8 Questions (Ch. 46), 7 Questions (Ch. 41), 5 Questions (Ch. 26), 5 Questions (Ch. 26), 2 Questions (Ch. 27), 2 Questions (Ch. 27), 3 Questions (Ch. 37), 4 Questions (Ch. 42), 7 Questions (Ch. 44), 5 Questions (Ch. 45), 3 Questions (Ch 16), 4 Questio...
The nurse is assessing a school-age child. The child stays with a parent who is recently divorced and has a meager income. The child does not like to mingle with other students at school. The child's performance is poor in studies and is cruel toward pets at home. Which factors in the child could most likely lead to pediatric social illness? Select all that apply. 1 Poverty 2 Pet cruelty 3 Single parent 4 Going to school 5 Behavior with others
1, 2, 3, 5 Pediatric social illness is a new morbidity in children. It refers to "the behavior, social, and educational problems that the children face". Poor socioeconomic status is a social problem. Animal cruelty is a behavioral problem. Problem within the family is a social problem Failure at school is an educational problem, and behavior with other children is also a behavioral problem. Any of these could cause pediatric social illness. Going to school does not cause social illness. It helps the child to gain knowledge, learn moral values, and to lead a successful life.
What important information should the nurse include when teaching the parents of an adolescent about nutrition? 1 Adolescents are usually mature enough to make healthy food choices. 2 Resources are available to assist lower income families to obtain enough protein. 3 Behavior problems in this age group are not related to nutritional deficiencies. 4 Parental influence has the greatest impact on food choices at this age.
2 Lower income families may need resources and information about how to obtain assistance in getting expensive foods such as meats to get enough protein intake. During adolescence, parental influence diminishes and the adolescent makes food choices related to peer acceptability and sociability. Occasionally these choices are detrimental to adolescents with chronic illnesses, such as diabetes, obesity, chronic lung disease, hypertension, cardiovascular risk factors, and renal disease. Families that struggle with lower incomes, homelessness, and migrant status generally lack the resources to provide their children with adequate food intake; nutritious foods, such as fresh fruits and vegetables; and appropriate protein intake. The result is nutritional deficiencies with subsequent growth and developmental delays, depression, and behavior problems. Behavior problems can indeed be related to nutritional deficiencies.
To establish evidence-based practice, the nurse has to collect high-quality evidence from various sources. Where does the nurse find the best quality of evidence? 1 Observational studies 2 Hospital patient records 3 Randomized clinical trials 4 Direct interview with patients
3 The nurse knows the best source for consistence and unbiased evidence is from well-performed randomized clinical trials (RCT). Observational studies have biased information, so are not reliable, unless the study is done meticulously. RCTs are preferred to hospital records or patient interviews. As biases can affect the establishment of evidence-based practice, the nurse should take precautions to avoid biased or low-quality evidence.
The earliest clinical manifestation of biliary atresia is: a. Jaundice. c. Hepatomegaly. b. Vomiting. d. Absence of stooling.
A Jaundice is the earliest and most striking manifestation of biliary atresia. It is first observed in the sclera and may be present at birth, but is usually not apparent until ages 2 to 3 weeks. Vomiting is not associated with biliary atresia. Hepatomegaly and abdominal distention are common but occur later. Stools are large and lighter in color than expected because of the lack of bile.
8.Therapeutic management of nephrosis includes: a. Corticosteroids. b. Antihypertensive agents. c. Long-term diuretics. d. Increased fluids to promote diuresis.
ANS: A Corticosteroids are the first line of therapy for nephrosis. Response is usually seen within 7 to 21 days. Antihypertensive agents and long-term diuretic therapy are usually not necessary. A diet that has fluid and salt restrictions may be indicated.
34. In which situation is there the greatest risk that a newborn infant will have a congenital heart defect (CHD)? a. Trisomy 21 detected on amniocentesis b. Family history of myocardial infarction c. Father has type 1 diabetes mellitus d. Older sibling born with Turner's syndrome
ANS: A The incidence of congenital heart disease is approximately 50% in children with trisomy 21 (Down syndrome). A family history of congenital heart disease, not acquired heart disease, increases the risk of giving birth to a child with CHD. Infants born to mothers who are insulin dependent have an increased risk of CHD. Infants identified as having certain genetic defects, such as Turner's syndrome, have a higher incidence of CHD. PTS: 1 DIF: Cognitive Level: Application REF: 1321 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
39.The nurse should expect to assess which clinical manifestations in an adolescent with Cushing's syndrome (Select all that apply)? a. Hyperglycemia b. Hyperkalemia c. Hypotension d. Cushingoid features e. Susceptibility to infections
ANS: A, D, E In Cushing's syndrome, physiologic disturbances seen are cushingoid features, hyperglycemia, susceptibility to infection, hypertension, and hypokalemia.
10.Exophthalmos (protruding eyeballs) may occur in children with: a. Hypothyroidism. b. Hyperthyroidism. c. Hypoparathyroidism. d. Hyperparathyroidism.
ANS: B Exophthalmos is a clinical manifestation of hyperthyroidism. Hypothyroidism, hypoparathyroidism, and hyperparathyroidism are not associated with exophthalmos.
12. A child is admitted with acute glomerulonephritis. The nurse would expect the urinalysis during this acute phase to show: a. Bacteriuria and hematuria. b. Hematuria and proteinuria. c. Bacteriuria and increased specific gravity. d. Proteinuria and decreased specific gravity.
ANS: B Urinalysis during the acute phase characteristically shows hematuria and proteinuria. Bacteriuria and changes in specific gravity are not usually present during the acute phase.
23.The diet of a child with chronic renal failure is usually characterized as: a. High in protein. b. Low in vitamin D. c. Low in phosphorus. d. Supplemented with vitamins A, E, and K.
ANS: C Dietary phosphorus is controlled to prevent or control the calcium/phosphorus imbalance by the reduction of protein and milk intake. Protein should be limited in chronic renal failure to decrease intake of phosphorus. Vitamin D therapy is administered in chronic renal failure to increase calcium absorption. Supplementation with vitamins A, E, and K is not part of dietary management in chronic renal disease.
22. The mother of a 1-month-old infant tells the nurse that she worries that her baby will get meningitis like her oldest son did when he was an infant. The nurse should base her response on knowing that: a. Meningitis rarely occurs during infancy. b. Often a genetic predisposition to meningitis is found. c. Vaccination to prevent all types of meningitis is now available. d. Vaccination to prevent Haemophilus influenzae type b meningitis has decreased the frequency of this disease in children.
ANS: D H. influenzae type B meningitis has virtually been eradicated in areas of the world where the vaccine is administered routinely. Bacterial meningitis remains a serious illness in children. It is significant because of the residual damage caused by undiagnosed and untreated or inadequately treated cases. The leading causes of neonatal meningitis are the group B streptococci and Escherichia coli organisms. Meningitis is an extension of a variety of bacterial infections. No genetic predisposition exists. Vaccinations are not available for all of the potential causative organisms.
24. A common, serious complication of rheumatic fever is: a. Seizures. c. Pulmonary hypertension. b. Cardiac arrhythmias. d. Cardiac valve damage.
ANS: D Cardiac valve damage is the most significant complication of rheumatic fever. Seizures, cardiac arrhythmias, and pulmonary hypertension are not common complications of rheumatic fever. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1345 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
15.The most common cause of acute renal failure in children is: a. Pyelonephritis. b. Tubular destruction. c. Urinary tract obstruction. d. Severe dehydration.
ANS: D The most common cause of acute renal failure in children is dehydration or other causes of poor perfusion that may respond to restoration of fluid volume. Pyelonephritis and tubular destruction are not common causes of acute renal failure in children. Obstructive uropathy may cause acute renal failure, but it is not the most common cause.
Which term refers to opacity of the crystalline lens that prevents light rays from entering the eye and refracting on the retina? a. Myopia b. Amblyopia c. Cataract d. Glaucoma
Answer: c. Cataract
An adolescent gets hit in the eye during a fight. The school nurse, using a flashlight, notes the presence of gross hyphema (hemorrhage into anterior chamber). The nurse should: a. Apply a Fox shield. b. Instruct the adolescent to apply ice for 24 hours. c. Have adolescent rest with eye closed and ice applied. d. Notify parents that adolescent needs to see an ophthalmologist.
Answer: d. Notify parents that adolescent needs to see an ophthalmologist.
3 The most common manifestation of distress in children is loss of appetite. The child is emotionally distressed by the parents' separation, and this stress can be manifested by a loss of appetite. Body aches, increased sleep, and rash over the body are physical symptoms that are very rarely seen in emotional distress. These symptoms may be caused by a viral infection.
Parents who are divorcing are worried about how the divorce will affect their child. Which symptom indicates unhealthy coping in the child? 1 Body aches 2 Increased sleep 3 Loss of appetite 4 Body rash
1 There are two types of social groups, primary and secondary. The primary group consists of peers and family who have a direct contact with and influence on the person. Secondary groups are indirectly related to the person. The examples include social organizations such as the church group, and professional groups such as office colleagues and professional seniors. Test-Taking Tip: Read carefully and answer the question asked; pay attention to specific details in the question.
The community health nurse is performing an assessment of an adolescent. Which group does the nurse ask the adolescent about when assessing the primary social group? 1 Peers 2 Church group 3 Work colleagues 4 Professional seniors
Leopold maneuvers would be an inappropriate method of assessment to determine: a. Gender of the fetus. b. Number of fetuses. c. Fetal lie and attitude. d. Degree of the presenting part's descent into the pelvis.
a. Gender of the fetus.
If a woman complains of back labor pain, the nurse could best suggest that she: a. Lie on her back for a while with her knees bent. b. Do less walking around. c. Take some deep, cleansing breaths. d. Lean over a birth ball with her knees on the floor.
d. Lean over a birth ball with her knees on the floor.
The nurse is teaching a pregnant woman to eat a nutritious diet and to attend regular antenatal health check-ups for the assessment of fetal well-being. The primary purpose of this nursing intervention is to reduce the neonatal mortality rate due to: 1 birth weight less than 2.5g. 2 gestational diabetes in mother. 3 birth weight of more than 3.5 g. 4 febrile convulsions in neonate
1 Birth weight of less than 2,500 grams or 5.5 pounds in considered low birth weight (LBW). LBW is associated with higher neonatal mortality rate in the United States when compared with other countries. The lower the birth weight, the higher the mortality rate. Birth weight of the neonates born to uncontrolled diabetic mother can be high. The mortality rate of neonates born with a birth weight of more than 3.5 g is lower than that of neonates born with LBW. Febrile convulsions seldom cause death in neonates. Test-Taking Tip: Key words or phrases in the stem of the question such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. As in life, no real absolutes exist in nursing; however, every rule has its exceptions, SO answer with care.
The senior nurse instructed the student nurse to check the website, www.ndvh.org. Information about which topic will the student nurse find on this website? 1 Domestic violence 2 Malnourishment 3 Infant mortality rate 4 Hospital administration
1 In USA, www.ndvh.org is the official website of the National Domestic Violence Hotline. Pediatric nurses can find valuable information on this website related to the signs of exposure to violence in children. This website also provides nonviolent problem-solving strategies, counseling, and referrals for children who are the victims of domestic abuse. Information about malnourishment, infant mortality rates, and hospital administration is not available at this website.
A patient is put on a ventilator in the intensive care unit of a tertiary hospital for long-term care. While caring for the patient, the nurse continuously assesses the health status of the patient. How does this intervention affect the patient's outcome? It prevents: 1 pneumonia. 2 lung cancer. 3 cystic fibrosis. 4 pulmonary edema.
1 One of the major disadvantages of long-term ventilator care is ventilator-associated pneumonia. The nurse has to assess the patient for ventilator-associated pneumonia or for the early detection of respiratory complications due to ventilators. Lung cancer is not associated with ventilator support. Cystic fibrosis is due to defect in chromosome number 7. Pulmonary edema is not the main concern associated with ventilators in the ICU.
The pediatric nurse is providing first aid to a child. The child sustained minor injuries while playing on the ground, and has severe pain in the knee joint. Which of the nursing interventions in the care of the child come under atraumatic care? Select all that apply. 1 Controlling pain 2 Allowing the child's privacy 3 Respecting cultural differences 4 Fostering the parent-child relationship 5 Giving vaccination for preventing tetanus
1, 2, 3, 4 Atraumatic care refers to the provision of the therapeutic interventions that would minimize or eliminate a patient's physical and psychologic distress. Atraumatic care includes interventions to reduce physical distress such as pain control measures. Interventions such as allowing the child privacy, respecting cultural differences, and fostering the parent-child relationship are examples of interventions those are helpful in minimizing psychologic distress in the child. Preventive measures such as vaccination for preventing tetanus are not an intervention included in a traumatic care.
The nurse is instructing the parents of a 6-month-old child about the dietary requirements and factors that may influence the eating habits of the child. Which statement made by the nurse is appropriate? Select all that apply. 1 "Culture will have some influence on children's eating habits." 2 "Cholesterol is required for the synthesis of neurons in child's brain." 3 "During adolescence, children tend to make food choices for sociability." 4 "First 3 years of life are crucial in establishing eating habits of children." 5 "Cholesterol content is high in nuts and vegetable oils so use them sparingly."
1, 2, 3, 4 The nurse should inform the parents that culture has some influence on children's eating habits, and the child is likely to follow it. Cholesterol is required for the synthesis of neurons in the child's brain and should be included in the diet. During adolescence, children tend to make food choices for sociability and the first 3 years of life are crucial in establishing eating habits of children. Cholesterol is present only in animal products such as meat, milk, and eggs but not present in plant products.
Parents inform the nurse that they had noticed some needle injuries on their child's left elbow and some syringes and needles in the child's school bag. What should the nurse suggest to the child's parent? Select all that apply. 1 Encourage the child to participate in scouts. 2 Discourage the child from participating in sports due to injury. 3 Encourage the child to participate in church activities. 4 Provide first aid to the child and apply bandage to elbow. 5 Educate the parent and children about the ill effects of drugs.
1, 3, 5 The nurse should understand that the child is taking to illicit drugs. Preventive measures to reduce the youth's illicit drug use include encouraging participation in organized sports, scouts, and other church activities. The children and parents should be educated on the ill effects of drugs. Sports are not contraindicated and first aid is not a preventive measure.
The nurse is reviewing mortality indicators in a city with a population of 30 million. In 2011, there were 3000 total live births, 60 stillbirths, 60 deaths younger than 28 weeks of age, 30 deaths younger than 4 weeks of age, and 90 deaths younger than 1 year (includes all subcategories of deaths younger than 1 year). What is the neonatal mortality rate of the city? Record your answer using a whole number. _____ per 1000 live births
10 Neonate refers to a baby who is younger than 28 days of age. The number of deaths younger than 28 days, or 4 weeks, was 30. Therefore, neonatal mortality rate = number of deaths younger than 28 days (4 weeks) / number of live births or 30 / 3000 = 10 / 1000.
The number of deaths of children in community are 24, 86, 100, and 200 respectively for the children under the age of 4 weeks, 4 months, 28 weeks, and 8 months per 2,000 live births. What is the neonatal mortality rate? Record your answer using whole number. _____/1,000 live births
12 Neonatal mortality rate is the number of deaths during the first 28 days of life per 1,000 live births. In this case, death rate of children under 4 weeks (28 days) in this community is 24/2,000 live births so this it is equal to 12/1,000 live births.
The pediatric nurse has recorded the birth weight, head circumference, axillary temperature, and crown to rump length of a newborn baby. What does the nurse consider while assessing the risk for mortality in this infant? 1 Measure head circumference on alternate weeks. 2 Use the birth weight for the assessment of infant mortality rate. 3 Prefer rectal temperature to axillary temperature in the new born. 4 Crown to rump length is the best indicator of infant mortality rate
2 Low birth weight is associated with high mortality rate so birth weight is considered in predicting the infant mortality rate. Head circumference, rectal temperature or axillary temperature, and crown to rump length are generally not preferred indicators as compared to birth weight. Large head may increase the susceptibility of the child to acquire a head injury. Body temperature fluctuates due to many physiologic and pathological reasons. Alterations in rectal or axillary temperature of a newborn do not indicate that the child has high infant mortality rate. The height (crown-rump length) of the newborn is not an indicator of infant mortality rate. Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds. Continue to analyze the options. If you can eliminate one more choice in a four-option question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago had seemed completely forgotten.
The nurse who works in a pediatric ward wants to explore his/her own ability to develop a therapeutic relationship with children and their families. The nurse does a self-assessment to evaluate the caregiving style by using an assessment questionnaire. In the questionnaire the nurse answers "yes" to a question, which indicates a positive action. What was the question to which the nurse answered as "yes"? 1 "Do you control visitor access to children by using excuses?" 2 "Do you periodically interview children to determine their current issues?" 3 "Do you become critical when parents do not visit their children?" 4 "Does the senior nurse appreciate you for being close to the child?"
2 The nurse should maintain a therapeutic relationship with the children and their families to provide effective care. While performing the self assessment of the ability to develop therapeutic relationship with children, the nurse should evaluate her or his positive actions and negative actions. To evaluate the positive action the nurse should check whether she or he is taking periodical interviews of the children. It helps to evaluate their health, emotions, and feelings. The negative actions include restricting the parents not to see their children. Children feel comfortable with their parents, so the nurse should not restrict them. The nurse should not be critical and judgmental, as it is unprofessional. The nurse can suggest the parents spend time with children. The nurse should not be too close with any child.
In 2010, there were 2000 live births in an area with a population of 20 million. There were 10 deaths among infants younger than 27 days old, 20 deaths among children ages 0 to 6 months, and 40 deaths among children younger than 1 year of age (includes all subcategories of deaths under 1 year). What is the infant mortality rate (IMR)? Record your answer using a whole number. _____________ per 1000 live births.
20 The infant mortality rate is the number of deaths during the first year of life per 1000 live births. The number of deaths of infants younger than 1 year of age was 40. Thus, IMR = number of deaths under 1 year / number of live births or 40 / 2000 = 20 / 1000.
The nurse is caring for a patient who is on long-term catheterization. According to the National Quality Forum, what should the nurse assess in this patient? 1 Oxygen saturation using arterial or venous blood 2 Monitoring of respiratory rate while in a sitting position 3 Signs and symptoms of a urinary tract infection 4 Abnormal changes in the electrocardiogram (ECG)
3 According to National Quality Forum, the nurse has to measure the patient-centered outcome. The nurse has to assess the patients in the intensive care unit (ICU) regularly to identify the urinary tract infections associated with the urinary catheter. Signs and symptoms of a urinary tract infection are fever, burning urination, and yellow urine. The urinalysis is done to confirm the presence of urinary tract infection (UTI). Urinary catheterization has no direct association with changes in arterial or venous oxygen saturation, respiratory, or cardiac complication.
Nurses play an important role in current issues and trends in health care. What is a current trend in pediatric nursing and health care today? 1 The patient is the unit of care for the health care provider. 2 Discharge planning begins when the physician writes the order. 3 Health promotion resources enable children to achieve their full potential. 4 The focus of pediatric health care is trending toward acute hospital care.
3 Health promotion provides opportunities to reduce differences in current health status among members of different groups and provides a better chance to achieve the fullest health potential. The patient and family is the unit of care for the health care provider. Discharge planning begins when the patient is admitted. The focus of pediatric health care is trending away from acute hospital settings.
The signs and symptoms in a nursing diagnosis describe: 1 projected changes in an individual's health status, clinical conditions, or behavior. 2 an individual's response to health pattern deficits in the child, family, or community. 3 a cluster of cues and/or defining characteristics that are derived from patient assessment and indicate actual health problems. 4 physiologic, situational, and maturational factors that cause the problem or influence its development.
3 Identifying characteristics derived from patient assessment is the third part of the nursing diagnosis , the signs and symptoms. Projected changes in health status are the outcomes or goals that are established. An individual's response to health pattern deficits is the definition of the problem statement, the first component of the nursing diagnosis. The factors that cause the problem or influence its development is the definition of etiology, the second component of the nursing diagnosis.
The pediatric nurse works efficiently in providing nursing care to an acutely ill child. After discharge, parents of the child ask the nurse to visit their home for dinner. What should the nurse do? 1 Accept it; otherwise it may adversely affect the good relationship. 2 Tell them to schedule it later as it is a busy day in hospital. 3 Reject it courteously and thank them for the invitation. 4 Ask them to invite other staff who were involved in the care as well.
3 The nurse is not supposed to develop personal relationships with the children and families during the care and after the discharge. Therefore, the nurse has to courteously reject such invitations that may lead to personnel relationships. Even if the nurse is busy, the nurse should not accept invitations for lunch, dinners, or other parties, or ask the families to invite other medical staff. This shows unprofessional behavior.
The parent of a newborn child asks the nurse the importance of breastfeeding. What should the nurse tell the parent? Select all that apply. 1 Breast milk is not rich in micronutrients. 2 Breast milk is not recommended for infants with fever. 3 Enzymes in breast milk are helpful in the digestion of milk. 4 Immunoglobulins in milk can prevent infections and diseases. 5 Breastfeeding can decrease infant mortality and morbidity.
3, 4, 5 Breast milk contains enzymes that are helpful in the digestion of milk and improve the bioavailability of all nutrients in the milk. Immunoglobulins in milk give immunity against infections and allergies. Hence, breastfeeding can decrease infant mortality and morbidity. Breast milk is rich in micronutrients. Breast milk has immunologic properties, so it can be given to the infants with fever.
The community nurse has conducted a survey on the frequency of occurrences of various diseases and health problems such as acne, headache, diarrhea, and upper respiratory tract infections (URTI) in children. What trend would the nurse most likely notice from the survey? The frequency of: 1 Acne decreases with age 2 URTI increases with age 3 Diarrhea increases with age 4 Headaches increases with age
4 Children who have had a particular type of problem are more likely to have that problem again. Therefore, the frequency of headaches increases with age. The activity of sebaceous glands increases with age and therefore the frequency of acne also increase with age. The immune system becomes stronger with age in children. Therefore, the frequency of upper respiratory tract infections (URTI) and diarrhea decreases with age.
Evidence-based practice, a current health care trend, is best described as: 1 gathering evidence of mortality and morbidity in children. 2 meeting physical and psychosocial needs of the child and family in all areas of practice. 3 using a professional code of ethics as a means for professional self-regulation. 4 questioning why something is effective and whether there is a better approach.
4 Evidence-based practice helps to focus on measurable outcomes and the use of demonstrated, effective interventions and questions whether there is a better approach. Gathering evidence of mortality and morbidity in children will assist the nurse in determining areas of concern and potential involvement. It is not possible to meet all needs of the family and child in all areas of practice. The nurse is an advocate for the family. This is part of the professional role and licensure. Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds. Continue to analyze the options. If you can eliminate one more choice in a four-option question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago had seemed completely forgotten.
The role of the pediatric nurse is influenced by trends in health care. The greatest trend in health care is: 1 primary focus on treatment of disease or disability. 2 national health care planning on a distributive or episodic basis. 3 accountability to professional codes and international standards. 4 shift of focus to prevention of illness and maintenance of health.
4 Prevention is the current focus of health care, one in which nursing plays a major role. Traditionally, treating disease or disability is the role of the physician. National health care planning is not a major trend. Accountability to professional codes is an established responsibility, not a trend.
The nurse is evaluating the quality of evidence of research found in the field of infectious diseases in infants. The nurse found unusually strong evidence from unbiased observational studies. What grade should be given to this research according to the GRADE criteria? 1 Low 2 High 3 Very low 4 Moderate
4 The GRADE criteria are used for grading the evidence of research by nurses. According to this, if evidence is found to be unusually strong from unbiased observational studies, it should be graded as moderate. Low grade is given to the evidence with at least one critical outcome from the observation studies. High grade is given to the studies with exceptionally strong evidence from unbiased observational studies and very low grade is given to studies with at least one critical outcome from very indirect evidence.
The nurse is leading an educational program for parents of 5- to 9-year-old children. Which topic should the nurse include in the teaching plan to prevent childhood mortality in children of this age? 1 Suicide 2 Being overweight 3 Heart diseases 4 Unintentional injuries
4 Unintentional injuries and accidents are the leading cause of death in children ages 5 to 9 because this age group have the ability to run and climb and may experience falls, burns, and collisions. Therefore, the nurse should focus mainly on reducing the risk of accidents. Suicide is not a significant cause of mortality in children under the age of 10. Being overweight is a significant problem in childhood, but not the leading cause of deaths in the 5-9 age group. Heart diseases are the most significant causes of mortality in children ages 1-4 years and 15-19 years.
The pediatric nurse is working on a project to contribute to research and evidence-based practice. What should the nurse do when caring for patients of different age groups? Arrange the following steps in the correct order. 1. Develop a care plan. 2. Evaluate the effectiveness of intervention 3. Collect information. 4. Identify specific questions.
4, 3, 1, 2 The responses of the nurse to health and illness have to be followed in an order. The nurse has to identify specific questions to collect appropriate information and develop a care plan to implement. Identification of specific questions to be asked to the patient would help to formulate a clear and precise assessment plan. Collection of subjective and objective information of the patient would be helpful in determining the needs of the patient. Developing a care plan of the patient would help in establish the desired outcomes and the interventions required to achieve those outcomes. Finally, the nurse should evaluate the effectiveness of the intervention to determine if the care plan designed for the patient was successful. Test-Taking Tip: In this Question Type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing a nursing action or skill such as those involved in medication administration.
The nurse has to follow a method of problem identification and problem solving. Arrange the steps of the nursing process model in an appropriate order. 1. Planning 2. Evaluation 3. Diagnosis 4. Assessment 5. Implementation
4, 3, 1, 5, 2 The five-step nursing process model is assessment, diagnosis, planning, implementation, and evaluation. The first step is assessment in which the nurse collects, and analyzes subjective and objective data of the patient. This step is very crucial in determining the Client Needs. The second step is the formulation of the nursing diagnosis. In this phase, the nurse interprets and makes decisions about the acquired data. The third step is planning wherein the nurse develops a care plan and establishes the desired outcomes in the patient. This care plan also includes the interventions that would help the patient to achieve the desired outcomes. The fourth step is implementation in which the interventions that have been listed in the care plan are carried out in a systematic manner. Evaluation is the last step of nursing process which establishes the efficacy of the interventions provided to the patient.
A mother calls the clinic nurse about her 4-year-old son who has acute diarrhea. She has been giving him the antidiarrheal drug loperamide (Imodium A-D). The nurse's response should be based on knowledge that this drug is: a. Not indicated. b. Indicated because it slows intestinal motility. c. Indicated because it decreases diarrhea. d. Indicated because it decreases fluid and electrolyte losses.
A Antidiarrheal medications are not recommended for the treatment of acute infectious diarrhea. These medications have adverse effects and toxicity, such as worsening of the diarrhea because of slowing of motility and ileus, or a decrease in diarrhea with continuing fluid losses and dehydration. Antidiarrheal medications are not recommended in infants and small children.
Marfan syndrome is an autosomal dominant genetic disorder that displays as weakness of the connective tissue, joint deformities, ocular dislocation, and weakness to the aortic wall and root. While providing care to a client with Marfan syndrome during labor, which intervention should the nurse complete first? a. Antibiotic prophylaxis c. Surgery b. -Blockers d. Regional anesthesia
A Because of the potential for cardiac involvement during the third trimester and after birth, treatment with prophylactic antibiotics is highly recommended. -Blockers and restricted activity are recommended as treatment modalities earlier in the pregnancy. Regional anesthesia is well tolerated by clients with Marfan syndrome; however, it is not essential to care. Adequate labor support may be all that is necessary if an epidural is not part of the woman's birth plan. Surgery for cardiovascular changes such as mitral valve prolapse, aortic regurgitation, root dilation, or dissection may be necessary. Mortality rates may be as high as 50% in women who have severe cardiac disease.
As related to the care of the patient with anemia, the nurse should be aware that: a. It is the most common medical disorder of pregnancy. b. It can trigger reflex brachycardia. c. The most common form of anemia is caused by folate deficiency. d. Thalassemia is a European version of sickle cell anemia.
