged immobilization on a 9-year-old child who has experienced significant trauma in a motor vehicle crash include which of the following? (select all that apply): A: orthostatic intolerance B: DVT C: pressure ulcer formation D: pneumonia E: diarrhea F: kidney stones G: sense of euphoria and elation H: constipation

A: orthostatic intolerance B: DVT C: pressure ulcer formation D: pneumonia F: kidney stones H: constipation

Which safe sun practices would the nurse include in the teaching care plan for a patient who has photosensitivity (select all that apply)? A: wear protective clothing B: apply sunscreen liberally and often C: emphasize short-term use of a tanning booth D: avoid exposure to the sun, especially during midday E: wear any sunscreen as long as it is purchased at a drugstore

A: wear protective clothing B: apply sunscreen liberally and often D: avoid exposure to the sun, especially during midday

A patient with osteomyelitis undergoes surgical debridement with implantation of antibiotic beads. When the patient asks why the beads are used, the nurse answers (select all that apply): A: "oral or IV antibiotics are not effective in most cases of bone infection" B: "the beads are an adjunct to debridement and antibiotics for deep infections" C: "the beads are used to deliver antibiotics directly to the site of the infection" D: "this is the safest method to deliver long-term antibiotic therapy for bone infection" E: "ischemia and bone death related to osteomyelitis are impenetrable to IV antibiotics"

B: "the beads are an adjunct to debridement and antibiotics for deep infections" C: "the beads are used to deliver antibiotics directly to the site of the infection"

When assessing a child's injury if the ED, a nurse suspects physical abuse. Based on this suspicion, the nurse's primary legal responsibility is: A: Assist the family in identifying resources for support B: Report the case in which the abuse is suspected to the local authorities C: Document the child's physical assessment findings accurately and thoroughly D: Refer the family to the hospital support group

B: Report the case in which the abuse is suspected to the local authorities

Age-related changes in the hair and nails include (select all that apply): A: Oily scalp B: Scaly scalp C: Thinner nails D: Thicker, brittle nails E: Longitudinal nail ridging

B: Scaly scalp D: Thicker, brittle nails E: Longitudinal nail ridging

The nurse determines that a patient with a diagnosis of which disorder is most at risk for spreading the disease? A: tine pedia B: impetigo on the face C: candidiasis of the nails D: psoriasis on the palms and soles

B: impetigo on the face

A patient is scheduled for an electromyogram (EMG). The nurse explains that this diagnostic test involves: A: incision or puncture of the joint capsule B: insertion of small needles into certain muscles C: administration of a radioisotope before the procedure D: placement of skin electrodes to record muscle activity

B: insertion of small needles into certain muscles

During the assessment of a patient, you note an area of red, sharply defined plaques covered with silvery scales that are mildly itchy on the patient's knees and elbows. You recognize this finding as: A: lentigo B: psoriasis C: actinic keratosis D: seborrheic keratosis

B: psoriasis

A patient with osteoarthritis is scheduled for a total hip arthroplasty. The nurse explains the purpose of this procedure is to (select all that apply): A: fuse the joint B: replace the joint C: prevent further damage D: improve or maintain ROM E: decrease the amount of destruction at the joint

B: replace the joint D: improve or maintain ROM

What is important to include in the teaching plan for a patient with osteopenia? A: lose weight B: stop smoking C: eat a high-protein diet D: start swimming for exercise

B: stop smoking

The nurse caring for a 4-month-old infant with biliary atresia (BA) and significant urticaria can anticipate: A: diphenhydramine B: ursodiol C: loratidine D: ranitidine (zantac)

B: ursodiol

Which action could inhibit the goal of obtaining 90° flexion after TKA? A. Placing a pillow under the knee while in bed B. Using CPM 6-8 hours/day C. Keeping HOB to 15° while using CPM in bed D. Starting the flexion at low levels and work upwards

C. Keeping HOB to 15° while using CPM in bed

Which discharge instruction will the emergency department nurse include for a patient with a sprained ankle? A. Keep the ankle loosely wrapped with gauze. B. Apply a heating pad to reduce muscle spasms. C. Use pillows to elevate the ankle above the heart. D. Gently move the ankle through the range of motion.

C. Use pillows to elevate the ankle above the heart.

While obtaining subjective assessment data related to the musculoskeletal system, the nurse must ask a patient about other medical problems such as: A: HTN B: thyroid problems C: DM D: chronic bronchitis

C: DM

The bone cells that function in the resorption of bone tissue are called: A: Osteoids B: Osteocytes C: Osteoclasts D: Osteoblasts

C: Osteoclasts

Nursing care of a child in the hospital with suspected abuse should include: A: Assign a variety of nurses to the child so that he can get to know and trust the whole staff B: Praise the child's ability to minimize feelings of shame and guilt C: Treat the child as someone with a specific problem, not as an "abuse" victim, to promote self-esteem and minimize feelings of guilt D: Talk with and ask question as often as possible to show interest and get to know the child better

C: Treat the child as someone with a specific problem, not as an "abuse" victim, to promote self-esteem and minimize feelings of guilt

The nurse suspects a neuromuscular problem based on assessment of: A: exaggerated strength with movement B: increased redness and heat below the injury C: decreased sensation distal to the fracture site D: purulent drainage at the site of an open fracture

C: decreased sensation distal to the fracture site

A 16-month-old has a history of diarrhea for 3 days with poor oral intake. He received IV fluids, has tolerated some oral fluids in the ED, and is being discharged home. Instructions for diet for this child should include: A: BRAT (bananas, rice, applesauce, and toast) diet for 24 hrs, then a soft diet as tolerated B: chicken or beef broth for 24 hrs, then resume a soft diet C: offer a regular diet as child's appetite warrants D: keep on clear liquids and toast for 24 hrs

C: offer a regular diet as child's appetite warrants

A 2-day-old infant in the newborn nursery is diagnosed with developmental dysplasia of the hip (DDH), and treatment is started by the orthopedist. The nurse assists the parents by providing home care instructions that include: A: return to the orthopedist's office in 2 weeks to remove the hip spica cast B: the infant's bilateral foot casts should be elevated on pillows as much as possible C: remove the Pavlik harness once a day for no more than 2 hrs and inspect skin D: remove the Pavlik harness while the infant is awake to allow "tummy time"

C: remove the Pavlik harness once a day for no more than 2 hrs and inspect skin

A normal assessment finding of the musculoskeletal system is: a. no deformity or crepitation. b. muscle and bone strength of 4. c. ulnar deviation and subluxation. d. angulation of bone toward midline.

a. no deformity or crepitation.

To prevent muscle atrophy, the nurse teaches the patient with a leg immobilized in traction to perform (select all that apply): a. flexion contractions. b. tetanic contractions. c. isotonic contractions. d. isometric contractions. e. extension contractions.

d. isometric contractions.

Which information about the patient's medications will be of most concern? A. Takes a multivitamin and calcium supplement B. Has migraines that are treated with NSAIDs C. Takes hormone replacement therapy to prevent hot flashes. D. Has asthma and requires frequent therapy with oral steroids

D. Has asthma and requires frequent therapy with oral steroids

What condition can lead to compartment syndrome? A. Prolonged nerve pressure after a crushing injury B. Metabolic acidosis resulting in electrolyte imbalance C. An amputation of an affected limb D. Increased tissue pressure leading to increased capillary perfusion.

D. Increased tissue pressure leading to increased capillary perfusion.

What is the best definition for remodeling of bone? A. older bone is dissolved and eliminated. B. thickening occurs with rapid proliferation of osteoblasts. C. periosteum produces new bone on the outside of the old bone D. existing bone is resorbed and reformed by new bone.

D. existing bone is resorbed and reformed by new bone.

A patient with a comminuted fracture of the tibia is to have and open reduction with internal fixation (ORIF) of the fracture. The nurse explains that ORIF is indicated when: A: the patient is unable to tolerate prolonged immobilization B: the patient cannot tolerate the surgery for a closed reduction C: a temporary cast would be too unstable to provide normal mobility D: adequate alignment cannot be obtained by other nonsurgical methods

D: adequate alignment cannot be obtained by other nonsurgical methods

A 12-year-old who was in an all-terrain vehicle (ATV) accident has a long-leg fiberglass cast on his left leg for a tibia-fibula fracture, He request pain medication at 2 am for pain he rates at a 10/10. The nurse brings the pain meds and notes that he has removed the pillows that kept his leg elevated. He complains of pain in the left foot, and she notes there is 3+ edema in the exposed leg and foot, and she is unable to slip a finger under the cast. The nurse's priority interventions in this situation should include: A: administer the pain med and elevate the child's leg on the pillows B: elevate the leg on the pillows and follow up within 2-3 hrs to see if the edema has decreased C: let the child know that he cannot have any additional pain meds until 6 am D: notify the surgeon of the findings immediately

D: notify the surgeon of the findings immediately

A patient with a stable, closed humeral fracture has a temporary splint with bulky padding applied with an elastic bandage. The nurse notifies the surgeon of possible early compartment syndrome wet the patient experiences: A: increasing edema of the limb B: muscle spasms of the lower arm C: bounding pulse at the fracture site D: pain when passively extending the fingers

D: pain when passively extending the fingers

A patient with suspected disc herniation is experiencing acute pain and muscle spasms. The nurse's responsibility is to: A: encourage total bed rest for several days B: teach principles of back strengthening exercises C: stress the importance of straight-leg raises to decrease pain D: promote use of cold and hot compresses and pain medication

D: promote use of cold and hot compresses and pain medication

A patient with acne vulgaris tells the nurse that she quit her job as a receptionist because she believes her facial appearance is unattractive to customers. The nursing diagnosis that best describes this patient response is: A: ineffective coping r/t lack of social support B: impaired skin integrity r/t presence of lesions C: anxiety r/t lack of knowledge of the disease process D: social isolation r/t decreased activities secondary to fear of rejection

D: social isolation r/t decreased activities secondary to fear of rejection

The nurse suspects and ankle sprain when a patient at the urgent care center describes: A: being hit by another soccer player during a game B: having ankle pain after sprinting around the track C: dropping a 10-lb weight on his lower leg at the health club D: twisting his ankle while running bases during a baseball game

D: twisting his ankle while running bases during a baseball game

13. The nurse is caring for an infant diagnosed with Hirschsprung disease. The mother states she is pregnant with a boy and wants to know if her new baby will likely have the disorder. Select the nurse's best response. 1. "Genetics play a small role in Hirschsprung disease, so there is a chance the baby will develop it as well." 2. "There is no evidence to support a genetic link, so it is very unlikely the baby will also have it." 3. "It is rarely seen in boys, so it is not likely your new baby will have Hirschsprung disease." 4. "Hirschsprung disease is seen only in girls, so your new baby will not be at risk."

1. "Genetics play a small role in Hirschsprung disease, so there is a chance the baby will develop it as well." *There is a genetic component to Hirschsprung disease, so any future siblings are also at risk.

47. The mother of a newborn relates that this is her first child, the baby seems to sleep a lot, and does not cry much. Which question would the nurse ask the mother? 1. "How many ounces of formula does your baby take at each feeding?" 2. "How many bowel movements does your baby have in a day?" 3. "How much sleep do you get every night?" 4. "How long does the baby stay awake at each feeding?"

1. "How many ounces of formula does your baby take at each feeding?" *Babies can lose up to 10% of birth weight but should regain it by 2 weeks of age. Knowing how much the baby eats can help the nurse determine if the infant is receiving adequate nutrition.

22. The client is diagnosed with Crohn's disease, also known as regional enteritis. Which statement by the client supports this diagnosis? 1. "My pain goes away when I have a bowel movement." 2. "I have bright red blood in my stool all the time." 3. "I have episodes of diarrhea and constipation." 4. "My abdomen is hard and rigid and I have a fever."

1. "My pain goes away when I have a bowel movement." *The terminal ileum is the most common site for regional enteritis, which causes right lower quadrant pain that is relieved by defecation.

53. The parent of a child being evaluated for celiac disease asks the nurse why it is important to make dietary changes. Select the nurse's best response. 1. "The body's response to gluten causes damage to the mucosal cells in the intestine, leading to absorption problems." 2. "The body's response to consumption of anything containing gluten is to create special cells called villi, which leads to more diarrhea." 3. "The body's response to gluten causes the intestine to become more porous and hang on to more of the fat-soluble vitamins, leading to vitamin toxicity." 4. "The body's response to gluten causes damage to the mucosal cells, leading to malabsorption of water and hard, constipated stools."

1. "The body's response to gluten causes damage to the mucosal cells in the intestine, leading to absorption problems." *The inability to digest protein leads to an accumulation of an amino acid that is toxic to the mucosal cells and villi, leading to absorption problems.

57. The nurse is teaching the parent of a child diagnosed with systemic lupus erythe- matosus (SLE). The nurse evaluates the teaching as effective when the parent states: 1. "The cause is unknown." 2. "There is no genetic involvement." 3. "Drugs are not a trigger for the illness." 4. "Antibodies improve disease outcome."

1. "The cause is unknown." *SLE is a complex disease; there are many triggers, but how the disease develops is not known.

29. The parent of a child with influenza asks the nurse when the child is most infectious. Which is the nurse's best response? 1. "Twenty-four hours before and after the onset of symptoms." 2. "Twenty-four hours after the onset of symptoms." 3. "One week after the onset of symptoms." 4. "One week before the onset of symptoms."

1. "Twenty-four hours before and after the onset of symptoms." *Influenza is most contagious 24 hours before and 24 hours after onset of symptoms

24. Which would be the nurse's best response if a mother asks if her baby still needs the Hib vaccine because he already had Hib? 1. "Yes, it is recommended that the baby still get the Hib vaccine." 2. "No, if he has had Hib, he will not need to receive the vaccine." 3. "Let me take a nasal swab first; if it is negative, he will receive the Hib vaccine." 4. "The physician will order a blood test, and depending on results, your child may need the vaccine."

1. "Yes, it is recommended that the baby still get the Hib vaccine." *The infant needs the Hib vaccine to ensure protection against many serious infections caused by Hib, such as bacterial meningitis, pneumonia, epiglottitis, sepsis, etc.

23. Which should the nurse include when teaching sexuality education to an adolescent with a spinal cord injury? 1. "You can enjoy a healthy sex life and most likely conceive children." 2. "You will never be able to conceive if you have no genital sensation." 3. "Development of secondary sex characteristics is delayed." 4. "A few females have regular menstrual periods after injury."

1. "You can enjoy a healthy sex life and most likely conceive children." *The reproductive system continues to function properly after a spinal cord injury. Much sexual activity and response occurs in the brain as well.

19. Which should the nurse include in the teaching plan for a child who had surgery to correct bilateral clubfeet and had the casts removed? Select all that apply. 1. "Your child will need to wear a brace on the feet 23 hours a day for at least 2 months." 2. "Your child should see an orthopedic surgeon regularly until the age of 18 years." 3. "Your child will not be able to participate in sports that require a lot of running." 4. "Your child may have a recurrence of clubfoot in a year or more." 5. "Most children treated for clubfeet develop feet that appear and function normally." 6. "Most children treated for clubfeet require surgery at puberty."

1. "Your child will need to wear a brace on the feet 23 hours a day for at least 2 months." 2. "Your child should see an orthopedic surgeon regularly until the age of 18 years." 4. "Your child may have a recurrence of clubfoot in a year or more." 5. "Most children treated for clubfeet develop feet that appear and function normally."

9. The parents of a 12-month-old with HIV are concerned about his receiving routine immunizations. What will the nurse tell them about immunizations? 1. "Your child will not receive routine immunizations today." 2. "Your child will receive the recommended vaccines today 3. "Your child is not severely immunocompromised, but I would still be concerned about his receiving them." 4. "Your child may develop infections if he gets his routine immunizations. Your child will not be immunized today."

1. "Your child will not receive routine immunizations today." *Immunocompromised HIV-infected children should not receive the varicella and MMR live vaccines

47. The nurse receives a call from the mother of a 6-month-old who describes her child as alternately sleepy and fussy. She states that her infant vomited once this morning and had two episodes of diarrhea. The last episode contained mucus and a small amount of blood. She asks the nurse what she should do. Select the nurse's best response. 1. "Your infant will need to have some tests in the emergency room to determine if anything serious is going on." 2. "Try feeding your infant in about 30 minutes; in the event of repeat vomiting, bring the infant to the emergency room for some tests and intravenous rehydration." 3. "Many infants display these symptoms when they develop an allergy to the for- mula they are receiving; try switching to a soy-based formula." 4. "Do not worry about the blood and mucus in the stool; it is not unusual for in- fants to have blood in their stools because their intestines are more sensitive."

1. "Your infant will need to have some tests in the emergency room to determine if anything serious is going on." *The infant is displaying signs of intussusception. This is an emergency that needs to be evaluated to prevent ischemia and perforation.

61. Which child may need extra fluids to prevent dehydration? Select all that apply. 1. 7-day-old receiving phototherapy. 2. 6-month-old with newly diagnosed pyloric stenosis. 3. 2-year-old with pneumonia. 4. 2-year-old with full-thickness burns to the chest, back, and abdomen. 5. 13-year-old who has just started her menses.

1. 7-day-old receiving phototherapy. 2. 6-month-old with newly diagnosed pyloric stenosis. 3. 2-year-old with pneumonia. 4. 2-year-old with full-thickness burns to the chest, back, and abdomen. *The lights in phototherapy increase insensible fluid loss, requiring the nurse to monitor fluid status closely. *The infant with pyloric stenosis is likely to be dehydrated due to persistent vomiting. *A 2-year-old with pneumonia may have increased insensible fluid loss due to tachypnea associated with respiratory illness. The nurse needs to monitor fluid status cautiously because fluid overload can result in increased respiratory distress. 4. The child with a burn experiences extensive extracellular fluid loss and is at great risk for dehydration. The younger child is at greater risk due to greater proportionate body surface area.

21. Which priority item should be placed at the bedside of a newborn with myelomeningocele? 1. A bottle of normal saline. 2. A rectal thermometer. 3. Extra blankets. 4. A blood pressure cuff.

1. A bottle of normal saline. *Before the surgical closure of the sac, the infant is at risk for infection. A sterile dressing is placed over the sac to keep it moist and help prevent it from tearing.

28. Who is at the highest priority to receive the flu vaccine? 1. A healthy 8-month-old who attends day care. 2. A 3-year-old who is undergoing chemotherapy. 3. A 7-year-old who attends public school. 4. An 18-year-old who is living in a college dormitory.

1. A healthy 8-month-old who attends day care. *Children between the ages of 6 and 23 months are at the highest risk for having complications as a result of the flu. Their immune systems are not as developed, so they are at a higher risk for influenza-related hospitalizations

33. Which is an accurate description of a Kasai procedure? 1. A palliative procedure in which the bile duct is attached to a loop of bowel to assist with bile drainage. 2. A curative procedure in which a connection is made between the bile duct and a loop of bowel to assist with bile drainage. 3. A curative procedure in which the bile duct is banded to prevent bile leakage. 4. A palliative procedure in which the bile duct is banded to prevent bile leakage.

1. A palliative procedure in which the bile duct is attached to a loop of bowel to assist with bile drainage. *The Kasai procedure is a palliative procedure in which the bile duct is attached to a loop of bowel to assist with bile drainage.

144. The nurse is caring for clients on a medical unit. Which client information should be brought to the attention of the HCP immediately? 1. A serum sodium of 128 mEq/L in a client diagnosed with obstipation. 2. The client diagnosed with fecal impaction who had two (2) hard formed stools. 3. A serum potassium level of 3.8 mEq/L in a client diagnosed with diarrhea. 4. The client with diarrhea who had two (2) semiliquid stools totaling 300 mL.

1. A serum sodium of 128 mEq/L in a client diagnosed with obstipation. *Normal serum sodium levels are 135 to 152 mEq/L, so the client's 128 mEq/L value requires intervention.

31. Which manifestation would the nurse expect to see in a 4-week-old infant with biliary atresia? 1. Abdominal distention, enlarged liver, enlarged spleen, clay-colored stool, and tea-colored urine. 2. Abdominal distention, multiple bruises, bloody stools, and hematuria. 3. Yellow sclera and skin tones, excessively oily skin, and prolonged bleeding times. 4. No manifestations until the disease has progressed to the advanced stage.

1. Abdominal distention, enlarged liver, enlarged spleen, clay-colored stool, and tea-colored urine. *The infant with biliary atresia usually has an enlarged liver and spleen. The stools appear clay-colored due to the absence of bile pigments. The urine is tea-colored due to the excretion of bile salts.

58. Which should the nurse do for a 6-year-old living in a rural area who is missing school shots and who has sustained a puncture wound? 1. Administer DTaP vaccine 2. Start the child on an antibiotic. 3. Clean the wound with hydrogen peroxide. 4. Send the child to the emergency department.

