322 exam 2 prepu
The parent of a child with Down syndrome calls the nurse and reports 3 weeks of a lack of energy, limping, and weight loss in the young child. What is the most appropriate response by the nurse?
"Bring your child to the primary health care provider to be examined."
The nurse is preparing to post a sign above the crib of an infant with a Wilms tumor. Which statement should the nurse post immediately?
"Do not palpate abdomen."
A parent expresses concern that the child has an autism spectrum disorder. The nurse obtains a health history of the symptoms to understand the parent's concern. Which question would the nurse ask first?
"Does your child interact with you when playing?"
A nurse is teaching a client with osteoporosis about dietary selections. What client statement indicates the teaching was effective?
"I will eat more dairy products to increase my calcium intake."
A nurse taking a health history from an adolescent female would become concerned about anorexia if the adolescent made which statement?
"I've been really tired lately, but I'm afraid that if I rest I will get fatter than I am already."
The nursing educator has completed an educational program for new nurses on eating disorders in teenagers. Which statement by a participant would indicate a need for further education?
"If they refuse to eat, we need to sit with them and not let them leave the table until they do eat something."
What is the best response by the nurse to the parents of a child with leukemia who express guilt because they did not take immediate action when their child seemed to develop one respiratory infection after another?
"Keep in mind that the signs of leukemia are often subtle and difficult to recognize."
A nurse is caring for four patients. Which patient is most likely at a greater risk for the development of blindness?
A 58-year-old Caucasian woman with macular degeneration
The nurse admits a client to the emergency department who has been referred by the eye clinic. Which condition is an emergency where the nurse should refer the client for medical treatment immediately?
Acute angle-closure glaucoma
An older adult client slipped on an area rug at home and fractured the left hip. The client is unable to have surgery immediately and is having severe pain. What interventions should the nurse provide for the patient to minimize energy loss in response to pain?
Administer prescribed analgesics around-the-clock.
The nurse is caring for a client with a hip fracture. The physician orders the client to start taking a bisphosphonate. Which medication would the nurse document as given?
Alendronate
Following cataract removal, discharge instructions will be provided to the client. Which of the following instructions is most important?
Avoid any activity that can increase intraocular pressure.
The nurse is providing health education for a male patient who is preparing to be discharged home following a recovery from total hip replacement surgery. When reviewing the guidelines for safe mobility and positioning to prevent injury, the nurse should teach the patient to:
Avoid crossing his legs for the next several months.
In a client with a dislocation, the nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable. Which complication does the assessments help the nurse to monitor?
Compartment syndrome
The RICE acronym is helpful for remembering treatment interventions for musculoskeletal injuries. Which of the following are components of the RICE acronym? Select all that apply.
Compression Rest Elevation Ice
An older adult female has a bone density test that reveals severe osteoporosis. What does the nurse understand can be a problem for this client due to the decrease in bone mass and density?
Compression fractures
A nurse is teaching a patient with glaucoma how to administer her eye drops to achieve maximum absorption. Where should the nurse teach the patient to instill the eye drop?
Conjunctival sac
Which of the following medications needs to be withheld for 5 to 7 days prior to cataract surgery?
Coumadin
The nurse cares for adolescents with cancer. Which recommended psychosocial interventions will the nurse use to help the adolescents cope with their disease? Select all that apply.
Encourage adolescents to engage in their usual activities. Be an advisor as well as a friend to the adolescents to promote cooperation in the care plan. Control the amount of information given out about an adolescent's condition. Encourage the adolescents to make plans for the future.
A parent contacts the oncology clinic nurse with concerns about mucositis following chemotherapy. Which are appropriate interventions for the nurse to include? Select all that apply.
Encourage rinsing the mouth with lukewarm water. Use a soft toothbrush and swish with an antibiotic mouthwash. Serve soft foods rather than hard or crunchy foods. Have the child drink fluids as often as possible to remain hydrated.
The nurse is planning an education program for women of childbearing years. What does the nurse recognize as the primary prevention of osteoporosis?
Ensuring adequate calcium and vitamin D intake
Which of the following eye disorders is caused by an elevated intraocular pressure (IOP)?
Glaucoma
A nurse notices a client lying on the floor at the bottom of the stairs. The client is alert and oriented and denies pain other than in the arm, which is swollen and appears deformed. After calling for help, what should the nurse do?
Immobilize the client's arm.
A nurse is giving instructions to the father of a boy who is receiving chemotherapy (including methotrexate) regarding how best to care for the boy during this period of treatment. What should the nurse mention to him?
Keep him away from people with known infections
A client undergoes open reduction with internal fixation to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in the postoperative care plan?
Keeping a pillow between the client's legs at all times
A patient is being discharged home from the ambulatory surgical center after cataract surgery. In reviewing the discharge instructions with the patient, the nurse instructs the patient to immediately call the office if he experiences what?