A Combined with any other complication, anemia can result in congestive heart failure. Reflex bradycardia is a slowing of the heart in response to the blood flow increases immediately after birth. The most common form of anemia is iron deficiency anemia. Both thalassemia and sickle cell hemoglobinopathy are hereditary but not directly related or confined to geographic areas
When the pregnant diabetic woman experiences hypoglycemia while hospitalized, the nurse should intervene by having the patient: a. Eat six saltine crackers. b. Drink 8 oz of orange juice with 2 tsp of sugar added. c. Drink 4 oz of orange juice followed by 8 oz of milk. d. Eat hard candy or commercial glucose wafers.
A Crackers provide carbohydrates in the form of polysaccharides. Orange juice and sugar will increase the blood sugar but not provide a slow-burning carbohydrate to sustain the blood sugar. Milk is a disaccharide and orange juice is a monosaccharide. They will provide an increase in blood sugar but will not sustain the level. Hard candy or commercial glucose wafers provide only monosaccharides.
Nurses must be alert for increased fluid requirements when a child has: a. Fever. b. Congestive heart failure. c. Mechanical ventilation. d. Increased intracranial pressure (ICP).
A Fever leads to great insensible fluid loss in young children because of increased body surface area relative to fluid volume. Respiratory rate influences insensible fluid loss and should be monitored in the mechanically ventilated child. Congestive heart failure is a case of fluid overload in children. ICP does not lead to increased fluid requirements in children.
In assessing the knowledge of a pregestational woman with type 1 diabetes concerning changing insulin needs during pregnancy, the nurse recognizes that further teaching is warranted when the client states: a. "I will need to increase my insulin dosage during the first 3 months of pregnancy." b. "Insulin dosage will likely need to be increased during the second and third trimesters." c. "Episodes of hypoglycemia are more likely to occur during the first 3 months." d. "Insulin needs should return to normal within 7 to 10 days after birth if I am bottle-feeding."
A Insulin needs are reduced in the first trimester because of increased insulin production by the pancreas and increased peripheral sensitivity to insulin. "Insulin dosage will likely need to be increased during the second and third trimesters," "Episodes of hypoglycemia are more likely to occur during the first 3 months," and "Insulin needs should return to normal within 7 to 10 days after birth if I am bottle-feeding" are accurate statements and signify that the woman has understood the teachings regarding control of her diabetes during pregnancy.
A young child is brought to the emergency department with severe dehydration secondary to acute diarrhea and vomiting. Therapeutic management of this child will begin with: a. Intravenous fluids. b. Oral rehydration solution (ORS). c. Clear liquids, 1 to 2 ounces at a time. d. Administration of antidiarrheal medication.
A Intravenous fluids are initiated in children with severe dehydration. ORS is acceptable therapy if the dehydration is not severe. Diarrhea is not managed by using clear liquids by mouth. These fluids have a high carbohydrate content, low electrolyte content, and high osmolality. Antidiarrheal medications are not recommended for the treatment of acute infectious diarrhea.
With one exception, the safest pregnancy is one in which the woman is drug and alcohol free. For women addicted to opioids, ________________________ treatment is the current standard of care during pregnancy. a. Methadone maintenance c. Smoking cessation b. Detoxification d. 4 Ps Plus
A Methadone maintenance treatment (MMT) is currently considered the standard of care for pregnant women who are dependent on heroin or other narcotics. Buprenorphine is another medication approved for opioid addiction treatment that is increasingly being used during pregnancy. Opioid replacement therapy has been shown to decrease opioid and other drug use, reduce criminal activity, improve individual functioning, and decrease rates of infections such as hepatitis B and C, HIV, and other sexually transmitted infections. Detoxification is the treatment used for alcohol addiction. Pregnant women requiring withdrawal from alcohol should be admitted for inpatient management. Women are more likely to stop smoking during pregnancy than at any other time in their lives. A smoking cessation program can assist in achieving this goal. The 4 Ps Plus is a screening tool designed specifically to identify pregnant women who need in-depth assessment related to substance abuse.
The nurse is caring for a boy with probable intussusception. He had diarrhea before admission but, while waiting for administration of air pressure to reduce the intussusception, he passes a normal brown stool. The most appropriate nursing action is to: a. Notify the practitioner. b. Measure abdominal girth. c. Auscultate for bowel sounds. d. Take vital signs, including blood pressure.
A Passage of a normal brown stool indicates that the intussusception has reduced itself. This is immediately reported to the practitioner, who may choose to alter the diagnostic/therapeutic plan of care.
Screening at 24 weeks of gestation reveals that a pregnant woman has gestational diabetes mellitus (GDM). In planning her care, the nurse and the woman mutually agree that an expected outcome is to prevent injury to the fetus as a result of GDM. The nurse identifies that the fetus is at greatest risk for: a. Macrosomia. b. Congenital anomalies of the central nervous system. c. Preterm birth. d. Low birth weight.
A Poor glycemic control later in pregnancy increases the rate of fetal macrosomia. Poor glycemic control during the preconception time frame and into the early weeks of the pregnancy is associated with congenital anomalies. Preterm labor or birth is more likely to occur with severe diabetes and is the greatest risk in women with pregestational diabetes. Increased weight, or macrosomia, is the greatest risk factor for this woman.
A high-fiber food that the nurse could recommend for a child with chronic constipation is: a. Popcorn. b. Muffins. c. Pancakes. d. Ripe bananas.
A Popcorn is a high-fiber food. Pancakes and muffins do not have significant fiber unless made with fruit or bran. Raw fruits, especially those with skins and seeds, other than ripe bananas and avocados are high in fiber.
With regard to the association of maternal diabetes and other risk situations affecting mother and fetus, nurses should be aware that: a. Diabetic ketoacidosis (DKA) can lead to fetal death at any time during pregnancy. b. Hydramnios occurs approximately twice as often in diabetic pregnancies. c. Infections occur about as often and are considered about as serious in diabetic and nondiabetic pregnancies. d. Even mild to moderate hypoglycemic episodes can have significant effects on fetal well-being.
A Prompt treatment of DKA is necessary to save the fetus and the mother. Hydramnios occurs 10 times more often in diabetic pregnancies. Infections are more common and more serious in pregnant women with diabetes. Mild to moderate hypoglycemic episodes do not appear to have significant effects on fetal well-being.
Prophylaxis of subacute bacterial endocarditis is given before and after birth when a pregnant woman has: a. Valvular disease. c. Arrhythmias. b. Congestive heart disease. d. Postmyocardial infarction.
A Prophylaxis for intrapartum endocarditis and pulmonary infection may be provided for women who have mitral valve stenosis. Prophylaxis for intrapartum endocarditis is not indicated for congestive heart disease, arrhythmias, or after myocardial infarction.
What food choice by the parent of a 2-year-old child with celiac disease indicates a need for further teaching? a. Oatmeal c. Corn muffin b. Rice cake d. Meat patty
A The child with celiac disease is unable to fully digest gluten, the protein found in wheat, barley, rye, and oats. Oatmeal contains gluten and is not an appropriate food selection. Rice is an appropriate choice because it does not contain gluten. Corn is digestible because it does not contain gluten. Meats do not contain gluten and can be included in the diet of a child with celiac disease.
What is characterized by a chronic inflammatory process that may involve any part of the gastrointestinal (GI) tract from mouth to anus? a. Crohn's disease b. Meckel's diverticulum c. Ulcerative colitis d. Irritable bowel syndrome
A The chronic inflammatory process of Crohn's disease involves any part of the GI tract from the mouth to the anus but most often affects the terminal ileum. Ulcerative colitis, Meckel's diverticulum, and irritable bowel syndrome do not affect the entire GI tract.
An important nursing consideration in the care of a child with celiac disease is to: a. Refer to a nutritionist for detailed dietary instructions and education. b. Help the child and family understand that diet restrictions are usually only temporary. c. Teach proper hand washing and Standard Precautions to prevent disease transmission. d. Suggest ways to cope more effectively with stress to minimize symptoms.
A The main consideration is helping the child adhere to dietary management. Considerable time is spent in explaining to the child and parents the disease process, the specific role of gluten in aggravating the condition, and those foods that must be restricted. Referral to a nutritionist would help in this process. The most severe symptoms usually occur in early childhood and adult life. Dietary avoidance of gluten should be lifelong. Celiac disease is not transmissible or stress related.
Which major neonatal complication is carefully monitored after the birth of the infant of a diabetic mother? a. Hypoglycemia c. Hypobilirubinemia b. Hypercalcemia d. Hypoinsulinemia
A The neonate is at highest risk for hypoglycemia because fetal insulin production is accelerated during pregnancy to metabolize excessive glucose from the mother. At birth, the maternal glucose supply stops and the neonatal insulin exceeds the available glucose, thus leading to hypoglycemia. Hypocalcemia is associated with preterm birth, birth trauma, and asphyxia, all common problems of the infant of a diabetic mother. Excess erythrocytes are broken down after birth and release large amounts of bilirubin into the neonate's circulation, with resulting hyperbilirubinemia. Because fetal insulin production is accelerated during pregnancy, the neonate presents with hyperinsulinemia.
The best chance of survival for a child with cirrhosis is: a. Liver transplantation. b. Treatment with immune globulin. c. Treatment with corticosteroids. d. Provision of nutritional support.
A The only successful treatment for end-stage liver disease and liver failure may be liver transplantation, which has improved the prognosis for many children with cirrhosis. Liver transplantation has revolutionized the approach to cirrhosis. Liver failure and cirrhosis are indications for transplantation. Liver transplantation reflects the failure of other medical and surgical measures, such as treatment with corticosteroids or immune globulin and nutritional support, to prevent or treat cirrhosis.
Bismuth subsalicylate, clarithromycin, and metronidazole are prescribed for a child with a peptic ulcer to: a. Eradicate Helicobacter pylori. b. Treat epigastric pain. c. Coat gastric mucosa. d. Reduce gastric acid production.
A This combination of drug therapy is effective in the treatment and eradication of H. pylori.
The nurse is caring for a neonate with a suspected tracheoesophageal fistula. Nursing care should include: a. Elevating the head but giving nothing by mouth. b. Elevating the head for feedings. c. Feeding glucose water only. d. Avoiding suctioning unless the infant is cyanotic.
A When a newborn is suspected of having tracheoesophageal fistula, the most desirable position is supine with the head elevated on an inclined plane of at least 30 degrees. It is imperative that any source of aspiration be removed at once; oral feedings are withheld. Feedings of fluids should not be given to infants suspected of having tracheoesophageal fistulas. The oral pharynx should be kept clear of secretion by oral suctioning. This is to avoid the cyanosis that is usually the result of laryngospasm caused by overflow of saliva into the larynx.
4 Adoptive parents should inform the boy about the availability of a birth certificate. Open and honest communication between the boy and the parents is essential for the welfare of the adopted child. Legally, adoptive parents are not permitted to obtain the birth certificate. Parents should understand the need of the child to search for his identity and extend encouragement and support. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer
A 14-year-old boy learns about his adoption from his relatives and wants to know his identity. He appears angry, embarrassed, and anxious. What should the nurse advise his parents to help resolve the conflict? 1 "Don't forget to obtain the boy's birth certificate." 2 "Don't reveal the information regarding the adoption." 3 "Don't encourage the boy to search for his identity in this situation." 4 "Don't forget to inform the child about the availability of a birth certificate."
2 Children placed in foster care are at greater risk to have problems perceiving a sense of belonging. Children adopted at birth have fewer problems with acceptance when parents follow preadoption counseling about disclosure. Children of divorced parents often fear abandonment. Children who gain a stepparent are at risk for having trust problems with the new parent.
A camp nurse is assessing a group of children attending summer camp. Based on the nurse's knowledge of special parenting situations, which group of children is at risk for a sense of belonging? 1 Children adopted as infants 2 Children recently placed in foster care 3 Children whose parents recently divorced 4 Children who recently gained a stepparent
1 The parents should set aside time and explain the separation to their child. They should answer the child's questions and give the child time to absorb the information. The parents should not hide the information from the child because it can damage trust between the parents and the child. It is healthier when the child finds this out from parents rather than somebody else, whether it is the grandparents or a psychiatrist.
A couple who is going through a divorce asks the nurse how to disclose this news to their 4-year-old child. What would be the nurse's best response? 1 "You should sit down and calmly explain the situation to your child." 2 "You should not discuss it with the child until after the divorce is final." 3 'You should ask the grandparents or another relative to break the news." 4 "You should take your child to see a psychiatrist to break the news."
3 Many communities follow the practice of burning. As the name suggests, small burns are made on the child's body in an attempt to cure disorders such as enuresis and temper tantrums. The nurse is most likely to find blisters on the child's body. Reddened blotches, rashes, and welt-like lesions may be signs of an allergic reaction.
A family presents to the emergency room with a child with enuresis. They tell the nurse that they have tried their traditional cure of burning to alleviate the problem. What can the nurse expect as a physical sign of this practice? 1 Reddened blotches on the skin 2 Rash covering the child's body 3 Small blisters on the child's body 4 Small welt-like lesions on the skin
1, 4, 5 Work overload is a common source of stress in a dual-earner family as both partners need to share the household chores. Social activities are significantly curtailed as most time is devoted in meeting the responsibilities of the household. Time demands and scheduling are major problems for all individuals who work. Dual income provides more economic stability rather than making them happy. It is usually an indirect stress to the child.
A female patient tells the nurse, "I am well educated and would like to start working full-time like my husband." How should the nurse respond? Select all that apply. 1 "You might potentially get really stressed with work and house chores." 2 "You may at times direct your stress toward children." 3 "Dual income would help you to lead a joyous life." 4 "You may not have adequate time for social activities." 5 "You may have problems fulfilling time demands."
3 The earlier the child knows of his adoption status, the better. Generally, older children display anger and sadness. This can often be manifested as depression. The child may feel abandoned, but a feeling of sympathy is rare. Similarly, happiness and excitement are not what a child feels after learning about being adopted.
A parent tells a 13-year-old child that he is adopted. What could happen as a result of telling the child at this age? 1 Sympathy 2 Happiness 3 Depression 4 Excitement
3 Split custody means that custody of one child is given to the mother and custody of the other child is given to the father. This arrangement ensures that both parents have a child, but it separates the siblings. Custody of the children is not given to the grandparents, it is not determined by who has the larger salary, nor is it given solely to the father with visitation privileges given to the mother.
A patient with two children is going through a divorce and does not understand what the term split custody means. What is the most appropriate answer? 1 Custody of both children is given to the grandparents. 2 Custody of both children is given to the parent who brings home the larger salary. 3 Custody of one child is given to the mother, and the father has custody of the other child. 4 Custody of the children is given to the father, and the mother is allowed to visit once a week.
4 Respite child care is a service available to help parents to relieve exhaustion and avoid burnout. Therefore, the patient should seek respite child care services. Hospitals are for patients who need medical attention. It would not be appropriate to change jobs because the stress of working would still be there. Adoption services are inappropriate in this situation.
A single working parent says that caring for a child and managing work is becoming difficult. The nurse determines that the patient is exhausted by these responsibilities. Which is the most appropriate service that would benefit the patient? 1 Hospital 2 Change of job 3 Adoption service 4 Respite child care
Congenital anomalies can occur with the use of antiepileptic drugs (AEDs), including (Select all that apply): a. Cleft lip. b. Congenital heart disease. c. Neural tube defects. d. Gastroschisis. e. Diaphragmatic hernia.
A, B, C Congenital anomalies that can occur with AEDs include cleft lip or palate, congenital heart disease, urogenital defects, and neural tube defects. Gastroschisis and diaphragmatic hernia are not associated with the use of AEDs.
Women who have participated in childbirth education classes often bring a "birth bag" or "Lamaze bag" with them to the hospital. These items often assist in reducing stress and providing comfort measures. The nurse caring for women in labor should be aware of common items that a client may bring, including (Select all that apply): a. Rolling pin. b. Tennis balls. c. Pillow. d. Stuffed animal or photo. e. Candles.
A, B, C, D
While caring for a child, the nurse provides small toys and works overtime to take care of the child, and even calls the hospital during off-duty time to find out whether the child is improving. The nurse regularly meets the mother outside of the hospital. The nurse asks the mother if she is involved in care of the child. Which actions of the nurse indicate a nontherapeutic nurse-patient relationship? Select all that apply. A Giving a toy to the child B Working overtime to look after the child C Calling the hospital frequently to inquire about the child D Asking whether the mother is involved in care of the child E Meeting the mother outside of the hospital to discuss the child
A, B, C, E Giving toys, clothes, food, and other items to the patient; working overtime to take care of a particular patient; calling the hospital or patient's home frequently to inquire about the patient's health; and meeting the patient or family outside of the hospital indicate that the nurse is overinvolved with the child and the family. Thus, such actions should be avoided to develop a good nurse-patient relationship. Asking if the mother is involved in the child's care indicates that the nurse is concerned about the patient and the family. It indicates a therapeutic relationship between the nurse and the child and family.
The nursing process is a method of problem identification and problem solving that describes what the nurse actually does. The five steps include (Select all that apply): a. Assessment. b. Diagnosis. c. Planning. d. Documentation e. Implementation. f. Evaluation
A, B, C, E, F
A nurse is caring for an African-American child recently admitted to the hospital. The nurse should be aware of which broad cultural characteristics for this child when planning care (Select all that apply)? a. Silence may indicate a lack of trust. b. Maintaining constant eye contact may be viewed as aggressive. c. Self-care and folk medicine do not play a role in health care. d. Illness may be seen as the "will of God." e. No importance is attached to nonverbal behavior.
A, B, D
Diabetes refers to a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin action, insulin secretion, or both. Over time, diabetes causes significant changes in the microvascular and macrovascular circulations. These complications include: a. Atherosclerosis. b. Retinopathy. c. IUFD. d. Nephropathy. e. Neuropathy.
A, B, D, E These structural changes are most likely to affect a variety of systems, including the heart, eyes, kidneys, and nerves. Intrauterine fetal death (stillbirth) remains a major complication of diabetes in pregnancy; however, this is a fetal complication.
Children are taught the values of their culture through observation and feedback relative to their own behavior. In teaching a class on cultural competence, the nurse should be aware that which factor(s) may be culturally determined (Select all that apply)? a. Degree of competition b. Racial variation c. Determination of status d. Social roles e. Geographic boundaries
A, C, D
A 9-month-old child has been treated after a choking incident. Which advice does the nurse give to the parents to prevent further incidents? Select all that apply. A "Never leave your child unattended." B "Your child is too young to be allowed to eat solid food." C "Make sure all cabinets, drawers, and containers are childproof." D "Marbles and LEGOs are not appropriate toys for children at that age." E "Allowing your child to crawl on the floor increases the risk for injury."
A, C, D Crawling infants may explore their environments through taste and touch. They tend to put everything in their mouths. Therefore, the nurse should advise the parents to always keep a watch on their child and never leave their child unattended. Children at 9 months of age will begin to be able to pull themselves up to standing positions, potentially giving them access to cabinets, drawers, and containers that they were unable to access before. Therefore, the parents need to thoroughly childproof the home. The parents should be warned about providing small, colorful toys or leaving small objects on the floor because the child will be attracted to such objects and may attempt to swallow them, which may result in choking. The child is 8 months old. By this age, solid foods are permitted. The child should be allowed to play and crawl on the floor, as this is helpful for the development of the child's gross motor skills.
Which interventions should a nurse implement when caring for a child with hepatitis (Select all that apply)? a. Provide a well-balanced, low-fat diet. b. Schedule playtime in the playroom with other children c. Teach parents not to administer any over-the-counter medications. d. Arrange for home schooling because the child will not be able to return to school. e. Instruct parents on the importance of good hand washing.
A, C, E The child with hepatitis should be placed on a well-balanced, low-fat diet. Parents should be taught to not give over-the-counter medications because of impaired liver function. Hand hygiene is the most important preventive measure for the spread of hepatitis. The child will be in contact isolation in the hospital, so playtime with other hospitalized children is not scheduled. The child will be on contact isolation for a minimum of 1 week after the onset of jaundice. After that period, the child will be allowed to return to school.
Which actions of the nurse indicate that the nurse is providing atraumatic care to the patient who is admitted in the intensive care unit and his or her family? Select all that apply. A The nurse patiently listens to the parent's concerns. B The nurse spends off-duty time playing with the child. C The nurse allows a parent to stay with the child at all times. D The nurse gives the appropriate pain medications to the child. E The nurse explains the treatment given to the child to the parents
A, D, E One important goal of atraumatic care is to reduce psychological distress of patients and their families. It is important that the nurse patiently listens to the parents' concerns and provides emotional support. Preventing and minimizing bodily pain is another important aspect of atraumatic care. Therefore, the nurse should give appropriate pain medications to the child. Another goal of atraumatic care is to keep the parents informed about the child's disease, treatments given, and the disease progression. Thus, the nurse should explain the treatments given to the parents. Spending off-duty time with the patient indicates that the nurse is overinvolved with the patient. Allowing a parent to stay with the child at all times is not part of atraumatic care.
COMPLETION 42.The clinic nurse is reviewing hemoglobin A1c levels on several children with type 1 diabetes. Hemoglobin A1c levels of less than _____ % are a goal for children with type 1 diabetes. Record your answer as a whole number.
ANS: 7 The measurement of glycosylated hemoglobin (hemoglobin A1c) levels is a satisfactory method for assessing control of type 1 diabetes. As red blood cells circulate in the bloodstream, glucose molecules gradually attach to the hemoglobin A molecules and remain there for the lifetime of the red blood cell, approximately 120 days. The attachment is not reversible; therefore, this glycosylated hemoglobin reflects the average blood glucose levels over the previous 2 to 3 months. The test is a satisfactory method for assessing control, detecting incorrect testing, monitoring the effectiveness of changes in treatment, defining patients' goals, and detecting nonadherence. Hemoglobin A1c levels of less than 7% are a well-established goal at most care centers.
31. Which type of seizure may be difficult to detect? a. Absence c. Simple partial b. Generalized d. Complex partial
ANS: A Absence seizures may go unrecognized because little change occurs in the child's behavior during the seizure. Generalized, simple partial, and complex partial seizures all have clinical manifestations that are observable.
26. When caring for the child with Reye's syndrome, the priority nursing intervention is to: a. Monitor intake and output. c. Observe for petechiae. b. Prevent skin breakdown. d. Do range-of-motion (ROM) exercises.
ANS: A Accurate and frequent monitoring of intake and output is essential for adjusting fluid volumes to prevent both dehydration and cerebral edema. Preventing skin breakdown, observing for petechiae, and doing ROM exercises are important interventions in the care of a critically ill or comatose child. Careful monitoring of intake and output is a priority.
33. Which clinical manifestations would suggest hydrocephalus in a neonate? a. Bulging fontanel and dilated scalp veins b. Closed fontanel and high-pitched cry c. Constant low-pitched cry and restlessness d. Depressed fontanel and decreased blood pressure
ANS: A Bulging fontanel, dilated scalp veins, and separated sutures are clinical manifestations of hydrocephalus in neonates. Closed fontanel and high-pitched cry, constant low-pitched cry and restlessness, and depressed fontanel and decreased blood pressure are not clinical manifestations of hydrocephalus, but all should be referred for evaluation.
9. Which drug would be used to treat a child who has increased intracranial pressure (ICP) resulting from cerebral edema? a. Mannitol c. Atropine sulfate b. Epinephrine hydrochloride d. Sodium bicarbonate
ANS: A For increased ICP, mannitol, an osmotic diuretic, administered intravenously, is the drug used most frequently for rapid reduction. Epinephrine, atropine sulfate, and sodium bicarbonate are not used to decrease ICP.
21. Which statement best describes a neuroblastoma? a. Diagnosis is usually made after metastasis occurs. b. Early diagnosis is usually possible because of the obvious clinical manifestations. c. It is the most common brain tumor in young children. d. It is the most common benign tumor in young children.
ANS: A Neuroblastoma is a silent tumor with few symptoms. In more than 70% of cases, diagnosis is made after metastasis occurs, with the first signs caused by involvement in the nonprimary site. In only 30% of cases is diagnosis made before metastasis. Neuroblastomas are the most common malignant extracranial solid tumors in children. The majority of tumors develop in the adrenal glands or the retroperitoneal sympathetic chain. They are not benign; they metastasize.
8. The priority nursing intervention when a child is unconscious after a fall is to: a. Establish an adequate airway. b. Perform neurologic assessment. c. Monitor intercranial pressure. d. Determine whether a neck injury is present.
ANS: A Respiratory effectiveness is the primary concern in the care of the unconscious child. Establishing an adequate airway is always the first priority. A neurologic assessment and determination of neck injury are performed after breathing and circulation are stabilized. Intracranial, not intercranial, pressure is monitored if indicated after airway, breathing, and circulation are maintained.
14. An adolescent boy is brought to the emergency department after a motorcycle accident. His respirations are deep, periodic, and gasping. There are extreme fluctuations in blood pressure. Pupils are dilated and fixed. What type of head injury should the nurse suspect? a. Brainstem c. Subdural hemorrhage b. Skull fracture d. Epidural hemorrhage
ANS: A Signs of brainstem injury include deep, rapid, periodic or intermittent, and gasping respirations. Wide fluctuations or noticeable slowing of the pulse, widening pulse pressure, or extreme fluctuations in blood pressure are consistent with a brainstem injury. Skull fracture and subdural and epidural hemorrhages are not consistent with these signs.
15. A toddler fell out of a second-story window. She had brief loss of consciousness and vomited four times. Since admission, she has been alert and oriented. Her mother asks why a computed tomography (CT) scan is required when she "seems fine." The nurse should explain that the toddler: a. May have a brain injury. c. May start having seizures. b. Needs this because of her age. d. Probably has a skull fracture.
ANS: A The child's history of the fall, brief loss of consciousness, and vomiting four times necessitate evaluation of a potential brain injury. The severity of a head injury may not be apparent on clinical examination but will be detectable on a CT scan. The need for the CT scan is related to the injury and symptoms, not the child's age, and is necessary to determine whether a brain injury has occurred.
5. Which test is never performed on a child who is awake? a. Oculovestibular response b. Doll's head maneuver c. Funduscopic examination for papilledema d. Assessment of pyramidal tract lesions
ANS: A The oculovestibular response (caloric test) involves the instillation of ice water into the ear of a comatose child. The caloric test is painful and is never performed on a child who is awake or one who has a ruptured tympanic membrane. Doll's head maneuver, funduscopic examination, and assessment of pyramidal tract lesions can be performed on children who are awake.
34. Which information should the nurse give to a child who is to have magnetic resonance imaging (MRI) of the brain? a. "Your head will be restrained during the procedure." b. "You will have to drink a special fluid before the test." c. "You will have to lie flat after the test is finished." d. "You will have electrodes placed on your head with glue."
ANS: A To reduce fear and enhance cooperation during the MRI, the child should be made aware that the head will be restricted to obtain accurate information. Drinking fluids is usually done for neurologic procedures. A child should lie flat after a lumbar puncture, not after an MRI. Electrodes are attached to the head for an electroencephalogram.
32. An important nursing intervention when caring for a child who is experiencing a seizure is to: a. Describe and record the seizure activity observed. b. Restrain the child when seizure occurs to prevent bodily harm. c. Place a tongue blade between the teeth if they become clenched. d. Suction the child during a seizure to prevent aspiration.
ANS: A When a child is having a seizure, the priority nursing care is observation of the child and seizure. The nurse then describes and records the seizure activity. The child should not be restrained, and nothing should be placed in his or her mouth. This may cause injury. To prevent aspiration, if possible, the child should be placed on his or her side, facilitating drainage.
9.A goiter is an enlargement or hypertrophy of which gland? a. Thyroid b. Adrenal c. Anterior pituitary d. Posterior pituitary
ANS: A A goiter is an enlargement or hypertrophy of the thyroid gland. Goiter is not associated with the adrenals or the anterior and posterior pituitaries.
34.The nurse is implementing care for a school-age child admitted to the pediatric intensive care in diabetic ketoacidosis (DKA). Which prescribed intervention should the nurse implement first? a. Begin 0.9% saline solution intravenously as prescribed. b. Administer regular insulin intravenously as prescribed. c. Place child on a cardiac monitor. d. Place child on a pulse oximetry monitor.