1. Administer DTaP vaccine

4. A 4-month-old is brought to the emergency department with severe dehydration. The heart rate is 198, and her blood pressure is 68/38. The infant's anterior fontanel is sunken. The nurse notes that the infant does not cry when the intravenous line is inserted. The child's parents state that she has not "held anything down" in 18 hours. The nurse obtains a finger-stick blood sugar of 94. Which would the nurse expect to do immediately? 1. Administer a bolus of normal saline. 2. Administer a bolus of D10W. 3. Administer a bolus of normal saline with 5% dextrose added to the solution. 4. Offer the child an oral rehydrating solution such as Pedialyte.

1. Administer a bolus of normal saline. *Dehydration is corrected with the administration of an isotonic solution, such as normal saline or lactated Ringer solution.

6. The nurse is caring for an adult client diagnosed with GERD. Which condition is the most common comorbid disease associated with GERD? 1. Adult-onset asthma. 2. Pancreatitis. 3. Peptic ulcer disease. 4. Increased gastric emptying.

1. Adult-onset asthma. *Of adult-onset asthma cases, 80% to 90% are caused by gastroesophageal reflux disease (GERD).

37. Which should be included in the plan of care for a 14-month-old whose cleft palate was repaired 12 hours ago? Select all that apply. 1. Allow the infant to have familiar items of comfort such as a favorite stuffed animal and a "sippy" cup. 2. Once liquids have been tolerated, encourage a bland diet such as soup, Jell-O, and saltine crackers. 3. Administer pain medication on a regular schedule, as opposed to an as-needed schedule. 4. Use a Yankauer suction catheter on the infant's mouth to decrease the risk of aspiration of oral secretions. 5. When discharged, remove elbow restraints.

1. Allow the infant to have familiar items of comfort such as a favorite stuffed animal and a "sippy" cup. 3. Administer pain medication on a regular schedule, as opposed to an as-needed schedule. *The child should not be allowed to use anything that creates suction in the mouth, such as pacifiers or straws. "Sippy" cups are acceptable. *Pain medication should be administered regularly to avoid crying, which places stress on the suture line.

70. The charge nurse is monitoring client laboratory values. Which value is expected in the client with cholecystitis who has chronic inflammation? 1. An elevated white blood cell count. 2. A decreased lactate dehydrogenase. 3. An elevated alkaline phosphatase. 4. A decreased direct bilirubin level.

1. An elevated white blood cell count. *The white blood cell count should be elevated in clients with chronic inflammation.

5. Which is the definition of talipes varus? 1. An inversion or bending inward of the foot. 2. An eversion or bending outward of the foot. 3. A high arch of the foot. 4. A low arch (flatfoot) of the foot.

1. An inversion or bending inward of the foot.

2. The nurse is assessing the client diagnosed with psoriasis. Which data would support that diagnosis? 1. Appearance of red, elevated plaques with silvery white scales. 2. A burning, prickling row of vesicles located along the torso. 3. Raised, flesh-colored papules with a rough surface area. 4. An overgrowth of tissue with an excessive amount of collagen.

1. Appearance of red, elevated plaques with silvery white scales.

62. The client two (2) hours postoperative laparoscopic cholecystectomy is complaining of severe pain in the right shoulder. Which nursing intervention should the nurse implement? 1. Apply a heating pad to the abdomen for 15 to 20 minutes. 2. Administer morphine sulfate intravenously after diluting with saline. 3. Contact the surgeon for an order to x-ray the right shoulder. 4. Apply a sling to the right arm, which was injured during surgery.

1. Apply a heating pad to the abdomen for 15 to 20 minutes. *A heating pad should be applied for 15 to 20 minutes to assist the migration of the CO2 used to insufflate the abdomen. Shoulder pain is an expected occurrence.

The mother of a 6-month-old states that since yesterday, the infant cries when anyone touches her arm. Which would be the priority assessment after the airway, breathing, and circulation had been assessed and found stable? 1. Ask the mother if she knows what happened. 2. Assess infant for other signs of potential physical abuse. 3. Prepare for radiological diagnostic studies. 4. Establish intravenous access, and draw blood for diagnostic testing.

1. Ask the mother if she knows what happened.

29. A 13-year-old just returned from surgery for scoliosis. Which nursing intervention(s) is/are appropriate in the first 24 hours? Select all that apply. 1. Assess for pain. 2. Logroll to change positions. 3. Get the teen to the bathroom 12 to 24 hours after surgery. 4. Check neurological status. 5. Monitor blood pressure.

1. Assess for pain. 2. Logroll to change positions. 4. Check neurological status. 5. Monitor blood pressure.

63. Nursing care of a child with a fractured extremity in whom there is suspected compartment syndrome includes which of the following? Select all that apply. 1. Assess pain. 2. Assess pulses. 3. Elevate extremity above the level of the heart. 4. Monitor capillary refill. 5. Provide pain medication as needed.

1. Assess pain. 2. Assess pulses. 4. Monitor capillary refill. 5. Provide pain medication as needed. *Elevating the extremity is important to decrease edema prior to the onset of compartment syndrome. However, once compartment syndrome is suspected, the extremity should be kept at the level of the heart to facilitate arterial and venous flow.

53. The unlicensed assistive personnel (UAP) reports a client with a fractured femur has "globs" floating in the urinal. What intervention should the nurse implement first? 1. Assess the client for dyspnea and altered mental status. 2. Obtain an arterial blood gas and order a portable chest x-ray. 3. Call the HCP for a ventilation/perfusion scan. 4. Instruct the UAP keep the client on strict bedrest.

1. Assess the client for dyspnea and altered mental status. *The nurse should assess the client for signs of hypoxia from a fat embolism, which is what the nurse should anticipate from "globs" in the urine.

49. The client is taken to the emergency department with an injury to the left arm. Which intervention should the nurse implement first? 1. Assess the nailbeds for capillary refill time. 2. Remove the client's clothing from the arm. 3. Call radiology for a STAT x-ray of the extremity. 4. Prepare the client for the application of a cast.

1. Assess the nailbeds for capillary refill time. *The nurse should assess the nailbeds for the capillary refill time. A prolonged time (greater than three [3] seconds) indicates impaired circulation to the extremity.

28. Which physical examination should the nurse implement first when assessing the client diagnosed with peptic ulcer disease? 1. Auscultate the client's bowel sounds in all four quadrants. 2. Palpate the abdominal area for tenderness. 3. Percuss the abdominal borders to identify organs. 4. Assess the tender area progressing to nontender.

1. Auscultate the client's bowel sounds in all four quadrants. *Auscultation should be used prior to palpation or percussion when assessing the abdomen. Manipulation of the abdomen can alter bowel sounds and give false information.

79. The client in end-stage liver failure has vitamin K deficiency. Which interventions should the nurse implement? Select all that apply. 1. Avoid rectal temperatures. 2. Use only a soft toothbrush. 3. Monitor the platelet count. 4. Use small-gauge needles. 5. Assess for asterixis.

1. Avoid rectal temperatures. 2. Use only a soft toothbrush. 3. Monitor the platelet count. 4. Use small-gauge needles. *Vitamin K deficiency causes impaired coagulation; therefore, rectal thermometers should be avoided to prevent bleeding. *Soft-bristle toothbrushes will help prevent bleeding of the gums. *Platelet count, PTT/PT, and INR should be monitored to assess coagulation status. *Injections should be avoided, if at all possible, because the client is unable to clot, but if they are absolutely necessarily, the nurse should use small-gauge needles.

13. The occupational health nurse is teaching a class on the risk factors for developing osteoarthritis (OA). Which is a modifiable risk factor for developing OA? 1. Being overweight. 2. Increasing age. 3. Previous joint damage. 4. Genetic susceptibility.

1. Being overweight. *Obesity is a well-recognized risk factor for the development of OA and it is modifiable because the client can lose weight.

37. The client comes to the emergency department complaining of pain in the left lower leg following a puncture wound from a nail in a board. The left lower leg is reddened with streaks, edematous, and hot to the touch, and the client has a temperature of 100.8 ̊F. Which condition would the nurse suspect the client is experiencing? 1. Cellulitis. 2. Lyme disease. 3. Impetigo. 4. Deep vein thrombosis.

1. Cellulitis.

48. The client comes to the emergency department complaining of pain in the right forearm. The nurse notes a large area of redness and edema over the forearm, and the client has an elevated temperature. Which condition should the nurse suspect? 1. Cellulitis. 2. Intravenous drug abuse. 3. Raynaud's phenomenon. 4. Thromboangiitis obliterans.

1. Cellulitis.

66. Which data should the nurse expect to assess in the client who had an upper gastrointestinal (UGI) series? 1. Chalky white stools. 2. Increased heart rate. 3. A firm hard abdomen. 4. Hyperactive bowel sounds.

1. Chalky white stools. *A UGI series requires the client to swallow barium, which passes through the intestines, making the stools a chalky white color.

136. The client has dark, watery, and shiny-appearing stool. Which intervention should the nurse implement first? 1. Check for a fecal impaction. 2. Encourage the client to drink fluids. 3. Check the chart for sodium and potassium levels. 4. Apply a protective barrier cream to the perianal area.

1. Check for a fecal impaction. *This is a symptom of diarrhea moving around an impaction higher up in the colon. The nurse should assess for an impaction when observing this finding.

17. The client diagnosed with IBD is prescribed total parental nutrition (TPN). Which intervention should the nurse implement? 1. Check the client's glucose level. 2. Administer an oral hypoglycemic. 3. Assess the peripheral intravenous site. 4. Monitor the client's oral food intake.

1. Check the client's glucose level. *TPN is high in dextrose, which is glucose; therefore, the client's blood glucose level must be monitored closely.

13. Why does spinal cord injury without radiographic abnormality sometimes occur in children? 1. Children can suffer momentary severe subluxation and trauma to the spinal cord. 2. The immature spinal column in children does not allow for quality films. 3. The hemorrhaging that occurs with injury obscures radiographic abnormalities. 4. Radiographic abnormalities are not evident because of incomplete ossification of the vertebrae.

1. Children can suffer momentary severe subluxation and trauma to the spinal cord. *Spinal cord injury without radiographic abnormality results from the spinal cord sliding between the vertebrae and then sliding back into place without injury to the bony spine. It is thought to be the result of an immature spinal column that allows for reduction after momentary subluxation.

64. Which signs and symptoms should the nurse report to the health-care provider for the client recovering from an open cholecystectomy? Select all that apply. 1. Clay-colored stools. 2. Yellow-tinted sclera. 3. Amber-colored urine. 4. Wound approximated. 5. Abdominal pain.

1. Clay-colored stools. 2. Yellow-tinted sclera. 5. Abdominal pain. *Clay-colored stools are caused by recurring stricture of the common bile duct, which is a sign of post-cholecystectomy syndrome. *Yellow-tinted sclera and skin indicate residual effects of stricture of the common bile duct, which is a sign of post-cholecystectomy syndrome. *Abdominal pain indicates a residual effect of a stricture of the common bile duct, inflammation, or calculi, which is a sign of post-cholecystectomy syndrome.

17. The paraplegic client is being admitted to a medical unit from home with a stage IV pressure ulcer over the right ischium. Which assessment tool should be completed on admission to the hospital? 1. Complete the Braden Scale. 2. Monitor the client on a Glasgow Coma Scale. 3. Assess for Babinski's sign. 4. Initiate a Brudzinski flow sheet.

1. Complete the Braden Scale.

A 2-month-old infant is brought to the emergency room after experiencing a seizure. The infant appears lethargic with very irregular respirations and periods of apnea. The parents report the baby is no longer interested in feeding and before the seizure, rolled off the couch. What additional testing should the nurse immediately prepare for? 1. Computed tomography (CT) scan of the head and dilation of the eyes. 2. Computed tomography (CT) scan of the head and electroencephalogram (EEG). 3. X-rays of the head. 4. X-rays of all long bones.

1. Computed tomography (CT) scan of the head and dilation of the eyes. *A CT scan of the head will reveal trauma. Dilating the eye is performed to check for retinal hemorrhages that are seen in an infant who has experienced SBS

17. The client comes to the clinic complaining of itching on the left wrist near a wristwatch. The nurse notes an erythematous area along with pruritic vesicles around the left wrist. Which condition should the nurse suspect? 1. Contact dermatitis. 2. Herpes simplex 1. 3. Impetigo. 4. Seborrheic dermatitis.

1. Contact dermatitis.

38. Which developmental milestone should the nurse be concerned about if a 10-month-old could not do it? 1. Crawl. 2. Cruise. 3. Walk. 4. Have a pincer grasp.

1. Crawl. *Most infants are able to crawl unassisted by 8 months.

59. The nurse is assessing a young mother who came to the clinic complaining of sores on her skin. Which assessment data would support that the client has chickenpox? 1. Crops of lesions that have pus and reddened base. 2. Oval scaling lesions that occur on the legs and arms. 3. Severe itching of the scalp with tiny eggs visible. 4. Ringed red lesions on the face, neck, trunk, and extremities.

1. Crops of lesions that have pus and reddened base.

19. The nurse is teaching the client diagnosed with atopic dermatitis. Which information should the nurse include in the teaching? 1. Discuss skin care using hydrating lotions and minimal soap. 2. Tell the client the methods of treating secondary infection. 3. Explain there are no adverse effects to using topical corticosteroids daily. 4. Warn the client inhaled allergens have been linked to exacerbations.

1. Discuss skin care using hydrating lotions and minimal soap.

65. Which interventions should be included in the discharge teaching for a client who had a total hip replacement? Select all that apply. 1. Discuss the client's weight-bearing limits. 2. Request the client demonstrate use of assistive devices. 3. Explain the importance of increasing activity gradually. 4. Instruct the client not to take medication prior to ambulating. 5. Tell the client to ambulate with open-toed house shoes.

1. Discuss the client's weight-bearing limits. 2. Request the client demonstrate use of assistive devices. 3. Explain the importance of increasing activity gradually. *Clients need to understand the amount of weight bearing to prevent injury. *Teaching the safe use of assistive devices is necessary prior to discharge. *Increases in activity should occur slowly to prevent complications.

6. A 5-year-old has been diagnosed with pseudohypertrophic muscular dystrophy. Which nursing intervention would be appropriate? 1. Discuss with the parents the potential need for respiratory support. 2. Explain that this disease is easily treated with medication. 3. Suggest exercises that will limit the use of muscles and prevent fatigue. 4. Assist the parents in finding a nursing facility for future care.

1. Discuss with the parents the potential need for respiratory support. *Muscles become weaker, including those needed for respiration, and a decision will need to be made about whether respiratory support will be provided.

57. The client with acute diverticulitis has a nasogastric tube draining green liquid bile. Which intervention should the nurse implement? 1. Document the findings as normal. 2. Assess the client's bowel sounds. 3. Determine the client's last bowel movement. 4. Insert the N/G tube at least 2 more inches.

1. Document the findings as normal. *Green bile contains hydrochloric acid and should be draining from the N/G tube; therefore, the nurse should take no action and document the findings.

3. Which can occur in untreated developmental dysplasia of the hip (DDH)? Select all that apply. 1. Duck gait. 2. Pain. 3. Osteoarthritis in adulthood. 4. Osteoporosis in adulthood. 5. Increased flexibility of the hip joint in adulthood.

1. Duck gait. 2. Pain. 3. Osteoarthritis in adulthood. *Due to abnormal hip joint function, thepatient's gait is stiff and waddling. *Due to abnormal femoral head placement, the patient may experience pain and decreased flexibility in adulthood. *Due to abnormal femoral head placement, the patient may experience osteoarthritis in the hip joint in adulthood.

33. Which oral medication should the nurse question before administering to the client with peptic ulcer disease? 1. E-mycin, an antibiotic. 2. Prilosec, a proton pump inhibitor. 3. Flagyl, an antimicrobial agent. 4. Tylenol, a nonnarcotic analgesic.

1. E-mycin, an antibiotic. *E-mycin is irritating to stomach, and its use in a client with peptic ulcer disease should be questioned.

58. The nurse is teaching a class on diverticulosis. Which interventions should the nurse discuss when teaching ways to prevent an acute exacerbation of diverticulosis? Select all that apply. 1. Eat a high-fiber diet. 2. Increase fluid intake. 3. Elevate the HOB after eating. 4. Walk 30 minutes a day. 5. Take an antacid every two (2) hours.

1. Eat a high-fiber diet. 2. Increase fluid intake. 4. Walk 30 minutes a day.

62. A 6-year-old involved in a bicycle crash has a spleen injury and a right tibia/fibula fracture that has been casted. Which is/are an early sign(s) of compartment syndrome in this child? Select all that apply. 1. Edema. 2. Numbness. 3. Severe pain. 4. Weak pulse. 5. Anular rash.

1. Edema. 2. Numbness. 4. Weak pulse. *Edema, numbness or tingling, and pain are early signs of compartment syndrome. *A weak pulse is a late sign of compartment syndrome.

31. A 14-year-old with osteogenesis imperfecta (OI) is confined to a wheelchair. Which nursing interventions will promote normal development? Select all that apply. 1. Encourage participation in groups with teens who have disabilities or chronic illness. 2. Encourage decorating the wheelchair with stickers. 3. Encourage transfer of primary care to an adult provider at age 18 years. 4. Allow the teen to view the radiographs. 5. Help the teen set realistic goals for the future. 6. Discourage discussion of sexuality, as the child is not likely to date.

1. Encourage participation in groups with teens who have disabilities or chronic illness. 2. Encourage decorating the wheelchair with stickers. 4. Allow the teen to view the radiographs. 5. Help the teen set realistic goals for the future.

26. The nurse is caring for a client diagnosed with rule-out peptic ulcer disease. Which test confirms this diagnosis? 1. Esophagogastroduodenoscopy. 2. Magnetic resonance imaging. 3. Occult blood test. 4. Gastric acid stimulation.

1. Esophagogastroduodenoscopy. The esophagogastroduodenoscopy (EGD) is an invasive diagnostic test which visualizes the esophagus, stomach, and duodenum to accurately diagnose an ulcer and evaluate the effectiveness of the client's treatment.

103. Which nursing problem is priority for the 76-year-old client diagnosed with gastroenteritis from staphylococcal food poisoning? 1. Fluid volume deficit. 2. Nausea. 3. Risk for aspiration. 4. Impaired urinary elimination.

1. Fluid volume deficit. *Fluid volume deficit secondary to diarrhea is the priority because of the potential for metabolic acidosis and hypokalemia, which are both life threatening, especially in the elderly.

82. The client has end-stage liver failure secondary to alcoholic cirrhosis. Which complication indicates the client is at risk for developing hepatic encephalopathy? 1. Gastrointestinal bleeding. 2. Hypoalbuminemia. 3. Splenomegaly. 4. Hyperaldosteronism.

1. Gastrointestinal bleeding. *Blood in the intestinal tract is digested as a protein, which increases serum ammonia levels and increases the risk of developing hepatic encephalopathy.

56. One nursing diagnosis for juvenile idiopathic arthritis (JIA) is impaired physical mobility. Select all that apply. 1. Give pain medication prior to ambulation. 2. Assist with range-of-motion activities. 3. Encourage the child to eat a high-fat diet. 4. Provide oxygen as necessary. 5. Use nonpharmacological methods, such as heat.

1. Give pain medication prior to ambulation. 2. Assist with range-of-motion activities. 5. Use nonpharmacological methods, such as heat. *Providing pain medication prior to ambulation helps decrease pain during ambulation. *Children with JIA need to do range-of-motion exercises to prevent joint stiffness. *Using nonpharmacological methods such as heat helps with flexibility and pain.

30. A 3-month-old with spina bifida is admitted to the nurse's unit. Which gross motor skills should the nurse assess at this age? 1. Head control. 2. Pincer grasp. 3. Sitting alone. 4. Rolling over.

1. Head control. *A 3-month-old has good head control.

62. The nurse is interviewing the parents of a 6-year-old who has been experiencing constipation. Which could be a causative factor? Select all that apply. 1. Hypothyroidism. 2. Muscular dystrophy. 3. Myelomeningocele. 4. Drinks a lot of milk. 5. Active in sports.

1. Hypothyroidism. 2. Muscular dystrophy. 3. Myelomeningocele. 4. Drinks a lot of milk. *Hypothyroidism can be a causative factor in constipation. *Weakened abdominal muscles can be seen in muscular dystrophy and can lead to constipation. *Myelomeningocele affects the innervation of the rectum and can lead to constipation. 4. Excessive milk consumption can lead to constipation.

4. The nurse is teaching about congenital clubfoot in infants. The nurse evaluates the teaching as successful when the parent states that clubfoot is best treated when? 1. Immediately after diagnosis. 2. At age 4 to 6 months. 3. Prior to walking (age 9 to 12 months). 4. After walking is established (age 15 to 18 months).

1. Immediately after diagnosis. *The best outcomes for clubfoot are seen if casting begins as soon as the diagnosis is made.

43. A child is admitted to the pediatric unit with spastic CP. Which would the nurse expect a child with spastic CP to demonstrate? Select all that apply. 1. Increased deep tendon reflexes. 2. Decreased muscle tone. 3. Scoliosis. 4. Contractures. 5. Scissoring. 6. Good control of posture. 7. Good fine motor skills.