New floater in vision
A family member is caring for an older adult client with osteomalacia in the home. When the home health nurse comes to evaluate the client, what should be a focus point of the visit?
Observing for safety hazards that could be a fall risk
The community nurse is visiting the home of a family with a child with mild intellectual disability. Which observation indicates that the family is adjusting to this child's learning capacity?
Parents support and engage the child in family conversation.
A client with metastatic bone cancer sustained a left hip fracture without injury. What type of fracture does the nurse understand occurs without trauma or fall?
Pathologic fracture
Nursing students are reviewing information about the causes associated with low vision and blindness. The students demonstrate a need for additional review when they identify which of the following as a common cause in older adults?
Presbyopia
A nurse is caring for an older woman with a hip fracture. What are appropriate risk factors for the nurse to consider related to the client's hip fracture? Select all that apply.
Presence of anemia Female gender Osteoporosis
An orthopedic trauma patient is receiving lower-body skeletal traction and will continue to do so for several weeks. When planning the patient's care, what nursing diagnosis should be prioritized?
Risk for impaired skin integrity
Which of the following is the most important nursing diagnosis for an elderly patient diagnosed with osteoporosis?
Risk for injury related to fractures due to osteoporosis
A 17-year-old girl has been diagnosed with bulimia nervosa. Which complication should the nurse carefully assess for in this client?
Severe erosion of teeth
Which is a risk-lowering strategy for osteoporosis?
Smoking cessation
A patient has been told he has cataracts in both eyes. The patient wants to know what his treatment options are. What is the most appropriate treatment option for patients with age-related cataracts that are affecting the patient's ability to function?
Surgical intervention
The nurse is caring for a 12-month-old child diagnosed with an autism spectrum disorder. What information from the mother during the health history should the nurse identify as being consistent with the disorder?
The child constantly stares at a rotating wheel on the crib mobile.
Which behavior by a parent would lead the postpartum nurse to become concerned about the potential for abusive parenting?
The mother does not choose to hold or feed her infant.
A female patient is sufficiently stable to be transferred from the PACU to the postsurgical unit following her total hip replacement surgery early this morning. When preparing to admit this patient, the nurse on the postsurgical unit should anticipate that the patient will require what positioning?
With her legs slightly abducted
The parents of a 9-year-old child tell the nurse, "We are so frustrated with our child. We do not know what to do. Our child makes careless mistakes on tests and homework despite being intelligent, is very disorganized, and never follows through with chores at home." The nurse anticipates this child may have which disorder?
attention deficit disorder
A client has a fractured femur and is being seen in the emergency department. The nurse assessing the area notices there is a grating sound that is suspected to be bone ends moving over one another. This would be called:
crepitus.
A child has been diagnosed with medical abuse by his mother. When setting goals, which goal is highest priority?
establishing the safety of the child
When obtaining the health history from a client with retinal detachment, a nurse expects the client to report:
light flashes and floaters in front of the eye.
A 10-year-old who is receiving chemotherapy has received ondansetron before this therapy session. About an hour later, the child tells the nurse that his mouth feels really dry. The child has urinated several times and his skin turgor is normal. Which response by the nurse would be most appropriate?
"The drug you got to help with the nausea can cause dry mouth."
A nurse is performing discharge teaching for an elderly client diagnosed with osteoporosis. Which statement about home safety should the nurse include?
"Most falls among the elderly occur in the home. These clients should remove throw rugs and install bathroom grab bars."
An adolescent is recovering from surgery, radiation, and chemotherapy following a diagnosis of Ewing sarcoma. Which statement by the family indicates that reteaching is needed?
"Our child is looking forward to playing football again."
An older adult man has been diagnosed with a femoral head fracture after falling outside his home, and his health care provider has chosen open reduction with internal fixation (ORIF). How should the nurse best explain this procedure to the patient?
"The surgeon will use pins and rods to keep your bones in place until they heal."
A 2-year-old child has been diagnosed with autism spectrum disorder. The parents ask the nurse for a treatment that will cure the disorder. Which is the best response by the nurse?
"There are no medications available to cure autism."
A young child has just received a prosthesis following enucleation due to retinoblastoma. Which nursing instruction is appropriate? Select all that apply.
Future testing will need to be done to determine if metastasis has occurred. All children in the family will need to have eye examinations. The prognosis for retinoblastoma is good. Follow-up evaluations will be needed for vision changes.
The nurse is teaching parents about help improving their child's nutritional status while on chemotherapy. What information would be included in the teaching? Select all that apply.
Provide nutritious snacks such as a milkshake. Suggest eating prior to chemotherapy. Maintain pleasant family meal times even if child is not hungry. Encourage the child to pick foods that are appetizing.