ANS: A All patients with DKA experience dehydration (10% of total body weight in severe ketoacidosis) because of the osmotic diuresis, accompanied by depletion of electrolytes (sodium, potassium, chloride, phosphate, and magnesium). The initial hydrating solution is 0.9% saline solution. Insulin therapy should be started after the initial rehydration bolus because serum glucose levels fall rapidly after volume expansion. The child should be placed on the cardiac and pulse oximetry monitors after the rehydrating solution has been initiated.
40. What is the nurse's first action when planning to teach the parents of an infant with a congenital heart defect (CHD)? a. Assess the parents' anxiety level and readiness to learn. b. Gather literature for the parents. c. Secure a quiet place for teaching. d. Discuss the plan with the nursing team.
ANS: A Any effort to organize the right environment, plan, or literature is of no use if the parents are not ready to learn or have high anxiety. Decreasing their level of anxiety is often needed before new information can be processed. A baseline assessment of prior knowledge should be taken into consideration before developing any teaching plan. Locating a quiet place for meeting with parents is appropriate; however, an assessment should be done before any teaching is done. Discussing a teaching plan with the nursing team is appropriate after an assessment of the parents' knowledge and readiness. PTS: 1 DIF: Cognitive Level: Application REF: 1339 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance
1. The nurse is assessing a child post-cardiac catheterization. Which complication might the nurse anticipate? a. Cardiac arrhythmia c. Congestive heart failure b. Hypostatic pneumonia d. Rapidly increasing blood pressure
ANS: A Because a catheter is introduced into the heart, a risk exists of catheter-induced arrhythmias occurring during the procedure. These are usually transient. Hypostatic pneumonia, congestive heart failure, and rapidly increasing blood pressure are not risks usually associated with cardiac catheterization. PTS: 1 DIF: Cognitive Level: Application REF: 1320 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
9. Which drug is an angiotensin-converting enzyme (ACE) inhibitor? a. Captopril (Capoten) c. Spironolactone (Aldactone) b. Furosemide (Lasix) d. Chlorothiazide (Diuril)
ANS: A Capoten is an ACE inhibitor. Lasix is a loop diuretic. Aldactone blocks the action of aldosterone. Diuril works on the distal tubules. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1332 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
4.What should the nurse recommend to prevent urinary tract infections in young girls? a. Wearing cotton underpants b. Limiting bathing as much as possible c. Increasing fluids; decreasing salt intake d. Cleansing the perineum with water after voiding
ANS: A Cotton underpants are preferable to nylon underpants. No evidence exists that limiting bathing, increasing fluids, decreasing salt intake, or cleansing the perineum with water decreases urinary tract infections in young girls.
8. A beneficial effect of administering digoxin (Lanoxin) is that it: a. Decreases edema. c. Increases heart size. b. Decreases cardiac output. d. Increases venous pressure.
ANS: A Digoxin has a rapid onset and is useful in increasing cardiac output, decreasing venous pressure, and as a result decreasing edema. Heart size is decreased by digoxin. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1332 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
35. Which intervention should be included in the plan of care for an infant with the nursing diagnosis of Excess Fluid Volume related to congestive heart failure? a. Weigh the infant every day on the same scale at the same time. b. Notify the physician when weight gain exceeds more than 20 g/day. c. Put the infant in a car seat to minimize movement. d. Administer digoxin (Lanoxin) as ordered by the physician.
ANS: A Excess fluid volume may not be overtly visible. Weight changes may indicate fluid retention. Weighing the infant on the same scale at the same time each day ensures consistency. An excessive weight gain for an infant is an increase of more than 50 g/day. With fluid volume excess, skin will be edematous. The infant's position should be changed frequently to prevent undesirable pooling of fluid in certain areas. Lanoxin is used in the treatment of congestive heart failure to improve cardiac function. Diuretics will help the body get rid of excess fluid. PTS: 1 DIF: Cognitive Level: Application REF: 1334 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
10. The nurse closely monitors the temperature of a child with nephrosis. The purpose of this is to detect an early sign of: a. Infection. b. Hypertension. c. Encephalopathy. d. Edema.
ANS: A Infection is a constant source of danger to edematous children and those receiving corticosteroid therapy. An increased temperature could be an indication of an infection, but it is not an indication of hypertension or edema. Encephalopathy is not a complication usually associated with nephrosis. The child will most likely have neurologic signs and symptoms.
2.A child with growth hormone (GH) deficiency is receiving GH therapy. The best time for the GH to be administered is: a. At bedtime. b. After meals. c. Before meals. d. On arising in the morning.
ANS: A Injections are best given at bedtime to more closely approximate the physiologic release of GH. Before or after meals and on arising in the morning are times that do not mimic the physiologic release of the hormone.
22. Which painful, tender, pea-sized nodules may appear on the pads of the fingers or toes in bacterial endocarditis? a. Osler's nodes c. Subcutaneous nodules b. Janeway lesions d. Aschoff's nodules
ANS: A Osler's nodes are red, painful, intradermal nodes found on pads of the phalanges in bacterial endocarditis. Janeway lesions are painless hemorrhagic areas on palms and soles in bacterial endocarditis. Subcutaneous nodules are nontender swellings located over bony prominences, commonly found in rheumatic fever. Aschoff's nodules are small nodules composed of cells and leukocytes found in the interstitial tissues of the heart in rheumatic myocarditis. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1344 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
25. A major clinical manifestation of rheumatic fever is: a. Polyarthritis. b. Osler's nodes. c. Janeway spots. d. Splinter hemorrhages of distal third of nails.
ANS: A Polyarthritis is swollen, hot, red, and painful joints. The affected joints will change every 1 to 2 days. Primarily the large joints are affected. Osler's nodes, Janeway spots, and splinter hemorrhages are characteristic of infective endocarditis. PTS: 1 DIF: Cognitive Level: Analysis REF: 1345 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
38. A child with pulmonary atresia exhibits cyanosis with feeding. On reviewing this child's laboratory values, the nurse is not surprised to notice which abnormality? a. Polycythemia c. Dehydration b. Infection d. Anemia
ANS: A Polycythemia is a compensatory response to chronic hypoxia. The body attempts to improve tissue oxygenation by producing additional red blood cells and thereby increases the oxygen-carrying capacity of the blood. Infection is not a clinical consequence of cyanosis. Although dehydration can occur in cyanotic heart disease, it is not a compensatory mechanism for chronic hypoxia. It is not a clinical consequence of cyanosis. Anemia may develop as a result of increased blood viscosity. Anemia is not a clinical consequence of cyanosis. PTS: 1 DIF: Cognitive Level: Analysis REF: 1337 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
14.What should the nurse include in a teaching plan for the parents of a child with vesicoureteral reflux? a. The importance of taking prophylactic antibiotics b. Suggestions for how to maintain fluid restrictions c. The use of bubble baths as an incentive to increase bath time d. The need for the child to hold urine for 6 to 8 hours
ANS: A Prophylactic antibiotics are used to prevent urinary tract infections (UTIs) in a child with vesicoureteral reflux, although this treatment plan has become controversial. Fluids are not restricted when a child has vesicoureteral reflux. In fact, fluid intake should be increased as a measure to prevent UTIs. Bubble baths should be avoided to prevent urethral irritation and possible UTI. To prevent UTIs, the child should be taught to void frequently and never resist the urge to urinate.
30. The nurse is conducting an assessment on a school-age child with urosepsis. Which assessment finding should the nurse expect? a. Fever with a positive blood culture b. Proteinuria and edema c. Oliguria and hypertension d. Anemia and thrombocytopenia
ANS: A Symptoms of urosepsis include a febrile urinary tract infection coexisting with systemic signs of bacterial illness; blood culture reveals the presence of a urinary pathogen. Proteinuria and edema are symptoms of minimal change nephrotic syndrome. Oliguria and hypertension are symptoms of acute glomerulonephritis. Anemia and thrombocytopenia are symptoms of hemolytic uremic syndrome.
5. Which structural defects constitute tetralogy of Fallot? a. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy b. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy c. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy d. Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy
ANS: A Tetralogy of Fallot has these four characteristics: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. There is pulmonic stenosis but not aortic stenosis in tetralogy of Fallot. Right ventricular hypertrophy, not left ventricular hypertrophy, is present in tetralogy of Fallot. There is a ventricular septal defect, not an atrial septal defect, and overriding aorta, not aortic hypertrophy, is present. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1327 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
15. Parents of a 3-year-old child with congenital heart disease are afraid to let their child play with other children because of possible overexertion. The nurse's reply should be based on knowing that: a. The child needs opportunities to play with peers. b. The child needs to understand that peers' activities are too strenuous. c. Parents can meet all the child's needs. d. Constant parental supervision is needed to avoid overexertion.
ANS: A The child needs opportunities for social development. Children usually limit their activities if allowed to set their own pace and regulate their activities. The child will limit activities as necessary. Parents must be encouraged to seek appropriate social activities for the child, especially before kindergarten. The child needs to have activities that foster independence. PTS: 1 DIF: Cognitive Level: Analysis REF: 1339 OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
49. The nurse is admitting a child with rheumatic fever. Which therapeutic management should the nurse expect to implement? a. Administering penicillin b. Avoiding salicylates (aspirin) c. Imposing strict bed rest for 4 to 6 weeks d. Administering corticosteroids if chorea develops
ANS: A The goal of medical management is the eradication of the hemolytic streptococci. Penicillin is the drug of choice. Salicylates can be used to control the inflammatory process, especially in the joints, and reduce the fever and discomfort. Bed rest is recommended for the acute febrile stage, but it does not need to be strict. The chorea is transient and will resolve without treatment. PTS: 1 DIF: Cognitive Level: Application REF: 1345 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
52. The nurse is caring for an infant with congestive heart disease (CHD). The nurse should plan which intervention to decrease cardiac demands? a. Organize nursing activities to allow for uninterrupted sleep. b. Allow the infant to sleep through feedings during the night. c. Wait for the infant to cry to show definite signs of hunger. d. Discourage parents from rocking the infant
ANS: A The infant requires rest and conservation of energy for feeding. Every effort is made to organize nursing activities to allow for uninterrupted periods of sleep. Whenever possible, parents are encouraged to stay with their infant to provide the holding, rocking, and cuddling that help children sleep more soundly. To minimize disturbing the infant, changing bed linens and complete bathing are done only when necessary. Feeding is planned to accommodate the infant's sleep and wake patterns. The child is fed at the first sign of hunger, such as when sucking on fists, rather than waiting until he or she cries for a bottle because the stress of crying exhausts the limited energy supply. Because infants with CHD tire easily and may sleep through feedings, smaller feedings every 3 hours may be helpful. PTS: 1 DIF: Cognitive Level: Application REF: 1335 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
48. The nurse is talking to a parent of an infant with heart failure about feeding the infant. Which statement about feeding the child is correct? a. "You may need to increase the caloric density of your infant's formula." b. "You should feed your baby every 2 hours." c. "You may need to increase the amount of formula your infant eats with each feeding." d. "You should place a nasal oxygen cannula on your infant during and after each feeding."
ANS: A The metabolic rate of infants with heart failure is greater because of poor cardiac function and increased heart and respiratory rates. Their caloric needs are greater than those of the average infants, yet their ability to take in the calories is diminished by their fatigue. Infants with heart failure should be fed every 3 hours; a 2-hour schedule does not allow for enough rest, and a 4-hour schedule is too long. Fluids must be carefully monitored because of the heart failure. Infants do not require supplemental oxygen with feedings. PTS: 1 DIF: Cognitive Level: Application REF: 1334 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
16.The primary clinical manifestations of acute renal failure are: a. Oliguria and hypertension. b. Hematuria and pallor. c. Proteinuria and muscle cramps. d. Bacteriuria and facial edema.
ANS: A The principal feature of acute renal failure is oliguria. Hematuria and pallor, proteinuria and muscle cramps, and bacteriuria and facial edema are not principal features of acute renal failure
1.Which diagnostic test allows visualization of the renal parenchyma and renal pelvis without exposure to external beam radiation or radioactive isotopes? a. Renal ultrasound b. Computed tomography c. Intravenous pyelography d. Voiding cystourethrography
ANS: A The transmission of ultrasonic waves through the renal parenchyma allows visualization of the renal parenchyma and renal pelvis without exposure to external beam radiation or radioactive isotopes. Computed tomography uses external radiation, and sometimes contrast media are used. Intravenous pyelography uses contrast medium and external radiation for x-ray films. Contrast medium is injected into the bladder through the urethral opening for voiding cystourethrography. External radiation for x-ray films is used before, during, and after voiding.
18. When a child has chronic renal failure, the progressive deterioration produces a variety of clinical and biochemical disturbances that eventually are manifested in the clinical syndrome known as: a. Uremia. b. Oliguria. c. Proteinuria. d. Pyelonephritis.
ANS: A Uremia is the retention of nitrogenous products, producing toxic symptoms. Oliguria is diminished urine output. Proteinuria is the presence of protein, usually albumin, in the urine. Pyelonephritis is an inflammation of the kidney and renal pelvis
46. A nurse should expect which cerebrospinal fluid (CSF) laboratory results on a child diagnosed with bacterial meningitis (Select all that apply)? a. Elevated white blood cell (WBC) count b. Decreased protein c. Decreased glucose d. Cloudy in color e. Increase in red blood cells (RBCs)
ANS: A, C, D The CSF laboratory results for bacterial meningitis include elevated WBC counts, cloudy or milky in color, and decreased glucose. The protein is elevated and there should be no RBCs present. RBCs are present when the tap was traumatic.
55. A child has a total cholesterol level of 180 mg/dL. What dietary recommendations should the nurse make to the child and the child's parents (Select all that apply)? a. Replace whole milk with 2% or 1% milk b. Increase servings of red meat c. Increase servings of fish d. Avoid excessive intake of fruit juices e. Limit servings of whole grain
ANS: A, C, D A low-fat diet includes using nonfat or low-fat dairy products, limiting red meat intake, and increasing intake of fish, vegetables, whole grains, and legumes. Children should avoid excessive intake of fruit juices and other sweetened drinks, sugars, and saturated fats. PTS: 1 DIF: Cognitive Level: Application REF: 1346 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
43. The treatment of brain tumors in children consists of which therapies (Select all that apply)? a. Surgery b. Bone marrow transplantation c. Chemotherapy d. Stem cell transplantation e. Radiation f. Myelography
ANS: A, C, E Treatment for brain tumors in children may consist of surgery, chemotherapy, and radiotherapy alone or in combination. Bone marrow, stem cell, and myelographuy are transplantation therapies are not used to treat brain tumors in children.
MULTIPLE RESPONSE 37.The nurse is caring for an infant with a suspected urinary tract infection. Which clinical manifestations would be observed (Select all that apply)? a. Vomiting b. Jaundice c. Failure to gain weight d. Swelling of the face e. Back pain f. Persistent diaper rash
ANS: A, C, F Vomiting, failure to gain weight, and persistent diaper rash are clinical manifestations observed in an infant with a urinary tract infection. Jaundice, swelling of the face, and back pain would not be observed in an infant with a urinary tract infection.
39.A school-age child is admitted to the hospital with acute glomerulonephritis and oliguria. Which dietary menu items should be allowed for this child (Select all that apply)? a. Apples b. Bananas c. Cheese d. Carrot sticks e. Strawberries
ANS: A, D, E Moderate sodium restriction and even fluid restriction may be instituted for children with acute glomerulonephritis. Foods with substantial amounts of potassium and sodium are generally restricted during the period of oliguria. Apples, carrot sticks, and strawberries would be items low in sodium and allowed. Bananas are high in potassium and cheese is high in sodium. Those items would be restricted.
36.Nursing care of a child diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) should include (Select all that apply): a. Weigh daily. b. Encourage fluids. c. Turn frequently. d. Maintain nothing by mouth. e. Restrict fluids.
ANS: A, E Increased secretion of ADH causes the kidney to resorb water, which increases fluid volume and decreases serum osmolarity with a progressive reduction in sodium concentration. The immediate management of the child is to restrict fluids. The child should also be weighed at the same time each day. Encouraging fluids, turning frequently, and maintaining nothing by mouth are not associated with SIADH.
45. An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Which interventions should be included in the child's postoperative care (Select all that apply)? a. Observe closely for signs of infection. b. Pump the shunt reservoir to maintain patency. c. Administer sedation to decrease irritability. d. Maintain Trendelenburg position to decrease pressure on the shunt. e. Maintain an accurate record of intake and output. f. Monitor for abdominal distention.
ANS: A, E, F Infection is a major complication of ventriculoperitoneal shunts. Observation for signs of infection is a priority nursing intervention. Intake and output should be measured carefully. Abdominal distention could be a sign of peritonitis or a postoperative ileus. Pumping the shunt reservoir, administering sedation, and maintaining Trendelenburg position are not interventions associated with this condition.
17. A school-age child has sustained a head injury and multiple fractures after being thrown from a horse. The child's level of consciousness is variable. The parents tell the nurse that they think their child is in pain because of periodic crying and restlessness. The most appropriate nursing action is to: a. Discuss with parents the child's previous experiences with pain. b. Discuss with practitioner what analgesia can be safely administered. c. Explain that analgesia is contraindicated with a head injury. d. Explain that analgesia is unnecessary when child is not fully awake and alert.
ANS: B A key nursing role is to provide sedation and analgesia for the child. Consultation with the appropriate practitioner is necessary to avoid conflict between the necessity to monitor the child's neurologic status and to promote comfort and relieve anxiety. Gathering information about the child's previous experiences with pain should be obtained as part of the assessment, but because of the severity of injury, analgesia should be provided as soon as possible. Analgesia can be used safely in individuals who have sustained head injuries and can decrease anxiety and resultant increased intracranial pressure.
12. Which statement best describes a subdural hematoma? a. Bleeding occurs between the dura and the skull. b. Bleeding occurs between the dura and the cerebrum. c. Bleeding is generally arterial, and brain compression occurs rapidly. d. The hematoma commonly occurs in the parietotemporal region.
ANS: B A subdural hematoma is bleeding that occurs between the dura and the cerebrum as a result of a rupture of cortical veins that bridge the subdural space. An epidural hemorrhage occurs between the dura and the skull, is usually arterial with rapid brain concussion, and occurs most often in the parietotemporal region.
6. The nurse is preparing a school-age child for a computed tomography (CT) scan to assess cerebral function. When preparing the child for the scan, which statement should the nurse include? a. "Pain medication will be given." b. "The scan will not hurt." c. "You will be able to move once the equipment is in place." d. "Unfortunately no one can remain in the room with you during the test."
ANS: B For CT scans, the child will not be allowed to move and must be immobilized. It is important to emphasize to the child that at no time is the procedure painful. Pain medication is not required; however, sedation is sometimes necessary. Someone is able to remain with the child during the procedure.
25. When taking the history of a child hospitalized with Reye's syndrome, the nurse should not be surprised that a week ago the child had recovered from: a. Measles. c. Meningitis. b. Varicella. d. Hepatitis.
ANS: B Most cases of Reye's syndrome follow a common viral illness such as varicella or influenza. Measles, meningitis, and hepatitis are not associated with Reye's syndrome.
2. Which term is used when a patient remains in a deep sleep, responsive only to vigorous and repeated stimulation? a. Coma c. Obtundation b. Stupor d. Persistent vegetative state
ANS: B Stupor exists when the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. Coma is the state in which no motor or verbal response occurs to noxious (painful) stimuli. Obtundation describes a level of consciousness in which the child can be aroused with stimulation. Persistent vegetative state describes the permanent loss of function of the cerebral cortex.
3. The Glasgow Coma Scale consists of an assessment of: a. Pupil reactivity and motor response. b. Eye opening and verbal and motor responses. c. Level of consciousness and verbal response. d. Intracranial pressure (ICP) and level of consciousness.
ANS: B The Glasgow Coma Scale assesses eye opening and verbal and motor responses. Pupil reactivity is not a part of the Glasgow Coma Scale but is included in the pediatric coma scale. Level of consciousness and ICP are not part of the Glasgow Coma Scale.
36. The nurse has received report on four children. Which child should the nurse assess first? a. A school-age child in a coma with stable vital signs b. A preschool child with a head injury and decreasing level of consciousness c. An adolescent admitted after a motor vehicle accident who is oriented to person and place d. A toddler in a persistent vegetative state with a low-grade fever
ANS: B The nurse should assess the child with a head injury and decreasing level of consciousness (LOC) first. Assessment of LOC remains the earliest indicator of improvement or deterioration in neurologic status. The next child the nurse should assess is a toddler in a persistent vegetative state with a low-grade fever. The school-age child in a coma with stable vital signs and the adolescent admitted to the hospital who is oriented to his or her surroundings would be of least worry to the nurse.
4. The nurse is closely monitoring a child who is unconscious after a fall and notices that the child suddenly has a fixed and dilated pupil. The nurse should interpret this as: a. Eye trauma. c. Severe brainstem damage. b. Neurosurgical emergency. d. Indication of brain death.
ANS: B The sudden appearance of a fixed and dilated pupil(s) is a neurosurgical emergency. The nurse should immediately report this finding. Although a dilated pupil may be associated with eye trauma, this child has experienced a neurologic insult. Pinpoint pupils or fixed, bilateral pupils for more than 5 minutes are indicative of brainstem damage. The unilateral fixed and dilated pupil is suggestive of damage on the same side of the brain. One fixed and dilated pupil is not suggestive of brain death.
23. The vector reservoir for agents causing viral encephalitis in the United States is: a. Tarantula spiders. c. Carnivorous wild animals. b. Mosquitoes and ticks. d. Domestic and wild animals.
ANS: B Viral encephalitis, not attributable to a childhood viral disease, is usually transmitted by mosquitoes and ticks. The vector reservoir for most agents pathogenic for humans and detected in the United States are mosquitoes and ticks; therefore, most cases of encephalitis appear during the hot summer months. Tarantulas, carnivorous wild animals, and domestic animals are not reservoirs for the agents that cause viral encephalitis.
26.What should a nurse advise the parents of a child with type 1 diabetes mellitus who is not eating as a result of a minor illness? a. Give the child half his regular morning dose of insulin. b. Substitute simple carbohydrates or calorie-containing liquids for solid foods. c. Give the child plenty of unsweetened, clear liquids to prevent dehydration. d. Take the child directly to the emergency department.
ANS: B A sick-day diet of simple carbohydrates or calorie-containing liquids will maintain normal serum glucose levels and decrease the risk of hypoglycemia. The child should receive his regular dose of insulin even if he does not have an appetite. If the child is not eating as usual, he needs calories to prevent hypoglycemia. During periods of minor illness, the child with type 1 diabetes mellitus can be managed safely at home.
14.Chronic adrenocortical insufficiency is also referred to as: a. Graves' disease. b. Addison's disease. c. Cushing's syndrome. d. Hashimoto's disease.
ANS: B Addison's disease is chronic adrenocortical insufficiency. Graves' and Hashimoto's diseases involve the thyroid gland. Cushing's syndrome is a result of excessive circulation of free cortisol.
29. One of the most frequent causes of hypovolemic shock in children is: a. Myocardial infarction. c. Anaphylaxis. b. Blood loss. d. Congenital heart disease.
ANS: B Blood loss and extracellular fluid loss are two of the most frequent causes of hypovolemic shock in children. Myocardial infarction is rare in a child; if it occurred, the resulting shock would be cardiogenic, not hypovolemic. Anaphylaxis results in distributive shock from extreme allergy or hypersensitivity to a foreign substance. Congenital heart disease tends to contribute to hypervolemia, not hypovolemia. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1355 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
18.What is the most appropriate intervention for the parents of a 6-year-old girl with precocious puberty? a. Advise the parents to consider birth control for their daughter. b. Explain the importance of having the child foster relationships with same-age peers. c. Assure the child's parents that there is no increased risk for sexual abuse because of her appearance. d. Counsel parents that there is no treatment currently available for this disorder.
ANS: B Despite the child's appearance, the child needs to be treated according to her chronologic age and to interact with children in the same age-group. An expected outcome is that the child will adjust socially by exhibiting age-appropriate behaviors and social interactions. Advising the parents of a 6-year-old to put their daughter on birth control is not appropriate and will not reverse the effects of precocious puberty. Parents need to be aware that there is an increased risk of sexual abuse for a child with precocious puberty. Treatment for precocious puberty is the administration of gonadotropin-releasing hormone blocker, which slows or reverses the development of secondary sexual characteristics and slows rapid growth and bone aging.
12. As part of the treatment for congestive heart failure, the child takes the diuretic furosemide. As part of teaching home care, the nurse encourages the family to give the child foods such as bananas, oranges, and leafy vegetables. These foods are recommended because they are high in: a. Chlorides. c. Sodium. b. Potassium. d. Vitamins.
ANS: B Diuretics that work on the proximal and distal renal tubules contribute to increased losses of potassium. The child's diet should be supplemented with potassium. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1333 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity
29.An adolescent is being seen in the clinic for evaluation of acromegaly. The nurse understands that which occurs with acromegaly? a. There is a lack of growth hormone (GH) being produced. b. There is excess GH after closure of the epiphyseal plates. c. There is an excess of GH before the closure of the epiphyseal plates. d. There is a lack of thyroid hormone being produced.
ANS: B Excess GH after closure of the epiphyseal plates results in acromegaly. A lack of growth hormone results in delayed growth or even dwarfism. Gigantism occurs when there is hypersecretion of GH before the closure of the epiphyseal plates. Cretinism is associated with hypothyroidism.
44. An adolescent being seen by the nurse practitioner for a sports physical is identified as having hypertension. On further testing, it is discovered the child has a cardiac abnormality. The initial treatment of secondary hypertension initially involves: a. Weight control and diet. b. Treating the underlying disease. c. Administration of digoxin. d. Administration of -adrenergic receptor blockers.
ANS: B Identification of the underlying disease should be the first step in treating secondary hypertension. Weight control and diet are nonpharmacologic treatments for primary hypertension. Digoxin is indicated in the treatment of congestive heart failure. -Adrenergic receptor blockers are indicated in the treatment of primary hypertension. PTS: 1 DIF: Cognitive Level: Application REF: 1350 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
14. The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The nurse recognizes that a risk of cerebrovascular accidents (strokes) exists. An important objective to decrease this risk is to: a. Minimize seizures. c. Promote cardiac output. b. Prevent dehydration. d. Reduce energy expenditure.
ANS: B In children with persistent hypoxia, polycythemia develops. Dehydration must be prevented in hypoxemic children because it potentiates the risk of strokes. Minimizing seizures, promoting cardiac output, and reducing energy expenditure will not reduce the risk of cerebrovascular accidents. PTS: 1 DIF: Cognitive Level: Analysis REF: 1337 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
31. Which clinical changes occur as a result of septic shock? a. Hypothermia c. Vasoconstriction b. Increased cardiac output d. Angioneurotic edema
ANS: B Increased cardiac output, which results in warm, flushed skin, is one of the manifestations of septic shock. Fever and chills are characteristic of septic shock. Vasodilation is more common in septic shock. Angioneurotic edema occurs as a manifestation in anaphylactic shock. PTS: 1 DIF: Cognitive Level: Analysis REF: 1356 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
36. A school-age child with chronic renal failure is admitted to the hospital with a serum potassium level of 5.2 mEq/L. Which prescribed medication should the nurse plan to administer? a. Spironolactone (Aldactone) b. Sodium polystyrene sulfonate (Kayexalate) c. Lactulose (Cephulac) d. Calcium carbonate (Calcitab)
ANS: B Normal serum potassium levels in a school-age child are 3.5 to 5 mEq/L. Sodium polystyrene sulfonate is administered to reduce serum potassium levels. Spironolactone is a potassium-sparing diuretic and should not be used if the serum potassium is elevated. Lactulose is administered to reduce ammonia levels in patients with liver disease. Calcium carbonate may be prescribed as a calcium supplement, but it will not reduce serum potassium levels.
22.Calcium carbonate is given with meals to a child with chronic renal disease. The purpose of this is to: a. Prevent vomiting. b. Bind phosphorus. c. Stimulate appetite. d. Increase absorption of fat-soluble vitamins.