1. Increased deep tendon reflexes. 3. Scoliosis. 4. Contractures. 5. Scissoring.

47. The female teacher comes to the school nurse's office and shows the nurse a rash on her hands. The nurse tells the teacher she has probably contracted impetigo from one of the students. Which intervention should the nurse implement? 1. Instruct the teacher to go to her HCP today. 2. Tell the teacher to wash her hands with soap and water. 3. Encourage the teacher to rub vitamin E oil on the lesions. 4. Explain that the rash will go away in a few days.

1. Instruct the teacher to go to her HCP today.

22. Which would the nurse instruct a parent to apply to treat a pediculosis infestation? 1. Lindane (Kwell) to the scalp, leaving it in place for 4 minutes, and then adding water. 2. Chlorhexidine (Hibiclens) to the scalp with sterile gloves. 3. Terbinafine (Lamisil) as a thin layer to the scalp twice a day. 4. Collagenase (Santyl) to the scalp with cotton applicator.

1. Lindane (Kwell) to the scalp, leaving it in place for 4 minutes, and then adding water.

17. Which symptoms will a child suffering from complete spinal cord injury experience? 1. Loss of motor and sensory function below the level of the injury. 2. Loss of interest in normal activities. 3. Extreme pain below the level of the injury. 4. Loss of some function, with sparing of function below the level of the injury.

1. Loss of motor and sensory function below the level of the injury. *Children with complete spinal cord injury lose motor and sensory function below the level of the injury as a result of interruption of nerve pathways.

38. The nurse is caring for a newborn with esophageal atresia. When reviewing the mother's history, which would the nurse expect to find? 1. Maternal polyhydramnios. 2. Pregnancy lasting more than 38 weeks. 3. Poor nutrition during pregnancy. 4. Alcohol consumption during pregnancy.

1. Maternal polyhydramnios. Maternal polyhydramnios is present because the infant cannot swallow and absorb the amniotic fluid in utero.

139. The client diagnosed with AIDS is experiencing voluminous diarrhea. Which inter- ventions should the nurse implement? Select all that apply. 1. Monitor diarrhea, charting amount, character, and consistency. 2. Assess the client's tissue turgor every day. 3. Encourage the client to drink carbonated soft drinks. 4. Weigh the client daily in the same clothes and at the same time. 5. Assist the client with a warm sitz bath PRN.

1. Monitor diarrhea, charting amount, character, and consistency. 4. Weigh the client daily in the same clothes and at the same time. 5. Assist the client with a warm sitz bath PRN.

128. The client who is morbidly obese has undergone gastric bypass surgery. Which immediate postoperative intervention has the greatest priority? 1. Monitor respiratory status. 2. Weigh the client daily. 3. Teach a healthy diet. 4. Assist in behavior modification.

1. Monitor respiratory status. *The morbidly obese client will have a large abdomen, preventing the lungs from expanding, which predisposes the client to respiratory complications.

69. The nurse is caring for a client with a right total knee repair. Which intervention should the nurse implement? 1. Monitor the continuous passive motion machine. 2. Apply thigh-high TED hose bilaterally. 3. Place the abductor pillow between the legs. 4. Encourage the family to perform ADLs for the client.

1. Monitor the continuous passive motion machine. *The CPM machine is used to ensure the client has adequate range of motion in the knee postoperatively.

37. The parent of a toddler newly diagnosed with cerebral palsy (CP) asks the nurse what caused it. The nurse should answer with which of the following? 1. Most cases are caused by unknown prenatal factors. 2. It is commonly caused by perinatal factors. 3. The exact cause is not known. 4. The exact cause is known in every instance.

1. Most cases are caused by unknown prenatal factors. *At least 80% of cases of CP result from unknown prenatal factors.

9. The mother of a child with Duchenne muscular dystrophy asks the nurse who in the family should have genetic screening. Who should the nurse say must be tested? Select all that apply. 1. Mother 2. Sister. 3. Brother. 4. Aunts and all female cousins. 5. Uncles and all male cousins.

1. Mother 2. Sister. 4. Aunts and all female cousins. *Genetic counseling is important in all inherited diseases. Duchenne muscular dystrophy is inherited as an X-linked recessive trait, meaning the defect is on the X chromosome. Women carry the disease, and males are affected. All female relatives should be tested.

6. The nurse tells the parent that other conditions can be associated with congenital clubfoot. Select all that apply. 1. Myelomeningocele. 2. Cerebral palsy. 3. Diastrophic dwarfism. 4. Breech position in utero. 5. Prematurity. 6. Fetal alcohol syndrome.

1. Myelomeningocele. 2. Cerebral palsy. 3. Diastrophic dwarfism. *There is an association between myelomeningocele and congenital clubfoot. *There is an association between some forms of cerebral palsy and congenital clubfoot. *There is an association between diastrophic dwarfism and congenital clubfoot.

8. Which will help a school-aged child with muscular dystrophy stay active longer? 1. Normal activities, such as swimming. 2. Using a treadmill every day. 3. Several periods of rest every day. 4. Using a wheelchair upon getting tired.

1. Normal activities, such as swimming. *Children who are active are usually able to postpone use of a wheelchair. It is important to keep using muscles for as long as possible, and aerobic activity is good for a child.

55. The client diagnosed with acute diverticulitis is complaining of severe abdominal pain. On assessment, the nurse finds a hard, rigid abdomen and T 102 ̊F. Which intervention should the nurse implement? 1. Notify the health-care provider. 2. Prepare to administer a Fleet's enema. 3. Administer an antipyretic suppository. 4. Continue to monitor the client closely.

1. Notify the health-care provider. *These are signs of peritonitis, which is life threatening. The health-care provider should be notified immediately.

59. The nurse is caring for a client diagnosed with a fracture of the right distal humerus. Which data indicate a complication? Select all that apply. 1. Numbness and mottled cyanosis. 2. Paresthesia and paralysis. 3. Proximal pulses and point tenderness. 4. Coldness of the extremity and crepitus. 5. Palpable radial pulse and functional movement.

1. Numbness and mottled cyanosis. 2. Paresthesia and paralysis. 4. Coldness of the extremity and crepitus. *The nurse should assess for numbness and mottled cyanosis, which might indicate nerve damage. *The presence of paresthesia and paralysis indicates impaired circulation. *Coldness indicates decreased blood supply. Crepitus indicates air in subcutaneous tissue and is not expected.

30. Which intervention is an example of a secondary nursing intervention when discussing osteoporosis? 1. Obtain a bone density evaluation test. 2. Perform non-weight-bearing exercises regularly. 3. Increase the intake of dietary calcium. 4. Refer clients to a smoking cessation program.

1. Obtain a bone density evaluation test. *This is an example of a secondary nursing intervention, which includes screening for early detection.

142. The client presents to the emergency department experiencing frequent watery, bloody stools after eating some undercooked meat at a fast-food restaurant. Which intervention should be implemented first? 1. Obtain a stool sample from the client. 2. Initiate antibiotic therapy intravenously. 3. Have the laboratory draw a complete blood count. 4. Administer the antidiarrheal medication Lomotil.

1. Obtain a stool sample from the client. *This client may have developed an infection from the undercooked meat. The nurse should obtain a stool spec- imen for the laboratory to analyze.

57. Which is the best advice to offer the parent of a 6-month-old with Werdnig-Hoffman disease on how to treat the infant's constipation? 1. Offer extra water every day. 2. Add corn syrup to two bottles a day. 3. Give the infant a glycerine suppository today. 4. Let the infant go 3 days without a stool before intervening.

1. Offer extra water every day. *Constipation means hard stools and infrequent passage. Adding extra water to the diet helps make the stool softer in this age child.

25. The nurse caring for a child with osteomyelitis assesses poor appetite. Which intervention(s) is/are most appropriate for this child? Select all that apply. 1. Offer high-calorie liquids. 2. Offer favorite foods. 3. Do not worry about intake, as appetite loss is expected. 4. Suggest intravenous removal to encourage oral intake. 5. Decrease pain medication that might cause nausea. 6. Offer frequent small meals.

1. Offer high-calorie liquids. 2. Offer favorite foods. 6. Offer frequent small meals.

53. The client is diagnosed with disseminated herpes zoster secondary to AIDS. Which interventions should the nurse implement? Select all that apply. 1. Place the client in contact isolation. 2. Administer a corticosteroid IVP. 3. Assess the client's pain on a 1-to-10 scale. 4. Request that the client not have any visitors. 5. Ensure that only nurses who have had chickenpox care for this client.

1. Place the client in contact isolation. 2. Administer a corticosteroid IVP. 3. Assess the client's pain on a 1-to-10 scale. 5. Ensure that only nurses who have had chickenpox care for this client.

7. When planning a rehabilitative approach for a child with osteogenesis imperfecta (OI), the nurse should prevent which of the following? Select all that apply. 1. Positional contractures and deformities. 2. Bone infection. 3. Muscle weakness. 4. Osteoporosis. 5. Misalignment of lower extremity joints.

1. Positional contractures and deformities. 3. Muscle weakness. 4. Osteoporosis. 5. Misalignment of lower extremity joints.

11. The nurse is performing an admission assessment on a client diagnosed with GERD. Which signs and symptoms would indicate GERD? 1. Pyrosis, water brash, and flatulence. 2. Weight loss, dysarthria, and diarrhea. 3. Decreased abdominal fat, proteinuria, and constipation. 4. Midepigastric pain, positive H. pylori test, and melena.

1. Pyrosis, water brash, and flatulence. *Pyrosis is heartburn, water brash is the feeling of saliva secretion as a result of reflux, and flatulence is gas—all symptoms of GERD.

26. The nurse on the pediatric floor is receiving a child with the possible diagnosis of septic arthritis of the elbow. Which would the nurse expect on assessment? Select all that apply. 1. Resistance to bending the elbow. 2. Nausea and vomiting. 3. Fever. 4. Bruising of the elbow. 5. Swelling of the elbow. 6. A history of nursemaid's elbow as a toddler.

1. Resistance to bending the elbow. 2. Nausea and vomiting. 3. Fever. 5. Swelling of the elbow.

46. Parents bring their 2-month-old into the clinic with concerns that the baby seems "floppy." The parents say the baby seems to be working hard to breathe, eats very slowly, and seems to fatigue quickly. The nurse assesses intercostal retractions, although the baby is otherwise in no distress. They add there was a cousin whose baby had similar symptoms. The nurse would be most concerned with what possible complications? 1. Respiratory compromise. 2. Dehydration. 3. Need for emotional support for the family. 4. Feeding intolerance.

1. Respiratory compromise. *This baby may have Werdnig-Hoffman disease, which is characterized by progressive generalized muscle weakness that eventually leads to respiratory failure. Respiratory compromise is the most important complication.

18. The nurse is planning care for a child with a T12 spinal cord injury. Which lifelong complications should the child and family know about? Select all that apply. 1. Skin integrity. 2. Incontinence. 3. Loss of large and small motor activity. 4. Loss of voice. 5. Flaccid paralysis.

1. Skin integrity. 2. Incontinence. *Spinal cord-injury patients experience many issues due to loss of innervation below the level of the injury. Skin in- tegrity and incontinence are issues because of immobility and loss of pain receptors below the level of the injury.

32. After the birth of an infant with clubfoot, the nursery nurse should do which when instructing the parents? Select all that apply. 1. Speak in simple language about the defect. 2. Avoid the parents unless providing direct care so they can grieve privately. 3. Keep the infant's feet covered at all times. 4. Present the infant as precious; emphasize the well-formed parts of the body. 5. Tell the parent that defects could be much worse. 6. Be prepared to answer questions multiple times.

1. Speak in simple language about the defect. 4. Present the infant as precious; emphasize the well-formed parts of the body. 6. Be prepared to answer questions multiple times.

33. The nurse is teaching a class to pregnant teenagers. Which information is most important when discussing ways to prevent osteoporosis? 1. Take at least 1,200 mg of calcium supplements a day. 2. Eat foods low in calcium and high in phosphorus. 3. Osteoporosis does not occur until around age 50 years. 4. Remain as active as possible until the baby is born.

1. Take at least 1,200 mg of calcium supplements a day.

54. Which would the nurse teach a patient when NSAIDs are prescribed for treating juvenile idiopathic arthritis (JIA)? 1. Take with food. 2. Take on an empty stomach. 3. Blood levels are required for drug dosages. 4. Good oral hygiene is needed.

1. Take with food. *NSAIDs can cause gastric bleeding with long-term use; food helps to reduce the exposure of the drug on the stomach lining.

2. The nurse caring for a client diagnosed with GERD writes the client problem of "behavior modification." Which intervention should be included for this problem? 1. Teach the client to sleep with a foam wedge under the head. 2. Encourage the client to decrease the amount of smoking. 3. Instruct the client to take over-the-counter medication for relief of pain. 4. Discuss the need to attend Alcoholics Anonymous to quit drinking.

1. Teach the client to sleep with a foam wedge under the head. *The client should elevate the head of the bed on blocks or use a foam wedge to use gravity to help keep the gastric acid in the stomach and prevent reflux into the esophagus. Behavior modification is changing one's behavior.

24. A child with a repaired myelomeningocele is in the clinic for a regular examination. The child has frequent constipation and has been crying at night because of pain in the legs. After an MRI, the diagnosis of a tethered cord is made. Which should the nurse tell the parent? 1. Tethered cord is a post-surgical complication. 2. Tethered cord occurs during times of slow growth. 3. Release of the tethered cord will be necessary only once. 4. Offering laxatives and acetaminophen daily will help control these problems.

1. Tethered cord is a post-surgical complication. *Tethered cord is caused by scar tissue formation from the surgical repair of the myelomeningocele and may affect bowel, bladder, or lower extremity functioning.

77. The client diagnosed with liver failure is experiencing pruritus secondary to severe jaundice. Which action by the unlicensed assistive personnel (UAP) warrants intervention by the nurse? 1. The UAP is assisting the client to take a hot soapy shower. 2. The UAP applies an emollient to the client's legs and back. 3. The UAP puts mittens on both hands of the client. 4. The UAP pats the client's skin dry with a clean towel.

1. The UAP is assisting the client to take a hot soapy shower. *Hot water increases pruritus, and soap will cause dry skin, which increases pruritus; therefore, the nurse should discuss this with the UAP.

27. Which signs/symptoms indicate to the nurse the client has developed osteoporosis? 1. The client has lost one (1) inch in height. 2. The client has lost 12 pounds in the last year. 3. The client's hands are painful to the touch. 4. The client's serum uric acid level is elevated.

1. The client has lost one (1) inch in height.

58. The nurse is preparing the care plan for a client with a fractured lower extremity. Which outcome is most appropriate for the client? 1. The client will maintain function of the leg. 2. The client will ambulate with assistance. 3. The client will be turned every two (2) hours. 4. The client will have no infection.

1. The client will maintain function of the leg. *The expected outcome for a client with a fracture is maintaining the function of the extremity.

24. The nurse is caring for the following clients. After receiving the shift report, which client should the nurse assess first? 1. The client with a total knee replacement who is complaining of a cold foot. 2. The client diagnosed with osteoarthritis who is complaining of stiff joints. 3. The client who needs to receive a scheduled intravenous antibiotic. 4. The client diagnosed with back pain who is scheduled for a lumbar myelogram.

1. The client with a total knee replacement who is complaining of a cold foot. *A cold foot in a client who has had surgery may indicate a neurovascular compromise and must be assessed first.

70. The nurse is caring for the client who had a right shoulder replacement. Which data warrant immediate intervention? 1. The client's hemoglobin is 8.1 g/dL. 2. The client's white blood cell count is 9,000/mm3. 3. The client's creatinine level is 0.8 mg/dL. 4. The client's potassium level is 4.2 mEq/L.

1. The client's hemoglobin is 8.1 g/dL. *The client's hemoglobin is near 8 g/dL, which indicates the client requires a blood transfusion. This information warrants intervention by the nurse.

14. The nurse is caring for an infant newly diagnosed with Hirschsprung disease. What does the nurse understand about this infant's condition? 1. There is a lack of peristalsis in the large intestine and an accumulation of bowel contents, leading to abdominal distention. 2. There is excessive peristalsis throughout the intestine, resulting in abdominal distention. 3. There is a small-bowel obstruction leading to ribbon-like stools. 4. There is inflammation throughout the large intestine, leading to accumulation of intestinal contents and abdominal distention.

1. There is a lack of peristalsis in the large intestine and an accumulation of bowel contents, leading to abdominal distention. *In Hirschsprung disease, a portion of the large intestine has an area lacking in ganglion cells. This results in a lack of peristalsis as well as an accumulation of bowel contents and abdominal distention.

Which statement is true of shaken baby syndrome? 1. There may be absence of external signs of injury. 2. Shaken babies usually do not have retinal hemorrhage. 3. Shaken babies usually do not have signs of a subdural hematoma. 4. Shaken babies have signs of external head injury.

1. There may be absence of external signs of injury.

65. A nurse is caring for a 5-year-old who has a fracture of the tibia involving the growth plate. When providing information to the parents, the nurse should indicate that: 1. This is a serious injury that could cause long-term growth issues. 2. The fracture usually heals within 6 weeks without further complications. 3. The child will never be able to play contact sports. 4. Fractures involving the growth plate require pain medication.

1. This is a serious injury that could cause long-term growth issues.

52. The nurse administered morphine sulfate, a narcotic analgesic, IVP 45 minutes ago to a client diagnosed with herpes zoster. On reassessment, the client complains the pain is at a "5" on a 1-to-10 scale. Which intervention should the nurse implement? 1. Turn on soft music and shut the blinds. 2. Apply warm, moist heat to the lesions. 3. Notify the HCP for more pain medication. 4. Encourage the client to ambulate with assistance.

1. Turn on soft music and shut the blinds.

13. Which sign/symptom should the nurse expect to find in a client diagnosed with ulcerative colitis? 1. Twenty bloody stools a day. 2. Oral temperature of 102 ̊F. 3. Hard, rigid abdomen. 4. Urinary stress incontinence.

1. Twenty bloody stools a day. *The colon is ulcerated and unable to absorb water, resulting in bloody diarrhea. Ten (10) to 20 bloody diarrhea stools is the most common symptom of ulcerative colitis.

13. Which would the nurse assess in a child diagnosed with osteomyelitis? Select all that apply. 1. Unwillingness to move affected extremity. 2. Severe pain. 3. Fever. 4. Previous closed fracture of an extremity. 5. Redness and swelling at the site.

1. Unwillingness to move affected extremity. 2. Severe pain. 3. Fever. 5. Redness and swelling at the site.

20. The nurse is discussing the importance of an exercise program for pain control to a client diagnosed with OA. Which intervention should the nurse include in the teaching? 1. Wear supportive tennis shoes with white socks when walking. 2. Carry a complex carbohydrate while exercising. 3. Alternate walking briskly and jogging when exercising. 4. Walk at least 30 minutes three (3) times a week.

1. Wear supportive tennis shoes with white socks when walking. *Safety should always be discussed when teaching about exercises. Supportive shoes will prevent shin splints. Colored socks have dye and may cause athlete's foot, which is why white socks are recommended.

29. Which foods should the nurse recommend to a client when discussing sources of dietary calcium? 1. Yogurt and dark-green, leafy vegetables. 2. Oranges and citrus fruits. 3. Bananas and dried apricots. 4. Wheat bread and bran.

1. Yogurt and dark-green, leafy vegetables. *The best dietary sources of calcium are milk and other dairy products. Other sources include oysters; canned sardines or salmon; beans; cauliflower; and dark-green, leafy vegetables.

14. The parent of a child diagnosed with osteomyelitis asks how the child acquired the illness. Which is the nurse's best response? 1. "Direct inoculation of the bone from stepping barefoot on a sharp stick." 2. "An infection from a scratched mosquito bite carried the infection through the bloodstream to the bone." 3. "The blood supply to the bone was disrupted because of the child's diabetes." 4. "An infection of the upper respiratory tract."

2. "An infection from a scratched mosquito bite carried the infection through the bloodstream to the bone" *Infection through the bloodstream is the most likely cause of osteomyelitis in a child.

22. The client who is debilitated and has developed multiple pressure ulcers complains to the nurse during a dressing change that he is "tired of it all." Which is the nurse's best therapeutic response? 1. "These wounds can heal if we get enough protein into you." 2. "Are you tired of the treatments and needing to be cared for?" 3. "Why would you say that? We are doing our best." 4. "Have you made out an advance directive to let the HCP know your wishes?"

2. "Are you tired of the treatments and needing to be cared for?"

59. The nurse is caring for an infant who has been diagnosed with short bowel syndrome (SBS). The parent asks how the disease will affect the child. Select the nurse's best response. 1. "Because your child has a shorter intestine than most, your child will likely experience constipation and will need to be placed on a bowel regimen." 2. "Because your child has a shorter intestine than most, he will not be able to absorb all the nutrients and vitamins in food and will need to get nutrients in other ways." 3. "Unfortunately, most children with this diagnosis do not do very well." 4. "The prognosis and course of the disease have changed because hyperalimentation is available."

2. "Because your child has a shorter intestine than most, he will not be able to absorb all the nutrients and vitamins in food and will need to get nutrients in other ways." *Because the intestine is used for absorption, children with SBS usually need alternative forms of nutrition such as hyperalimentation.