ANS: B Oral calcium carbonate preparations combine with phosphorus to decrease gastrointestinal absorption and the serum levels of phosphate; serum calcium levels are increased by the calcium carbonate, and vitamin D administration is necessary to increase calcium absorption. Calcium carbonate does not prevent vomiting, stimulate appetite, or increase the absorption of fat-soluble vitamins.
28. The narrowing of preputial opening of foreskin is called: a. Chordee b. Phimosis c. Epispadias d. Hypospadias
ANS: B Phimosis is the narrowing or stenosis of the preputial opening of the foreskin. Chordee is the ventral curvature of the penis. Epispadias is the meatal opening on the dorsal surface of the penis. Hypospadias is a congenital condition in which the urethral opening is located anywhere along the ventral surface of the penis.
6.The narrowing of the preputial opening of the foreskin is called: a. Chordee. b. Phimosis. c.Epispadias d.Hypospadias.
ANS: B Phimosis is the narrowing or stenosis of the preputial opening of the foreskin. Chordee is the ventral curvature of the penis. Epispadias is the meatal opening on the dorsal surface of the penis. Hypospadias is a congenital condition in which the urethral opening is located anywhere along the ventral surface of the penis.
26.Which statement is descriptive of renal transplantation in children? a. It is an acceptable means of treatment after age 10 years. b. It is preferred means of renal replacement therapy in children. c. Children can receive kidneys only from other children. d. The decision for transplantation is difficult since a relatively normal lifestyle is not possible.
ANS: B Renal transplantation offers the opportunity for a relatively normal lifestyle versus dependence on dialysis and is the preferred means of renal replacement therapy in end-stage renal disease. It can be done in children as young as age 6 months. Both children and adults can serve as donors for renal transplant purposes.
11. The diet of a child with nephrosis usually includes: a. High protein. b. Salt restriction. c. Low fat. d. High carbohydrate.
ANS: B Salt is usually restricted (but not eliminated) during the edema phase. The child has very little appetite during the acute phase. Favorite foods are provided (with the exception of high-salt ones) in an attempt to provide nutritionally complete meals.
24.The nurse is caring for an 11-year-old boy who has recently been diagnosed with diabetes. What should be included in the teaching plan for daily injections? a. The parents do not need to learn the procedure. b. He is old enough to give most of his own injections. c. Self-injections will be possible when he is closer to adolescence. d. He can learn about self-injections when he is able to reach all injection sites.
ANS: B School-age children are able to give their own injections. Parents should participate in learning and giving the insulin injections. He is already old enough to administer his own insulin. The child is able to use thighs, abdomen, part of the hip, and arm. Assistance can be obtained if other sites are used.
27.Which laboratory finding confirms that a child with type 1 diabetes is experiencing diabetic ketoacidosis? a. No urinary ketones b. Low arterial pH c. Elevated serum carbon dioxide d. Elevated serum phosphorus
ANS: B Severe insulin deficiency produces metabolic acidosis, which is indicated by a low arterial pH. Urinary ketones, often in large amounts, are present when a child is in diabetic ketoacidosis. Serum carbon dioxide is decreased in diabetic ketoacidosis. Serum phosphorus is decreased in diabetic ketoacidosis.
47. A nurse is teaching nursing students the physiology of congenital heart defects. Which defect results in decreased pulmonary blood flow? a. Atrial septal defect c. Ventricular septal defect b. Tetralogy of Fallot d. Patent ductus arteriosus
ANS: B Tetralogy of Fallot results in decreased blood flow to the lungs. The pulmonic stenosis increases the pressure in the right ventricle, causing the blood to go from right to left across the interventricular septal defect. Atrial and ventricular septal defects and patent ductus arteriosus result in increased pulmonary blood flow. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1327 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
16. When preparing a school-age child and the family for heart surgery, the nurse should consider: a. Not showing unfamiliar equipment. b. Letting child hear the sounds of an electrocardiograph monitor. c. Avoiding mentioning postoperative discomfort and interventions. d. Explaining that an endotracheal tube will not be needed if the surgery goes well.
ANS: B The child and family should be exposed to the sights and sounds of the intensive care unit. All positive, nonfrightening aspects of the environment are emphasized. The child should be shown unfamiliar equipment, and its use should be demonstrated on a doll. Carefully prepare the child for the postoperative experience, including intravenous lines, incision, and endotracheal tube. PTS: 1 DIF: Cognitive Level: Analysis REF: 1341 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
45. The nurse is preparing an adolescent for discharge after a cardiac catheterization. Which statement by the adolescent would indicate a need for further teaching? a. "I should avoid tub baths but may shower." b. "I have to stay on strict bed rest for 3 days." c. "I should remove the pressure dressing the day after the procedure." d. "I may attend school but should avoid exercise for several days."
ANS: B The child does not need to be on strict bed rest for 3 days. Showers are recommended; children should avoid a tub bath. The pressure dressing is removed the day after the catheterization and replaced by an adhesive bandage to keep the area clean. Strenuous activity must be avoided for several days, but the child can return to school. PTS: 1 DIF: Cognitive Level: Analysis REF: 1320 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
36. The nurse assessing a premature newborn infant auscultates a continuous machinery-like murmur. This finding is associated with which congenital heart defect? a. Pulmonary stenosis c. Ventricular septal defect b. Patent ductus arteriosus d. Coarctation of the aorta
ANS: B The classic murmur associated with patent ductus arteriosus is a machinery-like one that can be heard throughout both systole and diastole. A systolic ejection murmur that may be accompanied by a palpable thrill is a manifestation of pulmonary stenosis. The characteristic murmur associated with ventricular septal defect is a loud, harsh, holosystolic murmur. A systolic murmur that is accompanied by an ejection click may be heard on auscultation when coarctation of the aorta is present. PTS: 1 DIF: Cognitive Level: Application REF: 1323 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
35.A nurse is reviewing the laboratory results on a school-age child with hypoparathyroidism. Which results are consistent with this condition? a. Decreased serum phosphorus b. Decreased serum calcium c. Increased serum glucose d. Decreased serum cortisol
ANS: B The diagnosis of hypoparathyroidism is made on the basis of clinical manifestations associated with decreased serum calcium and increased serum phosphorus. Decreased serum phosphorus would be seen in hyperparathyroidism, elevated glucose in diabetes, and decreased serum cortisol in adrenocortical insufficiency (Addison's disease).
13. An 8-month-old infant has a hypercyanotic spell while blood is being drawn. The nurse's first action should be to: a. Assess for neurologic defects. b. Place the child in the knee-chest position. c. Begin cardiopulmonary resuscitation. d. Prepare the family for imminent death.
ANS: B The first action is to place the infant in the knee-chest position. Blow-by oxygen may be indicated. Neurologic defects are unlikely. The child should be assessed for airway, breathing, and circulation. Often calming the child and administering oxygen and morphine can alleviate the hypercyanotic spell; cardiopulmonary resuscitation is not necessary, and death is unlikely. PTS: 1 DIF: Cognitive Level: Application REF: 1337 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
34. The nurse is conducting teaching for an adolescent being discharged to home after a renal transplantation. The adolescent needs further teaching if which statement is made? a. "I will report any fever to my primary health care provider." b. "I am glad I only have to take the immunosuppressant medication for two weeks." c. "I will observe my incision for any redness or swelling." d. "I won't miss doing kidney dialysis every week."
ANS: B The immunosuppressant medications are taken indefinitely after a renal transplantation, so they should not be discontinued after 2 weeks. Reporting a fever and observing an incision for redness and swelling are accurate statements. The adolescent is correct in indicating dialysis will not need to be done after the transplantation.
15.A neonate born with ambiguous genitalia is diagnosed with congenital adrenogenital hyperplasia. Therapeutic management includes administration of: a. Vitamin D. b. Cortisone c. Stool softeners. d. Calcium carbonate.
ANS: B The most common biochemical defect with congenital adrenal hyperplasia is partial or complete 21-hydroxylase deficiency. With complete deficiency, insufficient amounts of aldosterone and cortisol are produced, so circulatory collapse occurs without immediate replacement. Vitamin D, stool softeners, and calcium carbonate have no role in the therapy of adrenogenital hyperplasia.
23. The primary nursing intervention necessary to prevent bacterial endocarditis is to: a. Institute measures to prevent dental procedures. b. Counsel parents of high risk children about prophylactic antibiotics. c. Observe children for complications such as embolism and heart failure. d. Encourage restricted mobility in susceptible children.
ANS: B The objective of nursing care is to counsel the parents of high risk children about both the need for prophylactic antibiotics for dental procedures and the necessity of maintaining excellent oral health. The child's dentist should be aware of the child's cardiac condition. Dental procedures should be done to maintain a high level of oral health. Prophylactic antibiotics are necessary. Observing for complications and encouraging restricted mobility in susceptible children should be done, but maintaining good oral health and using prophylactic antibiotics are most important.
7.An objective of care for the child with nephrosis is to: a. Reduce blood pressure. b. Reduce excretion of urinary protein. c. Increase excretion of urinary protein. d. Increase ability of tissues to retain fluid.
ANS: B The objectives of therapy for the child with nephrosis include reduction of the excretion of urinary protein, reduction of fluid retention, prevention of infection, and minimizing of complications associated with therapy. Blood pressure is usually not elevated in nephrosis. Increased excretion of urinary protein and increased ability of tissues to retain fluid are part of the disease process and must be reversed.
27. The leading cause of death after heart transplantation is: a. Infection. c. Cardiomyopathy. b. Rejection. d. Congestive heart failure.
ANS: B The posttransplantation course is complex. The leading cause of death after cardiac transplantation is rejection. Infection is a continued risk secondary to the immunosuppression necessary to prevent rejection. Cardiomyopathy is one of the indications for cardiac transplant. Congestive heart failure is not a leading cause of death. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1351 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
6.Diabetes insipidus is a disorder of the: a. Anterior pituitary. b. Posterior pituitary. c. Adrenal cortex. d. Adrenal medulla.
ANS: B The principal disorder of posterior pituitary hypofunction is diabetes insipidus. The anterior pituitary produces hormones such as growth hormone, thyroid-stimulating hormone, adrenocorticotropic hormone, gonadotropin, prolactin, and melanocyte-stimulating hormone. The adrenal cortex produces aldosterone, sex hormones, and glucocorticoids. The adrenal medulla produces catecholamines.
3.Which factor predisposes a child to urinary tract infections? a. Increased fluid intake b. Short urethra in young girls c. Prostatic secretions in males d. Frequent emptying of the bladder
ANS: B The short urethra in females provides a ready pathway for invasions of organisms. Increased fluid intake and frequent bladder emptying offer protective measures against urinary tract infections. Prostatic secretions have antibacterial properties that inhibit bacteria.
42. What is the appropriate priority nursing action for the infant with a CHD who has an increased respiratory rate, is sweating, and is not feeding well? a. Recheck the infant's blood pressure. c. Withhold oral feeding. b. Alert the physician. d. Increase the oxygen rate.
ANS: B These are signs of early congestive heart failure, and the physician should be notified. Although rechecking blood pressure may be indicated, it is not the priority action. Withholding the infant's feeding is an incomplete response to the problem. Increasing oxygen may alleviate symptoms; however, medications such as digoxin and furosemide are necessary to improve heart function and fluid retention. Notifying the physician is the priority nursing action. PTS: 1 DIF: Cognitive Level: Analysis REF: 1331 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
21. One of the clinical manifestations of chronic renal failure is uremic frost. What best describes this term? a. Deposits of urea crystals in urine b. Deposits of urea crystals on skin c. Overexcretion of blood urea nitrogen d. Inability of body to tolerate cold temperatures
ANS: B Uremic frost is the deposition of urea crystals on the skin, not in the urine. The kidneys are unable to excrete blood urea nitrogen, leading to elevated levels. There is no relation between cold temperatures and uremic frost.
10. The nurse is evaluating a child who is taking digoxin for her cardiac condition. The nurse is cognizant that a common sign of digoxin toxicity is: a. Seizures. c. Bradypnea. b. Vomiting. d. Tachycardia.
ANS: B Vomiting is a common sign of digoxin toxicity. Seizures are not associated with digoxin toxicity. The child will have a slower heart rate, not respiratory rate. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1335 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
37.Which children admitted to the pediatric unit would the nurse monitor closely for development of syndrome of inappropriate antidiuretic hormone (SIADH) (Select all that apply)? a. A newly diagnosed preschooler with type 1 diabetes b. A school-age child returning from surgery for removal of a brain tumor c. An infant with suspected meningitis d. An adolescent with blunt abdominal trauma following a car accident e. A school-age child with head trauma
ANS: B, C, E Childhood SIADH usually is caused by disorders affecting the central nervous system, such as infections (meningitis), head trauma, and brain tumors. Type 1 diabetes and blunt abdominal trauma are not likely to cause SIADH.
48. The nurse is monitoring an infant for signs of increased intracranial pressure (ICP). Which are late signs of increased ICP in an infant (Select all that apply)? a. Tachycardia b. Alteration in pupil size and reactivity c. Increased motor response d. Extension or flexion posturing e. Cheyne-Stokes respirations
ANS: B, D, E Late signs of ICP in an infant or child include bradycardia, alteration in pupil size and reactivity, decreased motor response, extension or flexion posturing, and Cheyne-Stokes respirations.
38.A child is diagnosed with hypothyroidism. The nurse should expect to assess which symptoms associated with hypothyroidism (Select all that apply)? a. Weight loss b. Fatigue c. Diarrhea d. Dry, thick skin e. Cold intolerance
ANS: B, D, E A child with hypothyroidism will display fatigue; dry, thick skin; and cold intolerance. Weight loss and diarrhea are signs of hyperthyroidism.
40.A school-age child has been admitted to the hospital with an exacerbation of nephrotic syndrome. Which clinical manifestations should the nurse expect to assess (Select all that apply)? a. Weight loss b. Facial edema c. Cloudy, smoky brown-colored urine d. Fatigue e. Frothy-appearing urine
ANS: B, D, E A child with nephrotic syndrome will present with facial edema, fatigue, and frothy-appearing urine (proteinuria). Weight gain, not loss, is expected because of the fluid retention. Cloudy, smoky brown-colored urine is seen with acute glomerulonephritis but not with nephrotic syndrome because there is no gross hematuria associated with nephrotic syndrome.
7. Which neurologic diagnostic test gives a visualized horizontal and vertical cross section of the brain at any axis? a. Nuclear brain scan c. Computed tomography (CT) scan b. Echoencephalography d. Magnetic resonance imaging (MRI)
ANS: C A CT scan provides visualization of the horizontal and vertical cross sections of the brain at any axis. A nuclear brain scan uses a radioisotope that accumulates where the blood-brain barrier is defective. Echoencephalography identifies shifts in midline structures of the brain as a result of intracranial lesions. MRI permits visualization of morphologic features of target structures and tissue discrimination that is unavailable with any other techniques.
10. Which statement is most descriptive of a concussion? a. Petechial hemorrhages cause amnesia. b. Visible bruising and tearing of cerebral tissue occur. c. It is a transient, reversible neuronal dysfunction. d. A slight lesion develops remote from the site of trauma.
ANS: C A concussion is a transient, reversible neuronal dysfunction with instantaneous loss of awareness and responsiveness resulting from trauma to the head. Petechial hemorrhages along the superficial aspects of the brain along the point of impact are a type of contusion but are not necessarily associated with amnesia. A contusion is visible bruising and tearing of cerebral tissue. Contrecoup is a lesion that develops remote from the site of trauma as a result of an acceleration/deceleration injury.
42. A child has been seizure-free for 2 years. A father asks the nurse how much longer the child will need to take the antiseizure medications. The nurse includes which intervention in the response? a. Medications can be discontinued at this time. b. The child will need to take the drugs for 5 years after the last seizure. c. A stepwise approach will be used to reduce the dosage gradually. d. Seizure disorders are a lifelong problem. Medications cannot be discontinued.
ANS: C A predesigned protocol is used to wean a child gradually off antiseizure medications, usually when the child is seizure-free for 2 years and has a normal electroencephalogram. Medications must be gradually reduced to minimize the recurrence of seizures. Seizure medications can be safely discontinued. The risk of recurrence is greatest within the first year.
40. A 10-year-old boy has been hit by a car while riding his bicycle in front of the school. The school nurse immediately assesses airway, breathing, and circulation. The next nursing action should be to: a. Place on side. c. Stabilize neck and spine. b. Take blood pressure. d. Check scalp and back for bleeding.
ANS: C After determining that the child is breathing and has adequate circulation, the next action is to stabilize the neck and spine to prevent any additional trauma. The child's position should not be changed until the neck and spine are stabilized. Blood pressure is a later assessment. Less urgent, but an important assessment, is inspection of the scalp for bleeding.
19. A 3-year-old child is hospitalized after a near-drowning accident. The child's mother complains to the nurse, "This seems unnecessary when he is perfectly fine." The nurse's best reply is: a. "He still needs a little extra oxygen." b. "I'm sure he is fine, but the doctor wants to make sure." c. "The reason for this is that complications could still occur." d. "It is important to observe for possible central nervous system problems."
ANS: C All children who have a near-drowning experience should be admitted to the hospital for observation. Although many children do not appear to have suffered adverse effects from the event, complications such as respiratory compromise and cerebral edema may occur up to 24 hours after the incident. Stating that, "He still needs a little extra oxygen" does not respond directly to the mother's concern. Why is her child still receiving oxygen? The nurse should clarify that different complications can occur up to 24 hours later and that observations are necessary.
29. Which type of seizure involves both hemispheres of the brain? a. Focal c. Generalized b. Partial d. Acquired
ANS: C Clinical observations of generalized seizures indicate that the initial involvement is from both hemispheres. Focal seizures may arise from any area of the cerebral cortex, but the frontal, temporal, and parietal lobes are most commonly affected. Partial seizures are caused by abnormal electrical discharges from epileptogenic foci limited to a circumscribed region of the cerebral cortex. A seizure disorder that is acquired is a result of a brain injury from a variety of factors; it does not specify the type of seizure.
27. A young child's parents call the nurse after their child was bitten by a raccoon in the woods. The nurse's recommendation should be based on knowing that: a. The child should be hospitalized for close observation. b. No treatment is necessary if thorough wound cleaning is done. c. Antirabies prophylaxis must be initiated. d. Antirabies prophylaxis must be initiated if clinical manifestations appear.
ANS: C Current therapy for a rabid animal bite consists of a thorough cleansing of the wound and passive immunization with human rabies immune globulin (HRIG) as soon as possible. Hospitalization is not necessary. The wound cleansing, passive immunization, and immune globulin administration can be done as an outpatient. The child needs to receive both HRIG and rabies vaccine.
11. Which type of fracture describes traumatic separation of cranial sutures? a. Basilar c. Diastatic b. Compound d. Depressed
ANS: C Diastatic skull fractures are traumatic separations of the cranial sutures. A basilar fracture involves the basilar portion of the frontal, ethmoid, sphenoid, temporal, or occipital bone. A compound fracture has the bone exposed through the skin. A depressed fracture has the bone pushed inward, causing pressure on the brain.
20. The most common clinical manifestation of brain tumors in children is: a. Irritability. c. Headaches and vomiting. b. Seizures. d. Fever and poor fine motor control.
ANS: C Headaches, especially on awakening, and vomiting that is not related to feeding are the most common clinical manifestations of brain tumors in children. Irritability, seizures, and fever and poor fine motor control are clinical manifestations of brain tumors, but headaches and vomiting are the most common.
30. The initial clinical manifestation of generalized seizures is: a. Being confused. c. Losing consciousness. b. Feeling frightened. d. Seeing flashing lights.
ANS: C Loss of consciousness is a frequent occurrence in generalized seizures and is the initial clinical manifestation. Being confused, feeling frightened, and seeing flashing lights are clinical manifestations of a complex partial seizure.
1. Which term is used to describe a child's level of consciousness when the child can be aroused with stimulation? a. Stupor c. Obtundation b. Confusion d. Disorientation
ANS: C Obtundation describes a level of consciousness in which the child can be aroused with stimulation. Stupor is a state in which the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. Confusion is impaired decision making. Disorientation is confusion regarding time and place.
39. An appropriate nursing intervention when caring for an unconscious child should be to: a. Change the child's position infrequently to minimize the chance of increased intracranial pressure (ICP). b. Avoid using narcotics or sedatives to provide comfort and pain relief. c. Monitor fluid intake and output carefully to avoid fluid overload and cerebral edema. d. Give tepid sponge baths to reduce fever because antipyretics are contraindicated.
ANS: C Often comatose patients cannot cope with the quantity of fluids that they normally tolerate. Overhydration must be avoided to prevent fatal cerebral edema. The child's position should be changed frequently to avoid complications such as pneumonia and skin breakdown. Narcotics and sedatives should be used as necessary to reduce pain and discomfort, which can increase ICP. Antipyretics are the method of choice for fever reduction.
28. A child is brought to the emergency department after experiencing a seizure at school. There is no previous history of seizures. The father tells the nurse that he cannot believe the child has epilepsy. The nurse's best response is: a. "Epilepsy is easily treated." b. "Very few children have actual epilepsy." c. "The seizure may or may not mean that your child has epilepsy." d. "Your child has had only one convulsion; it probably won't happen again."
ANS: C Seizures are the indispensable characteristic of epilepsy; however, not every seizure is epileptic. Epilepsy is a chronic seizure disorder with recurrent and unprovoked seizures. The treatment of epilepsy involves a thorough assessment to determine the type of seizure the child is having and the cause of events, followed by individualized therapy to allow the child to have as normal a life as possible. The nurse should not make generalized comments like "Very few children have actual epilepsy" and "Your child has had only one convulsion; it probably won't happen again" until further assessment is made.
18. A 5-year-old girl sustained a concussion when she fell out of a tree. In preparation for discharge, the nurse is discussing home care with her mother. Which statement made by the mother indicates a correct understanding of the teaching? a. "I should expect my child to have a few episodes of vomiting." b. "If I notice sleep disturbances, I should contact the physician immediately." c. "I should expect my child to have some behavioral changes after the accident." d. "If I notice diplopia, I will have my child rest for 1 hour."
ANS: C The parents are advised of probably post-traumatic symptoms that may be expected, including behavioral changes. If the child has episodes of vomiting, sleep disturbances, or diplopia, they should be immediately reported for evaluation.
28.A child with hypopituitarism is being started on growth hormone (GH) therapy. Nursing considerations should be based on which of the following? a. Treatment is most successful if it is started during adolescence. b. Treatment is considered successful if children attain full stature by adulthood. c. Replacement therapy requires daily subcutaneous injections. d. Replacement therapy will be required throughout the child's lifetime.
ANS: C Additional support is required for children who require hormone replacement therapy, such as preparation for daily subcutaneous injections and education for self-management during the school-age years. Young children, obese children, and those who are severely GH deficient have the best response to therapy. When therapy is successful, children can attain their actual or near-final adult height at a slower rate than their peers. Replacement therapy is not needed after attaining final height. They are no longer GH deficient.
33.To help the adolescent deal with diabetes, the nurse must consider which characteristic of adolescence? a. Desire to be unique b. Preoccupation with the future c. Need to be perfect and similar to peers d. Need to make peers aware of the seriousness of hypoglycemic reactions
ANS: C Adolescence is a time when the individual wants to be perfect and similar to peers. Having diabetes makes adolescents different from their peers. Adolescents do not wish to be unique; they desire to fit in with the peer group and are usually not future oriented. Forcing peer awareness of the seriousness of hypoglycemic reactions would further alienate the adolescent with diabetes. The peer group would focus on the differences.
32. A child is brought to the emergency department experiencing an anaphylactic reaction to a bee sting. While an airway is being established, what medication should the nurse prepare for immediate administration? a. Diphenhydramine (Benadryl) c. Epinephrine b. Dopamine d. Calcium chloride
ANS: C After the first priority of establishing an airway, epinephrine is the drug of choice. Benadryl is not a strong enough antihistamine for this severe a reaction. Dopamine and calcium chloride are not appropriate drugs for this type of reaction. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1358 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
51. A preschool child is scheduled for an echocardiogram. Parents ask the nurse whether they can hold the child during the procedure. The nurse should answer with which response? a. "You will be able to hold your child during the procedure." b. "Your child can be active during the procedure, but can't sit in your lap." c. "Your child must lie quietly; sometimes a mild sedative is administered before the procedure." d. "The procedure is invasive so your child will be restrained during the echocardiogram."
ANS: C Although an echocardiogram is noninvasive, painless, and associated with no known side effects, it can be stressful for children. The child must lie quietly in the standard echocardiographic positions; crying, nursing, being held, or sitting up often leads to diagnostic errors or omissions. Therefore, infants and young children may need a mild sedative; older children benefit from psychologic preparation for the test. The distraction of a video or movie is often helpful. PTS: 1 DIF: Cognitive Level: Application REF: 1352 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
35. The nurse is teaching parents of a child with chronic renal failure (CRF) about the use of recombinant human erythropoietin (rHuEPO) subcutaneous injections. Which statement indicates the parents have understood the teaching? a. "These injections will help with the hypertension." b. "We're glad the injections only need to be given once a month." c. "The red blood cell count should begin to improve with these injections." d. "Urine output should begin to improve with these injections."
ANS: C Anemia in children with CRF is related to decreased production of erythropoietin. Recombinant human erythropoietin (rHuEPO) is being offered to these children as thrice-weekly or weekly subcutaneous injections and is replacing the need for frequent blood transfusions. The parents understand the teaching if they say that the red blood cell count will begin to improve with these injections.
4. Which defect results in increased pulmonary blood flow? a. Pulmonic stenosis c. Atrial septal defect b. Tricuspid atresia d. Transposition of the great arteries
ANS: C Atrial septal defect results in increased pulmonary blood flow. Blood flows from the left atrium (higher pressure) into the right atrium (lower pressure) and then to the lungs via the pulmonary artery. Pulmonic stenosis is an obstruction to blood flowing from the ventricles. Tricuspid atresia results in decreased pulmonary blood flow. Transposition of the great arteries results in mixed blood flow. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1322 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
20.A parent asks the nurse why self-monitoring of blood glucose is being recommended for her child with diabetes. The nurse should base the explanation on knowing that: a. It is a less expensive method of testing. b. It is not as accurate as laboratory testing. c. Children are better able to manage the diabetes. d. The parents are better able to manage the disease.
ANS: C Blood glucose self-management has improved diabetes management and can be used successfully by children from the time of diagnosis. Insulin dosages can be adjusted based on blood sugar results. Blood glucose monitoring is more expensive but provides improved management. It is as accurate as equivalent testing done in laboratories. The ability to self-test allows the child to balance diet, exercise, and insulin. The parents are partners in the process, but the child should be taught how to manage the disease.
11.The nurse is teaching the parents of a child who is receiving propylthiouracil for the treatment of hyperthyroidism (Graves' disease). Which statement made by the parent indicates a correct understanding of the teaching? a. "I would expect my child to gain weight while taking this medication." b. "I would expect my child to experience episodes of ear pain while taking this medication." c. "If my child develops a sore throat and fever, I should contact the physician immediately." d. "If my child develops the stomach flu, my child will need to be hospitalized."
ANS: C Children being treated with propylthiouracil must be carefully monitored for the side effects of the drug. Parents must be alerted that sore throat and fever accompany the grave complication of leukopenia. These symptoms should be immediately reported. Weight gain, episodes of ear pain, and stomach flu are not usually associated with leukopenia.
19. A major complication in a child with chronic renal failure is: a. Hypokalemia. b. Metabolic alkalosis. c. Water and sodium retention. d. Excessive excretion of blood urea nitrogen.
ANS: C Chronic renal failure leads to water and sodium retention, which contributes to edema and vascular congestion. Hyperkalemia, metabolic acidosis, and retention of blood urea nitrogen are complications of chronic renal failure.
30.The nurse is admitting a toddler with the diagnosis of juvenile hypothyroidism. Which is a common clinical manifestation of this disorder? a. Insomnia b. Diarrhea c. Dry skin d. Accelerated growth
ANS: C Dry skin, mental decline, and myxedematous skin changes are associated with juvenile hypothyroidism. Children with hypothyroidism are usually sleepy. Constipation is associated with hypothyroidism. Decelerated growth is common in juvenile hypothyroidism.
8.A common clinical manifestation of juvenile hypothyroidism is: a. Insomnia. b. Diarrhea. c. Dry skin. d. Accelerated growth.
ANS: C Dry skin, mental decline, and myxedematous skin changes are associated with juvenile hypothyroidism. Children with hypothyroidism are usually sleepy. Constipation is associated with hypothyroidism. Decelerated growth is common in juvenile hypothyroidism.
21.The parents of a child who has just been diagnosed with type 1 diabetes ask about exercise. The nurse should explain that: a. Exercise will increase blood glucose. b. Exercise should be restricted. c. Extra snacks are needed before exercise. d. Extra insulin is required during exercise.
ANS: C Exercise lowers blood glucose levels, which can be compensated for by extra snacks. Exercise is encouraged and not restricted unless indicated by other health conditions. Extra insulin is contraindicated because exercise decreases blood glucose levels.
32. The nurse is teaching the parent about the diet of a child experiencing severe edema associated with acute glomerulonephritis. Which information should the nurse include in the teaching? a. "You will need to decrease the number of calories in your child's diet." b. "Your child's diet will need an increased amount of protein." c. "You will need to avoid adding salt to your child's food." d. "Your child's diet will consist of low-fat, low-carbohydrate foods."
ANS: C For most children, a regular diet is allowed, but it should contain no added salt. The child should be offered a regular diet with favorite foods. Severe sodium restrictions are not indicated.
13.The most appropriate nursing diagnosis for the child with acute glomerulonephritis is: a. Risk for Injury related to malignant process and treatment. b. Deficient Fluid Volume related to excessive losses. c. Excess Fluid Volume related to decreased plasma filtration. d. Excess Fluid Volume related to fluid accumulation in tissues and third spaces.
ANS: C Glomerulonephritis has a decreased filtration of plasma. The decrease in plasma filtration results in an excessive accumulation of water and sodium that expands plasma and interstitial fluid volumes, leading to circulatory congestion and edema. No malignant process is involved in acute glomerulonephritis. A fluid volume excess is found. The fluid accumulation is secondary to the decreased plasma filtration, not fluid accumulation.
19. The nurse is caring for a child after heart surgery. What should she or he do if evidence is found of cardiac tamponade? a. Increase analgesia. b. Apply warming blankets. c. Immediately report this to the physician. d. Encourage the child to cough, turn, and breathe deeply.
ANS: C If evidence is noted of cardiac tamponade (blood or fluid in the pericardial space constricting the heart), the physician is notified immediately of this life-threatening complication. Increasing analgesia may be done before the physician drains the fluid, but the physician must be notified. Warming blankets are not indicated at this time. Encouraging the child to cough, turn, and breathe deeply should be deferred until after the evaluation by the physician. PTS: 1 DIF: Cognitive Level: Analysis REF: 1342 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
18. An important nursing consideration when suctioning a young child who has had heart surgery is to: a. Perform suctioning at least every hour. b. Suction for no longer than 30 seconds at a time. c. Administer supplemental oxygen before and after suctioning. d. Expect symptoms of respiratory distress when suctioning.
ANS: C If suctioning is indicated, supplemental oxygen is administered with a manual resuscitation bag before and after the procedure to prevent hypoxia. Suctioning should be done only as indicated, not on a routine basis. The child should be suctioned for no more than 5 seconds at one time. Symptoms of respiratory distress are to be avoided by using the appropriate technique. PTS: 1 DIF: Cognitive Level: Application REF: 1342 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
1.Which statement best describes hypopituitarism? a. Growth is normal during the first 3 years of life. b. Weight is usually more retarded than height. c. Skeletal proportions are normal for age. d. Most of these children have subnormal intelligence.
ANS: C In children with hypopituitarism, the skeletal proportions are normal. Growth is within normal limits for the first year of life. Height is usually more delayed than weight. Intelligence is not affected by hypopituitarism.
3.What is the priority nursing goal for a 14-year-old with Graves' disease? a. Relieving constipation b. Allowing the adolescent to make decisions about whether or not to take medication c. Verbalizing the importance of adherence to the medication regimen d. Developing alternative educational goals
ANS: C In order to adhere to the medication schedule, children need to understand that the medication must be taken two or three times per day. The adolescent with Graves' disease is not likely to be constipated. Adherence to the medication schedule is important to ensure optimal health and wellness. Medications should not be skipped and dose regimens should not be tapered by the child without consultation with the child's medical provider. The management of Graves' disease does not interfere with school attendance and does not require alternative educational plans.
20. An important nursing consideration when chest tubes will be removed from a child is to: a. Explain that it is not painful. b. Explain that only a Band-Aid will be needed. c. Administer analgesics before the procedure. d. Expect bright red drainage for several hours after removal.
ANS: C It is appropriate to prepare the child for the removal of chest tubes with analgesics. Short-acting medications can be used that are administered through an existing intravenous line. It is not a pain-free procedure. A sharp, momentary pain is felt, and this should not be misrepresented to the child. A petroleum gauze/airtight dressing is needed. Little or no drainage should be found on removal. PTS: 1 DIF: Cognitive Level: Analysis REF: 1342 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity
4.At what age is sexual development in boys and girls considered to be precocious? a. Boys, 11 years; girls, 9 years b. Boys, 12 years; girls, 10 years c. Boys, 9 years; girls, 8 years d. Boys, 10 years; girls, 9.5 years
ANS: C Manifestations of sexual development before age 9 in boys and age 8 in girls are considered precocious and should be investigated. Boys older than 9 years of age and girls older than 8 years of age fall within the expected range of pubertal onset.
50. Which action by the school nurse is important in the prevention of rheumatic fever? a. Encourage routine cholesterol screenings. b. Conduct routine blood pressure screenings. c. Refer children with sore throats for throat cultures. d. Recommend salicylates instead of acetaminophen for minor discomforts.
ANS: C Nurses have a role in prevention—primarily in screening school-age children for sore throats caused by group A -hemolytic streptococci. They can achieve this by actively participating in throat culture screening or by referring children with possible streptococcal sore throats for testing. Cholesterol and blood pressure screenings do not facilitate the recognition and treatment of group A -hemolytic streptococci. Salicylates should be avoided routinely because of the risk of Reye's syndrome after viral illnesses. PTS: 1 DIF: Cognitive Level: Application REF: 1346 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential
7. A clinical manifestation of the systemic venous congestion that can occur with congestive heart failure is: a. Tachypnea. c. Peripheral edema. b. Tachycardia. d. Pale, cool extremities.
ANS: C Peripheral edema, especially periorbital edema, is a clinical manifestation of systemic venous congestion. Tachypnea is a manifestation of pulmonary congestion. Tachycardia and pale, cool extremities are clinical manifestations of impaired myocardial function. PTS: 1 DIF: Cognitive Level: Analysis REF: 1332 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
43. A nurse is teaching an adolescent about primary hypertension. The nurse knows that which of the following is correct? a. Primary hypertension should be treated with diuretics as soon as it is detected. b. Congenital heart defects are the most common cause of primary hypertension. c. Primary hypertension may be treated with weight reduction. d. Primary hypertension is not affected by exercise.
ANS: C Primary hypertension in children may be treated with weight reduction and exercise programs. If ineffective, pharmacologic intervention may be needed. Primary hypertension is considered an inherited disorder. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1350 OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance
6. What is best described as the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures? a. Pulmonary congestion c. Congestive heart failure b. Congenital heart defect d. Systemic venous congestion
ANS: C The definition of congestive heart failure is the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures to meet the metabolic demands of the body. Pulmonary congestion is an excessive accumulation of fluid in the lungs. Congenital heart defect is a malformation of the heart present at birth. Systemic venous congestion is an excessive accumulation of fluid in the systemic vasculature. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1331 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
16.What is characteristic of the immune-mediated type 1 diabetes mellitus? a. Ketoacidosis is infrequent. b. Onset is gradual. c. Age at onset is usually younger than 18 years. d. Oral agents are often effective for treatment.
ANS: C The immune-mediated type 1 diabetes mellitus typically has its onset in children or young adults. Peak incidence is between the ages of 10 and 15 years. Infrequent ketoacidosis, gradual onset, and treatment with oral agents are more consistent with type 2 diabetes.
29. The nurse is admitting a school-age child in acute renal failure with reduced glomerular filtration rate. Which urine test is the most useful clinical indication of glomerular filtration rate? a. pH b. Osmolality c. Creatinine clearance d. Protein level
ANS: C The most useful clinical indication of glomerular filtration is the clearance of creatinine. It is a substance that is freely filtered by the glomerulus and secreted by the renal tubule cells. The pH and osmolality are not estimates of glomerular filtration. Although protein in the urine demonstrates abnormal glomerular permeability, it is not a measure of filtration rate.
13.Glucocorticoids, mineralocorticoids, and sex steroids are secreted by the: a. Thyroid gland. b. Parathyroid glands. c. Adrenal cortex. d. Anterior pituitary.
ANS: C These hormones are secreted by the adrenal cortex. The thyroid gland produces thyroid hormone and thyrocalcitonin. The parathyroid glands produce parathyroid hormone. The anterior pituitary produces hormones such as growth hormone, thyroid-stimulating hormone, adrenocorticotropic hormone, gonadotropin, prolactin, and melanocyte-stimulating hormone.
12.A child with hypoparathyroidism is receiving vitamin D therapy. The parents should be advised to watch for which sign of vitamin D toxicity? a. Headache and seizures b. Physical restlessness and voracious appetite without weight gain c. Weakness and lassitude d. Anorexia and insomnia
ANS: C Vitamin D toxicity can be a serious consequence of therapy. Parents are advised to watch for signs including weakness, fatigue, lassitude, headache, nausea, vomiting, and diarrhea. Renal impairment is manifested through polyuria, polydipsia, and nocturia. Headaches may be a sign of vitamin D toxicity, but seizures are not. Physical restlessness and a voracious appetite with weight loss are manifestations of hyperthyroidism. Anorexia and insomnia are not characteristic of vitamin D toxicity.
39. When assessing a child for possible congenital heart defects (CHDs), where should the nurse measure blood pressure? a. The right arm c. All four extremities b. The left arm d. Both arms while the child is crying
ANS: C When a CHD is suspected, the blood pressure should be measured in all four extremities while the child is quiet. Discrepancies between upper and lower extremities may indicate cardiac disease. Blood pressure measurements for upper and lower extremities are compared during an assessment for CHDs. Blood pressure measurements when the child is crying are likely to be elevated; thus the readings will be inaccurate. PTS: 1 DIF: Cognitive Level: Application REF: 1334 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
40.A nurse is planning care for a school-age child with type 1 diabetes. Which insulin preparations are rapid and short acting (Select all that apply)? a. Novolin N b. Lantus c. NovoLog d. Novolin R
ANS: C, D Rapid-acting insulin (e.g., NovoLog) reaches the blood within 15 minutes after injection. The insulin peaks 30 to 90 minutes later and may last as long as 5 hours. Short-acting (regular) insulin (e.g., Novolin R) usually reaches the blood within 30 minutes after injection. The insulin peaks 2 to 4 hours later and stays in the blood for about 4 to 8 hours. Intermediate-acting insulins (e.g., Novolin N) reach the blood 2 to 6 hours after injection. The insulins peak 4 to 14 hours later and stay in the blood for about 14 to 20 hours. Long-acting insulin (e.g., Lantus) takes 6 to 14 hours to start working. It has no peak or a very small peak 10 to 16 hours after injection. The insulin stays in the blood between 20 and 24 hours.
47. The nurse is caring for a neonate with suspected meningitis. Which clinical manifestations should the nurse prepare to assess if meningitis is confirmed (Select all that apply)? a. Headache b. Photophobia c. Bulging anterior fontanel d. Weak cry e. Poor muscle tone
ANS: C, D, E Assessment findings in a neonate with meningitis include bulging anterior fontanel, weak cry, and poor muscle tone. Headache and photophobia are signs seen in an older child.
44. Clinical manifestations of increased intracranial pressure (ICP) in infants are (Select all that apply): a. Low-pitched cry. b. Sunken fontanel. c. Diplopia and blurred vision. d. Irritability. e. Distended scalp veins. f. Increased blood pressure.
ANS: C, D, E Diplopia and blurred vision, irritability, and distended scalp veins are signs of increased ICP in infants. Low-pitched cry, sunken fontanel, and increased blood pressure are not clinical manifestations associated with ICP in infants.
41.The nurse is caring for a school-age child with hyperthyroidism (Graves' disease). Which clinical manifestations should the nurse monitor that may indicate a thyroid storm (Select all that apply)? a. Constipation b. Hypotension c. Hyperthermia d. Tachycardia e. Vomiting
ANS: C, D, E A child with a thyroid storm will have severe irritability and restlessness, vomiting, diarrhea, hyperthermia, hypertension, severe tachycardia, and prostration.
56. A nurse is conducting discharge teaching to parents about the care of their infant after cardiac surgery. The nurse instructs the parents to notify the physician if what conditions occur (Select all that apply)? a. Respiratory rate of 36 at rest b. Appetite slowly increasing c. Temperature above 37.7° C (100° F) d. New, frequent coughing e. Turning blue or bluer than normal
ANS: C, D, E The parents should be instructed to notify the physician after their infant's cardiac surgery for a temperature above 37.7° C (100° F); new, frequent coughing; and any episodes of the infant turning blue or bluer than normal. A respiratory rate of 36 at rest for an infant is within normal expectations, and it is expected that the appetite will increase slowly. PTS: 1 DIF: Cognitive Level: Application REF: 1342 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
57. The nurse is conducting discharge teaching about signs and symptoms of heart failure to parents of an infant with a repaired tetralogy of Fallot. Which signs and symptoms should the nurse include (Select all that apply)? a. Warm flushed extremities b. Weight loss c. Decreased urinary output d. Sweating (inappropriate) e. Fatigue
ANS: C, D, E The signs and symptoms of heart failure include decreased urinary output, sweating, and fatigue. Other signs include pale, cool extremities, not warm and flushed, and weight gain, not weight loss.
54. Which clinical manifestations would the nurse expect to see as shock progresses in a child and becomes decompensated shock (Select all that apply)? a. Thirst and diminished urinary output b. Irritability and apprehension c. Cool extremities and decreased skin turgor d. Confusion and somnolence e. Normal blood pressure and narrowing pulse pressure f. Tachypnea and poor capillary refill time
ANS: C, D, F Cool extremities, decreased skin turgor, confusion, somnolence, tachypnea, and poor capillary refill time are beginning signs of decompensated shock. PTS: 1 DIF: Cognitive Level: Analysis REF: 1356 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
53. Nursing interventions for the child after a cardiac catheterization include which of the following (Select all that apply)? a. Allow ambulation as tolerated. b. Monitor vital signs every 2 hours. c. Assess the affected extremity for temperature and color. d. Check pulses above the catheterization site for equality and symmetry. e. Remove pressure dressing after 4 hours. f. Maintain a patent peripheral intravenous catheter until discharge.
ANS: C, F The extremity that was used for access for the cardiac catheterization must be checked for temperature and color. Coolness and blanching may indicate arterial occlusion. The child should have a patent peripheral intravenous line to ensure adequate hydration. Allowing ambulation, monitoring vital signs every 2 hours, checking pulses, and removing the pressure dressing after 4 hours are interventions that do not apply to a child after a cardiac catheterization. PTS: 1 DIF: Cognitive Level: Application REF: 1320 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
24. What action may be beneficial in reducing the risk of Reye's syndrome? a. Immunization against the disease b. Medical attention for all head injuries c. Prompt treatment of bacterial meningitis d. Avoidance of aspirin and ibuprofen for children with varicella or those suspected of having influenza
ANS: D Although the etiology of Reye's syndrome is obscure, most cases follow a common viral illness, either varicella or influenza. A potential association exists between aspirin therapy and the development of Reye's syndrome; thus use of aspirin is avoided. No immunization currently exists for Reye's syndrome. Reye's syndrome is not correlated with head injuries or bacterial meningitis.
13. The nurse should recommend medical attention if a child with a slight head injury experiences: a. Sleepiness. c. Headache, even if slight. b. Vomiting, even once. d. Confusion or abnormal behavior.
ANS: D Medical attention should be sought if the child exhibits confusion or abnormal behavior; loses consciousness; or has amnesia, fluid leaking from the nose or ears, blurred vision, or unsteady gait. Sleepiness alone does not require evaluation. If the child is difficult to arouse from sleep, medical attention should be obtained. Vomiting more than three times requires medical attention. Severe or worsening headache or one that interferes with sleep should be evaluated.
38. The nurse is caring for a child with severe head trauma after a car accident. Which is an ominous sign that often precedes death? a. Papilledema c. Doll's head maneuver b. Delirium d. Periodic and irregular breathing
ANS: D Periodic or irregular breathing is an ominous sign of brainstem (especially medullary) dysfunction that often precedes complete apnea. Papilledema is edema and inflammation of the optic nerve. It is commonly a sign of increased intracranial pressure. Delirium is a state of mental confusion and excitement marked by disorientation to time and place. The doll's head maneuver is a test for brainstem or oculomotor nerve dysfunction.
37. The nurse is performing a Glasgow Coma Scale (GCS) on a school-age child with a head injury. The child opens eyes spontaneously, obeys commands, and is oriented to person, time, and place. Which is the score the nurse should record? a. 8 c. 13 b. 11 d. 15
ANS: D The GCS consists of a three-part assessment: eye opening, verbal response, and motor response. Numeric values of 1 through 5 are assigned to the levels of response in each category. The sum of these numeric values provides an objective measure of the patient's level of consciousness (LOC). A person with an unaltered LOC would score the highest, 15. The child who opens eyes spontaneously, obeys commands, and is oriented is scored at a 15.
35. How should the nurse explain positioning for a lumbar puncture to a 5-year-old child? a. "You will be on your knees with your head down on the table." b. "You will be able to sit up with your chin against your chest." c. "You will be on your side with the head of your bed slightly raised." d. "You will lie on your side and bend your knees so that they touch your chin."
ANS: D The child should lie on his or her side with knees bent and chin tucked in to the knees. This position exposes the area of the back for the lumbar puncture. The knee-chest position is not appropriate for a lumbar puncture. An infant can be placed in a sitting position with the infant facing the nurse and the head steadied against the nurse's body. A side-lying position with the head of the bed elevated is not appropriate for a lumbar puncture.
16. The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. The most essential part of the nursing assessment to detect early signs of a worsening condition is: a. Posturing. c. Focal neurologic signs. b. Vital signs. d. Level of consciousness.
ANS: D The most important nursing observation is assessment of the child's level of consciousness. Alterations in consciousness appear earlier in the progression of head injury than do alterations of vital signs or focal neurologic signs. Neurologic posturing indicates neurologic damage. Vital signs and focal neurologic signs are later signs of progression when compared with level-of-consciousness changes.
41. A child is unconscious after a motor vehicle accident. The watery discharge from the nose tests positive for glucose. The nurse should recognize that this suggests: a. Diabetic coma. c. Upper respiratory tract infection. b. Brainstem injury. d. Leaking of cerebrospinal fluid (CSF).
ANS: D Watery discharge from the nose that is positive for glucose suggests leaking of CSF from a skull fracture and is not associated with diabetes or respiratory tract infection. The fluid is probably CSF from a skull fracture and does not signify whether the brainstem is involved.
31. A mother asks the nurse what would be the first indication that acute glomerulonephritis is improving. The nurse's best response should be that the: a. Blood pressure will stabilize. . b. Child will have more energy. c. Urine will be free of protein d. Urinary output will increase.
ANS: D An increase in urinary output may signal resolution of the acute glomerulonephritis. If blood pressure is elevated, stabilization usually occurs with the improvement in renal function. The child having more energy and the urine being free of protein are related to the improvement in urinary output.
30. What type of shock is characterized by a hypersensitivity reaction causing massive vasodilation and capillary leaks, which may occur with drug or latex allergy? a. Neurogenic shock c. Hypovolemic shock b. Cardiogenic shock d. Anaphylactic shock
ANS: D Anaphylactic shock results from extreme allergy or hypersensitivity to a foreign substance. Neurogenic shock results from loss of neuronal control, such as the interruption of neuronal transmission that occurs from a spinal cord injury. Cardiogenic shock is decreased cardiac output. Hypovolemic shock is a reduction in the size of the vascular compartment, decreasing blood pressure, and low central venous pressure. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1356 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
20. Which clinical manifestation would be seen in a child with chronic renal failure? a. Hypotension b. Massive hematuria c. Hypokalemia d. Unpleasant "uremic" breath odor
ANS: D Children with chronic renal failure have a characteristic breath odor resulting from the retention of waste products. Hypertension may be a complication of chronic renal failure. With chronic renal failure, little or no urine output occurs. Hyperkalemia is a concern in chronic renal failure.
11. The parents of a young child with congestive heart failure tell the nurse that they are "nervous" about giving digoxin. The nurse's response should be based on knowing that: a. It is a safe, frequently used drug. b. It is difficult to either overmedicate or undermedicate with digoxin. c. Parents lack the expertise necessary to administer digoxin. d. Parents must learn specific, important guidelines for administration of digoxin.
ANS: D Digoxin has a narrow therapeutic range. The margin of safety between therapeutic, toxic, and lethal doses is very small. Specific guidelines are available for parents to learn how to administer the drug safely and monitor for side effects. Digoxin is a frequently used drug, but it has a narrow therapeutic range. Very small amounts of the liquid are given to infants, which makes it easy to overmedicate or undermedicate. Parents may lack the necessary expertise to administer the drug at first, but with discharge preparation they should be prepared to administer the drug safely. PTS: 1 DIF: Cognitive Level: Analysis REF: 1351 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
7.The nurse is caring for a child with suspected diabetes insipidus. Which clinical manifestation would she or he expect to observe? a. Oliguria b. Glycosuria c. Nausea and vomiting d. Polyuria and polydipsia
ANS: D Excessive urination accompanied by insatiable thirst is the primary clinical manifestation of diabetes. These symptoms may be so severe that the child does little other than drink and urinate. Oliguria is decreased urine production and is not associated with diabetes insipidus. Glycosuria is associated with diabetes mellitus. Nausea and vomiting are associated with inappropriate antidiuretic hormone secretion.
27.Which intervention is appropriate when examining a male infant for cryptorchidism? a. Cooling the examiner's hands b. Taking a rectal temperature c. Eliciting the cremasteric reflex d. Warming the room
ANS: D For the infant's comfort, the infant should be examined in a warm room with the examiner's hands warmed. Testes can retract into the inguinal canal if the infant is upset or cold. Examining the infant with cold hands is uncomfortable for the infant and likely to cause the infant's testes to retract into the inguinal canal. It may also cause the infant to be uncooperative during the examination. A rectal temperature yields no information about cryptorchidism. Testes can retract into the inguinal canal if the cremasteric reflex is elicited. This can lead to an incorrect diagnosis.
26. When discussing hyperlipidemia with a group of adolescents, the nurse should explain that high levels of what substance are thought to protect against cardiovascular disease? a. Cholesterol c. Low-density lipoproteins (LDLs) b. Triglycerides d. High-density lipoproteins (HDLs).
ANS: D HDLs contain very low concentrations of triglycerides, relatively little cholesterol, and high levels of proteins. It is thought that HDLs protect against cardiovascular disease. Cholesterol, triglycerides, and LDLs do not protect against cardiovascular disease. PTS: 1 DIF: Cognitive Level: Application REF: 1346 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
17.Which symptom is considered a cardinal sign of diabetes mellitus? a. Nausea b. Seizures c. Impaired vision d. Frequent urination
ANS: D Hallmarks of diabetes mellitus are glycosuria, polyuria, and polydipsia. Nausea and seizures are not clinical manifestations of diabetes mellitus. Impaired vision is a long-term complication of the disease.
28. When caring for the child with Kawasaki disease, the nurse should understand that: a. The child's fever is usually responsive to antibiotics within 48 hours. b. The principal area of involvement is the joints. c. Aspirin is contraindicated. d. Therapeutic management includes administration of gamma globulin and aspirin.
ANS: D High-dose intravenous gamma globulin and aspirin therapy are indicated to reduce the incidence of coronary artery abnormalities when given within the first 10 days of the illness. The fever of Kawasaki disease is unresponsive to antibiotics and antipyretics. Involvement of mucous membranes and conjunctiva, changes in the extremities, and cardiac involvement are seen. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1354 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
17. The nurse is caring for a child with acute renal failure. What clinical manifestation should he or she recognize as a sign of hyperkalemia? a. Dyspnea b. Seizure c. Oliguria d. Cardiac arrhythmia
ANS: D Hyperkalemia is the most common threat to the life of the child. Signs of hyperkalemia include electrocardiographic anomalies such as prolonged QRS complex, depressed ST segments, peaked T waves, bradycardia, or heart block. Dyspnea, seizure, and oliguria are not manifestations of hyperkalemia.
5.The nurse is assisting the pediatric provider with a newborn examination. The provider notes that the infant has hypospadias. The nurse understands that hypospadias refers to: a. Absence of a urethral opening. b. Penis shorter than usual for age. c. Urethral opening along dorsal surface of penis. d. Urethral opening along ventral surface of penis.
ANS: D Hypospadias is a congenital condition in which the urethral opening is located anywhere along the ventral surface of the penis. The urethral opening is present, but not at the glans. Hypospadias does not refer to the size of the penis. When the urethral opening is along the dorsal surface of the penis, it is known as epispadias.
3. The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells the nurse that her bandage is "too wet." The nurse finds the bandage and bed soaked with blood. The most appropriate initial nursing action is to: a. Notify the physician. b. Apply a new bandage with more pressure. c. Place the child in the Trendelenburg position. d. Apply direct pressure above the catheterization site.
ANS: D If bleeding occurs, direct continuous pressure is applied 2.5 cm (1 inch) above the percutaneous skin site to localize pressure over the vessel puncture. Notifying the physician and applying a new bandage with more pressure can be done after pressure is applied. The nurse can have someone else notify the physician while the pressure is being maintained. The Trendelenburg position would not be helpful; it would increase the drainage from the lower extremities. PTS: 1 DIF: Cognitive Level: Analysis REF: 1320 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
17. Seventy-two hours after cardiac surgery, a young child has a temperature of 37.7 C (101 F). The nurse should: a. Keep the child warm with blankets. b. Apply a hypothermia blanket. c. Record the temperature on nurses' notes. d. Report findings to physician.
ANS: D In the first 24 to 48 hours after surgery, the body temperature may increase to 37.7 C (100 F) as part of the inflammatory response to tissue trauma. If the temperature is higher or an elevated temperature continues after this period, it is most likely a sign of an infection and immediate investigation is indicated. Blankets should be removed from the child to keep the temperature from increasing. A hypothermia blanket is not indicated for this level of temperature. The temperature should be recorded, but the physician must be notified for evaluation. PTS: 1 DIF: Cognitive Level: Analysis REF: 1341 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
2.Which diagnostic finding is present when a child has primary nephrotic syndrome? a. Hyperalbuminemia b. Positive ASO titer c. Leukocytosis d. Proteinuria
ANS: D Large amounts of protein are lost through the urine as a result of an increased permeability of the glomerular basement membrane. Hypoalbuminemia is present because of loss of albumin through the defective glomerulus and the liver's inability to synthesize proteins to balance the loss. ASO titer is negative in a child with primary nephrotic syndrome. Leukocytosis is not a diagnostic finding in primary nephrotic syndrome.
24.The nurse is caring for an adolescent who has just started dialysis. The child seems always angry, hostile, or depressed. The nurse should recognize that this is most likely related to: a. Neurologic manifestations that occur with dialysis. b. Physiologic manifestations of renal disease. c. Adolescents having few coping mechanisms. d. Adolescents often resenting the control and enforced dependence imposed by dialysis.
ANS: D Older children and adolescents need control. The necessity of dialysis forces the adolescent into a dependent relationship, which results in these behaviors. Neurologic manifestations that occur with dialysis and physiologic manifestations of renal disease are a function of the age of the child, not neurologic or physiologic manifestations of the dialysis. Adolescents do have coping mechanisms, but they need to have some control over their disease management.