39. The school nurse is discussing impetigo with the teachers in an elementary school. One of the teachers asks the nurse, "How can I prevent getting impetigo?" Which statement would be the most appropriate response? 1. "Wash your hands after using the bathroom." 2. "Do not touch any affected areas without gloves." 3. "Apply a topical antibiotic to your hands." 4. "Keep the child with impetigo isolated in the room."

2. "Do not touch any affected areas without gloves."

A 3-year-old boy has been hospitalized because he fell down the stairs. His mother is crying and states, "This is all my fault." Which is the nurse's best response? 1. "Accidents happen. You shouldn't blame yourself." 2. "Falls are one of the most common injuries in this age group." 3. "It may be a good idea to put a baby gate on the stairs." 4. "Your son should be proficient at walking down the stairs by now."

2. "Falls are one of the most common injuries in this age group."

134. The nurse is caring for a client who uses cathartics frequently. Which statement made by the client indicates an understanding of the discharge teaching? 1. "In the future I will eat a banana every time I take the medication." 2. "I don't have to have a bowel movement every day." 3. "I should limit the fluids I drink with my meals." 4. "If I feel sluggish, I will eat a lot of cheese and dairy products."

2. "I don't have to have a bowel movement every day." *It is not necessary to have a bowel movement every day to have normal bowel functioning.

63. The nurse is teaching a client recovering from a laparoscopic cholecystectomy. Which statement indicates the discharge teaching is effective? 1. "I will take my lipid-lowering medicine at the same time each night." 2. "I may experience some discomfort when I eat a high-fat meal." 3. "I need someone to stay with me for about a week after surgery." 4. "I should not splint my incision when I deep breathe and cough."

2. "I may experience some discomfort when I eat a high-fat meal." *After removal of the gallbladder, some clients experience abdominal discomfort when eating fatty foods.

84. The client is admitted with end-stage liver failure and is prescribed the laxative lactulose (Chronulac). Which statement indicates the client needs more teaching concerning this medication? 1. "I should have two to three soft stools a day." 2. "I must check my ammonia level daily." 3. "If I have diarrhea, I will call my doctor." 4. "I should check my stool for any blood."

2. "I must check my ammonia level daily." *There is no instrument used at home to test daily ammonia levels. The ammonia level is a serum level requiring venipuncture and laboratory diagnostic equipment.

54. Which statement by the client diagnosed with chickenpox indicates that the client understands the teaching? 1. "I should put rubbing alcohol on the lesions twice a day." 2. "I should not scratch myself if at all possible. It might lead to scarring." 3. "I can go to work when my lesions have all disappeared." 4. "I need to take all my antibiotics no matter how I feel."

2. "I should not scratch myself if at all possible. It might lead to scarring."

10. Which statement made by the client indicates to the nurse the client may be experiencing GERD? 1. "My chest hurts when I walk up the stairs in my home." 2. "I take antacid tablets with me wherever I go." 3. "My spouse tells me I snore very loudly at night." 4. "I drink six (6) to seven (7) soft drinks every day."

2. "I take antacid tablets with me wherever I go." *Frequent use of antacids indicates an acid reflux problem.

20. The client diagnosed with ulcerative colitis has an ileostomy. Which statement indicates the client needs more teaching concerning the ileostomy? 1. "My stoma should be pink and moist." 2. "I will irrigate my ileostomy every morning." 3. "If I get a red, bumpy, itchy rash I will call my HCP." 4. "I will change my pouch if it starts leaking."

2. "I will irrigate my ileostomy every morning." *An ileostomy will drain liquid all the time and should not routinely be irrigated. A sigmoid colostomy may need daily irrigation to evacuate feces.

29. Which should the nurse tell the parent of an infant with spina bifida? 1. "Bone growth will be more than that of babies who are not sick because your baby will be less active." 2. "Physical and occupational therapy will be helpful to stimulate the senses and improve cognitive skills." 3. "Nutritional needs for your infant will be calculated based on activity level." 4. "Fine motor skills will be delayed because of the disability."

2. "Physical and occupational therapy will be helpful to stimulate the senses and improve cognitive skills." *Children with decreased activity due to illness or trauma are helped by physical and occupational therapy. The varied activities stimulate the senses.

20. The nurse is administering Prilosec (omeprazole) to a 3-month-old with gastro- esophageal reflux (GER). The child's parents ask the nurse how the medication works. Select the nurse's best response. 1. "Prilosec is a proton pump inhibitor that is commonly used for reflux in infants." 2. "Prilosec decreases stomach acid, so it will not be as irritating when your child spits up." 3. "Prilosec helps food move through the stomach quicker, so there will be less chance for reflux." 4. "Prilosec relaxes the pressure of the lower esophageal sphincter."

2. "Prilosec decreases stomach acid, so it will not be as irritating when your child spits up."

Which statement by the mother would lead the nurse to suspect sexual abuse in a 4-year-old? 1. "She has just started masturbation." 2. "She has lots more temper tantrums." 3. "She now has an invisible friend." 4. "She wants to spend time with her sister."

2. "She has lots more temper tantrums."

35. The nurse is caring for a newborn with a cleft lip and palate. The mother states, "I will not be able to breastfeed my baby." Select the nurse's best response. 1. "It sounds like you are feeling discouraged. Would you like to talk about it?" 2. "Sometimes breastfeeding is still an option for babies with a cleft lip and palate. Would you like more information?" 3. "Although breastfeeding is not an option, you have the option of pumping your milk and then feeding it to your baby with a special nipple." 4. "We usually discourage breastfeeding babies with cleft lip and palate as it puts them at an increased risk for aspiration."

2. "Sometimes breastfeeding is still an option for babies with a cleft lip and palate. Would you like more information?" *Some mothers are able to breastfeed their infants who have a cleft lip and palate. The breast can help fill in the cleft and help the infant create suction.

10. The mother of a newborn asks the nurse when the infant will receive the first hepatitis B immunization. Which is the nurse's best response? 1. "Babies receive the hepatitis B vaccine only if their mother is hepatitis B-positive." 2. "The first dose of the hepatitis B vaccine will be given prior to discharge today." 3. "The first dose of hepatitis B vaccine is given at 1 year of age." 4. "Babies receive their first hepatitis B vaccine at 6 months of age."

2. "The first dose of the hepatitis B vaccine will be given prior to discharge today."

30. A 6-week-old is admitted to the hospital with influenza. The child is crying, and the father tells the nurse that his son is hungry. The nurse explains that the baby is not to have anything by mouth. The parent does not understand why the child cannot eat. Which is the nurse's best response to the parent? 1. "We are giving your child intravenous fluids, so there is no need for anything by mouth." 2. "The shorter and narrower airway of infants increases their chances of aspiration so your child should not have anything to eat now." 3. "When your child eats, he burns too many calories; we want to conserve the child's energy." 4. "Your child has too much nasal congestion; if we feed the child by mouth, the distress will likely increase."

2. "The shorter and narrower airway of infants increases their chances of aspiration so your child should not have anything to eat now." *Infants are at higher risk of aspiration because their airways are shorter and narrower than those of adults. An infant with influenza has lots of nasal secretions and coughs up mucus. With all the secretions, the infant is at an even higher risk of aspiration

50. The nurse is providing discharge instructions to the parents of an infant who has had surgery to open a low imperforate anus. The nurse knows that the discharge instructions have been understood when the child's parents say: 1. "We will use an oral thermometer because we cannot use a rectal one." 2. "We will call the physician if the stools change in consistency." 3. "Our infant will never be toilet-trained." 4. "We understand that it is not unusual for our infant's urine to contain stool."

2. "We will call the physician if the stools change in consistency." *A change in stool consistency is important to report because it could indicate stenosis of the rectum.

1. The male client tells the nurse he has been experiencing "heartburn" at night that awakens him. Which assessment question should the nurse ask? 1. "How much weight have you gained recently?" 2. "What have you done to alleviate the heartburn?" 3. "Do you consume many milk and dairy products?" 4. "Have you been around anyone with a stomach virus?"

2. "What have you done to alleviate the heartburn?" *Most clients with GERD have been self-medicating with over-the-counter medications prior to seeking advice from a health-care provider. It is important to know what the client has been using to treat the problem.

42. The nurse is doing a follow-up assessment of a 9-month-old. The infant rolls both ways, sits with some support, pushes food out of the mouth, and pushes away when held. The parent asks about the infant's development. The nurse responds by saying which of the following? 1. "Your child is developing normally." 2. "Your child needs to see the primary care provider." 3. "You need to help your child learn to sit unassisted." 4. "Push the food back when your child pushes food out."

2. "Your child needs to see the primary care provider." *A 9-month-old should be able to sit alone, crawl, pull up, not push food out of the mouth (tongue thrust), and push away when held when wanting to get down. This child is not developing normally and must see the primary care provider.

10. The nurse is caring for the client diagnosed with contact dermatitis. Which collaborative intervention should the nurse implement? 1. Encourage the use of support stockings. 2. Administer a topical anti-inflammatory cream. 3. Remove scales frequently by shampooing. 4. Shampoo with lindane 1%, an antiparasitic, weekly.

2. Administer a topical anti-inflammatory cream.

40. The nurse is caring for a newborn who has just been diagnosed with tracheo- esophageal fistula and is scheduled for surgery. Which should the nurse expect to do in the pre-operative period? 1. Keep the child in a monitored crib, obtain frequent vital signs, and allow the parents to visit but not hold their infant. 2. Administer intravenous fluids and antibiotics. 3. Place the infant on 100% oxygen via a non-rebreather mask. 4. Have the mother feed the infant slowly in a monitored area, stopping all feedings 4 to 6 hours before surgery.

2. Administer intravenous fluids and antibiotics. *Intravenous fluids are administered to prevent dehydration because the infant is NPO. Intravenous antibiotics are administered to prevent pneumonia because aspiration of secretions is likely.

55. Why are chemotherapeutic agents such as methotrexate and cyclophosphamide sometimes used to treat juvenile idiopathic arthritis (JIA)? 1. Effective against cancer-like JIA. 2. Affect the immune system. 3. Are similar to NSAIDs. 4. Are absorbed into the synovial fluid.

2. Affect the immune system. *These drugs affect the immune system to reduce its ability to attack itself, as in the case of JIA.

44. A 3-year-old child with CP is admitted for dehydration following an episode of diar- rhea. The nurse's assessment follows: awake, pale, thin child lying in bed, multiple contractures, drooling, coughing spells noted when parent feeds. T 97.8°F (36.5°C), P 75, R 25, weight 7.2 kg, no diarrheal stool for 48 hours. Which nursing diagnosis is most important? 1. Potential for skin breakdown: lying in one position. 2. Alteration in nutrition: less than body requirements. 3. Potential for impaired social support: mother sole caretaker. 4. Alteration in elimination: diarrhea.

2. Alteration in nutrition: less than body requirements. *This is the priority nursing diagnosis for this severely underweight child. Weight is average for a 4-month-old. The coughing episodes while feeding may indicate aspiration. The parent needs help to learn how to feed so less coughing occurs.

5. The nurse is planning the care of a client diagnosed with psoriasis. Which psychosocial problem should be included in the plan? 1. Alteration in comfort. 2. Altered body image. 3. Anxiety. 4. Altered family processes.

2. Altered body image.

51. Which interventions should the nurse implement for the client diagnosed with an open fracture of the left ankle? Select all that apply. 1. Apply an immobilizer snugly to prevent edema. 2. Apply an ice pack for 10 minutes and remove for 20 minutes. 3. Place the extremity in the dependent position to allow drainage. 4. Obtain an x-ray of the ankle after applying the immobilizer. 5. Administer tetanus toxoid, 0.5 mL intramuscularly, in the deltoid.

2. Apply an ice pack for 10 minutes and remove for 20 minutes. 5. Administer tetanus toxoid, 0.5 mL intramuscularly, in the deltoid. *Ice packs should be applied 10 minutes on and 20 minutes off. This allows for vasoconstriction and decreases edema. Ice is a nonpharmacological pain management technique. *Anytime trauma occurs, tetanus should be considered. In an open fracture, this is an appropriate treatment.

54. The nurse is preparing to administer the initial dose of an aminoglycoside antibiotic to the client diagnosed with acute diverticulitis. Which intervention should the nurse implement? 1. Obtain a serum trough level. 2. Ask about drug allergies. 3. Monitor the peak level. 4. Assess the vital signs.

2. Ask about drug allergies. *The nurse should always ask about allergies to medication when administering medications, but especially when administering antibiotics, which are notorious for allergic reactions.

What would be the priority intervention when a 10-year-old comes to the nurse's office because of a headache, and the nurse notices various stages of bruising on the inner aspects of the upper arms? 1. Call her mother and ask if acetaminophen can be given for the headache. 2. Ask the child what happened to her arms, and have her describe the headache. 3. Inquire about the child's headache and bruising on her arms; file mandatory reporting forms. 4. Call her mother to pick her up from school, and complete required school nurse visit forms.

2. Ask the child what happened to her arms, and have her describe the headache.

23. The nurse writes the problem "impaired skin integrity" for a client with stage IV pressure ulcers. Which interventions should be included in the plan of care? Select all that apply. 1. Turn the client every three (3) to four (4) hours. 2. Ask the dietitian to consult. 3. Have the client sign a consent for pictures of the wounds. 4. Obtain an order for a low air-loss bed. 5. Elevate the head of the bed at all times.

2. Ask the dietitian to consult.

Which would be the nurse's priority intervention if a 7-year-old's mother tells the nurse she has noticed excessive masturbation? 1. Tell her it is normal development for children of this age. 2. Ask the mother if anyone is abusing the child. 3. Talk with the child and find out why she is touching herself down there. 4. Investigate thoroughly the circumstances in which she masturbates.

2. Ask the mother if anyone is abusing the child.

15. The client diagnosed with inflammatory bowel disease has a serum potassium level of 3.4 mEq/L. Which action should the nurse implement first? 1. Notify the health-care provider. 2. Assess the client for muscle weakness. 3. Request telemetry for the client. 4. Prepare to administer potassium IV.

2. Assess the client for muscle weakness. *Muscle weakness may be a sign of hypokalemia; hypokalemia can lead to cardiac dysrhythmias and can be life threatening. Assessment is priority for a potassium level just below normal level, which is 3.5 to 5.5 mEq/L.

7. Which would be the priority intervention for a child diagnosed with chickenpox (varicella) who was prescribed diphenhydramine (Benadryl) for itching? 1. Give a warm bath with mild soap before lotion application. 2. Avoid Caladryl lotion while taking diphenhydramine (Benadryl). 3. Apply Caladryl lotion generously to decrease itching. 4. Give a cool shower with mild soap to decrease itching.

2. Avoid Caladryl lotion while taking diphenhydramine (Benadryl).

21. When a child is suspected of having osteomyelitis, the nurse can prepare the family to expect which of the following? Select all that apply. 1. Pain medication is contraindicated so that symptoms are not masked. 2. Blood cultures will be obtained. 3. Pus will be aspirated from the subperiosteum. 4. An intravenous line with antibiotics will be started. 5. Surgery will be necessary.

2. Blood cultures will be obtained. 3. Pus will be aspirated from the subperiosteum. 4. An intravenous line with antibiotics will be started.

56. Which manifestation suggests that an infant is developing necrotizing enterocolitis (NEC)? 1. Absorption of bolus orogastric feedings at a faster rate than previous feedings. 2. Bloody diarrhea. 3. Increased bowel sounds. 4. Appears hungry right before a scheduled feeding.

2. Bloody diarrhea. *Bloody diarrhea can indicate that the infant has NEC.

138. The dietitian and the nurse in a long-term care facility are planning the menu for the day. Which foods should be recommended for the immobile clients for whom swallowing is not an issue? 1. Cheeseburger and milk shake. 2. Canned peaches and a sandwich on whole-wheat bread. 3. Mashed potatoes and mechanically ground red meat. 4. Biscuits and gravy with bacon.

2. Canned peaches and a sandwich on whole-wheat bread. *Canned peaches are soft and can be chewed and swallowed easily while providing some fiber; whole-wheat bread is higher in fiber than white bread. These foods will be helpful for clients whose gastric motility is slowed as a result of lack of exercise or immobility.

19. After spinal cord surgery, an adolescent suddenly complains of a severe headache. Which should be the nurse's first action? 1. Check the blood pressure. 2. Check for a full bladder. 3. Ask if pain is present somewhere else. 4. Ask if other symptoms are present.

2. Check for a full bladder. *The sympathetic nervous system responds to a full bladder or bowel resulting from an uncontrolled, paroxysmal, continuous lower motor neuron reflex arc. This response is usually from stimulation of sensory receptors (e.g., distended bladder or bowel). Because the efferent pulse cannot pass through the spinal cord, the vagus nerve is not "turned off," and profound symptomatic bradycardia may occur.

20. An adolescent with a T4 spinal cord injury suddenly becomes dangerously hyperten- sive and bradycardic. Which intervention is appropriate? 1. Call the neurosurgeon immediately, as this sounds like sudden intracranial hypertension. 2. Check to be certain that the patient's bladder is not distended. 3. Administer Hyperstat to treat the blood pressure. 4. Administer atropine for bradycardia.

2. Check to be certain that the patient's bladder is not distended. *Check to be certain that the bladder is not distended, which would trigger autonomic dysreflexia.

49. The parents of a toddler diagnosed with Werdnig-Hoffmann disease ask the nurse what they can feed their child that would be quality food. Which would be good choices for the nurse to recommend? 1. A hot dog and chips. 2. Chicken and broccoli. 3. A banana and almonds. 4. A milkshake and a hamburger.

2. Chicken and broccoli. *Chicken is a good source of protein, and broccoli is a good choice for naturally occurring vitamins.

6. Which would be the priority intervention for a child suspected of having varicella (chickenpox)? 1. Contact precautions. 2. Contact and droplet respiratory precautions. 3. Droplet respiratory precautions. 4. Universal precautions and standard precautions.

2. Contact and droplet respiratory precautions.

50. The parent of a child diagnosed with Werdnig-Hoffmann disease notes times of not being able to hear the child breathing. Which should the nurse do first? 1. Check pulse oximetry on the child. 2. Count the child's respirations. 3. Listen to the child's lung sounds. 4. Ask the parent if the child coughs at night.

2. Count the child's respirations. *The first intervention is to check the respiratory rate of the child to see if it is abnormal, then listen to the lung sounds, and then check pulse oximetry.

3. The nurse is preparing the plan of care for a client diagnosed with psoriasis. Which intervention should the nurse include in the plan of care? 1. Apply a thin dusting with Mycostatin, an antifungal powder, over the area. 2. Cover the area with an occlusive dressing after applying a steroid cream. 3. Administer Acyclovir, an antiviral medication, to the affected areas six (6) times a day. 4. Teach the client the risks and hazards of implanted radiation therapy.

2. Cover the area with an occlusive dressing after applying a steroid cream.

129. The client who is obese presents to the clinic before beginning a weight loss program. Which interventions should the nurse teach? Select all that apply. 1. Walk for 30 minutes three (3) times a day. 2. Determine situations that initiate eating behavior. 3. Weigh at the same time every day. 4. Limit sodium in the diet. 5. Refer to a weight support group.

2. Determine situations that initiate eating behavior. 5. Refer to a weight support group.

10. The nurse knows that teaching was successful when a parent states which of the following are early signs of muscular dystrophy? 1. Increased muscle strength. 2. Difficulty climbing stairs. 3. High fevers and tiredness. 4. Respiratory infections and obesity.

2. Difficulty climbing stairs. *Difficulty climbing stairs, running, and riding a bicycle are frequently the first symptoms of Duchenne muscular dystrophy.

21. What would be the priority nursing action on finding the varicella vaccine at room temperature on the shelf in the medication room? 1. Ensure the varicella vaccine's integrity is intact; if intact, follow the five rights of medication administration. 2. Do not administer this batch of vaccine. 3. Ensure the varicella vaccine's integrity is intact; if intact, give the vaccine after verifying proper physician orders. 4. Ask the mother if the child has had any prior reactions to varicella.

2. Do not administer this batch of vaccine.

49. The nurse is discussing the prevention of herpes simplex 2. Which intervention should the nurse discuss with the client? 1. Encourage the client to get the chickenpox immunization. 2. Do not engage in oral sex if you have a cold sore on the mouth. 3. Wear nonsterile gloves when cleaning the genital area. 4. Do not share any type of towel or washcloth with another person.

2. Do not engage in oral sex if you have a cold sore on the mouth.

97. The female client came to the clinic complaining of abdominal cramping and at least 10 episodes of diarrhea every day for the last two (2) days. The client just returned from a trip to Mexico. Which intervention should the nurse implement? 1. Instruct the client to take a cathartic laxative daily. 2. Encourage the client to drink lots of Gatorade. 3. Discuss the need to increase protein in the diet. 4. Explain the client should weigh herself daily.

2. Encourage the client to drink lots of Gatorade. *The client probably has traveler's diarrhea, and oral rehydration is the preferred choice for replacing fluids lost as a result of diarrhea. An oral glucose electrolyte solution, such as Gatorade, All-Sport, or Pedialyte, is recommended.

55. The client admitted with a diagnosis of a fractured hip who is in Buck's traction is complaining of severe pain. Which intervention should the nurse implement? 1. Adjust the patient-controlled analgesia (PCA) machine for a lower dose. 2. Ensure the weights of the Buck's traction are off the floor and hang freely. 3. Raise the head of the bed to 45 degrees and the foot to 15 degrees. 4. Turn the client on the affected leg using pillows to support the other leg.

2. Ensure the weights of the Buck's traction are off the floor and hang freely. *Weights from traction should be off the floor and hanging freely. Buck's traction is used to reduce muscle spasms preoperatively in clients who have fractured hips.

31. The female client diagnosed with osteoporosis tells the nurse she is going to perform swim aerobics for 30 minutes every day. Which response is most appropriate by the nurse? 1. Praise the client for committing to do this activity. 2. Explain to the client walking 30 minutes a day is a better activity. 3. Encourage the client to swim every other day instead of daily. 4. Discuss with the client how sedentary activities help prevent osteoporosis.

2. Explain to the client walking 30 minutes a day is a better activity. *Weight-bearing activity, such as walking, is beneficial in preventing or slowing bone loss. The mechanical force of weight-bearing exercises promotes bone growth.

30. What would be the best plan of care for a newborn whose mother's hepatitis B antigen status is unknown? 1. Give the infant the hepatitis B vaccine within 12 hours of birth. 2. Give the infant the hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth. 3. Give the infant the hepatitis B vaccine within 24 hours of birth. 4. Give the infant the hepatitis B vaccine and hepatitis B immune globulin within 24 hours of birth.

2. Give the infant the hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth. *Infants born to mothers of unknown hepatitis B antigen status should be given the hepatitis B immune globulin and hepatitis B vaccine within 12 hours of birth. If the mother is positive for hepatitis B antigen, then the baby should receive the hepatitis B immune globulin as soon as possible within 12 hours of birth. Timely administration of the hepatitis B vaccine is important to prevent passive acquisition of hepatitis B from the mother

36. The client with a history of peptic ulcer disease is admitted into the intensive care unit with frank gastric bleeding. Which priority intervention should the nurse implement? 1. Maintain a strict record of intake and output. 2. Insert a nasogastric tube and begin saline lavage. 3. Assist the client with keeping a detailed calorie count. 4. Provide a quiet environment to promote rest.

2. Insert a nasogastric tube and begin saline lavage. *Inserting a nasogastric tube and lavaging the stomach with saline is the most important intervention because this directly stops the bleeding.

101. The client diagnosed with gastroenteritis is being discharged from the emergency department. Which intervention should the nurse include in the discharge teaching? 1. If diarrhea persists for more than 96 hours, contact the health-care provider. 2. Instruct the client to wash hands thoroughly before handling any type of food. 3. Explain the importance of decreasing steroids gradually as instructed. 4. Discuss how to collect all stool samples for the next 24 hours.

2. Instruct the client to wash hands thoroughly before handling any type of food. *Washing hands should be done by the client at all times, but especially when the client has gastroenteritis. The bacteria in feces may be transferred to other people via food if hands are not washed properly.

21. The HCP prescribes glucosamine and chondroitin for a client diagnosed with OA. What is the scientific rationale for prescribing this medication? 1. It will help decrease the inflammation in the joints. 2. It improves tissue function and retards breakdown of cartilage. 3. It is a potent medication which decreases the client's joint pain. 4. It increases the production of synovial fluid in the joint.

2. It improves tissue function and retards breakdown of cartilage.

14. The client is diagnosed with osteoarthritis. Which sign/symptom should the nurse expect the client to exhibit? 1. Severe bone deformity. 2. Joint stiffness. 3. Waddling gait. 4. Swan-neck fingers.

2. Joint stiffness. *Pain, stiffness, and functional impairment are the primary clinical manifestations of OA. Stiffness of the joints is commonly experienced after resting but usually lasts less than 30 minutes and decreases with movement.

46. The nurse is caring for a 7-week-old scheduled for a pyloromyotomy in 24 hours. Which would the nurse expect to find in the plan of care? 1. Keep infant NPO; begin intravenous fluids at maintenance. 2. Keep infant NPO; begin intravenous fluids at maintenance; place nasogastric tube (NGT) to low wall suction. 3. Obtain serum electrolytes; keep infant NPO; do not attempt to pass NGT due to obstruction. 4. Offer infant small frequent feedings; keep NPO 6 to 8 hours before surgery.

2. Keep infant NPO; begin intravenous fluids at maintenance; place nasogastric tube (NGT) to low wall suction. *In addition to giving fluids intravenously and keeping the infant NPO, an NGT is placed to decompress the stomach.

130. The 22-year-old female who is obese is discussing weight loss programs with the nurse. Which information should the nurse teach? 1. Jog for two (2) to three (3) hours every day. 2. Lifestyle behaviors must be modified. 3. Eat one (1) large meal every day in the evening. 4. Eat 1,000 calories a day and don't take vitamins.

2. Lifestyle behaviors must be modified.

60. The client is admitted to the medical floor with acute diverticulitis. Which collaborative intervention should the nurse anticipate the health-care provider ordering? 1. Administer total parenteral nutrition. 2. Maintain NPO and nasogastric tube. 3. Maintain on a high-fiber diet and increase fluids. 4. Obtain consent for abdominal surgery.

2. Maintain NPO and nasogastric tube. *The bowel must be put at rest. Therefore, the nurse should anticipate orders for maintaining the client NPO and a nasogastric tube.

41. The nurse writes the client problem of "acute pain and itching secondary to bacterial skin lesions." Which interventions should be included in the care plan? Select all that apply. 1. Keep humidity at less than 20%. 2. Maintain a cool environment. 3. Use a mild soap for sensitive skin. 4. Keep lesions covered at all times. 5. Apply skin lotion after bathing.

2. Maintain a cool environment. 3. Use a mild soap for sensitive skin. 5. Apply skin lotion after bathing.

18. Which client goal is most appropriate for a client diagnosed with OA? 1. Perform passive range-of-motion exercises. 2. Maintain optimal functional ability. 3. Client will walk three (3) miles every day. 4. Client will join a health club.

2. Maintain optimal functional ability. *The two main goals of treatment for OA are pain management and optimizing functional ability of the joints to ensure movement of the joints.

58. A child is admitted to the pediatric unit with the diagnosis of systemic lupus erythe- matosus (SLE). On assessment, the nurse expects the child to have: 1. Leukemia. 2. Malar rash. 3. Weight gain. 4. Heart failure.

2. Malar rash. *The "butterfly," or malar, rash is the most common manifestation of SLE.

26. Which should the nurse do first when caring for an infant who just had a repair of a myelomeningocele? 1. Weigh diapers for 24-hour urine output. 2. Measure head circumference. 3. Offer clear fluids. 4. Assess for infection.

2. Measure head circumference. *Hydrocephalus occurs in about 90% of infants with myelomeningocele, so measuring the head circumference daily and watching for an increase are important. Accumulation of cerebrospinal fluid can occur after closure of the sac.

107. Which nursing interventions should be included in the care plan for the 84-year- old client diagnosed with acute gastroenteritis? Select all that apply. 1. Assess the skin turgor on the back of the client's hands. 2. Monitor the client for orthostatic hypotension. 3. Record the frequency and characteristics of sputum. 4. Use Standard Precautions when caring for the client. 5. Institute safety precautions when ambulating the client.

2. Monitor the client for orthostatic hypotension. 4. Use Standard Precautions when caring for the client. 5. Institute safety precautions when ambulating the client.

What is the most likely cause of a child's illness if it is unexplained, prolonged, recurrent, and extremely rare, and usually occurs when the mother is present? 1. Genetic disorder. 2. Munchausen syndrome by proxy. 3. Duchenne muscular dystrophy. 4. Syndrome of inappropriate antidiuretic hormone.

2. Munchausen syndrome by proxy.

34. A child with a newly applied left leg cast initially feels fine, then starts to cry and tells his mother his leg hurts. Which assessment would be the nurse's first priority? 1. Cast integrity. 2. Neurovascular integrity. 3. Musculoskeletal integrity. 4. Soft-tissue integrity.

2. Neurovascular integrity. *Neurovascular integrity should be assessed first and frequently because neurovascular compromise may cause serious consequences. Neurovascular integrity should be assessed using the 5 Ps: increased Pain out of proportion with injury, Pallor of extremity, Paresthesia, Pulselessness at distal part of extremity, and Paralysis post cast application.

12. Which discharge instruction for a child diagnosed with encopresis should the nurse question? 1. Limit the intake of milk. 2. Offer a diet high in protein. 3. Obtain a complete dietary log. 4. Follow up with a child psychologist.

2. Offer a diet high in protein. *A diet high in protein will cause more constipation.

16. The nurse is planning the care for the client with multiple stage IV pressure ulcers. Which complication results from these pressure ulcers? 1. Wasting syndrome. 2. Osteomyelitis. 3. Renal calculi. 4. Cellulitis.

2. Osteomyelitis.

71. The nurse is assessing the client who is postoperative total knee replacement. Which assessment data warrant immediate intervention? 1. T 99 ̊F, HR 80, RR 20, and BP 128/76. 2. Pain in the unaffected leg during dorsiflexion of the ankle. 3. Bowel sounds heard intermittently in four quadrants. 4. Diffuse, crampy abdominal pain.

2. Pain in the unaffected leg during dorsiflexion of the ankle. *Pain with dorsiflexion of the ankle indicates deep vein thrombosis. This can be from immobility or surgery; therefore, pain should be assessed in both legs.

24. Which is most important when teaching a parent about preventing osteomyelitis? 1. Parents can stop worrying about bone infection once their child reaches school age. 2. Parents need to clean open wounds thoroughly with soap and water. 3. Children will always get a fever if they have osteomyelitis. 4. Children should wear long pants when playing outside because their legs might get scratched.

2. Parents need to clean open wounds thoroughly with soap and water. *Because bacteria from an open wound can lead to osteomyelitis, thorough cleaning with soap and water is the best prevention.

30. A 9-year-old is in a spica cast and complains of pain 1 hour after receiving intravenous opioid analgesia. What should the nurse do first? 1. Give more pain medication. 2. Perform a neuromuscular assessment. 3. Call the surgeon for orders. 4. Tell the child to wait another hour for the medication to work.

2. Perform a neuromuscular assessment.

27. Which should be the priority nursing diagnosis for a 12-hour-old newborn with a myelomeningocele at L2? 1. Altered bowel elimination related to neurological deficits. 2. Potential for infection related to the physical defect. 3. Altered nutrition related to neurological deficit. 4. Disturbance in self-concept related to physical disability.

2. Potential for infection related to the physical defect. *Because this infant has not had a repair, the sac is exposed. It could rupture, allowing organisms to enter the cerebrospinal fluid, so this is the priority.

9. When counseling the parents of a child with osteogenesis imperfecta (OI), the nurse should include which of the following? Select all that apply. 1. Discourage future children because the condition is inherited. 2. Provide education about the child's physical limitations. 3. Give the parents a letter signed by the primary care provider explaining OI. 4. Provide information on contacting the Osteogenesis Imperfecta Foundation. 5. Encourage the parents to treat the child like their other children. 6. Encourage use of calcium to decrease risk of fractures.

2. Provide education about the child's physical limitations. 3. Give the parents a letter signed by the primary care provider explaining OI. 4. Provide information on contacting the Osteogenesis Imperfecta Foundation. *OI is frequently confused with child abuse

23. Which nursing intervention should take place prior to all vaccination administrations? 1. Document the vaccination to be administered on the immunization record and medical record. 2. Provide the vaccine information statement handout, and answer all questions. 3. Administer the most painful vaccination first, and then alternate injection sites. 4. Refer to the vaccination as "baby shots" so the parent understands the baby will be receiving an injection.

2. Provide the vaccine information statement handout, and answer all questions.

16. The client is diagnosed with an acute exacerbation of ulcerative colitis. Which intervention should the nurse implement? 1. Provide a low-residue diet. 2. Rest the client's bowel. 3. Assess vital signs daily. 4. Administer antacids orally.

2. Rest the client's bowel. *Whenever a client has an acute exacerbation of a gastrointestinal disorder, the first intervention is to place the bowel on rest. The client should be NPO with intravenous fluids to prevent dehydration.

35. Which assessment data indicate to the nurse the client's gastric ulcer has perforated? 1. Complaints of sudden, sharp, substernal pain. 2. Rigid, boardlike abdomen with rebound tenderness. 3. Frequent, clay-colored, liquid stool. 4. Complaints of vague abdominal pain in the right upper quadrant.

2. Rigid, boardlike abdomen with rebound tenderness. *A rigid, boardlike abdomen with rebound tenderness is the classic sign/symptom of peritonitis, which is a complication of a perforated gastric ulcer.

Which assessment is most important after any injury in a child? 1. History of loss of consciousness and length of time unconscious. 2. Serial assessments of level of consciousness. 3. Initial neurological assessment. 4. Initial vital signs and oxygen saturation level.

2. Serial assessments of level of consciousness.

73. The client diagnosed with end-stage liver failure is admitted with esophageal bleeding. The HCP inserts and inflates a triple-lumen nasogastric tube (Sengstaken- Blakemore). Which nursing intervention should the nurse implement for this treatment? 1. Assess the gag reflex every shift. 2. Stay with the client at all times. 3. Administer the laxative lactulose (Chronulac). 4. Monitor the client's ammonia level.

2. Stay with the client at all times. *While the balloons are inflated, the client must not be left unattended in case they become dislodged and occlude the airway. This is a safety issue.

59. Which is an important nursing intervention to teach about photosensitivity to the parents of a child with systemic lupus erythematosus (SLE)? 1. Regular clothing is appropriate for sun exposure. 2. Sunscreen application is necessary for protection. 3. Teenage patients cannot participate in outdoor sports. 4. Uncovered fluorescent lights offer no danger.

2. Sunscreen application is necessary for protection. *Sunscreen helps reduce accelerated burning due to sensitivity.

105. The 79-year-old client diagnosed with acute gastroenteritis is admitted to the medical unit. Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Evaluate the client's intake and output. 2. Take the client's vital signs. 3. Change the client's intravenous solution. 4. Assess the client's perianal area.

2. Take the client's vital signs.

28. Over the last week, an infant with a repaired myelomeningocele has had a high- pitched cry and been irritable. Length, weight, and head circumference have been at the 50th percentile. Today length is at the 50th percentile, weight is at the 70th per- centile, and head circumference is at the 90th percentile. The nurse should do which of the following? 1. Tell the parent this is normal for an infant with a repaired myelomeningocele. 2. Tell the parent this might mean the baby has increased intracranial pressure. 3. Suspect the baby's intracranial pressure is low because of a leak. 4. Refer the baby to the neurologist for follow-up care.

2. Tell the parent this might mean the baby has increased intracranial pressure. *The increase in head size is one of the first signs of increased intracranial pressure; other signs include high-pitched cry and irritability.

80. A 12-year-old cut a hand while climbing a barbed-wire fence. What should the nurse discuss with the parents regarding need for tetanus vaccine? Select all that apply. 1. No tetanus vaccine is necessary; it is too soon since the child's scheduled Tdap was given. 2. Tetanus is a potentially fatal disease. 3. Puncture wounds are less susceptible to tetanus. 4. There will be mild soreness at the injection site. 5. Tdap should be administered. 6. Td should be administered.

2. Tetanus is a potentially fatal disease. 5. Tdap should be administered.

72. The nurse is working on an orthopedic floor. Which client should the nurse assess first after the change-of-shift report? 1. The 84-year-old female with a fractured right femoral neck in Buck's traction. 2. The 64-year-old female with a left total knee replacement who has confusion. 3. The 88-year-old male post-right total hip replacement with an abduction pillow. 4. The 50-year-old postop client with a continuous passive motion (CPM) device.

2. The 64-year-old female with a left total knee replacement who has confusion. *This is an abnormal occurrence from this information. This client should be seen first because confusion is a symptom of hypoxia.

4. An 18-month-old is discharged from the hospital after having a febrile seizure secondary to exanthem subitum (roseola). On discharge, the mother asks the nurse if her 6-year-old twins will get sick. Which teaching about the transmission of roseola would be most accurate? 1. The child should be isolated in the home until the vesicles have dried. 2. The child does not need to be isolated from the older siblings. 3. Administer acetaminophen to the older siblings to prevent seizures. 4. Monitor older children for seizure development.

2. The child does not need to be isolated from the older siblings.

51. The nurse is caring for a neonate with an anorectal malformation. The nurse notes that the infant has not passed any stool per rectum but the infant's urine contains meconium. The nurse can make which assumption? 1. The child likely has a low anorectal malformation. 2. The child likely has a high anorectal malformation. 3. The child will not need a colostomy. 4. This malformation will be corrected with a nonoperative rectal pull-through.

2. The child likely has a high anorectal malformation. *The presence of stool in the urine indicates that the anorectal malformation is high.

69. Which assessment data indicate to the nurse the client recovering from an open cholecystectomy may require pain medication? 1. The client's pulse is 65 beats per minute. 2. The client has shallow respirations. 3. The client's bowel sounds are 20 per minute. 4. The client uses a pillow to splint when coughing.

2. The client has shallow respirations. *An open cholecystecomy requires a large incision under the diaphragm. Deep breathing places pressure on the diaphragm and the incision, causing pain. Shallow respirations indicate inadequate pain control, and the nurse should intervene.

31. Which expected outcome should the nurse include for a client diagnosed with peptic ulcer disease? 1. The client's pain is controlled with the use of NSAIDs. 2. The client maintains lifestyle modifications. 3. The client has no signs and symptoms of hemoptysis. 4. The client takes antacids with each meal.

2. The client maintains lifestyle modifications. *Maintaining lifestyle changes such as following an appropriate diet and reducing stress indicate the client is complying with the medical regimen. Compliance is the goal of treatment to prevent complications.

15. Which expected outcome should the nurse include in the plan of care for the client diagnosed with seborrheic dermatitis? 1. The client will have no further outbreaks. 2. The client will follow medical protocol. 3. The client will shampoo three (3) times a week. 4. The client will apply bacitracin twice daily.

2. The client will follow medical protocol.

78. The nurse identifies the client problem "excess fluid volume" for the client in liver failure. Which short-term goal would be most appropriate for this problem? 1. The client will not gain more than two (2) kg a day. 2. The client will have no increase in abdominal girth. 3. The client's vital signs will remain within normal limits. 4. The client will receive a low-sodium diet.

2. The client will have no increase in abdominal girth. *Excess fluid volume could be secondary to portal hypertension. Therefore, no increase in abdominal girth would be an appropriate short-term goal, indicating no excess of fluid volume.

137. The charge nurse has just received the shift report. Which client should the nurse see first? 1. The client diagnosed with Crohn's disease who had two (2) semiformed stools on the previous shift. 2. The elderly client admitted from another facility who is complaining of constipation. 3. The client diagnosed with AIDS who had a 200-mL diarrhea stool and has elastic skin tissue turgor. 4. The client diagnosed with hemorrhoids who had some spotting of bright red blood on the toilet tissue.

2. The elderly client admitted from another facility who is complaining of constipation. *This client has just arrived, so the nurse does not know if the complaint is valid and needs intervention unless assessed. The elderly have difficulty with constipation as a result of decreased gastric motility, medications, poor diet, and immobility.

18. The nurse knows that Nissen fundoplication involves which of the following? 1. The fundus of the stomach is wrapped around the inferior stomach, mimicking a lower esophageal sphincter. 2. The fundus of the stomach is wrapped around the inferior esophagus, mimicking a cardiac sphincter. 3. The fundus of the stomach is wrapped around the middle portion of the stomach, decreasing the capacity of the stomach. 4. The fundus of the stomach is dilated, decreasing the likelihood of reflux.

2. The fundus of the stomach is wrapped around the inferior esophagus, mimicking a cardiac sphincter. *The Nissen fundoplication involves wrapping the fundus of the stomach around the inferior esophagus, creating a lower esophageal sphincter or cardiac sphincter.

94. The client diagnosed with liver problems asks the nurse, "Why are my stools clay-colored?" On which scientific rationale should the nurse base the response? 1. There is an increase in serum ammonia level. 2. The liver is unable to excrete bilirubin. 3. The liver is unable to metabolize fatty foods. 4. A damaged liver cannot detoxify vitamins.

2. The liver is unable to excrete bilirubin. *Bilirubin, the by-product of red blood cell destruction, is metabolized in the liver and excreted via the feces, which causes the feces to be brown in color. If the liver is damaged, the bilirubin is excreted via the urine and skin.

28. Which would be the priority intervention for the newborn of a mother positive for hepatitis antigen? 1. The newborn should be given the first dose of hepatitis B vaccine by 2 months of age. 2. The newborn should receive the hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth. 3. The newborn should receive the hepatitis B vaccine and hepatitis B immune globulin within 24 hours of birth. 4. The newborn should receive hepatitis B immune globulin within 12 hours of birth.