31.Which clinical manifestation may occur in the child who is receiving too much methimazole (Tapazole) for the treatment of hyperthyroidism (Graves' disease)? a. Seizures b. Enlargement of all lymph glands c. Pancreatitis or cholecystitis d. Lethargy and somnolence
ANS: D Parents should be aware of the signs of hypothyroidism that can occur from overdosage of the drug. The most common manifestations are lethargy and somnolence. Seizures and pancreatitis are not associated with the administration of Tapazole. Enlargement of the salivary and cervical lymph glands occurs.
25.An advantage of peritoneal dialysis is that: a. Treatments are done in hospitals. b. Protein loss is less extensive. c. Dietary limitations are not necessary. d. Parents and older children can perform treatments.
ANS: D Peritoneal dialysis is the preferred form of dialysis for parents, infants, and children who wish to remain independent. Parents and older children can perform the treatments themselves. Treatments can be done at home. Protein loss is not significantly different. The dietary limitations are necessary, but they are not as stringent as those for hemodialysis.
19.Type 1 diabetes mellitus is suspected in an adolescent. Which clinical manifestation may be present? a. Moist skin b. Weight gain c. Fluid overload d. Poor wound healing
ANS: D Poor wound healing is often an early sign of type 1 diabetes mellitus. Dry skin, weight loss, and dehydration are clinical manifestations of type 1 diabetes mellitus.
5.A child will start treatment for precocious puberty. This involves injections of synthetic: a. Thyrotropin. b. Gonadotropins. c. Somatotropic hormone. d. Luteinizing hormone-releasing hormone.
ANS: D Precocious puberty of central origin is treated with monthly subcutaneous injections of luteinizing hormone-releasing hormone. Thyrotropin, gonadotropin, and somatotropic hormone are not appropriate therapies for precocious puberty.
2. José is a 4-year-old child scheduled for a cardiac catheterization. Preoperative teaching should be: a. Directed at his parents because he is too young to understand. b. Detailed in regard to the actual procedures so he will know what to expect. c. Done several days before the procedure so that he will be prepared. d. Adapted to his level of development so that he can understand.
ANS: D Preoperative teaching should always be directed at the child's stage of development. The caregivers also benefit from the same explanations. The parents may ask additional questions, which should be answered, but the child needs to receive the information based on developmental level. This age group does not understand in-depth descriptions. Preschoolers should be prepared close to the time of the cardiac catheterization. PTS: 1 DIF: Cognitive Level: Application REF: 1320 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
41. For what reason might a newborn infant with a cardiac defect, such as coarctation of the aorta, that results in a right-to-left shunt receive prostaglandin E1? a. To decrease inflammation c. To decrease respirations b. To control pain d. To improve oxygenation
ANS: D Prostaglandin E1 is given to infants with a right-to-left shunt to keep the ductus arteriosus patent. This will improve oxygenation and increase pulmonary blood flow. PTS: 1 DIF: Cognitive Level: Analysis REF: 1324 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
9.A common side effect of corticosteroid therapy is: a. Fever. b. Hypertension. c. Weight loss. d. Increased appetite.
ANS: D Side effects of corticosteroid therapy include an increased appetite. Fever is not a side effect of therapy. It may be an indication of infection. Hypertension is not usually associated with initial corticosteroid therapy. Weight gain, not weight loss, is associated with corticosteroid therapy.
23.Manifestations of hypoglycemia include: a. Lethargy. b. Thirst. c. Nausea and vomiting. d. Shaky feeling and dizziness.
ANS: D Some of the clinical manifestations of hypoglycemia include shaky feelings; dizziness; difficulty concentrating, speaking, focusing, and coordinating; sweating; and pallor. Lethargy, thirst, and nausea and vomiting are manifestations of hyperglycemia.
21. The most common causative agent of bacterial endocarditis is: a. Staphylococcus albus. c. Staphylococcus albicans. b. Streptococcus hemolyticus. d. Streptococcus viridans.
ANS: D Staphylococcus viridans is the most common causative agent in bacterial (infective) endocarditis. Staphylococcus albus, Streptococcus hemolyticus, and Staphylococcus albicans are not common causative agents. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1344 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
22.A child eats some sugar cubes after experiencing symptoms of hypoglycemia. This rapid-releasing sugar should be followed by: a. Saturated and unsaturated fat. b. Fruit juice. c. Several glasses of water. d. Complex carbohydrate and protein.
ANS: D Symptoms of hypoglycemia are treated with a rapid-releasing sugar source followed by a complex carbohydrate and protein. Saturated and unsaturated fat, fruit juice, and several glasses of water do not provide the child with complex carbohydrate and protein necessary to stabilize the blood sugar.
25.The nurse is discussing various sites used for insulin injections with a child and her family. Which site usually has the fastest rate of absorption? a. Arm b. Leg c. Buttock d. Abdomen
ANS: D The abdomen has the fastest rate of absorption but the shortest duration. The arm has a fast rate of absorption but short duration. The leg has a slow rate of absorption but a long duration. The buttock has the slowest rate of absorption and the longest duration.
33. Which postoperative intervention should be questioned for a child after a cardiac catheterization? a. Continue intravenous (IV) fluids until the infant is tolerating oral fluids. b. Check the dressing for bleeding. c. Assess peripheral circulation on the affected extremity. d. Keep the affected leg flexed and elevated.
ANS: D The child should be positioned with the affected leg straight for 4 to 6 hours after the procedure. IV fluid administration continues until the child is taking and retaining adequate amounts of oral fluids. The insertion site dressing should be observed frequently for bleeding. The nurse should also look under the child to check for pooled blood. Peripheral perfusion is monitored after catheterization. Distal pulses should be palpable, although they may be weaker than in the contralateral extremity. PTS: 1 DIF: Cognitive Level: Analysis REF: 1320 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
37. What is an expected assessment finding in a child with coarctation of the aorta? a. Orthostatic hypotension b. Systolic hypertension in the lower extremities c. Blood pressure higher on the left side of the body d. Disparity in blood pressure between the upper and lower extremities
ANS: D The classic finding in children with coarctation of the aorta is a disparity in pulses and blood pressures between the upper and lower extremities. Orthostatic hypotension is not present with coarctation of the aorta. Systolic hypertension may be detected in the upper extremities. The left arm may not accurately reflect systolic hypertension because the left subclavian artery can be involved in the coarctation. PTS: 1 DIF: Cognitive Level: Application REF: 1324 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
46. Surgical closure of the ductus arteriosus would: a. Stop the loss of unoxygenated blood to the systemic circulation. b. Decrease the edema in legs and feet. c. Increase the oxygenation of blood. d. Prevent the return of oxygenated blood to the lungs.
ANS: D The ductus arteriosus allows blood to flow from the higher-pressure aorta to the lower-pressure pulmonary artery, causing a right-to-left shunt. If this is surgically closed, no additional oxygenated blood (from the aorta) will return to the lungs through the pulmonary artery. The aorta carries oxygenated blood to the systemic circulation. Because of the higher pressure in the aorta, blood is shunted into the pulmonary artery and the pulmonary circulation. Edema in the legs and feet is usually a sign of heart failure. This repair would not directly affect the edema. Increasing the oxygenation of blood would not interfere with the return of oxygenated blood to the lungs. PTS: 1 DIF: Cognitive Level: Analysis REF: 1323 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
33. A preschool child is being admitted to the hospital with dehydration and a urinary tract infection (UTI). Which urinalysis result should the nurse expect with these conditions? a. WBC <1; specific gravity 1.008 b. WBC <2; specific gravity 1.025 c. WBC >2; specific gravity 1.016 d. WBC >2; specific gravity 1.030
ANS: D The white blood cell count (WBC) in a routine urinalysis should be <1 or 2. Over that amount indicates a urinary tract inflammatory process. The urinalysis specific gravity for children with normal fluid intake is 1.016 to 1.022. When the specific gravity is high, dehydration is indicated. A low specific gravity is seen with excessive fluid intake, distal tubular dysfunction, or insufficient antidiuretic hormone secretion.
32.The parent of a child with diabetes mellitus asks the nurse when urine testing will be necessary. The nurse should explain that urine testing is necessary for which? a. Glucose is needed before administration of insulin. b. Glucose is needed four times a day. c. Glycosylated hemoglobin is required. d. Ketonuria is suspected.
ANS: D Urine testing is still performed to detect evidence of ketonuria. Urine testing for glucose is no longer indicated because of the poor correlation between blood glucose levels and glycosuria. Glycosylated hemoglobin analysis is performed on a blood sample.
38.A child with secondary enuresis who complains of dysuria or urgency should be evaluated for what condition (Select all that apply)? a. Hypocalciuria b. Nephrotic syndrome c. Glomerulonephritis d. Urinary tract infection (UTI) e. Diabetes mellitus
ANS: D, E Complaints of dysuria or urgency from a child with secondary enuresis suggest the possibility of a UTI. If accompanied by excessive thirst and weight loss, these symptoms may indicate the onset of diabetes mellitus. An excessive loss of calcium in the urine (hypercalciuria) can be associated with complaints of painful urination, urgency, frequency, and wetting. Nephrotic syndrome is not usually associated with complaints of dysuria or urgency. Glomerulonephritis is not a likely cause of dysuria or urgency.
3 In Jewish culture, first haircut is done for boys at age 3 years. This is called the "upsherenish ceremony." Therefore, the nurse should have gotten consent from the parents before shaving the scalp of the boy. Intravenous infusions and scalp vein insertion are allowed in the Jewish culture. Touching the head after touching the foot is considered disrespectful in the Vietnamese culture.
After giving a bed bath and cleaning the feet of a 2-year-old boy, an intravenous line is inserted into a small area by shaving the scalp. His Jewish parents are upset with this procedure. What could be the most probable reason behind the parents' discontent? 1 Intravenous infusions are against Jewish culture. 2 Scalp vein insertions are against the Jewish culture. 3 Cutting the hair before 3 years of age is not permitted in Jewish culture. 4 Touching the head after touching the foot is disrespectful in Jewish culture.
Which assessment findings indicate to the nurse a child has Down syndrome (select all that apply)? a. High-arched, narrow palate b. Protruding tongue c. Long, slender fingers d. Transverse palmar crease e. Hypertonic muscle tone
Answer: A, B, D
A nurse is instructing a nursing assistant on techniques to facilitate lipreading with a hearing-impaired child who lip-reads. Which techniques should the nurse include (select all that apply)? a. Speak at eye level. b. Stand at a distance from the child. c. Speak words in a loud tone. d. Use facial expressions while speaking. e. Keep sentences short.
Answer: A, D, E
Autism is a complex developmental disorder. The diagnostic criteria for autism include delayed or abnormal functioning in which area(s) with onset before age 3 years (select all that apply)? a. Language as used in social communication b. Gross motor development c. Growth below the 5th percentile for height and weight d. Symbolic or imaginative play e. Social interaction
Answer: A, D, E
Which interventions should the nurse plan when caring for a child with a visual impairment (select all that apply)? a. Touch the child upon entering the room before speaking. b. Keep items in the room in the same location. c. Describe the placement of the eating utensils on the meal tray. d. Use color examples to describe something to a child who has been blind since birth. e. Identify noises for the child.
Answer: B, C, E
The nurse is talking to the parent of a 13-month-old child. The mother states, "My child does not make noises like 'da' or 'na' like my sister's baby, who is only 9 months old." Which statement by the nurse would be most appropriate to make? a. "I am going to request a referral to a hearing specialist." b. "You should not compare your child to your sister's child." c. "I think your child is fine, but we will check again in 3 months." d. "You should ask other parents what noises their children made at this age."
Answer: a. "I am going to request a referral to a hearing specialist."
When should children with cognitive impairment be referred for stimulation and educational programs? a. As young as possible b. As soon as they have the ability to communicate in some way c. At age 3 years, when schools are required to provide services d. At age 5 or 6 years, when schools are required to provide services
Answer: a. As young as possible
Prevention of hearing impairment in children is a major goal for the nurse. This can be achieved through: a. Being involved in immunization clinics for children. b. Assessing a newborn for hearing loss. c. Answering parents' questions about hearing aids. d. Participating in hearing screening in the community.
Answer: a. Being involved in immunization clinics for children.
The most common type of hearing loss, which results from interference of transmission of sound to the middle ear, is called: a. Conductive. c. Mixed conductive-sensorineural. b. Sensorineural. d. Central auditory imperceptive.
Answer: a. Conductive.
A nurse would suspect possible visual impairment in a child who displays: a. Excessive rubbing of the eyes. b. Rapid lateral movement of the eyes. c. Delay in speech development. d. Lack of interest in casual conversation with peers.
Answer: a. Excessive rubbing of the eyes.
Parents have learned that their 6-year-old child has autism. The nurse may help the parents to cope by explaining that the child may: a. Have an extremely developed skill in a particular area. b. Outgrow the condition by early adulthood. c. Have average social skills. d. Have age-appropriate language skills.
Answer: a. Have an extremely developed skill in a particular area.
A child with autism spectrum disorder (ASD) is admitted to the hospital with pneumonia. The nurse should plan which priority intervention when caring for the child? a. Maintain a structured routine and keep stimulation to a minimum. b. Place the child in a room with a roommate of the same age. c. Maintain frequent touch and eye contact with the child. d. Take the child frequently to the playroom to play with other children.
Answer: a. Maintain a structured routine and keep stimulation to a minimum.
The major consideration when selecting toys for a child who is cognitively impaired is: a. Safety. b. Age appropriateness. c. Ability to provide exercise. d. Ability to teach useful skills.
Answer: a. Safety
Which action best facilitates lipreading by the hearing-impaired child? a. Speaking at an even rate b. Exaggerating pronunciation of words c. Avoiding using facial expressions d. Repeating in exactly the same way if child does not understand
Answer: a. Speaking at an even rate
A nurse is providing a parent information regarding autism. Which statement made by the parent indicates understanding of the teaching? a. "Autism is characterized by periods of remission and exacerbation." b. "The onset of autism usually occurs before 3 years of age." c. "Children with autism have imitation and gesturing skills." d. "Autism can be treated effectively with medication."
Answer: b. "The onset of autism usually occurs before 3 years of age."
When a child with mild cognitive impairment reaches the end of adolescence, what characteristic would be expected? a. Achieves a mental age of 5 to 6 years b. Achieves a mental age of 8 to 12 years c. Is unable to progress in functional reading or arithmetic d. Acquires practical skills and useful reading and arithmetic to an eighth-grade level
Answer: b. Achieves a mental age of 8 to 12 years
The school nurse is caring for a child with a penetrating eye injury. Emergency treatment includes: a. Applying a regular eye patch. b. Applying a Fox shield to the affected eye and any type of patch to the other eye. c. Applying ice until the physician is seen. d. Irrigating the eye copiously with a sterile saline solution.
Answer: b. Applying a Fox shield to the affected eye and any type of patch to the other eye.
A child with autism is hospitalized with asthma. The nurse should plan care so that the: a. Parents' expectations are met. b. Child's routine habits and preferences are maintained. c. Child is supported through the autistic crisis. d. Parents need not be at the hospital.
Answer: b. Child's routine habits and preferences are maintained.
An implanted ear prosthesis for children with sensorineural hearing loss is a(n): a. Hearing aid. c. Auditory implant. b. Cochlear implant. d. Amplification device.
Answer: b. Cochlear implant.
A newborn assessment shows separated sagittal suture, oblique palpebral fissures, depressed nasal bridge, protruding tongue, and transverse palmar creases. These findings are most suggestive of: a. Microcephaly. c. Cerebral palsy. b. Down syndrome. d. Fragile X syndrome.
Answer: b. Down syndrome
Appropriate interventions to facilitate socialization of the cognitively impaired child include to: a. Provide age-appropriate toys and play activities. b. Provide peer experiences such as Special Olympics when older. c. Avoid exposure to strangers who may not understand cognitive development. d. Emphasize mastery of physical skills because they are delayed more often than verbal skills.
Answer: b. Provide peer experiences such as Special Olympics when older.
Distortion of sound and problems in discrimination are characteristic of which type of hearing loss? a. Conductive b. Sensorineural c. Mixed conductive-sensorineural d. Central auditory imperceptive
Answer: b. Sensorineural
A parent asks the nurse why a developmental assessment is being conducted for a child during a routine well-child visit. The nurse answers based on the knowledge that routine developmental assessments during well-child visits are: a. Not necessary unless the parents request them. b. The best method for early detection of cognitive disorders. c. Frightening to parents and children and should be avoided. d. Valuable in measuring intelligence in children.
Answer: b. The best method for early detection of cognitive disorders.
A young child who has an intelligence quotient (IQ) of 45 would be described as: a. Within the lower limits of the range of normal intelligence. b. Mildly cognitively impaired but educable. c. Moderately cognitively impaired but trainable. d. Severely cognitively impaired and completely dependent on others for care.
Answer: c. Moderately cognitively impaired but trainable.
A 10-year-old patient is talking to the nurse about wanting to try contact lenses instead of wearing glasses. She states that the other children at her school call her "four-eyes." Contact lenses should be prescribed for a child who is: a. At least 12 years of age. b. Able to read all the written information and instructions. c. Able to independently care for the lenses in a responsible manner. d. Confident that she really wants contact lenses.
Answer: c. Able to independently care for the lenses in a responsible manner.
The child with Down syndrome should be evaluated for what characteristic before participating in some sports? a. Hyperflexibility b. Cutis marmorata c. Atlantoaxial instability d. Speckling of iris (Brushfield's spots)
Answer: c. Atlantoaxial instability
When caring for a newborn with Down syndrome, the nurse should be aware that the most common congenital anomaly associated with Down syndrome is: a. Hypospadias. c. Congenital heart disease. b. Pyloric stenosis. d. Congenital hip dysplasia.
Answer: c. Congenital heart disease.
A nurse is preparing to perform a dressing change on a 6-year-old child with mild cognitive impairment (CI) who sustained a minor burn. Which strategy should the nurse use to prepare the child for this procedure? a. Verbally explain what will be done. b. Have the child watch a video on dressing changes. c. Demonstrate a dressing change on a doll. d. Explain the importance of keeping the burn area clean.
Answer: c. Demonstrate a dressing change on a doll.
Which action is contraindicated when a child with Down syndrome is hospitalized? a. Determine the child's vocabulary for specific body functions. b. Assess the child's hearing and visual capabilities. c. Encourage parents to leave the child alone for extended periods of time. d. Have meals served at the child's usual mealtimes.
Answer: c. Encourage parents to leave the child alone for extended periods of time.
The nurse is discussing sexuality with the parents of an adolescent girl with moderate cognitive impairment. Which should the nurse consider when dealing with this issue? a. Sterilization is recommended for any adolescent with cognitive impairment. b. Sexual drive and interest are limited in individuals with cognitive impairment. c. Individuals with cognitive impairment need a well-defined, concrete code of sexual conduct. d. Sexual intercourse rarely occurs unless the individual with cognitive impairment is sexually abused.
Answer: c. Individuals with cognitive impairment need a well-defined, concrete code of sexual conduct.
A father calls the emergency department nurse saying that his daughter's eyes burn after getting some dishwasher detergent in them. The nurse recommends that the child be seen in the emergency department or by an ophthalmologist. What should the nurse recommend before the child is transported? a. Keep the eyes closed. b. Apply cold compresses. c. Irrigate eyes copiously with tap water for 20 minutes. d. Prepare a normal saline solution (salt and water) and irrigate eyes for 20 minutes.
Answer: c. Irrigate eyes copiously with tap water for 20 minutes
An appropriate nursing diagnosis for a child with a cognitive dysfunction who has a limited ability to anticipate danger is: a. Impaired Social Interaction. b. Deficient Knowledge. c. Risk for Injury. d. Ineffective Coping.
Answer: c. Risk for Injury.
The nurse is talking with a 10-year-old boy who wears bilateral hearing aids. The left hearing aid is making an annoying whistling sound that the child cannot hear. The most appropriate nursing action is to: a. Ignore the sound. b. Ask him to reverse the hearing aids in his ears. c. Suggest that he reinsert the hearing aid. d. Suggest that he raise the volume of the hearing aid.
Answer: c. Suggest that he reinsert the hearing aid
What should the nurse keep in mind when planning to communicate with a child who has autism? a. The child has normal verbal communication. b. The child is expected to use sign language. c. The child may exhibit monotone speech and echolalia. d. The child is not listening if she is not looking at the nurse.
Answer: c. The child may exhibit monotone speech and echolalia.
The pediatric nurse understands that fragile X syndrome is: a. A chromosome defect affecting only females. b. A chromosome defect that follows the pattern of X-linked recessive disorders. c. The second most common genetic cause of cognitive impairment. d. The most common cause of noninherited cognitive impairment.
Answer: c. The second most common genetic cause of cognitive impairment.
Which teaching guideline helps prevent eye injuries during sports and play activities? a. Restrict helmet use to those who wear eyeglasses or contact lenses. b. Discourage the use of goggles with helmets. c. Wear eye protection when participating in high-risk sports such as paintball. d. Wear a face mask when playing any sport or playing roughly.
Answer: c. Wear eye protection when participating in high-risk sports such as paintball.
The most common clinical manifestation of retinoblastoma is: a. Glaucoma. c. White eye reflex. b. Amblyopia. d. Sunken eye socket.
Answer: c. White eye reflex.
A nurse is preparing a teaching session for parents on prevention of childhood hearing loss. The nurse should include that the most common cause of hearing impairment in children is: a. Auditory nerve damage. c. Congenital rubella. b. Congenital ear defects. d. Chronic otitis media.
Answer: d. Chronic otitis media.
The teaching plan for the parents of a 3-year-old child with amblyopia ("lazy eye") should include what instruction? a. Apply a patch to the child's eyeglass lenses. b. Apply a patch only during waking hours. c. Apply a patch over the "bad" eye to strengthen it. d. Cover the "good" eye completely with a patch.
Answer: d. Cover the "good" eye completely with a patch.
A 2-year-old girl has excessive tearing and corneal haziness. The nurse knows that these symptoms may indicate: a. Viral conjunctivitis. c. Congenital cataract. b. Paralytic strabismus. c. Congenital cataract. d. Infantile glaucoma.
Answer: d. Infantile glaucoma.
An adolescent male visits his primary care provider complaining of difficulty with his vision. When the nurse asks the adolescent to explain what visual deficits he is experiencing, the adolescent states, "I am having difficulty seeing distant objects; they are less clear than things that are close." What disorder does the nurse suspect the adolescent has? a. Hyphema b. Astigmatism c. Amblyopia d. Myopia
Answer: d. Myopia
Mark, a 9-year-old with Down syndrome, is mainstreamed into a regular third-grade class for part of the school day. His mother asks the school nurse about programs such as Cub Scouts that he might join. The nurse's recommendation should be based on knowing that: a. Programs such as Cub Scouts are inappropriate for children who are cognitively impaired. b. Children with Down syndrome have the same need for socialization as other children. c. Children with Down syndrome socialize better with children who have similar disabilities. d. Parents of children with Down syndrome encourage programs such as scouting because they deny that their children have disabilities.
Answer; b. Children with Down syndrome have the same need for socialization as other children.
A parent whose child has been diagnosed with a cognitive deficit should be counseled that intellectual impairment: a. Is usually due to a genetic defect. b. May be caused by a variety of factors. c. Is rarely due to first-trimester events. d. Is usually caused by parental intellectual impairment.
Answer; b. May be caused by a variety of factors.
Which statement by a parent about a child's conjunctivitis indicates that further teaching is needed? a. "I'll have separate towels and washcloths for each family member." b. "I'll notify my doctor if the eye gets redder or the drainage increases." c. "When the eye drainage improves, we'll stop giving the antibiotic ointment." d. "After taking the antibiotic for 24 hours, my child can return to school."
Answer; c. "When the eye drainage improves, we'll stop giving the antibiotic ointment."
A woman has a history of drug use and is screened for hepatitis B during the first trimester. What is an appropriate action? a. Provide a low-protein diet. b. Offer the vaccine. c. Discuss the recommendation to bottle-feed her baby. d. Practice respiratory isolation.
B A person who has a history of high risk behaviors should be offered the hepatitis B vaccine. Care is supportive and includes bed rest and a high-protein, low-fat diet. The first trimester is too early to discuss feeding methods with a woman in the high risk category. Hepatitis B is transmitted through blood.
Acute diarrhea is often caused by: a. Hirschsprung's disease. c. Hypothyroidism. b. Antibiotic therapy. d. Meconium ileus.
B Acute diarrhea is a sudden increase in frequency and change in consistency of stools and may be associated with antibiotic therapy. Hirschsprung's disease, hypothyroidism, and meconium ileus are usually manifested with constipation rather than diarrhea.
Concerning the use and abuse of legal drugs or substances, nurses should be aware that: a. Although cigarette smoking causes a number of health problems, it has little direct effect on maternity-related health. b. Caucasian women are more likely to experience alcohol-related problems. c. Coffee is a stimulant that can interrupt body functions and has been related to birth defects. d. Prescription psychotherapeutic drugs taken by the mother do not affect the fetus; otherwise, they would not have been prescribed.
B African-American and poor women are more likely to use illicit substances, particularly cocaine, whereas Caucasian and educated women are more likely to use alcohol. Cigarette smoking impairs fertility and is a cause of low birth weight. Caffeine consumption has not been related to birth defects. Psychotherapeutic drugs have some effect on the fetus, and that risk must be weighed against their benefit to the mother.
While providing care in an obstetric setting, the nurse should understand that postpartum care of the woman with cardiac disease: a. Is the same as that for any pregnant woman. b. Includes rest, stool softeners, and monitoring of the effect of activity. c. Includes ambulating frequently, alternating with active range of motion. d. Includes limiting visits with the infant to once per day.
B Bed rest may be ordered, with or without bathroom privileges. Bowel movements without stress or strain for the woman are promoted with stool softeners, diet, and fluid. Care of the woman with cardiac disease in the postpartum period is tailored to the woman's functional capacity. The woman will be on bed rest to conserve energy and reduce the strain on the heart. Although the woman may need help caring for the infant, breastfeeding and infant visits are not contraindicated.
An 18-year-old client who has reached 16 weeks of gestation was recently diagnosed with pregestational diabetes. She attends her centering appointment accompanied by one of her girlfriends. This young woman appears more concerned about how her pregnancy will affect her social life than about her recent diagnosis of diabetes. Several nursing diagnoses are applicable to assist in planning adequate care. The most appropriate diagnosis at this time is: a. Risk for injury to the fetus related to birth trauma. b. Noncompliance related to lack of understanding of diabetes and pregnancy and requirements of the treatment plan. c. Deficient knowledge related to insulin administration. d. Risk for injury to the mother related to hypoglycemia or hyperglycemia.
B Before a treatment plan is developed or goals for the outcome of care are outlined, this client must come to an understanding of diabetes and the potential effects on her pregnancy. She appears to have greater concern for changes to her social life than adoption of a new self-care regimen. Risk for injury to the fetus related to either placental insufficiency or birth trauma may come much later in the pregnancy. At this time the client is having difficulty acknowledging the adjustments that she needs to make to her lifestyle to care for herself during pregnancy. The client may not yet be on insulin. Insulin requirements increase with gestation. The importance of glycemic control must be part of health teaching for this client. However, she has not yet acknowledged that changes to her lifestyle need to be made, and she may not participate in the plan of care until understanding takes place.
Maternal phenylketonuria (PKU) is an important health concern during pregnancy because: a. It is a recognized cause of preterm labor. b. The fetus may develop neurologic problems. c. A pregnant woman is more likely to die without dietary control. d. Women with PKU are usually retarded and should not reproduce.
B Children born to women with untreated PKU are more likely to be born with mental retardation, microcephaly, congenital heart disease, and low birth weight. Maternal PKU has no effect on labor. Women without dietary control of PKU are more likely to miscarry or bear a child with congenital anomalies. Screening for undiagnosed maternal PKU at the first prenatal visit may be warranted, especially in individuals with a family history of the disorder, with low intelligence of uncertain etiology, or who have given birth to microcephalic infants.