2. The newborn should receive the hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth. *The newborn should receive both hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth to prevent hepatitis B infection

12. A mother requests that her child receive the varicella vaccine at the 9-month well-child checkup. The nurse tells the mother that: 1. Children who are vaccinated will likely develop a mild case of the disease. 2. The vaccine cannot be given at that visit. 3. The vaccine will be administered after the physician examines the child. 4. A booster vaccination will be needed at 18 months of age.

2. The vaccine cannot be given at that visit. *Do not administer prior to one year of age

Which statement is true of abused children? 1. They will tell the truth if asked about their injuries. 2. They will repeat the same story that their parents tell. 3. They usually are not noted to have any changes in behavior. 4. They will have outgoing personalities and be active in school activities.

2. They will repeat the same story that their parents tell.

32. The nurse is caring for an infant with biliary atresia. The parents ask why the child is receiving cholestyramine. Select the nurse's best response. 1. To lower your child's cholesterol. 2. To relieve your child's itching. 3. To help your child gain weight. 4. To help feedings be absorbed in a more efficient manner.

2. To relieve your child's itching. *The primary reason cholestyramine is administered to the child with biliary atresia is to relieve pruritus.

8. Which classification of osteogenesis imperfecta (OI) is lethal in utero and in infancy? 1. Type I. 2. Type II. 3. Type III. 4. Type IV.

2. Type II. *Type II is lethal in utero and in infancy because of multiple fractures and deformities and underdeveloped lungs.

49. What are the two organizations in the United States that make and govern the recommendations for immunization policies and procedures? 1. National Advisory Committee on Immunization and American Medical Association. 2. U.S. Public Health Service Centers for Disease Control and American Academy of Pediatrics. 3. National Immunization Program and Pediatric Infectious Disease Association. 4. National Institutes of Health and Minister of National Health and Welfare.

2. U.S. Public Health Service Centers for Disease Control and American Academy of Pediatrics.

61. Because estrogen is a possible trigger for a systemic lupus erythematosus (SLE) flare, advice for a teenager who may become sexually active includes which of the follow- ing? Select all that apply. 1. Use Ortho Tri-Cyclen. 2. Use Depo-Provera. 3. Practice abstinence. 4. Use condoms. 5. Use Ortho Evra.

2. Use Depo-Provera. 3. Practice abstinence. 4. Use condoms. *Depo-Provera is progesterone, the only contraceptive that is approved for use in sexually active women with SLE.

27. Which specific data should the nurse obtain from the client who is suspected of having peptic ulcer disease? 1. History of side effects experienced from all medications. 2. Use of nonsteroidal anti-inflammatory drugs (NSAIDs). 3. Any known allergies to drugs and environmental factors. 4. Medical histories of at least three (3) generations.

2. Use of nonsteroidal anti-inflammatory drugs (NSAIDs). *Use of NSAIDs places the client at risk for peptic ulcer disease and hemorrhage. NSAIDs suppress the production of prostaglandin in the stomach, which is a protective mechanism to prevent damage from hydrochloric acid.

58. The 55-year-old client contracted chickenpox from his grandchild. The client had to be hospitalized because of the seriousness of the condition. Which complication is the client at risk for developing secondary to chickenpox? 1. Deep vein thrombosis. 2. Varicella pneumonia. 3. Pericarditis. 4. Scarring of the skin.

2. Varicella pneumonia.

68. There is an outbreak of scabies in a long-term care facility. Which instruction should the infection control nurse provide to all client care staff concerning the transmission of this parasitic infection? 1. Use only hand-washing foam when caring for clients with scabies. 2. Wear gloves when providing hands-on care for a client with scabies. 3. Wash all linen and clothes in cold water and dry them outside in the sun. 4. Instruct clients to use plastic eating utensils for meals.

2. Wear gloves when providing hands-on care for a client with scabies.

29. Which instruction would be of highest priority for the mother of an infant receiving his first oral rotavirus vaccine? 1. "Call the physician if he develops fever or cough." 2. "Call the physician if he develops fever, redness, or swelling at the injection site." 3. "Call the physician if he develops a bloody stool or diarrhea." 4. "Call the physician if he develops constipation and irritability."

3. "Call the physician if he develops a bloody stool or diarrhea." *There is a very small incidence of infants developing intussusception, signaled by the onset of bloody stool or diarrhea after receiving oral rotavirus vaccine

10. The parents of a 4-year-old ask the nurse how to manage their child's constipation. Select the nurse's best response. 1. "Add 2 ounces of apple or pear juice to the child's diet." 2. "Be sure your child eats a lot of fresh fruit such as apples and bananas." 3. "Encourage your child to drink more fluids." 4. "Decrease bulky foods such as whole-grain breads and rice."

3. "Encourage your child to drink more fluids." *Increasing fluid consumption helps to decrease the hardness of the stool.

38. The client comes to the clinic complaining of sudden onset of high fever, chills, and a headache. The nurse assesses a patchy macular rash on the trunk and a circular type of rash that looks like an insect bite. Which question would be most appropriate for the nurse to ask during the interview? 1. "Do you own dogs that stay in the yard?" 2. "Have you been working in your garden lately?" 3. "Have you been deer hunting in the last week?" 4. "Do you use sunscreen when you are outside?"

3. "Have you been deer hunting in the last week?"

19. The client diagnosed with Crohn's disease is crying and tells the nurse, "I can't take it anymore. I never know when I will get sick and end up here in the hospital." Which statement is the nurse's best response? 1. "I understand how frustrating this must be for you." 2. "You must keep thinking about the good things in your life." 3. "I can see you are very upset. I'll sit down and we can talk." 4. "Are you thinking about doing anything like committing suicide?"

3. "I can see you are very upset. I'll sit down and we can talk."

106. Which statement indicates to the emergency department nurse the client diagnosed with acute gastroenteritis understands the discharge teaching? 1. "I will probably have some leg cramps while I have gastroenteritis." 2. "I should decrease my fluid intake until the diarrhea subsides." 3. "I should reintroduce solid foods very slowly back into my diet." 4. "I should only drink bottled water until the abdominal cramping stops."

3. "I should reintroduce solid foods very slowly back into my diet." *Reintroducing solid foods slowly, in small amounts, will allow the bowel to rest and the mucosa to return to normal functioning after acute gastroenteritis.

22. The nurse is admitting the client with OA to the medical floor. Which statement by the client indicates an alternative form of treatment for OA? 1. "I take medication every two (2) hours for my pain." 2. "I use a heating pad when I go to bed at night." 3. "I wear a copper bracelet to help with my OA." 4. "I always wear my ankle splints when I sleep."

3. "I wear a copper bracelet to help with my OA." *Alternative forms of treatment have not been proved efficacious in the treatment of a disease. The nurse should be nonjudgmental and open to discussions about alternative treatment, unless it interferes with the medical regimen.

41. The nurse is giving discharge instructions to the parent of a 1-month-old infant with tracheoesophageal fistula and a gastrostomy tube (GT). The nurse knows the mother understands the discharge teaching when she states: 1. "I will give my baby feedings through the GT but place liquid medications in the corner of the mouth to be absorbed." 2. "I will flush the GT with 2 ounces of water after each feeding to prevent the GT from clogging." 3. "I will clean the area around the GT with soap and water every day." 4. "I will place petroleum jelly around the GT if any redness develops."

3. "I will clean the area around the GT with soap and water every day."

52. The nurse is caring for a newborn with an anorectal malformation and a colostomy. The nurse knows that more education is needed when the infant's parent states which of the following? 1. "I will make sure the stoma is red." 2. "There should not be any discharge or irritation around the outside of the stoma." 3. "I will keep a bag attached to avoid the contents of the small intestine coming in contact with the baby's skin." 4. "As my baby grows, a pattern will develop over time, and there should be predictable bowel movements."

3. "I will keep a bag attached to avoid the contents of the small intestine coming in contact with the baby's skin." *The colostomy contains stool from the large intestine; an ileostomy contains the very irritating stool from the small intestine.

45. The parent of an infant with CP asks the nurse if the infant will be mentally retarded. Which is the nurse's best response? 1. "Children with CP have some amount of mental retardation." 2. "Approximately 20% of children with CP have normal intelligence." 3. "Many children with CP have normal intelligence." 4. "Mental retardation is expected if motor and sensory deficits are severe."

3. "Many children with CP have normal intelligence."

40. The parent of a young child with CP brings the child to the clinic for a checkup. Which parent's statement indicates an understanding of the child's long-term needs? 1. "My child will need all my attention for the next 10 years." 2. "Once in school, my child will catch up and be like the other children." 3. "My child will grow up and need to learn to do things independently." 4. "I'm the one who knows the most about my child and can do the most for my child."

3. "My child will grow up and need to learn to do things independently."

6. The parent of a 5-year-old states that the child has been having diarrhea for 24 hours, vomited twice 2 hours ago, and now claims to be thirsty. The parent asks what to offer the child because the child is refusing Pedialyte. Select the nurse's most appropriate response. 1. "You can offer clear diet soda such as Sprite and ginger ale." 2. "Pedialyte is really the best thing for your child, who, if thirsty enough, will eventually drink it." 3. "Pedialyte is really the best thing for your child. Allow your child some choice in the way to take it by offering small amounts in a spoon, medicine cup, or syringe." 4. "It really does not matter what your child drinks as long as it is kept down. Try offering small amounts of fluids in medicine cups."

3. "Pedialyte is really the best thing for your child. Allow your child some choice in the way to take it by offering small amounts in a spoon, medicine cup, or syringe." *Pedialyte is the first choice, as recommended by the American Academy of Pediatrics. Offering the child appropriate choices may allow the child to feel empowered and less likely to refuse the Pedialyte. Small, frequent amounts are usually better tolerated.

44. The nurse is caring for an infant with pyloric stenosis. The parent asks if any future children will likely have pyloric stenosis. Select the nurse's best response. 1. "You seem worried; would you like to discuss your concerns?" 2. "It is very rare for a family to have more than one child with pyloric stenosis." 3. "Pyloric stenosis can run in families. It is more common among males." 4. "Although there can be a genetic link, it is very unusual for girls to have pyloric stenosis."

3. "Pyloric stenosis can run in families. It is more common among males."

45. The nurse is caring for an 8-week-old infant being evaluated for pyloric stenosis. Which statement by the parent would be typical for a child with this diagnosis? 1. "The baby is a very fussy eater and just does not want to eat." 2. "The baby tends to have a very forceful vomiting episode about 30 minutes after most feedings." 3. "The baby is always hungry after vomiting so I refeed." 4. "The baby is happy in spite of getting really upset after spitting up."

3. "The baby is always hungry after vomiting so I refeed." *Infants with pyloric stenosis are always hungry and often appear malnourished.

48. The nurse is caring for a 5-month-old infant with a diagnosis of intussusception. The infant has periods of irritability during which the knees are brought to chest and the infant cries, alternating with periods of lethargy. Vital signs are stable and within age-appropriate limits. The physician elects to give an enema. The parents ask the purpose of the enema. Select the nurse's most appropriate response. 1. "The enema will confirm the diagnosis. If the test result is positive, your child will need to have surgery to correct the intussusception." 2. "The enema will confirm the diagnosis. Although very unlikely, the enema may also help fix the intussusception so that your child will not immediately need surgery." 3. "The enema will help confirm the diagnosis and has a good chance of fixing the intussusception." 4. "The enema will help confirm the diagnosis and may temporarily fix the intussusception. If the bowel returns to normal, there is a strong likelihood that the intussusception will recur."

3. "The enema will help confirm the diagnosis and has a good chance of fixing the intussusception." *In most cases of intussusception in young children, an enema is successful in reducing the intussusception.

Which statement would be most therapeutic to a child the nurse suspects has been abused? 1. "Who did this to you? This is not right." 2. "This is wrong that your mother did not protect you." 3. "This is not your fault; you are not to blame for this." 4. "I will not tell anyone."

3. "This is not your fault; you are not to blame for this."

60. The nurse is caring for a 3-month-old infant who has short bowel syndrome (SBS) and has been receiving total parenteral nutrition (TPN). The parents ask if their child will ever be able to eat. Select the nurse's best response. 1. "Children with SBS are never able to eat and must receive all of their nutrition in intravenous form." 2. "You will have to start feeding your child because children cannot be on TPN longer than 6 months." 3. "We will start feeding your child soon so that the bowel continues to receive stimulation." 4. "Your child will start receiving tube feedings soon but will never be able to eat by mouth."

3. "We will start feeding your child soon so that the bowel continues to receive stimulation." *It is important to begin feedings as soon as the bowel is healed so that it receives stimulation and does not atrophy.

81. Which assessment question is priority for the nurse to ask the client diagnosed with end-stage liver failure secondary to alcoholic cirrhosis? 1. "How many years have you been drinking alcohol?" 2. "Have you completed an advance directive?" 3. "When did you have your last alcoholic drink?" 4. "What foods did you eat at your last meal?"

3. "When did you have your last alcoholic drink?" *The nurse must know when the client had the last alcoholic drink to be able to determine when and if the client will experience delirium tremens, the physical withdrawal from alcohol.

83. The client is diagnosed with end-stage liver failure. The client asks the nurse, "Why is my doctor decreasing the doses of my medications?" Which statement is the nurse's best response? 1. "You are worried because your doctor has decreased the dosage." 2. "You really should ask your doctor. I am sure there is a good reason." 3. "You may have an overdose of the medications because your liver is damaged." 4. "The half-life of the medications is altered because the liver is damaged."

3. "You may have an overdose of the medications because your liver is damaged."

39. The nurse receives a call from a parent of a child with leukemia in remission. The parent says the child has been exposed to chickenpox. The child has never had chickenpox. Which of the following responses is most appropriate for the nurse? 1. "You need to monitor the child's temperature frequently and call back if the temperature is greater than 101°F (38.3°C)." 2. "At this time there is no need to be concerned." 3. "You need to bring the child to the clinic for a chickenpox immunoglobulin vaccine." 4. "Your child will need to be isolated for the next 2 weeks."

3. "You need to bring the child to the clinic for a chickenpox immunoglobulin vaccine." *The child should receive varicella zoster immune globulin within 96 hours of the exposure

33. Which would be the most appropriate discharge instructions for a child with a right wrist sprain 3 hours ago? 1. "You should rest, elevate the wrist above the heart, apply heat wrapped in a towel, and use the sling when walking." 2. "You can use the wrist, but stop if it hurts; elevate the wrist when not in use, and use the sling when walking." 3. "You should rest, apply ice wrapped in a towel, elevate the wrist above the heart, and use the sling when walking." 4. "You do not have to take any special precautions; do not use any movements that cause pain, and apply alternate heat and ice, each wrapped in a towel.

3. "You should rest, apply ice wrapped in a towel, elevate the wrist above the heart, and use the sling when walking." *For the first 24 hours, rest, ice, compression, and elevation (RICE) are recommended for acute injury.

19. The nurse is caring for a 4-month-old with gastroesophageal reflux (GER). The infant is due to receive Zantac (rantadine). Based on the medication's mechanism of action, when should this medication be administered? 1. Immediately before a feeding. 2. 30 minutes after the feeding. 3. 30 minutes before the feeding. 4. At bedtime.

3. 30 minutes before the feeding. *Zantac decreases gastric acid secretion and should be administered 30 minutes before a feeding.

59. The nurse is working in an outpatient clinic. Which client is most likely to have a diagnosis of diverticulosis? 1. A 60-year-old male with a sedentary lifestyle. 2. A 72-year-old female with multiple childbirths. 3. A 63-year-old female with hemorrhoids. 4. A 40-year-old male with a family history of diverticulosis.

3. A 63-year-old female with hemorrhoids. *Hemorrhoids would indicate the client has chronic constipation, which is a strong risk factor for diverticulosis. Constipation increases the intraluminal pressure in the sigmoid colon, leading to weakness in the intestinal lining, which, in turn, causes outpouchings, or diverticula.

32. The nurse has been assigned to care for a client diagnosed with peptic ulcer disease. Which assessment data require further intervention? 1. Bowel sounds auscultated fifteen (15) times in one (1) minute. 2. Belching after eating a heavy and fatty meal late at night. 3. A decrease in systolic BP of 20 mm Hg from lying to sitting. 4. A decreased frequency of distress located in the epigastric region.

3. A decrease in systolic BP of 20 mm Hg from lying to sitting. *A decrease of 20 mm Hg in blood pressure after changing position from lying, to sitting, to standing is orthostatic hypotension. This could indicate the client is bleeding.

100. The client is diagnosed with gastroenteritis. Which laboratory data warrant imme- diate intervention by the nurse? 1. A serum sodium level of 137 mEq/L. 2. Arterial blood gases of pH 7.37, PaO2 95, PaCO2 43, HCO3 24. 3. A serum potassium level of 3.3 mEq/L. 4. A stool sample positive for fecal leukocytes.

3. A serum potassium level of 3.3 mEq/L. *In gastroenteritis, diarrhea often results in metabolic acidosis and loss of potassium. The normal serum potassium level is 3.5 to 5.5 mEq/L; therefore, a level of 3.3 mEq/L would require immediate intervention.

30. The nurse is caring for a client diagnosed with hemorrhaging duodenal ulcer. Which collaborative interventions should the nurse implement? Select all that apply. 1. Perform a complete pain assessment. 2. Assess the client's vital signs frequently. 3. Administer a proton pump inhibitor intravenously. 4. Obtain permission and administer blood products. 5. Monitor the intake of a soft, bland diet.

3. Administer a proton pump inhibitor intravenously. 4. Obtain permission and administer blood products. *This is a collaborative intervention the nurse should implement. It requires an order from the HCP. *Administering blood products is collaborative, requiring an order from the HCP.

133. The client being admitted from the emergency department is diagnosed with a fecal impaction. Which nursing intervention should be implemented? 1. Administer an antidiarrheal medication every day and PRN. 2. Perform bowel training every two (2) hours. 3. Administer an oil retention enema. 4. Prepare for an upper gastrointestinal (UGI) series x-ray.

3. Administer an oil retention enema. *Oil retention enemas will help to soften the feces and evacuate the stool.

5. The nurse is caring for a 2-year-old child who was admitted to the pediatric unit for moderate dehydration due to vomiting and diarrhea. The child is restless, with periods of irritability. The child is afebrile with a heart rate of 148 and a blood pressure of 90/42. Baseline laboratory tests reveal the following: Na 152, Cl 119, and glucose 115. The parents state that the child has not urinated in 12 hours. After establishing a saline lock, the nurse reviews the physician's orders. Which order should the nurse question? 1. Administer a saline bolus of 10 mL/kg, which may be repeated if the child does not urinate. 2. Recheck serum electrolytes in 12 hours. 3. After the saline bolus, begin maintenance fluids of D5 1/4 NS with 10 mEq KCl/L. 4. Give clear liquid diet as tolerated.

3. After the saline bolus, begin maintenance fluids of D5 1/4 NS with 10 mEq KCl/L. *Potassium is contraindicated because the child has not yet urinated. Potassium is not added to the maintenance fluid until kidney function has been verified.

65. The nurse is caring for the immediate postoperative client who had a laparoscopic cholecystectomy. Which task could the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Check the abdominal dressings for bleeding. 2. Increase the IV fluid if the blood pressure is low. 3. Ambulate the client to the bathroom. 4. Auscultate the breath sounds in all lobes.

3. Ambulate the client to the bathroom. *A day surgery client can be ambulated to the bathroom, so this task can be delegated to the UAP.

102. Which medication should the nurse expect the HCP to order to treat the client diagnosed with botulism secondary to eating contaminated canned goods? 1. An antidiarrheal medication. 2. An aminoglycoside antibiotic. 3. An antitoxin medication. 4. An ACE inhibitor medication.

3. An antitoxin medication. *A botulism antitoxin neutralizes the circulating toxin and is prescribed for a client with botulism.

3. A 4-month-old has had vomiting and diarrhea for 24 hours. The infant is fussy, and the anterior fontanel is sunken. The nurse notes the infant does not produce tears when crying. Which task will help confirm the diagnosis of dehydration? 1. Urinalysis obtained by bagged specimen. 2. Urinalysis obtained by sterile catheterization. 3. Analysis of serum electrolytes. 4. Analysis of cerebrospinal fluid.

3. Analysis of serum electrolytes. *The analysis of serum electrolytes offers the most information and assists with the diagnosis of dehydration.

56. The nurse is providing discharge teaching to the 12-year-old with a fractured humerus and the parents. Which information should the nurse include regarding cast care? 1. Keep the fractured arm at heart level. 2. Use a wire hanger to scratch inside the cast. 3. Apply an ice pack to any itching area. 4. Explain foul smells are expected occurrences.

3. Apply an ice pack to any itching area. *Applying ice packs to the cast will relieve itching, and nothing should be placed down a cast to scratch. Skin becomes fragile inside the cast and is torn easily. Alteration in the skin's integrity can become infected.

What should parents understand is one of the most common causes of injury and death for a 7-month-old infant? 1. Poisoning. 2. Child abuse. 3. Aspiration. 4. Dog bites.

3. Aspiration.

60. An 88-year-old client is admitted to the orthopedic floor with the diagnosis of fractured pelvis. Which intervention should the nurse implement first? 1. Insert an indwelling catheter. 2. Administer a Fleet's enema. 3. Assess abdomen for bowel sounds. 4. Apply Buck's traction.

3. Assess abdomen for bowel sounds. *Assessing the bowel sounds should be the first intervention to determine if an ileus has occurred. This is a common complication of a fractured pelvis.

67. The client is one (1) hour post-endoscopic retrograde cholangiopancreatogram (ERCP). Which intervention should the nurse include in the plan of care? 1. Instruct the client to cough forcefully. 2. Encourage early ambulation. 3. Assess for return of a gag reflex. 4. Administer held medications.

3. Assess for return of a gag reflex. *The ERCP requires an anesthetic spray be used prior to insertion of the endoscope. If medications, food, or fluid are given orally prior to the return of the gag reflex, the client may aspirate.

48. The nurse is teaching a class on how to prevent Lyme disease. Which intervention should be included in the discussion? 1. Instruct the clients to wear dark clothes when hunting. 2. Use a sunscreen of at least SPF 30 when outside. 3. Avoid dense undergrowth when in a wooded area. 4. Do not use any type of insect repellant when deer hunting.

3. Avoid dense undergrowth when in a wooded area.

43. The client is diagnosed with acne vulgaris. Which psychosocial problem is priority? 1. Impaired skin integrity. 2. Ineffective grieving. 3. Body image disturbance. 4. Knowledge deficit.

3. Body image disturbance.

34. A newborn with a repaired myelomeningocele is assessed for hydrocephalus. Which would the nurse expect in an infant with hydrocephalus? 1. Low-pitched cry and depressed fontanel. 2. Low-pitched cry and bulging fontanel. 3. Bulging fontanel and downwardly rotated eyes. 4. Depressed fontanel and upwardly rotated eyes.

3. Bulging fontanel and downwardly rotated eyes. *An alteration in the circulation of the cerebrospinal fluid causes hydrocephalus. The anterior fontanel bulges because of an increase in cerebrospinal fluid, and an increase in intracranial pressure causes a high-pitched cry in infants and downward deviation of the eyes, also called sunset eyes. With sun-set eyes the sclera can be seen above the iris.

52. A child with GBS has had lots of oral fluids but has not urinated for 8 hours. Which is the nurse's first action? 1. Check the child's serum blood-urea-nitrogen level. 2. Check the child's complete blood count. 3. Catheterize the child in and out. 4. Run water in the bathroom to stimulate urination.

3. Catheterize the child in and out. *The child must be in-and-out catheterized to avoid the possibility of developing a urinary tract infection from urine left in the bladder for too long.

18. The parent of a 3-week-old states that the infant was recasted this morning for clubfoot and has been crying for the past hour. Which intervention should the nurse suggest the parent do first? 1. Give pain medication. 2. Reposition the infant in the crib. 3. Check the neurocirculatory status of the foot. 4. Use a cool blow-dryer to blow into the cast to control itching.

3. Check the neurocirculatory status of the foot.

52. The nurse is discussing the therapeutic diet for the client diagnosed with diverticulosis. Which meal indicates the client understands the discharge teaching? 1. Fried fish, mashed potatoes, and iced tea. 2. Ham sandwich, applesauce, and whole milk. 3. Chicken salad on whole-wheat bread and water. 4. Lettuce, tomato, and cucumber salad and coffee.

3. Chicken salad on whole-wheat bread and water. *Chicken salad, which has vegetables such as celery, grapes, and apples, and whole-wheat bread are high in fiber, which is the therapeutic diet prescribed for clients with diverticulosis. An adequate intake of water helps prevent constipation.

80. Which gastrointestinal assessment data should the nurse expect to find when assessing the client in end-stage liver failure? 1. Hypoalbuminemia and muscle wasting. 2. Oligomenorrhea and decreased body hair. 3. Clay-colored stools and hemorrhoids. 4. Dyspnea and caput medusae.

3. Clay-colored stools and hemorrhoids. *Clay-colored stools and hemorrhoids are gastrointestinal effects of liver failure.

7. The nurse is caring for a 9-month-old with diarrhea secondary to rotavirus. The child has not vomited and is mildly dehydrated. Which is likely to be included in the discharge teaching? 1. Administer Imodium as needed. 2. Administer Kaopectate as needed. 3. Continue breastfeeding per routine. 4. The infant may return to day care 24 hours after antibiotics have been started.

3. Continue breastfeeding per routine. *Breastfeeding is usually well tolerated and helps prevent death of intestinal villi and malabsorption.

4. The nurse should tell the parents of a child with Duchenne (pseudohypertrophic) muscular dystrophy that some of the progressive complications include: 1. Dry skin and hair, hirsutism, protruding tongue, and mental retardation. 2. Anorexia, gingival hyperplasia, and dry skin and hair. 3. Contractures, obesity, and pulmonary infections. 4. Trembling, frequent loss of consciousness, and slurred speech.

3. Contractures, obesity, and pulmonary infections. *The major complications of muscular dystrophy include contractures, disuse atrophy, infections, obesity, respiratory complications, and cardiopulmonary problems.

41. A child with spastic CP had an intrathecal dose of baclofen in the early afternoon. What is the expected result 31/2 hours post dose that suggests the child would benefit from a baclofen pump? 1. The ability to self-feed. 2. The ability to walk with little assistance. 3. Decreased spasticity. 4. Increased spasticity.

3. Decreased spasticity. *If baclofen were going to work for this child, one could tell because spasticity would be decreased.

52. The nurse is caring for a client with a fractured left tibia and fibula. Which data should the nurse report to the health-care provider immediately? 1. Localized edema and discoloration occurring hours after the injury. 2. Generalized weakness and increasing sensitivity to touch. 3. Dorsalis pedal pulse cannot be located with a Doppler and increasing pain. 4. Pain relieved after taking four (4) mg hydromorphone, a narcotic analgesic.

3. Dorsalis pedal pulse cannot be located with a Doppler and increasing pain. *If the nurse cannot hear the pedal pulse with a Doppler and the client's pain is increasing, the nurse should notify the health-care provider. These are signs of neurovascular compromise.

28. The client is being evaluated for osteoporosis. Which diagnostic test is the most accurate when diagnosing osteoporosis? 1. X-ray of the femur. 2. Serum alkaline phosphatase. 3. Dual-energy x-ray absorptiometry (DEXA). 4. Serum bone Gla-protein test.

3. Dual-energy x-ray absorptiometry (DEXA). *This test measures bone density in the lumbar spine or hip and is considered to be highly accurate.

4. The nurse is planning the care of a client diagnosed with lower esophageal sphincter dysfunction. Which dietary modifications should be included in the plan of care? 1. Allow any of the client's favorite foods as long as the amount is limited. 2. Have the client perform eructation exercises several times a day. 3. Eat four (4) to six (6) small meals a day and limit fluids during mealtimes. 4. Encourage the client to consume a glass of red wine with one (1) meal a day.

3. Eat four (4) to six (6) small meals a day and limit fluids during mealtimes. *Clients should eat small, frequent meals and limit fluids with the meals to prevent reflux into the esophagus from a distended stomach.

7. The client diagnosed with diabetes mellitus type 2 is admitted to the hospital with cellulitis of the right foot secondary to an insect bite. Which intervention should the nurse implement first? 1. Administer intravenous antibiotics. 2. Apply warm moist packs every two (2) hours. 3. Elevate the right foot on two (2) pillows. 4. Teach the client about skin and foot care.

3. Elevate the right foot on two (2) pillows.

26. Which medication is most important to have available in all clinics and offices if immunizations are administered? 1. Benadryl (diphenhydramine) injection. 2. Benadryl (diphenhydramine) liquid. 3. Epinephrine 1:1000 injection. 4. Epinephrine 1:10,000 injection.

3. Epinephrine 1:1000 injection.

12. Which disease is the client diagnosed with GERD at greater risk for developing? 1. Hiatal hernia. 2. Gastroenteritis. 3. Esophageal cancer. 4. Gastric cancer.

3. Esophageal cancer. *Barrett's esophagus results from long-term erosion of the esophagus as a result of reflux of stomach contents secondary to GERD. This is a precursor to esophageal cancer.

143. The clinic nurse is talking on the phone to a client who has diarrhea. Which inter- vention should the nurse discuss with the client? 1. Tell the client to measure the amount of stool. 2. Recommend the client come to the clinic immediately. 3. Explain the client should follow the BRAT diet. 4. Discuss taking an over-the-counter histamine-2 blocker.

3. Explain the client should follow the BRAT diet. *The BRAT (bananas, rice, applesauce, and toast) diet is recommended for a client with diarrhea because it is low residue and produces nutrition while not irritating the GI system.

25. The nurse is discussing osteoporosis with a group of women. Which factor will the nurse identify as a nonmodifiable risk factor? 1. Calcium deficiency. 2. Tobacco use. 3. Female gender. 4. High alcohol intake.

3. Female gender.

21. A child comes to the clinic for diphtheria, pertussis, and tetanus (DTaP) and inacti- vated poliovirus vaccines. The child does not appear ill but has a temperature of 101°F (38.3°C). The nurse should take which action? 1. Withhold the vaccines, and reschedule when the child is afebrile. 2. Administer Tylenol, and give the vaccine. 3. Give the vaccines, and instruct the parent to give Tylenol every 4 hours as needed. 4. Have the physician order an antibiotic and give the vaccine.

3. Give the vaccines, and instruct the parent to give Tylenol every 4 hours as needed.

62. The client one (1) day postoperative total hip replacement complains of hearing a "popping sound" when turning. Which assessment data should the nurse report immediately to the surgeon? 1. Dark red-purple discoloration. 2. Equal length of lower extremities. 3. Groin pain in the affected leg. 4. Edema at the incision site.

3. Groin pain in the affected leg. *Groin pain or increasing discomfort in the affected leg and the "popping sound" indicate the leg has dislocated, which should be reported immediately to the HCP for a possible closed reduction.

8. Which laboratory test should the nurse monitor to identify an allergic reaction for the client diagnosed with contact dermatitis? 1. IgA. 2. IgD. 3. IgE. 4. IgG.

3. IgE.

15. The nurse is caring for a 3-month-old being evaluated for possible Hirschsprung disease. His parents call the nurse and show her his diaper containing a large amount of mucus and bloody diarrhea. The nurse notes that the infant is irritable and his abdomen appears very distended. Which should be the nurse's next action? 1. Reassure the parents that this is an expected finding and not uncommon. 2. Call a code for a potential cardiac arrest, and stay with the infant. 3. Immediately obtain all vital signs with a quick head-to-toe assessment. 4. Obtain a stool sample for occult blood.

3. Immediately obtain all vital signs with a quick head-to-toe assessment. *All vital signs need to be evaluated because the child with enterocolitis can quickly progress to a state of shock. A quick head-to-toe assessment will allow the nurse to evaluate the child's circulatory system.

53. Which would the nurse teach an adolescent is a complication of corticosteroids used in the treatment of juvenile idiopathic arthritis (JIA)? 1. Fat loss. 2. Adrenal stimulation. 3. Immune suppression. 4. Hypoglycemia.

3. Immune suppression. *Steroids cause immune suppression, which is the reason behind its use in JIA; it reduces the body's attack on itself.

53. The nurse is planning care for a child who was recently admitted with GBS. Which is a priority nursing diagnosis? 1. Risk for constipation related to immobility. 2. Chronic sorrow related to presence of chronic disability. 3. Impaired skin integrity related to infectious disease process. 4. Activity intolerance related to ineffective cardiac muscle function.

3. Impaired skin integrity related to infectious disease process. *The goal is to prevent complications related to immobility. Efforts include maintaining skin integrity, maintaining respiratory function, and preventing contractures.

48. The mother of an infant diagnosed with Werdnig-Hoffmann disease asks the nurse what she could have done during her pregnancy to prevent this. The nurse explains that the cause of Werdnig-Hoffmann is which of the following? 1. Unknown. 2. Restricted movement in utero. 3. Inherited as an autosomal-recessive trait. 4. Inherited as an autosomal-dominant trait.

3. Inherited as an autosomal-recessive trait.

50. A nurse is working in a well-child clinic administering immunizations to preschoolers. Which procedure will minimize local reactions to the injections? 1. Apply EMLA cream 1 hour before. 2. Change the needle on the syringe after drawing up the biological drug. 3. Inject into the vastus lateralis or ventrogluteal muscle. 4. Use distraction such as telling the child to hold the breath.

3. Inject into the vastus lateralis or ventrogluteal muscle.

35. The client is taking calcium carbonate (Tums) to help prevent further development of osteoporosis. Which teaching should the nurse implement? 1. Encourage the client to take Tums with at least eight (8) ounces of water. 2. Teach the client to take Tums with the breakfast meal only. 3. Instruct the client to take Tums 30 to 60 minutes before a meal. 4. Discuss the need to get a monthly serum calcium level.

3. Instruct the client to take Tums 30 to 60 minutes before a meal. *Free hydrochloric acid is needed for calcium absorption; therefore, Tums should be taken on an empty stomach.

46. Which would the nurse assess in a 4-week-old infant who has developmental dysplasia of the hip and is wearing a Pavlik harness? 1. Diaper dermatitis. 2. Talipes equinovarus. 3. Leg shortening and limited abduction. 4. Pain.

3. Leg shortening and limited abduction.

12. The nurse knows that teaching has been successful when the parent of a child with muscle weakness states that the diagnostic test for muscular dystrophy is which of the following? 1. Electromyelogram. 2. Nerve conduction velocity. 3. Muscle biopsy. 4. Creatine kinase level.

3. Muscle biopsy. *Muscle biopsy confirms the type of myopathy that the patient has.

59. Which is assessed to diagnose pediculosis capitis? Select all that apply. 1. Crawling insects. 2. White flakes in the hair. 3. Nits attached close to scalp. 4. Inflammatory papules. 5. Dark brown hair.

3. Nits attached close to scalp. 4. Inflammatory papules.

15. A 10-year-old with osteomyelitis has been on intravenous antibiotics for 48 hours. The child is allergic to amoxicillin. Vital signs are T 101.8°F (38.8°C), BP 100/60, P 96, R 24. Which is the primary reason for surgical treatment? 1. Young age. 2. Drug allergies. 3. Nonresponse to intravenous antibiotics. 4. Physician preference.

3. Nonresponse to intravenous antibiotics. *If a patient does not respond to an appropriate antibiotic within 48 hours, surgery may be indicated.

55. Which would the nurse expect to be included in the diagnostic workup of a child with suspected celiac disease? 1. Obtain complete blood count and serum electrolytes. 2. Obtain complete blood count and stool sample; keep child NPO. 3. Obtain stool sample and prepare child for jejunal biopsy. 4. Obtain complete blood count and serum electrolytes; monitor child's response to gluten-containing diet.

3. Obtain stool sample and prepare child for jejunal biopsy. *A stool sample for analysis of fat and a jejunal biopsy can confirm the diagnosis.

11. A child is diagnosed with chronic constipation that has been unresponsive to dietary and activity changes. Which pharmacological measure is most appropriate? 1. Natural supplements and herbs. 2. Stimulant laxative. 3. Osmotic agent. 4. Pharmacological measures are not used in pediatric constipation.

3. Osmotic agent. *A stool softener is the drug of choice because it will lead to easier evacuation.

25. The school nurse is preparing to teach a health promotion class to high school seniors. Which information regarding self-care should be included in the teaching? 1. Wear a sunscreen with a protection factor of 10 or less when in the sun. 2. Try to stay out of the sun between 0300 and 0500 daily. 3. Perform a thorough skin check monthly. 4. Remember caps and long sleeves do not help prevent skin cancer.

3. Perform a thorough skin check monthly.

25. Which should be included in the plan of care for a newborn with a myelomeningocele who will have a surgical repair tomorrow? 1. Offer formula every 3 hours. 2. Turn the infant back to front every 2 hours. 3. Place a wet dressing on the sac. 4. Provide pain medication every 4 hours.

3. Place a wet dressing on the sac. *Priority care for an infant with a myelomeningocele is to protect the sac. A wet dressing keeps it moist with less chance of tearing.

74. The client has had a liver biopsy. Which postprocedure intervention should the nurse implement? 1. Instruct the client to void immediately. 2. Keep the client NPO for eight (8) hours. 3. Place the client on the right side. 4. Monitor BUN and creatinine level.

3. Place the client on the right side. *Direct pressure is applied to the site, and then the client is placed on the right side to maintain site pressure.

57. The nurse is caring for a 1-month-old term infant who experienced an anoxic episode at birth. The health-care team suspects that the infant is developing necrotizing en- terocolitis (NEC). Which would the nurse expect to be included in the plan of care? 1. Immediately remove the feeding nasogastric tube (NGT) from the infant. 2. Obtain vital signs every 4 hours. 3. Prepare to administer antibiotics intravenously. 4. Change feedings to half-strength, administer slowly via a feeding pump.

3. Prepare to administer antibiotics intravenously. *Intravenous antibiotics are administered to prevent or treat sepsis.

51. The client is admitted to the medical unit with a diagnosis of acute diverticulitis. Which health-care provider's order should the nurse question? 1. Insert a nasogastric tube. 2. Start an IV with D5W at 125 mL/hr. 3. Put client on a clear liquid diet. 4. Place client on bedrest with bathroom privileges.

3. Put client on a clear liquid diet. *The nurse should question a clear liquid diet because the bowel must be put on total rest, which means NPO.

18. The client is diagnosed with an acute exacerbation of IBD. Which priority intervention should the nurse implement first? 1. Weigh the client daily and document in the client's chart. 2. Teach coping strategies such as dietary modifications. 3. Record the frequency, amount, and color of stools. 4. Monitor the client's oral fluid intake every shift.

3. Record the frequency, amount, and color of stools. *The severity of the diarrhea helps determine the need for fluid replacement. The liquid stool should be measured as part of the total output.

14. Which should a nurse in the ED be prepared for in a child with a possible spinal cord injury? 1. Severe pain. 2. Elevated temperature. 3. Respiratory depression. 4. Increased intracranial pressure.

3. Respiratory depression. *A spinal cord injury can occur at any level. The higher the level of the injury, the more likely the child is to have respiratory insufficiency or failure. The nurse should be prepared to support the child's respiratory system.

22. The nurse is caring for an infant with myelomeningocele who is going to surgery later today for closure of the sac. Which would be a priority nursing diagnosis before surgery? 1. Alteration in parent-infant bonding. 2. Altered growth and development. 3. Risk of infection. 4. Risk for weight loss.

3. Risk of infection. *A normal saline dressing is placed over the sac to prevent tearing, which would allow the cerebrospinal fluid to escape and microorganisms to enter and cause an infection.

23. The client diagnosed with ulcerative colitis is prescribed a low-residue diet. Which meal selection indicates the client understands the diet teaching? 1. Grilled hamburger on a wheat bun and fried potatoes. 2. A chicken salad sandwich and lettuce and tomato salad. 3. Roast pork, white rice, and plain custard. 4. Fried fish, whole grain pasta, and fruit salad.

3. Roast pork, white rice, and plain custard. *A low-residue diet is a low-fiber diet. Products made of refined flour or finely milled grains, along with roasted, baked, or broiled meats, are recommended.

63. The elderly client is admitted from the long-term care facility diagnosed with congestive heart failure. The client complains of severe itching on both hands and the nurse notes wavy, brown, threadlike lesions between the client's fingers. Which comorbid condition would the nurse suspect the client of having based on these assessment data? 1. Tinea capitis. 2. Herpes simplex 2. 3. Scabies. 4. Psoriasis.

3. Scabies.

27. A 12-year-old diagnosed with scoliosis is to wear a brace for 23 hours a day. What is the most likely reason the child will not wear it for that long? 1. Pain from the brace. 2. Difficulty in putting the brace on. 3. Self-consciousness about appearance. 4. Not understanding what the brace is for.

3. Self-consciousness about appearance. *Children this age are very conscious of their appearance and fitting in with their peers, so they might be very resistant to wearing a brace.

56. The nurse is admitting an 88-year-old client diagnosed with a viral skin infection. Which nursing task could the nurse delegate to the unlicensed assistive personnel? 1. Measure and document the client's skin lesions. 2. Apply the antihistamine cream to the lesions. 3. Set up the isolation equipment for the client. 4. Determine if the client has prepared an advance directive.

3. Set up the isolation equipment for the client.

16. The nurse expects the blood culture report of an 8-year-old with septic arthritis to grow which causative organism? 1. Streptococcus pneumoniae. 2. Escherichia coli. 3. Staphylococcus aureus. 4. Neisseria gonorrhoeae.

3. Staphylococcus aureus. *S. aureus is a common organism found on the skin and is frequently the cause of septic arthritis.

36. The nurse is caring for a 4-month-old who has just had an isolated cleft lip repaired. Select the best position for the child in the immediate post-operative period. 1. Right side-lying. 2. Left side-lying. 3. Supine. 4. Prone.

3. Supine. *The supine position is preferred because there is decreased risk of the infant rubbing the suture line.

Which assessment of an 18-month-old with burns on his feet would cause suspicion of child abuse? 1. Splash marks on his right lower leg. 2. Burns noted on right arm. 3. Symmetrical burns on both feet. 4. Burns mainly noted on right foot.