Nurses caring for antepartum women with cardiac conditions should be aware that: a. Stress on the heart is greatest in the first trimester and the last 2 weeks before labor. b. Women with class II cardiac disease should avoid heavy exertion and any activity that causes even minor symptoms. c. Women with class III cardiac disease should have 8 to 10 hours of sleep every day and limit housework, shopping, and exercise. d. Women with class I cardiac disease need bed rest through most of the pregnancy and face the possibility of hospitalization near term.
B Class II cardiac disease is symptomatic with ordinary activity. Women in this category need to avoid heavy exertion and limit regular activities as symptoms dictate. Stress is greatest between weeks 28 and 32, when homodynamic changes reach their maximum. Class III cardiac disease is symptomatic with less than ordinary activity. These women need bed rest most of the day and face the possibility of hospitalization near term. Class I cardiac disease is asymptomatic at normal levels of activity. These women can carry on limited normal activities with discretion, although they still need a good amount of sleep.
Diabetes in pregnancy puts the fetus at risk in several ways. Nurses should be aware that: a. With good control of maternal glucose levels, sudden and unexplained stillbirth is no longer a major concern. b. The most important cause of perinatal loss in diabetic pregnancy is congenital malformations. c. Infants of mothers with diabetes have the same risks for respiratory distress syndrome because of the careful monitoring. d. At birth the neonate of a diabetic mother is no longer in any risk.
B Congenital malformations account for 30% to 50% of perinatal deaths. Even with good control, sudden and unexplained stillbirth remains a major concern. Infants of diabetic mothers are at increased risk for respiratory distress syndrome. The transition to extrauterine life often is marked by hypoglycemia and other metabolic abnormalities.
An infant with short bowel syndrome will be discharged home on total parenteral nutrition (TPN) and gastrostomy feedings. Nursing care should include: a. Preparing the family for impending death. b. Teaching the family signs of central venous catheter infection. c. Teaching the family how to calculate caloric needs. d. Securing TPN and gastrostomy tubing under diaper to lessen risk of dislodgment.
B During TPN therapy, care must be taken to minimize the risk of complications related to the central venous access device, such as catheter infections, occlusions, or accidental removal. This is an important part of family teaching. The prognosis for patients with short bowel syndrome depends in part on the length of residual small intestine. It has improved with advances in TPN. Although parents need to be taught about nutritional needs, the caloric needs and prescribed TPN and rate are the responsibility of the health care team. The tubes should not be placed under the diapers because of risk of infection.
A newborn was admitted to the nursery with a complete bilateral cleft lip and palate. The physician explained the plan of therapy and its expected good results. However, the mother refuses to see or hold her baby. Initial therapeutic approach to the mother should be to: a. Restate what the physician has told her about plastic surgery. b. Encourage her to express her feelings. c. Emphasize the normalcy of her baby and the baby's need for mothering. d. Recognize that negative feelings toward the child continue throughout childhood.
B For parents, cleft lip and cleft palate deformities are particularly disturbing. The nurse must place emphasis not only on the infant's physical needs but also on the parents' emotional needs. The mother needs to be able to express her feelings before the acceptance of her child can occur. Although discussing plastic surgery will be addressed, it is not part of the initial therapeutic approach. As the mother expresses her feelings, the nurse's actions should convey to the parents that the infant is a precious human being. The child's normalcy is emphasized, and the mother is assisted to recognize the child's uniqueness. A focus on abnormal maternal-infant attachment would be inappropriate at this time.
A 4-month-old infant has gastroesophageal reflux disease (GERD) but is thriving without other complications. What should the nurse suggest to minimize reflux? a. Place in Trendelenburg position after eating. b. Thicken formula with rice cereal. c. Give continuous nasogastric tube feedings. d. Give larger, less frequent feedings.
B Giving small frequent feedings of formula combined with 1 teaspoon to 1 tablespoon of rice cereal per ounce of formula has been recommended. Milk thickening agents have been shown to decrease the number of episodes of vomiting and increase the caloric density of the formula. This may benefit infants who are underweight as a result of GERD. Placing the child in Trendelenburg position would increase the reflux. Continuous nasogastric feedings are reserved for infants with severe reflux and failure to thrive. Smaller, more frequent feedings are recommended in reflux.
The use of methamphetamine (meth) has been described as a significant drug problem in the United States. In order to provide adequate nursing care to this client population the nurse must be cognizant that methamphetamine: a. Is similar to opiates. b. Is a stimulant with vasoconstrictive characteristics. c. Should not be discontinued during pregnancy. d. Is associated with a low rate of relapse.
B Methamphetamines are stimulants with vasoconstrictive characteristics similar to cocaine and are used similarly. As is the case with cocaine users, methamphetamine users are urged to immediately stop all use during pregnancy. Unfortunately, because methamphetamine users are extremely psychologically addicted, the rate of relapse is very high.
A new mother with which of these thyroid disorders would be strongly discouraged from breastfeeding? a. Hyperthyroidism c. Hypothyroidism b. Phenylketonuria (PKU) d. Thyroid storm
B PKU is a cause of mental retardation in infants; mothers with PKU pass on phenylalanine. A woman with hyperthyroidism or hypothyroidism would have no particular reason not to breastfeed. A thyroid storm is a complication of hyperthyroidism.
Preconception counseling is critical to the outcome of diabetic pregnancies because poor glycemic control before and during early pregnancy is associated with: a. Frequent episodes of maternal hypoglycemia. b. Congenital anomalies in the fetus. c. Polyhydramnios. d. Hyperemesis gravidarum.
B Preconception counseling is particularly important because strict metabolic control before conception and in the early weeks of gestation is instrumental in decreasing the risks of congenital anomalies. Frequent episodes of maternal hypoglycemia may occur during the first trimester (not before conception) as a result of hormone changes and the effects on insulin production and usage. Hydramnios occurs about 10 times more often in diabetic pregnancies than in nondiabetic pregnancies. Typically it is seen in the third trimester of pregnancy. Hyperemesis gravidarum may exacerbate hypoglycemic events because the decreased food intake by the mother and glucose transfer to the fetus contribute to hypoglycemia.
The nurse is caring for an infant whose cleft lip was repaired. Important aspects of this infant's postoperative care include: a. Arm restraints, postural drainage, and mouth irrigations. b. Cleansing of suture line, supine and side-lying positions, and arm restraints. c. Mouth irrigations, prone position, and cleansing of suture line. d. Supine and side-lying positions, postural drainage, and arm restraints.
B The suture line should be cleansed gently after feeding. The child should be positioned on back or side or in an infant seat. Elbows are restrained to prevent the child from accessing the operative site. Postural drainage is not indicated. This would increase the pressure on the operative site when the child is placed in different positions. Mouth irrigations would not be indicated.
An infant is brought to the emergency department with poor skin turgor, weight loss, lethargy, and tachycardia. This is suggestive of: a. Overhydration. c. Sodium excess. b. Dehydration. d. Calcium excess.
B These clinical manifestations indicate dehydration. Symptoms of overhydration are edema and weight gain. Regardless of extracellular sodium levels, total body sodium is usually depleted in dehydration. Symptoms of hypocalcemia are a result of neuromuscular irritability and manifest as jitteriness, tetany, tremors, and muscle twitching.
A 26-year-old primigravida has come to the clinic for her regular prenatal visit at 12 weeks. She appears thin and somewhat nervous. She reports that she eats a well-balanced diet, although her weight is 5 pounds less than it was at her last visit. The results of laboratory studies confirm that she has a hyperthyroid condition. Based on the available data, the nurse formulates a plan of care. What nursing diagnosis is most appropriate for the woman at this time? a. Deficient fluid volume b. Imbalanced nutrition: less than body requirements c. Imbalanced nutrition: more than body requirements d. Disturbed sleep pattern
B This client's clinical cues include weight loss, which would support the nursing diagnosis of Imbalanced nutrition: less than body requirements. No clinical signs or symptoms support the nursing diagnosis of Deficient fluid volume. This client reports weight loss, not weight gain. Imbalanced nutrition: more than body requirements is not an appropriate nursing diagnosis. Although the client reports nervousness, based on the client's other clinical symptoms the most appropriate nursing diagnosis would be Imbalanced nutrition: less than body requirements.
In terms of the incidence and classification of diabetes, maternity nurses should know that: a. Type 1 diabetes is most common. b. Type 2 diabetes often goes undiagnosed. c. Gestational diabetes mellitus (GDM) means that the woman will be receiving insulin treatment until 6 weeks after birth. d. Type 1 diabetes may become type 2 during pregnancy.
B Type 2 diabetes often goes undiagnosed because hyperglycemia develops gradually and often is not severe. Type 2 diabetes, sometimes called adult onset diabetes, is the most common. GDM refers to any degree of glucose intolerance first recognized during pregnancy. Insulin may or may not be needed. People do not go back and forth between types 1 and 2 diabetes.
Which vaccine is now recommended for the immunization of all newborns? a. Hepatitis A vaccine c. Hepatitis C vaccine b. Hepatitis B vaccine d. Hepatitis A, B, and C vaccines
B Universal vaccination for hepatitis B is now recommended for all newborns. A vaccine is available for hepatitis A, but it is not yet universally recommended. No vaccine is currently available for hepatitis C. Only hepatitis B vaccine is recommended for newborns.
A nurse is working in a clinic that serves a culturally diverse population of children. The nurse should plan care, understanding that the following complementary and alternative practices may be used by this patient population (Select all that apply): a. Seeking another doctor's opinion b. Seeking advice from a curandero or curandera c. Using acupuncture or acupressure as a therapy d. Consulting an herbalist e. Consulting a kahuna
B, C, D, E
Autoimmune disorders often occur during pregnancy because a large percentage of women with an autoimmune disorder are of childbearing age. Identify all disorders that fall into the category of collagen vascular disease. a. Multiple sclerosis b. Systemic lupus erythematosus c. Antiphospholipid syndrome d. Rheumatoid arthritis e. Myasthenia gravis
B, C, D, E Multiple sclerosis is not an autoimmune disorder. This patchy demyelinization of the spinal cord may be a viral disorder. Autoimmune disorders (collagen vascular disease) make up a large group of conditions that disrupt the function of the immune system of the body. They include those listed, as well as systemic sclerosis.
Which statements regarding hepatitis B are correct (Select all that apply)? a. Hepatitis B cannot exist in a carrier state. b. Hepatitis B can be prevented by hepatitis B virus vaccine. c. Hepatitis B can be transferred to an infant of a breastfeeding mother. d. The onset of hepatitis B is insidious. e. Immunity to hepatitis B occurs after one attack.
B, C, D, E The vaccine elicits the formation of an antibody to the hepatitis B surface antigen, which is protective against hepatitis B. Hepatitis B can be transferred to an infant of a breastfeeding mother, especially if the mother's nipples are cracked. The onset of hepatitis B is insidious. Immunity develops after one exposure to hepatitis B. Hepatitis B can exist in a carrier state.
Which behaviors by the nurse indicate a therapeutic relationship with children and families? (Select all that apply.) a. Spending off-duty time with children and families b. Asking questions if families are not participating in the care c. Clarifying information for families d. Buying toys for a hospitalized child e. Learning about the family's religious preferences
B, C, E
The nurse finds that a child spends several hours each day playing video games and lives in a home environment with limited access to safe playgrounds and parks. What health risks does the nurse expect based on these findings? Select all that apply. A Tooth decay B Hypertension C Diabetes D Growth delays E Hypercholesterolemia
B, C, E A child's home environment with limited access to safe outdoor play areas and abundant access to television and video games is a major contributing factor for childhood obesity. Childhood obesity increases the risk for hypertension, diabetes, and hypercholesterolemia, among other conditions. Tooth decay is associated with poor dental care, not lack of exercise contributing to childhood obesity. Growth delays are associated with malnutrition, not lack of exercise contributing to childhood obesity.
A mother who intended to breastfeed has given birth to an infant with a cleft palate. Nursing interventions should include (Select all that apply): a. Giving medication to suppress lactation. b. Encouraging and helping mother to breastfeed. c. Teaching mother to feed breast milk by gavage. d. Recommending use of a breast pump to maintain lactation until infant can suck.
B, D The mother who wishes to breastfeed may need encouragement and support because the defect does present some logistical issues. The nipple must be positioned and stabilized well back in the infant's oral cavity so that the tongue action facilitates milk expression. The suction required to stimulate milk, absent initially, may be useful before nursing to stimulate the let-down reflex. Because breastfeeding is an option, if the mother wishes to breastfeed, medications should not be given to suppress lactation. Because breastfeeding can usually be accomplished, gavage feedings are not indicated.
The nurse is preparing to care for an infant returning from pyloromyotomy surgery. Which prescribed orders should the nurse anticipate implementing (Select all that apply)? a. Nothing by mouth for 24 hours b. Administration of analgesics for pain c. Ice bag to the incisional area d. Intravenous (IV) fluids continued until tolerating fluids by mouth e. Clear liquids as the first feeding
B, D, E Feedings are usually instituted soon after a pyloromyotomy surgery, beginning with clear liquids and advancing to formula or breast milk as tolerated. IV fluids are administered until the infant is taking and retaining adequate amounts by mouth. Appropriate analgesics should be given around the clock because pain is continuous. Ice should not be applied to the incisional area as it vasoconstricts and would reduce circulation to the incisional area and impair healing.
3 The nurse should first ask the patient the purpose of wearing the necklace. The amulet may be worn as a religious ritual or simply as an accessory. After assessing why the necklace is worn, the nurse can explain the reason for having to remove the necklace for the procedure. The first step is to assess. Placing tape around the neck is not an appropriate action and could be unsafe. The necklace should be left with family members if possible or in a locked cabinet, rather than at the nurse's station. Test-Taking Tip: Many times the correct answer is the longest alternative given, but do not count on it. NCLEX item writers (those who write the questions) are also aware of this and attempt to avoid offering you such "helpful hints."
Before transporting a 16-year-old American Indian female for a magnetic resonance imaging (MRI) scan, the nurse notices the girl is wearing a decorated amulet necklace. The nurse's next best action is to: 1 remove the necklace and place it at the nurse's station. 2 explain the risks of wearing the necklace during the MRI. 3 ask the patient if there is a special reason for wearing the necklace. 4 place tape around the neck covering the necklace.
The nurse providing care for a woman with gestational diabetes understands that a laboratory test for glycosylated hemoglobin Alc: a. Is now done for all pregnant women, not just those with or likely to have diabetes. b. Is a snapshot of glucose control at the moment. c. Would be considered evidence of good diabetes control with a result of 5% to 6%. d. Is done on the patient's urine, not her blood.
C A score of 5% to 6% indicates good control. This is an extra test for diabetic women, not one done for all pregnant women. This test defines glycemic control over the previous 4 to 6 weeks. Glycosylated hemoglobin level tests are done on the blood.
For what clinical manifestation should a nurse be alert when suspecting a diagnosis of esophageal atresia? a. A radiograph in the prenatal period indicates abnormal development. b. It is visually identified at the time of delivery. c. A nasogastric tube fails to pass at birth. d. The infant has a low birth weight.
C Atresia is suspected when a nasogastric tube fails to pass 10 to 11 cm beyond the gum line. Abdominal radiographs will confirm the diagnosis. Prenatal radiographs do not provide a definitive diagnosis. The defect is not externally visible. Bronchoscopy and endoscopy can be used to identify this defect. Infants with esophageal atresia may have been born prematurely and with a low birth weight, but neither is suggestive of the presence of an esophageal atresia.
Which statement is most descriptive of Meckel's diverticulum? a. It is more common in females than in males. b. It is acquired during childhood. c. Intestinal bleeding may be mild or profuse. d. Medical interventions are usually sufficient to treat the problem.
C Blood stools are often a presenting sign of Meckel's diverticulum. It is associated with mild-to-profuse intestinal bleeding. It is twice as common in males as in females, and complications are more frequent in males. Meckel's diverticulum is the most common congenital malformation of the gastrointestinal tract and is present in 1% to 4% of the general population. The standard therapy is surgical removal of the diverticulum.
Constipation has recently become a problem for a school-age girl. She is healthy except for seasonal allergies, which are now being successfully treated with antihistamines. The nurse should suspect that the constipation is most likely caused by: a. Diet. c. Antihistamines. b. Allergies. d. Emotional factors.
C Constipation may be associated with drugs such as antihistamines, antacids, diuretics, opioids, antiepileptics, and iron. Because this is the only known recent change in her habits, the addition of antihistamines is most likely the etiology of the diarrhea, rather than diet, allergies, or emotional factors. With a change in bowel habits, the presence and role of any recently prescribed medications should be assessed.
What is used to treat moderate-to-severe inflammatory bowel disease? a. Antacids c. Corticosteroids b. Antibiotics d. Antidiarrheal medications
C Corticosteroids such as prednisone and prednisolone are used in short bursts to suppress the inflammatory response in inflammatory bowel disease. Antacids and antidiarrheals are not drugs of choice to treat the inflammatory process of inflammatory bowel disease. Antibiotics may be used as adjunctive therapy to treat complications.
A parasite that causes acute diarrhea is: a. Shigella organisms. c. Giardia lamblia. b. Salmonella organisms. d. Escherichia coli.
C Giardia is a parasite that represents 15% of nondysenteric illness in the United States. Shigella, Salmonella, and E. coli are bacterial pathogens.
To manage her diabetes appropriately and ensure a good fetal outcome, the pregnant woman with diabetes will need to alter her diet by: a. Eating six small equal meals per day. b. Reducing carbohydrates in her diet. c. Eating her meals and snacks on a fixed schedule. d. Increasing her consumption of protein.
C Having a fixed meal schedule will provide the woman and the fetus with a steadier blood sugar level, provide better balance with insulin administration, and help prevent complications. It is more important to have a fixed meal schedule than equal division of food intake. Approximately 45% of the food eaten should be in the form of carbohydrates.
Which statement best characterizes hepatitis A? a. The incubation period is 6 weeks to 6 months. b. The principal mode of transmission is through the parenteral route. c. Onset is usually rapid and acute. d. There is a persistent carrier state.
C Hepatitis A is the most common form of acute hepatitis in most parts of the world. It is characterized by a rapid acute onset. The incubation period is approximately 3 weeks for hepatitis A. The principal mode of transmission for hepatitis A is the fecal-oral route. Hepatitis A does not have a carrier state.
Nursing intervention for the pregnant diabetic patient is based on the knowledge that the need for insulin: a. Increases throughout pregnancy and the postpartum period. b. Decreases throughout pregnancy and the postpartum period. c. Varies depending on the stage of gestation. d. Should not change because the fetus produces its own insulin.
C Insulin needs decrease during the first trimester, when nausea, vomiting, and anorexia are a factor. They increase during the second and third trimesters, when the hormones of pregnancy create insulin resistance in maternal cells. Insulin needs increase during the second and third trimesters, when the hormones of pregnancy create insulin resistance in maternal cells. The insulin needs change throughout the different stages of pregnancy.
The nurse is explaining to a parent how to care for a child with vomiting associated with a viral illness. The nurse should include: a. Avoiding carbohydrate-containing liquids. b. Giving nothing by mouth for 24 hours. c. Brushing teeth or rinsing mouth after vomiting. d. Giving plain water until vomiting ceases for at least 24 hours.
C It is important to emphasize the need for the child to brush the teeth or rinse the mouth after vomiting to dilute the hydrochloric acid that comes in contact with the teeth. Administration of a glucose-electrolyte solution to an alert child will help restore water and electrolytes satisfactorily. It is important to include carbohydrates to spare body protein and avoid ketosis.
Therapeutic management of the child with acute diarrhea and dehydration usually begins with: a. Clear liquids. b. Adsorbents such as kaolin and pectin. c. Oral rehydration solution (ORS). d. Antidiarrheal medications such as paregoric.
C ORS is the first treatment for acute diarrhea. Clear liquids are not recommended because they contain too much sugar, which may contribute to diarrhea. Adsorbents are not recommended and neither are antidiarrheals because they do not get rid of pathogens.
Which heart condition is not a contraindication for pregnancy? a. Peripartum cardiomyopathy c. Heart transplant b. Eisenmenger syndrome d. All of these contraindicate pregnancy.
C Pregnancy is contraindicated for peripartum cardiomyopathy and Eisenmenger syndrome. Women who have had heart transplants are successfully having babies. However, conception should be postponed for at least 1 year after transplantation.
Metabolic changes throughout pregnancy that affect glucose and insulin in the mother and the fetus are complicated but important to understand. Nurses should understand that: a. Insulin crosses the placenta to the fetus only in the first trimester, after which the fetus secretes its own. b. Women with insulin-dependent diabetes are prone to hyperglycemia during the first trimester because they are consuming more sugar. c. During the second and third trimesters, pregnancy exerts a diabetogenic effect that ensures an abundant supply of glucose for the fetus. d. Maternal insulin requirements steadily decline during pregnancy.
C Pregnant women develop increased insulin resistance during the second and third trimesters. Insulin never crosses the placenta; the fetus starts making its own insulin around the tenth week. As a result of normal metabolic changes during pregnancy, insulin-dependent women are prone to hypoglycemia (low levels). Maternal insulin requirements may double or quadruple by the end of pregnancy.
Which description of a stool is characteristic of intussusception? a. Ribbon-like stools c. "Currant jelly" stools b. Hard stools positive for guaiac d. Loose, foul-smelling stools
C Pressure on the bowel from obstruction leads to passage of "currant jelly" stools. Ribbon-like stools are characteristic of Hirschsprung's disease. With intussusception, passage of bloody mucus-coated stools occurs. Stools will not be hard. Loose, foul-smelling stools may indicate infectious gastroenteritis.
Which factor is known to increase the risk of gestational diabetes mellitus? a. Underweight before pregnancy b. Maternal age younger than 25 years c. Previous birth of large infant d. Previous diagnosis of type 2 diabetes mellitus
C Previous birth of a large infant suggests gestational diabetes mellitus. Obesity (BMI of 30 or greater) creates a higher risk for gestational diabetes. A woman younger than 25 years generally is not at risk for gestational diabetes mellitus. The person with type 2 diabetes mellitus already has diabetes and will continue to have it after pregnancy. Insulin may be required during pregnancy because oral hypoglycemia drugs are contraindicated during pregnancy.
A woman with asthma is experiencing a postpartum hemorrhage. Which drug would not be used to treat her bleeding because it may exacerbate her asthma? a. Pitocin b. Nonsteroidal antiinflammatory drugs (NSAIDs) c. Hemabate d. Fentanyl
C Prostaglandin derivatives should not be used to treat women with asthma, because they may exacerbate symptoms. Pitocin would be the drug of choice to treat this woman's bleeding because it would not exacerbate her asthma. NSAIDs are not used to treat bleeding. Fentanyl is used to treat pain, not bleeding.
What is the most important information to be included in the discharge planning for an infant with gastroesophageal reflux? a. Teach parents to position the infant on the left side. b. Reinforce the parents' knowledge of the infant's developmental needs. c. Teach the parents how to do infant cardiopulmonary resuscitation (CPR). d. Have the parents keep an accurate record of intake and output.
C Risk of aspiration is a priority nursing diagnosis for the infant with gastroesophageal reflux. The parents must be taught infant CPR. Correct positioning minimizes the risk for aspiration. The correct position for the infant is on the right side after feeding and supine for sleeping. Knowledge of developmental needs should be included in discharge planning for all hospitalized infants, but it is not the most important in this case. Keeping a record of intake and output is not a priority and may not be necessary.
The viral pathogen that frequently causes acute diarrhea in young children is: a. Giardia organisms. c. Rotavirus. b. Shigella organisms. d. Salmonella organisms.
C Rotavirus is the most frequent viral pathogen that causes diarrhea in young children. Giardia and Salmonella are bacterial pathogens that cause diarrhea. Shigella is a bacterial pathogen that is uncommon in the United States.
When caring for a child with probable appendicitis, the nurse should be alert to recognize that a sign of perforation is: a. Bradycardia. c. Sudden relief from pain. b. Anorexia. d. Decreased abdominal distention.
C Signs of peritonitis, in addition to fever, include sudden relief from pain after perforation. Tachycardia, not bradycardia, is a manifestation of peritonitis. Anorexia is already a clinical manifestation of appendicitis. Abdominal distention usually increases in addition to an increase in pain (usually diffuse and accompanied by rigid guarding of the abdomen).
What is the major focus of the therapeutic management for a child with lactose intolerance? a. Compliance with the medication regimen b. Providing emotional support to family members c. Teaching dietary modifications d. Administration of daily normal saline enemas
C Simple dietary modifications are effective in the management of lactose intolerance. Symptoms of lactose intolerance are usually relieved after instituting a lactose-free diet. Medications are not typically ordered in the management of lactose intolerance. Providing emotional support to family members is not specific to this medical condition. Diarrhea is a manifestation of lactose intolerance. Enemas are contraindicated for this alteration in bowel elimination.
_____ use/abuse during pregnancy causes vasoconstriction and decreased placental perfusion, resulting in maternal and neonatal complications. a. Alcohol c. Tobacco b. Caffeine d. Chocolate
C Smoking in pregnancy is known to cause a decrease in placental perfusion and has serious health risks, including bleeding complications, low birth weight, prematurity, miscarriage, stillbirth, and sudden infant death syndrome. Prenatal alcohol exposure is the single greatest preventable cause of mental retardation. Alcohol use during pregnancy can cause high blood pressure, miscarriage, premature birth, stillbirth, and anemia. Caffeine and chocolate may safely be consumed in small quantities during pregnancy.
A 3-year-old child with Hirschsprung's disease is hospitalized for surgery. A temporary colostomy will be necessary. The nurse should recognize that preparing this child psychologically is: a. Not necessary because of child's age. b. Not necessary because the colostomy is temporary. c. Necessary because it will be an adjustment. d. Necessary because the child must deal with a negative body image.
C The child's age dictates the type and extent of psychologic preparation. When a colostomy is performed, the child who is at least preschool age is told about the procedure and what to expect in concrete terms with the use of visual aids. It is necessary to prepare this age child for procedures. The preschooler is not yet concerned with body image.
The most common neurologic disorder accompanying pregnancy is: a. Eclampsia. c. Epilepsy. b. Bell's palsy. d. Multiple sclerosis.
C The effects of pregnancy on epilepsy are unpredictable. Eclampsia sometimes may be confused with epilepsy, which is the most common neurologic disorder accompanying pregnancy. Bell's palsy is a form of facial paralysis. Multiple sclerosis is a patchy demyelinization of the spinal cord that does not affect the normal course of pregnancy or birth.
A histamine receptor antagonist such as cimetidine (Tagamet) or ranitidine (Zantac) is ordered for an infant with gastroesophageal reflux. The purpose of this is to: a. Prevent reflux. c. Reduce gastric acid production. b. Prevent hematemesis. d. Increase gastric acid production.
C The mechanism of action of histamine receptor antagonists is to reduce the amount of acid present in gastric contents and may prevent esophagitis. Preventing reflux and hematemesis and increasing gastric acid production are not the modes of action of histamine receptor antagonists.
During the first few days after surgery for cleft lip, which intervention should the nurse do? a. Leave infant in crib at all times to prevent suture strain. b. Keep infant heavily sedated to prevent suture strain. c. Remove restraints periodically to cuddle infant. d. Alternate position from prone to side-lying to supine.
C The nurse should remove restraints periodically, while supervising the infant, to allow him or her to exercise arms and to provide cuddling and tactile stimulation. The infant should not be left in the crib, but should be removed for appropriate holding and stimulation. Analgesia and sedation are administered for pain. Heavy sedation is not indicated. The child should not be placed in the prone position.
The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation would indicate pyloric stenosis? a. Abdominal rigidity and pain on palpation b. Rounded abdomen and hypoactive bowel sounds c. Visible peristalsis and weight loss d. Distention of lower abdomen and constipation
C Visible gastric peristaltic waves that move from left to right across the epigastrium are observed in pyloric stenosis, as is weight loss. Abdominal rigidity and pain on palpation, and rounded abdomen and hypoactive bowel sounds, are usually not present. The upper abdomen is distended, not the lower abdomen.