3. Symmetrical burns on both feet.

14. The client with type 2 diabetes is prescribed prednisone, a steroid, for an acute exacerbation of inflammatory bowel disease. Which intervention should the nurse discuss with the client? 1. Take this medication on an empty stomach. 2. Notify the HCP if experiencing a moon face. 3. Take the steroid medication as prescribed. 4. Notify the HCP if the blood glucose is over 160.

3. Take the steroid medication as prescribed. *This medication must be tapered off to prevent adrenal insufficiency; therefore, the client must take this medication as prescribed.

76. The client diagnosed with end-stage renal failure and ascites is scheduled for a paracentesis. Which client teaching should the nurse discuss with the client? 1. Explain the procedure will be done in the operating room. 2. Instruct the client a Foley catheter will have to be inserted. 3. Tell the client vital signs will be taken frequently after the procedure. 4. Provide instructions on holding the breath when the HCP inserts the catheter.

3. Tell the client vital signs will be taken frequently after the procedure. *The client is at risk for hypovolemia; therefore, vital signs will be assessed frequently to monitor for signs of hemorrhaging.

8. The nurse is preparing a client diagnosed with GERD for surgery. Which information warrants notifying the HCP? 1. The client's Bernstein esophageal test was positive. 2. The client's abdominal x-ray shows a hiatal hernia. 3. The client's WBC count is 14,000/mm3. 4. The client's hemoglobin is 13.8 g/dL.

3. The client's WBC count is 14,000/mm3. *The client's WBC count is elevated, indicating a possible infection, which warrants notifying the HCP.

2. The mother of a newborn asks the nurse why the infant has to nurse so frequently. Which is the best response? 1. Formula tends to be more calorically dense, and formula-fed babies require fewer feedings than breastfed babies. 2. The newborn's stomach capacity is small, and peristalsis is slow. 3. The newborn's stomach capacity is small, and peristalsis is more rapid than in older children. 4. Breastfed babies tend to take longer to complete a feeding than formula-fed babies.

3. The newborn's stomach capacity is small, and peristalsis is more rapid than in older children. *The small-stomach capacity and rapid movement of fluid through the digestive system account for the need for small frequent feedings.

64. The nurse finds small, fluid-filled lesions on the margins of the client's surgical dressing. Which statement is the most appropriate scientific rationale for this occurrence? 1. These were caused by the cautery unit in the operating room. 2. These are papular wheals from herpes zoster. 3. These are blisters from the tape used to anchor the dressing. 4. These macular lesions are from a latex allergy.

3. These are blisters from the tape used to anchor the dressing.

51. A child presents with a history of having had an upper respiratory tract infection 2 weeks ago; complains of symmetrical lower extremity weakness, back pain, muscle tenderness; and has absent deep tendon reflexes in the lower extremities. Which is important regarding this condition? 1. The disease process is probably bacterial. 2. The recent upper respiratory infection is not important information. 3. This may be an acute inflammatory demyelinating neuropathy. 4. CN involvement is rare.

3. This may be an acute inflammatory demyelinating neuropathy. *This child probably has GBS, which is an acute inflammatory demyelinating neuropathy.

51. The client is diagnosed with herpes simplex 2 and prescribed the antiviral medication valacyclovir (Valtrex). Which instructions should the nurse teach? 1. This medication will prevent pregnancy and treat the virus. 2. This medication must be tapered when discontinuing the medication. 3. This medication will suppress symptoms but does not cure the disease. 4. This medication may cause the client's urine to turn orange.

3. This medication will suppress symptoms but does not cure the disease.

15. The client diagnosed with OA is a resident in a long-term care facility. The resident is refusing to bathe because she is hurting. Which instruction should the nurse give the unlicensed assistive personnel (UAP)? 1. Allow the client to stay in bed until the pain becomes bearable. 2. Tell the UAP to give the client a bed bath this morning. 3. Try to encourage the client to get up and go to the shower. 4. Notify the family the client is refusing to be bathed.

3. Try to encourage the client to get up and go to the shower. *Pain will decrease with movement, and warm or hot water will help decrease the pain. The worst thing the client can do is not move.

72. The nurse assesses a large amount of red drainage on the dressing of a client who is six (6) hours postoperative open cholecystectomy. Which intervention should the nurse implement? 1. Measure the abdominal girth. 2. Palpate the lower abdomen for a mass. 3. Turn client onto side to assess for further drainage. 4. Remove the dressing to determine the source.

3. Turn client onto side to assess for further drainage. *Turning the client to the side to assess the amount of drainage and possible bleeding is important prior to contacting the surgeon.

70. The nurse is assessing the client diagnosed with scabies. Which assessment technique would be most appropriate? 1. Gently palpate the affected area using sterile gloves. 2. Apply vinegar to the affected area to identify the scabies. 3. Use a magnifying glass and a penlight to visualize the skin. 4. Obtain a Doppler to assess the movement of the mites.

3. Use a magnifying glass and a penlight to visualize the skin.

23. The client is complaining of joint stiffness, especially in the morning. Which diagnostic tests should the nurse expect the health-care provider to order to R/O osteoarthritis? 1. Full-body magnetic resonance imaging scan. 2. Serum studies for synovial fluid amount. 3. X-ray of the affected joints. 4. Serum erythrocyte sedimentation rate (ESR).

3. X-ray of the affected joints. *X-rays reveal loss of joint cartilage, which appears as a narrowing of the joint space in clients diagnosed with OA.

63. The nurse is discharging a client who had a total hip replacement. Which statement indicates further teaching is needed? 1. "I should not cross my legs because my hip may come out of the socket." 2. "I will call my HCP if I have a sudden increase in pain." 3. "I will sit on a chair with arms and a firm seat." 4. "After three (3) weeks, I don't have to worry about infection."

4. "After three (3) weeks, I don't have to worry about infection." *Infections are possible months after surgery. Clients should monitor temperatures and report any signs of infection.

16. The nurse is caring for an 8-week-old male who has just been diagnosed with Hirschsprung disease. The parents ask what they should expect. Select the nurse's best response. 1. "It is really an easy disease to manage. Most children are placed on stool softeners to help with constipation until it resolves." 2. "A permanent stool diversion, called a colostomy, will be placed by the surgeon to bypass the narrowed area." 3. "Daily bowel irrigations will help your child maintain regular bowel habits." 4. "Although your child will require surgery, there are different ways to manage the disease, depending on how much bowel is involved."

4. "Although your child will require surgery, there are different ways to manage the disease, depending on how much bowel is involved." *The aganglionic portion needs to be removed. Although most children have a temporary colostomy placed, many infants are able to bypass the colostomy and have the bowel immediately reattached.

9. The nurse receives a call from the parent of a 10-month-old who has vomited three times in the past 8 hours. The parent describes the baby as playful and wanting to drink. The parent asks the nurse what to give the child. Select the nurse's best response. 1. "Replace the next feeding with regular water, and see if that is better tolerated." 2. "Do not allow your baby to eat any solids; give half the normal formula feeding, and see if that is better tolerated." 3. "Do not let your baby eat or drink anything for 24 hours to give the stomach a chance to rest." 4. "Give your child 1/2 ounce of Pedialyte every 10 minutes. If vomiting continues, wait an hour, and then repeat what you previously gave."

4. "Give your child 1/2 ounce of Pedialyte every 10 minutes. If vomiting continues, wait an hour, and then repeat what you previously gave." *Offering small amounts of clear liquids is usually well tolerated. If the child vomits, make NPO to allow the stom- ach to rest and then restart fluids. The child in this scenario is described as playful and therefore does not appear to be at risk for dehydration.

61. The school nurse is assessing a teacher who has pediculosis. Which statement by the teacher makes the nurse suspect that the teacher did not comply with the instructions that were discussed in the classroom with the children? 1. "I used the comb to remove all the nits." 2. "I washed my hair with Kwell shampoo." 3. "I removed all the sheets from my bed." 4. "I had to fix my daughter's hair with my brush."

4. "I had to fix my daughter's hair with my brush."

57. Which statement by the client diagnosed with a fractured ulna indicates to the nurse the client needs further teaching? 1. "I need to eat a high-protein diet to ensure healing." 2. "I need to wiggle my fingers every hour to increase circulation." 3. "I need to take my pain medication before my pain is too bad." 4. "I need to keep this immobilizer on when lying down only."

4. "I need to keep this immobilizer on when lying down only." *The immobilizer should be kept on at all times. This indicates the client does not understand the teaching and needs the nurse to provide more instruction.

3. The nurse is preparing a client diagnosed with GERD for discharge following an esophagogastroduodenoscopy. Which statement indicates the client understands the discharge instructions? 1. "I should not eat for at least one (1) day following this procedure." 2. "I can lie down whenever I want after a meal. It won't make a difference." 3. "The stomach contents won't bother my esophagus but will make me nauseous." 4. "I should avoid orange juice and eating tomatoes until my esophagus heals."

4. "I should avoid orange juice and eating tomatoes until my esophagus heals." *Orange juice and tomatoes are acidic, and the client diagnosed with GERD should avoid acidic foods until the esophagus has had a chance to heal.

5. The mother of a child diagnosed with erythema infectiosum (fifth disease). is crying, and says, "I am afraid. Will my unborn baby die? I have a planned cesarean section next week." Which statement would be the most therapeutic response? 1. "Let me get the physician to come and talk with you." 2. "I understand. I would be afraid, too." 3. "Would you like me to call your obstetrician to have you seen as soon as possible?" 4. "I understand you are afraid. Can we can talk about your concerns?"

4. "I understand you are afraid. Can we can talk about your concerns?"

39. The parent of an infant asks the nurse what to watch for to determine if the infant has CP. Which is the nurse's best response? 1. "If the infant cannot sit up without support before 8 months." 2. "If the infant demonstrates tongue thrust before 4 months." 3. "If the infant has poor head control after 2 months." 4. "If the infant has clenched fists after 3 months."

4. "If the infant has clenched fists after 3 months." *Clenched fists after 3 months of age may be a sign of CP.

58. More education about necrotizing enterocolitis (NEC) is needed in a nursing in-service when one of the participants states: 1. "Encouraging the mother to pump her milk for the feedings helps prevent NEC." 2. "Some sources state that the occurrence of NEC has increased because so many preterm infants are surviving." 3. "When signs of sepsis appear, the infant will likely deteriorate quickly." 4. "NEC occurs only in preemies and low-birth-weight infants."

4. "NEC occurs only in preemies and low-birth-weight infants." *Although much more common in preterm and low-birth-weight infants, NEC is also seen in term infants as well.

26. The client diagnosed with osteoporosis asks the nurse, "Why does smoking cigarettes cause my bones to be brittle?" Which response by the nurse is most appropriate? 1. "Smoking causes nutritional deficiencies which contribute to osteoporosis." 2. "Tobacco causes an increase in blood supply to the bones, causing osteoporosis." 3. "Smoking low-tar cigarettes will not cause your bones to become brittle." 4. "Nicotine impairs the absorption of calcium, causing decreased bone strength."

4. "Nicotine impairs the absorption of calcium, causing decreased bone strength." *Nicotine slows the production of osteoblasts and impairs the absorption of calcium, contributing to decreased bone density.

4. The nurse has completed the teaching plan for the client diagnosed with psoriasis. Which statement indicates the need for further teaching? 1. "I will check my skin every day for redness with tenderness." 2. "I must take my psoralen medication two (2) hours before my treatment." 3. "I will wear dark glasses during my treatment and the rest of the day." 4. "The coal-tar ointments and lotions will not stain my clothes."

4. "The coal-tar ointments and lotions will not stain my clothes."

34. The parents of a newborn diagnosed with a cleft lip and palate ask the nurse when their child's lip and palate will most likely be repaired. Select the nurse's best response. 1. "The palate and the lip are usually repaired in the first few weeks of life so that the baby can grow and gain weight." 2. "The palate and the lip are usually not repaired until the baby is approximately 6 months old so that the mouth has had enough time to grow." 3. "The lip is repaired in the first few months of life, but the palate is not usually repaired until the child is 3 years old." 4. "The lip is repaired in the first few weeks of life, but the palate is not usually repaired until the child is 18 months old."

4. "The lip is repaired in the first few weeks of life, but the palate is not usually repaired until the child is 18 months old."

22. Which would be the most therapeutic response for the mother of a 6-month-old who tells the nurse she does not want her infant to have the DTaP vaccine because the infant had localized redness the last time she received the vaccine? 1. "I will let the physician know, and we will not administer the DTaP vaccination today." 2. "Every child has that allergic reaction, and your child will still get the DTaP today." 3. "I will let the physician know that you refuse further immunizations for your daughter." 4. "Would you mind if we discussed your concerns?"

4. "Would you mind if we discussed your concerns?"

27. Which is the nurse's best response to the mother of a 2-month-old who is going to get IPV immunization when the mother tells the nurse the older brother is immunocompromised? 1. "Your baby should not be immunized because your immunocompromised son could develop polio." 2. "Your baby should receive the oral poliovirus vaccine instead so your immuno- compromised son does not get sick." 3. "You should separate your 2-month-old child from the immunocompromised son for 7 to 14 days after the IPV." 4. "Your baby can be immunized with the IPV; he will not be contagious."

4. "Your baby can be immunized with the IPV; he will not be contagious." *Siblings can and should be immunized as recommended. The infant will not shed the poliovirus

1. The parent of a newborn asks, "Will my baby spit out the formula if it is too hot or too cold?" Select the nurse's best response. 1. "Babies have a tendency to reject hot fluids but not cold fluids, which could result in abdominal discomfort." 2. "Babies have a tendency to reject cold fluids but not hot fluids, which could result in esophageal burns." 3. "Your baby would most likely spit out formula that was too hot, but your baby could swallow some of it, which could result in a burn." 4. "Your baby is too young to be physically capable of spitting out fluids and will automatically swallow anything."

4. "Your baby is too young to be physically capable of spitting out fluids and will automatically swallow anything." *Swallowing is a reflex in infants younger than 6 weeks.

25. What would be the nurse's best response if the foster mother of a 15-month-old with an unknown immunization history comes to the clinic requesting immunizations? 1. "Your foster child will not receive any immunizations today." 2. "Your foster child will receive the MMR, Hib, IPV, and hepatitis B vaccines." 3. "Your foster child could have harmful effects if we revaccinate with prior vaccines." 4. "Your foster child will receive only the Hib and DTaP vaccines today."

4. "Your foster child will receive only the Hib and DTaP vaccines today." *Vaccines routinely done at 15 months include Hib and DTaP. To catch up missed immunizations the nurse would need the child's immunization record to verify what he has received

34. The nurse has administered an antibiotic, a proton pump inhibitor, and Pepto-Bismol for peptic ulcer disease secondary to H. pylori. Which data would indicate to the nurse the medications are effective? 1. A decrease in alcohol intake. 2. Maintaining a bland diet. 3. A return to previous activities. 4. A decrease in gastric distress.

4. A decrease in gastric distress. *Antibiotics, proton pump inhibitors, and Pepto-Bismol are administered to decrease the irritation of the ulcerative area and cure the ulcer. A decrease in gastric distress indicates the medication is effective.

7. The nurse is administering morning medications at 0730. Which medication should have priority? 1. A proton pump inhibitor. 2. A nonnarcotic analgesic. 3. A histamine receptor antagonist. 4. A mucosal barrier agent.

4. A mucosal barrier agent. *A mucosal barrier agent must be administered on an empty stomach for the medication to coat the stomach.

11. The nurse is caring for a school-aged child with Duchenne muscular dystrophy in the elementary school. Which would be an appropriate nursing diagnosis? 1. Anticipatory grieving. 2. Anxiety reduction. 3. Increased pain. 4. Activity intolerance.

4. Activity intolerance. *The child would not be able to keep up with peers because of weakness, pro- gressive loss of muscle fibers, and loss of muscle strength.

71. Which problem is highest priority for the nurse to identify in the client who had an open cholecystectomy surgery? 1. Alteration in nutrition. 2. Alteration in skin integrity. 3. Alteration in urinary pattern. 4. Alteration in comfort.

4. Alteration in comfort. *Acute pain management is the highest priority client problem after surgery because pain may indicate a life-threatening problem.

36. The nurse evaluates teaching of parents of a child newly diagnosed with cerebral palsy (CP) as successful when the parents state that CP is which of the following? 1. Inability to speak and uncontrolled drooling. 2. Involuntary movements of lower extremities only. 3. Involuntary movements of upper extremities only. 4. An increase in muscle tone and deep tendon reflexes.

4. An increase in muscle tone and deep tendon reflexes. *The primary disorder is of muscle tone, but there may be other neurological disorders such as seizures, vision disturbances, and impaired intelligence. Spastic CP is the most common type and is characterized by a generalized increase in muscle tone, increased deep tendon reflexes, and rigidity of the limbs on both flexion and extension.

50. The client is complaining of burning, lancinating, stabbing pain that radiates around the left rib cage area. The nurse cannot find any type of skin abnormality. Which action should the nurse implement? 1. Transfer the client to the ED for a cardiac work-up. 2. Inform the client that the nurse can't see anything. 3. Administer a nonnarcotic analgesic to the client. 4. Ask the client if he or she has ever had chickenpox.

4. Ask the client if he or she has ever had chickenpox.

49. The client diagnosed with diverticulitis is complaining of severe pain in the left lower quadrant and has an oral temperature of 100.6 ̊F. Which intervention should the nurse implement first? 1. Notify the health-care provider. 2. Document the findings in the chart. 3. Administer an oral antipyretic. 4. Assess the client's abdomen.

4. Assess the client's abdomen. *The nurse should assess the client to determine if the abdomen is soft and nontender. A rigid tender abdomen may indicate peritonitis.

54. Which should the nurse expect as an intervention in a child in the recovery phase of GBS? 1. Assess for respiratory compromise. 2. Assess for swallowing difficulties. 3. Evaluate neuropsychological functioning. 4. Begin an active physical therapy program.

4. Begin an active physical therapy program. *Beginning active physical therapy is important for helping muscle recovery and preventing contractures.

104. Which data should the nurse expect to assess in the client diagnosed with acute gastroenteritis? 1. Decreased gurgling sounds on auscultation of the abdominal wall. 2. A hard, firm, edematous abdomen on palpation. 3. Frequent, small melena-type liquid bowel movements. 4. Bowel assessment reveals loud, rushing bowel sounds.

4. Bowel assessment reveals loud, rushing bowel sounds. *Borborygmi, or loud, rushing bowel sounds, indicates increased peristalsis, which occurs in clients with diarrhea and is the primary clinical manifestation in a client diagnosed with acute gastroenteritis.

60. Which is an important nursing intervention to monitor in a child with systemic lupus erythematosus (SLE) and renal involvement? 1. Monitor weight. 2. Check for uric salts in urine. 3. Watch for hypotension. 4. Check for protein in urine.

4. Check for protein in urine. *Protein in urine is a sign of renal impairment, even in nephrotic syndrome, in which the kidneys are losing protein.

54. The nurse is caring for a 14-year-old with celiac disease. The nurse knows that the patient understands the diet instructions by ordering which of the following meals? 1. Eggs, bacon, rye toast, and lactose-free milk. 2. Pancakes, orange juice, and sausage links. 3. Oat cereal, breakfast pastry, and nonfat skim milk. 4. Cheese, banana slices, rice cakes, and whole milk.

4. Cheese, banana slices, rice cakes, and whole milk. *Cheese, banana slices, rice cakes, and whole milk do not contain gluten.

38. The nurse goes to the kindergarten classroom to evaluate a rash. A 5-year-old has patches of itchy vesicles on the chest and face. The teacher tells the nurse the child had a runny nose a couple of days ago. The nurse suspects that the rash is caused by which virus? 1. Fifth disease (Parvovirus B19). 2. Roseola (Herpesvirus type 6). 3. Scarlet fever (group A beta-hemolytic streptococcus). 4. Chickenpox (varicella zoster).

4. Chickenpox (varicella zoster).

1. The nurse is caring for an elderly client diagnosed with a herniated nucleus pulposus of L4-5. Which scientific rationale explains the incidence of a ruptured disk in the elderly? 1. The client did not use good body mechanics when lifting an object. 2. There is an increased blood supply to the back as the body ages. 3. Older clients develop atherosclerotic joint disease as a result of fat deposits. 4. Clients develop intervertebral disk degeneration as they age.

4. Clients develop intervertebral disk degeneration as they age. *Less blood supply, degeneration of the disk, and arthritis are reasons elderly people develop back problems.

25. Which assessment data support to the nurse the client's diagnosis of gastric ulcer? 1. Presence of blood in the client's stool for the past month. 2. Reports of a burning sensation moving like a wave. 3. Sharp pain in the upper abdomen after eating a heavy meal. 4. Complaints of epigastric pain 30 to 60 minutes after ingesting food.

4. Complaints of epigastric pain 30 to 60 minutes after ingesting food. *In a client diagnosed with a gastric ulcer, pain usually occurs 30 to 60 minutes after eating, but not at night. In contrast, a client with a duodenal ulcer has pain during the night often relieved by eating food. Pain occurs 1 to 3 hours after meals.