In caring for a pregnant woman with sickle cell anemia, the nurse is aware that signs and symptoms of sickle cell crisis include: a. Anemia. c. Fever and pain. b. Endometritis. d. Urinary tract infection.
C Women with sickle cell anemia have recurrent attacks (crisis) of fever and pain, most often in the abdomen, joints, and extremities. These attacks are attributed to vascular occlusion when RBCs assume the characteristic sickled shape. Crises are usually triggered by dehydration, hypoxia, or acidosis. Women with sickle cell anemia are not iron deficient. Therefore, routine iron supplementation, even that found in prenatal vitamins, should be avoided in order to prevent iron overload. Women with sickle cell trait usually are at greater risk for postpartum endometritis (uterine wall infection); however, this is not likely to occur in pregnancy and is not a sign of crisis. These women are at an increased risk for UTIs; however, this is not an indication of sickle cell crisis.
A nurse is conducting dietary teaching on high-fiber foods for parents of a child with constipation. Which foods should the nurse include as being high in fiber (Select all that apply)? a. White rice b. Avocados c. Whole grain breads d. Bran pancakes e. Raw carrots
C, D, E High-fiber foods include whole grain breads, bran pancakes, and raw carrots. Unrefined (brown) rice is high in fiber but white rice is not. Raw fruits, especially those with skins or seeds, other than ripe banana or avocados are high in fiber.
1, 3, 4 Social roles are influenced by culture. Cultures that value individual resourcefulness/competition of status is acceptable. Determination of status is culturally determined and varies according to each culture. Racial variation refers to transmissible traits. Culture is composed of beliefs, values, practices, and social relationships that are learned. Cultural development may be limited by geography. The geographic boundaries are not culturally determined.
Children are taught the values of their culture through observation and feedback on their own behavior. A nurse teaching a class on cultural awareness-competence should be aware of which factor(s) that may be culturally determined? Select all that apply. 1 Social roles 2 Racial variation 3 Degree of competition 4 Determination of status 5 Geographic
A woman with gestational diabetes has had little or no experience reading and interpreting glucose levels. She shows the nurse her readings for the past few days. Which one should the nurse tell her indicates a need for adjustment (insulin or sugar)? a. 75 mg/dL before lunch. This is low; better eat now. b. 115 mg/dL 1 hour after lunch. This is a little high; maybe eat a little less next time. c. 115 mg/dL 2 hours after lunch; This is too high; it is time for insulin. d. 60 mg/dL just after waking up from a nap. This is too low; maybe eat a snack before going to sleep.
D 60 mg/dL after waking from a nap is too low. During hours of sleep glucose levels should not be less than 70 mg/dL. Snacks before sleeping can be helpful. The premeal acceptable range is 65 to 95 mg/dL. The readings 1 hour after a meal should be less than 140 mg/dL. Two hours after eating, the readings should be less than 120 mg/dL.
Which type of hernia has an impaired blood supply to the herniated organ? a. Hiatal hernia b. Omphalocele c. Incarcerated hernia d. Strangulated hernia
D A strangulated hernia is one in which the blood supply to the herniated organ is impaired. A hiatal hernia is the intrusion of an abdominal structure, usually the stomach, through the esophageal hiatus. An incarcerated hernia is a hernia that cannot be reduced easily. Omphalocele is the protrusion of intraabdominal viscera into the base of the umbilical cord. The sac is covered with peritoneum and not skin.
What should the nurse stress in a teaching plan for the mother of an 11-year-old boy with ulcerative colitis? a. Preventing the spread of illness to others b. Nutritional guidance and preventing constipation c. Teaching daily use of enemas d. Coping with stress and avoiding triggers
D Coping with the stress of chronic illness and the clinical manifestations associated with ulcerative colitis (diarrhea, pain) are important teaching foci. Avoidance of triggers can help minimize the impact of the disease and its effect on the child. Ulcerative colitis is not infectious. Although nutritional guidance is a priority teaching focus, diarrhea is a problem with ulcerative colitis, not constipation. Daily enemas are not part of the therapeutic plan of care.
Since the gene for cystic fibrosis was identified in 1989, data can be collected for the purposes of genetic counseling for couples regarding carrier status. According to statistics, how often does cystic fibrosis occur in Caucasian live births? a. 1 in 100 c. 1 in 2500 b. 1 in 1200 d. 1 in 3000
D Cystic fibrosis occurs in about 1 in 3000 Caucasian live births.
Careful hand washing before and after contact can prevent the spread of which condition in day care and school settings? a. Irritable bowel syndrome b. Hepatic cirrhosis c. Ulcerative colitis d. Hepatitis A
D Hepatitis A is spread person to person, by the fecal-oral route, and through contaminated food or water. Good hand washing is critical in preventing its spread. The virus can survive on contaminated objects for weeks. Irritable bowel syndrome is the result of increased intestinal motility and is not contagious. Ulcerative colitis is not infectious. Cirrhosis is not infectious.
Which type of dehydration results from water loss in excess of electrolyte loss? a. Isotonic dehydration b. Hypotonic dehydration c. Isosmotic dehydration d. Hypertonic dehydration
D Hypertonic dehydration results from water loss in excess of electrolyte loss. This is the most dangerous type of dehydration. It is caused by feeding children fluids with high amounts of solute. Isotonic dehydration occurs in conditions in which electrolyte and water deficits are present in balanced proportion. Isosmotic dehydration is another term for isotonic dehydration. Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the serum hypotonic.
An infant with pyloric stenosis experiences excessive vomiting that can result in: a. Hyperchloremia. c. Metabolic acidosis. b. Hypernatremia. d. Metabolic alkalosis.
D Infants with excessive vomiting are prone to metabolic alkalosis from the loss of hydrogen ions. Chloride ions and sodium are lost with vomiting. Metabolic alkalosis, not acidosis, is likely.
What form of heart disease in women of childbearing years usually has a benign effect on pregnancy? a. Cardiomyopathy c. Congenital heart disease b. Rheumatic heart disease d. Mitral valve prolapse
D Mitral valve prolapse is a benign condition that is usually asymptomatic. Cardiomyopathy produces congestive heart failure during pregnancy. Rheumatic heart disease can lead to heart failure during pregnancy. Some congenital heart diseases produce pulmonary hypertension or endocarditis during pregnancy.
Therapeutic management of most children with Hirschsprung's disease is primarily: a. Daily enemas. b. Low-fiber diet. c. Permanent colostomy. d. Surgical removal of affected section of bowel.
D Most children with Hirschsprung's disease require surgical rather than medical management. Surgery is done to remove the aganglionic portion of the bowel, relieve obstruction, and restore normal bowel motility and function of the internal anal sphincter. Preoperative management may include enemas and low-fiber, high-calorie, high-protein diet until the child is physically ready for surgery. The colostomy that is created in Hirschsprung's disease is usually temporary.
A stool specimen from a child with diarrhea shows the presence of neutrophils and red blood cells. This is most suggestive of which condition? a. Protein intolerance b. Fat malabsorption c. Parasitic infection d. Bacterial gastroenteritis
D Neutrophils and red blood cells in stool indicate bacterial gastroenteritis. Protein intolerance is suspected in the presence of eosinophils. Parasitic infection is indicated by eosinophils. Fat malabsorption is indicated by foul-smelling, greasy, bulky stools.
Which intervention should be included in the nurse's plan of care for a 7-year-old child with encopresis who has cleared the initial impaction? a. Have the child sit on the toilet for 30 minutes when he gets up in the morning and at bedtime. b. Increase sugar in the child's diet to promote bowel elimination. c. Use a Fleet enema daily. d. Give the child a choice of beverage to mix with a laxative.
D Offering realistic choices is helpful in meeting the school-age child's sense of control. To facilitate bowel elimination, the child should sit on the toilet for 5 to 10 minutes after breakfast and dinner. Decreasing the amount of sugar in the diet will help keep stools soft. Daily Fleet enemas can result in hypernatremia and hyperphosphatemia, and are used only during periods of fecal impaction.
Which clinical manifestation would most suggest acute appendicitis? a. Rebound tenderness b. Bright red or dark red rectal bleeding c. Abdominal pain that is relieved by eating d. Abdominal pain that is most intense at McBurney's point
D Pain is the cardinal feature. It is initially generalized and usually periumbilical. The pain localizes to the right lower quadrant at McBurney's point. Rebound tenderness is not a reliable sign and is extremely painful to the child. Abdominal pain that is relieved by eating and bright or dark red rectal bleeding are not signs of acute appendicitis.
Glucose metabolism is profoundly affected during pregnancy because: a. Pancreatic function in the islets of Langerhans is affected by pregnancy. b. The pregnant woman uses glucose at a more rapid rate than the nonpregnant woman. c. The pregnant woman increases her dietary intake significantly. d. Placental hormones are antagonistic to insulin, thus resulting in insulin resistance.
D Placental hormones, estrogen, progesterone, and human placental lactogen (HPL) create insulin resistance. Insulin also is broken down more quickly by the enzyme placental insulinase. Pancreatic functioning is not affected by pregnancy. The glucose requirements differ because of the growing fetus. The pregnant woman should increase her intake by 200 calories a day.
When caring for a pregnant woman with cardiac problems, the nurse must be alert for signs and symptoms of cardiac decompensation, which include: a. A regular heart rate and hypertension. b. An increased urinary output, tachycardia, and dry cough. c. Shortness of breath, bradycardia, and hypertension. d. Dyspnea; crackles; and an irregular, weak pulse.
D Signs of cardiac decompensation include dyspnea; crackles; an irregular, weak, rapid pulse; rapid respirations; a moist, frequent cough; generalized edema; increasing fatigue; and cyanosis of the lips and nail beds. A regular heart rate and hypertension are not generally associated with cardiac decompensation. Tachycardia would indicate cardiac decompensation, but increased urinary output and a dry cough would not. Shortness of breath would indicate cardiac decompensation, but bradycardia and hypertension would not.
During a physical assessment of an at-risk client, the nurse notes generalized edema, crackles at the base of the lungs, and some pulse irregularity. These are most likely signs of: a. Euglycemia. c. Pneumonia. b. Rheumatic fever. d. Cardiac decompensation.
D Symptoms of cardiac decompensation may appear abruptly or gradually. Euglycemia is a condition of normal glucose levels. These symptoms indicate cardiac decompensation. Rheumatic fever can cause heart problems, but it does not manifest with these symptoms, which indicate cardiac decompensation. Pneumonia is an inflammation of the lungs and would not likely generate these symptoms, which indicate cardiac decompensation.
Caring for the newborn with a cleft lip and palate before surgical repair includes: a. Gastrostomy feedings. b. Keeping the infant in near-horizontal position during feedings. c. Allowing little or no sucking. d. Providing satisfaction of sucking needs.
D Using special or modified nipples for feeding techniques helps to meet the infant's sucking needs. Gastrostomy feedings are usually not indicated. Feeding is best accomplished with the infant's head in an upright position. The child requires both nutritive and nonnutritive sucking.
In planning for the care of a 30-year-old woman with pregestational diabetes, the nurse recognizes that the most important factor affecting pregnancy outcome is the: a. Mother's age. b. Number of years since diabetes was diagnosed. c. Amount of insulin required prenatally. d. Degree of glycemic control during pregnancy.
D Women with excellent glucose control and no blood vessel disease should have good pregnancy outcomes.
4 Communication is important to avoid wrong diagnosis and interpretations. The nurse should ask the parents about the burn injuries to understand their cultural and religious practices. If the child exhibits temper tantrums, some Southeast Asian cultural groups follow the practice of causing burn injuries on the skin for treatment. These burn injuries are not considered to be abusive by this cultural group even though the dominant culture and legal system may consider this to be child abuse. Therefore, there is no need to call the police or report child abuse. The nurse can inform the health care provider after discussing with the parents.
During the assessment of a 5-year-old child whose parents are from Southeast Asia, the nurse notices small burn injuries on the skin. The nurse learns that the child has a history of temper tantrums. Which is the immediate nursing action? 1 Call the police. 2 Report child abuse. 3 Inform the health care provider. 4 Ask the parents about the injury.
2 Cultural competence has five components. Cultural knowledge is formal and informal education about various cultures and cultural practices. It does not involve interacting with people from different cultures -- this is a cultural encounter. It also does not involve cultural appreciation by the nurse; this is cultural awareness. It does not consist of knowledge of nursing interventions.
How should the nurse obtain cultural knowledge? 1 By interacting with people of different cultures 2 By seeking formal and informal education about various cultures and cultural practices 3 By learning to appreciate different cultural values 4 By seeking training in various nursing interventions
1 A 53-year-old woman is likely to have attained menopause and may be able to have children only through adoption. Therefore, the nurse should refer the woman to a local adoption agency. Prenatal classes are recommended for women who are of childbearing age. Explaining the woman's inability to have children after menopause might not solve the problem. The woman likely will have attained menopause and would be unable to produce ovum, so surrogacy is not possible. Test-Taking Tip: Look for options that are similar in nature. If all are correct, either the question is poor or all options are incorrect; the latter of which is more likely. Example: If the answer you are seeking is directed to a specific treatment and all but one option deal with signs and symptoms, you would be correct in choosing the treatment-specific option.
How should the nurse respond to a 53-year-old woman who appears anxious and distressed who wants to have children and approaches the nurse for counseling? 1 Refer her to local adoption agencies. 2 Advise the woman to attend prenatal classes. 3 Explain the consequences of having children later in life. 4 Explain the process of having children through surrogate mother.
1 Peer orientation is typically seen in adolescents from large families. Democratic participation, developed autonomous inner controls, and depending on parents for advice are not normal behavioral patterns seen in adolescents from large families.
On assessing a large family, the nurse finds one of the adolescents is less peer-oriented, lacks autonomous inner controls, and does not tend to participate democratically in family interactions or depend on parents for advice. Which behavior of the adolescent will the nurse think to be uncharacteristic of an adolescent belonging to a large family? 1 Less peer orientation 2 Democratic participation 3 Autonomous inner controls 4 Depending on parents for advice
2 Teenagers do not always verbalize their feelings, so one sign may be a decline in school grades. The child's temper and social behaviors may also be altered. Nausea and vomiting may be a sign of a viral infection. Increased thirst and polyuria are signs diabetes mellitus. Disturbances in elimination are common in infants after stress; however, they are uncommon in adolescence. Test-Taking Tip: The computerized NCLEX exam is an individualized testing experience in which the computer chooses your next question based on the ability and competency you have demonstrated on previous questions. The minimum number of questions will be 75 and the maximum 265. You must answer each question before the computer will present the next question, and you cannot go back to any previously answered questions. Remember that you do not have to answer all of the questions correctly to pass.
The nurse is assessing a 14-year-old child who has recently discovered he or she is adopted. What may be a sign that the child is not handling this information well? 1 Nausea and vomiting 2 Decline in school grades 3 Increased thirst and polyuria 4 Changes in elimination
2 Many cultures have health practices and traditions different from those of the Western world. The nurse can ask questions about their health and illness beliefs. These include all the health practices, medicines, and food of the patient's culture. This can help the nurse and patient develop mutually acceptable goals. Asking a patient whether he or she had an advance directive is important but will not provide information about cultural health practices. How often the patient prays is not related to cultural health practices. The nurse should ask questions about when the symptoms developed, but this does not relate to cultural health practices.
The nurse is assessing a traditional Hindu woman. What should the nurse ask in order to learn about the patient's health traditions? 1 "Do you have an advance directive for medical decisions?" 2 "What are your beliefs about health and illness?" 3 "How often do you pray or visit a place of worship?" 4 "Can you tell me when you developed the symptoms?"
3 The nurse should try to avoid hurting the family's feelings. If the amulet is an obstacle to medical care, the nurse should explain that to the family and obtain their permission to remove the amulet for the procedure. The nurse should replace it as soon as the procedure is over. Continuing the procedure without taking off the amulet may interfere with the procedure or hurt the child. The nurse should not cancel the procedure because it is essential for the child's care. The nurse should not ask the family to remove the amulet permanently because it does not impede all medical care; affects only this procedure.
The nurse is caring for a 7-year-old child. The child wears an amulet because the family believes that it will protect the child from the evil eye. For a diagnostic procedure, the nurse has to take this amulet off. What should the nurse do? 1 Allow the child to continue to wear the amulet for comfort during all aspects of the procedure. 2 Do not perform the prescribed procedure because removing the amulet will hurt the family's feelings. 3 Get permission from the family to remove it for the procedure and replace it afterwards. 4 Ask the family to remove the amulet and not to let the child wear it because it obstructs medical care.
3 Many Buddhists are strictly vegetarian. This may explain why the patient does not touch the meal tray. The nurse should ask the patient what his or her dietary preferences are and provide what the patient wants. However, the nurse should not provide food choices that go against any dietary restrictions placed by the health care provider. It is inappropriate to start an IV line because IV fluids do not provide nutrition. The nurse should not force the patient to eat or ignore the patient.
The nurse is caring for a Buddhist patient. The nurse finds that the patient has not touched the food tray. The food tray holds chicken, bread, soup, and fruits. What is the most appropriate action by the nurse? 1 Start an intravenous (IV) infusion because the patient is not eating. 2 Advise the patient to eat the food because it is essential for health. 3 Ask the patient whether there is a problem with the food provided. 4 Ignore the behavior.
3 Many religions believe in supernatural causes and cures of diseases. Many Mexican people wear amulets and necklaces, which they believe ward off evil and protect a person from evil eye and diseases. The nurse took off the amulet and necklace without speaking to the parents or asking their permission. This is the most likely cause of the parents' displeasure. The parents brought the child to the hospital, which suggests they have no objection to modern medicine or nursing care.
The nurse is caring for a Mexican patient with severe febrile seizures. As a part of the care, the nurse removes the child's clothing and provides a bath while maintaining privacy. The nurse also takes off an amulet and necklace worn by the child. Later in the day, the child's parents refuse to speak to the nurse. What is the likely cause for their behavior? 1 They oppose treatments in conventional medicine. 2 They did not like the nurse touching and bathing their child. 3 They did not want the amulet and necklace to be removed. 4 Their spiritual healer forbids them to talk to the nurse
2 Islam has specific rituals for bathing and wrapping the body in cloth before it is to be moved. The nurse should contact someone from the person's mosque to assist. Family may be present. No baptism is performed at this time. Test-Taking Tip: Attempt to select the answer that is most complete and includes the other answers within it. For example, a stem might read, "A child's intelligence is influenced by:" and three options might be genetic inheritance, environmental factors, and past experiences. The fourth option might be multiple factors, which is a more inclusive choice and therefore the correct answer.
The nurse is caring for a dying boy whose religion is Islam (Muslim/Moslem). An important nursing consideration related to his impending death and religion is that: 1 there are no special rites. 2 there are specific practices to be followed. 3 the family is expected to "wait" away from the dying person. 4 baptism should be performed if it has not been done previously.
2 Many traditional Chinese people avoid direct eye contact as a sign of respect. It may be normal for this patient. The nurse cannot conclude that the patient has major depression or low self-esteem just from this behavior. Other assessment data are needed. There is also no evidence that this patient needs a psychiatric referral because he or she does not make eye contact. Test-Taking Tip: Pace yourself during the testing period and work as accurately as possible. Do not be pressured into finishing early. Do not rush! Students who achieve higher scores on examinations are typically those who use their time judiciously.
The nurse is caring for a traditional Chinese patient. The patient avoids direct eye contact with the nurse. What should the nurse conclude from this behavior? 1 The patient has major depression. 2 The behavior is acceptable and normal. 3 The patient demonstrates low self-esteem. 4 The nurse should get a psychiatric referral.
3, 5 Family, friends, and rabbi should be allowed to visit. Individuals of the Jewish faith generally are prohibited from eating pork or shellfish. Ritual circumcision of male infants is custom on the eighth day and performed by a mohel. Asking males to remove shawls or yarmulkes is inconsistent with acceptance of religious values.
The nurse should expect to possibly incorporate which religious and cultural practices into the plan of care when caring for a 35-year-old Jewish mother who just gave birth to a healthy baby boy? Select all that apply. 1 Circumcision in hospital 2 Ordering house diet lunch tray of roasted pork with mashed potatoes 3 Allowing family, friends, and rabbi to visit patient often 4 Ask males to remove shawl and yarmulke while visiting 5 Ordering house diet with the exception of shellfish
1, 3, 4 In order to be an effective parent, the family should convey four external assets to the child so that the child can learn to make the correct choices. The parents should provide support, care, and love at home and in the community. It is also important to establish clear and concise boundaries and expectations both at home and in the community. It is also important for parents to discuss good decision-making strategies with their children to empower them to make correct choices. The adolescent is not displaying any behaviors that warrant an inpatient psychiatric admission, nor does she need to be grounded.
The parents of a teenaged child tell the nurse they are worried that their child is hanging out with the wrong type of friends. What can the nurse advise the parents to do to help the adolescent make better choices? Select all that apply. 1 Provide support and love at home to make the child feel wanted. 2 Bring the adolescent to an inpatient psychiatric facility. 3 Establish clear and concise boundaries, rules, and expectations. 4 Talk to the child and allow the child to make her own decisions. 5 Ground the child until she shows appropriate behavior with friends.
1, 2, 5 Primary and secondary are the two types of social groups. The primary group includes family and peer, and is characterized by intimate and face-to-face contacts. The features of primary social group are intimacy, mutual support, and constraint of individual members' behavior. Professional association and less concern for members' behavior are features of a secondary social group. STUDY TIP: Avoid planning other activities that will add stress to your life between now and the time you take the licensure examination. Enough will happen spontaneously; do not plan to add to it.
What are the unique features of a primary social group as part of social and cultural roles? Select all that apply. 1 The members of the social group are intimate with each other. 2 The members of the social group are mutually supportive. 3 The members of the social group a part of professional association. 4 The member of the social group has less concern for other member's behavior. 5 The behaviorof the individual member of a social group is constrained
1, 2, 5 Providing individualized support, strengthening the family resources, and building on qualities that makes the family work better are the ways a nurse may help the family to meet its demands. Efforts should be made to share work in groups rather than delineating work. Families actually cope and respond to stressful events, which has to be identified and appreciated.
What are the ways the nurse may help a family meet its needs based on family strength and functioning styles? Select all that apply. 1 Providing individualized support 2 Strengthening the family resources 3 Helping to delineate the individualized work 4 Training the family members to avoid stressful events 5 Building on qualities that make family function in a better manner
1, 3, 5 Discussing adoption with the adopted child requires utmost care. The parents should always be honest with their children. This strengthens the relationship between the parents and the adopted child. Revealing information early leads to less chance of misunderstanding and better continuance of relationship. Adoption information causes concern and anxiety in children but should not be avoided. Information about the adoption has to be revealed before any third party reveals it. Adoption information should not be withheld; the child has the right to know about the parents.
What instructions should the nurse give to parents who have adopted a child? Select all that apply. 1 "You should reveal the adoption information as soon as possible." 2 "You should ask a third party to reveal the adoption information." 3 "You should always be honest and open toward the child." 4 "You should never reveal to the child that the child is adopted." 5 "Revealing adoption information causes concern and anxiety in children."
3 Reconstituted families are families made up of stepfathers or stepmothers with or without their respective children. Children staying with another family with legal guardianship are in foster care. Children staying with their grandparents are in kinship care. Families where both parents work are called dual-earner families.
Which statement describes a reconstituted family? 1 A child who lives with another family that has legal guardianship 2 A child staying with grandparents, away from the parents 3 A child staying with the father and the new stepmother 4 A child living in a family with both parents working for a living
The nurse is teaching a group of new parents about the experience of role transition. Which statement by a parent indicates a correct understanding of the teaching? a. "My marital relationship can have a positive or negative effect on the role transition." b. "If an infant has special care needs, the parents' sense of confidence in their new role is strengthened." c. "Young parents can adjust to the new role more easily than older parents." d. "A parent's previous experience with children makes the role transition more difficult."
a. "My marital relationship can have a positive or negative effect on the role transition."
A young child from Mexico is hospitalized for a serious illness. The father tells the nurse that "the child is being punished by God for being bad." The nurse should recognize this as: a. A health belief common in this culture. b. An early indication of potential child abuse. c. A misunderstanding of the family's common beliefs. d. A belief common when fortune tellers have been used.
a. A health belief common in this culture.
A nurse is planning a class on accident prevention for parents of toddlers. Which safety topic is the priority for this class? a. Appropriate use of car seat restraints b. Safety crossing the street c. Helmet use when riding a bicycle d. Poison control numbers
a. Appropriate use of car seat restraints
In which cultural group is good health considered to be a balance between yin and yang? a. Asians b. Australian aborigines c. Native Americans d. African-Americans
a. Asians
A laboring woman is lying in the supine position. The most appropriate nursing action at this time is to: a. Ask her to turn to one side. b. Elevate her feet and legs. c. Take her blood pressure. d. Determine whether fetal tachycardia is present.
a. Ask her to turn to one side.
What type of family is one in which all members are related by blood? a. Consanguineous b. Affinal c. Family of origin d. Household
a. Consanguineous
When assessing a woman in the first stage of labor, the nurse recognizes that the most conclusive sign that uterine contractions are effective would be: a. Dilation of the cervix. b.Descent of the fetus. c. Rupture of the amniotic membranes. d. Increase in bloody show.
a. Dilation of the cervix.
When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. These measures include: a. Encouraging the woman to try various upright positions, including squatting and standing. b. Telling the woman to start pushing as soon as her cervix is fully dilated. c. Continuing an epidural anesthetic so pain is reduced and the woman can relax. d. Coaching the woman to use sustained, 10- to 15-second, closed-glottis bearing-down efforts with each contraction.
a. Encouraging the woman to try various upright positions, including squatting and standing.
What is an essential part of nursing care for the laboring woman? a. Helping the woman manage the pain b. Eliminating the pain associated with labor c. Sharing personal experiences regarding labor and delivery to decrease her anxiety d. Feeling comfortable with the predictable nature of intrapartum care
a. Helping the woman manage the pain
A pregnant woman is in her third trimester. She asks the nurse to explain how she can tell true labor from false labor. The nurse would explain that "true" labor contractions: a. Increase with activity such as ambulation. b. Decrease with activity. c. Are always accompanied by the rupture of the bag of waters. d. Alternate between a regular and an irregular pattern.
a. Increase with activity such as ambulation.
When planning care for a laboring woman whose membranes have ruptured, the nurse recognizes that the woman's risk for _________________________ has increased. a. Intrauterine infection b. Hemorrhage c. Precipitous labor d. Supine hypotension
a. Intrauterine infection
The most critical nursing action in caring for the newborn immediately after birth is: a. Keeping the newborn's airway clear. b. Fostering parent-newborn attachment. c. Drying the newborn and wrapping the infant in a blanket. d. Administering eye drops and vitamin K.
a. Keeping the newborn's airway clear.
As the United States and Canada continue to become more culturally diverse, it is increasingly important for the nursing staff to recognize a wide range of varying cultural beliefs and practices. Nurses need to develop respect for these culturally diverse practices and learn to incorporate these into a mutually agreed on plan of care. Although it is common practice in the United States for the father of the baby to be present at the birth, in many societies this is not the case. When implementing care, the nurse would anticipate that a woman from which country would have the father of the baby in attendance? a. Mexico c. Iran b. China d. India
a. Mexico
Which of the following is descriptive of deaths caused by unintentional injuries? a. More deaths occur in males. b. More deaths occur in females. c. The pattern of deaths varies widely in Western societies. d. The pattern of deaths does not vary according to age and sex.
a. More deaths occur in males.
The father of a hospitalized child tells the nurse, "He can't have meat. We are Buddhist and vegetarians." The nurse's best intervention is to: a. Order the child a meatless tray. b. Ask a Buddhist priest to visit. c. Explain that hospital patients are exempt from dietary rules. d. Help the parent understand that meat provides protein needed for healing.
a. Order the child a meatless tray.
A 3-year-old girl was adopted immediately after birth. The parents have just asked the nurse how they should tell the child that she is adopted. Which guideline concerning adoption should the nurse use in planning her response? a. Telling the child is an important aspect of their parental responsibilities. b. The best time to tell the child is between ages 7 and 10 years. c. It is not necessary to tell the child who was adopted so young. d. It is best to wait until the child asks about it.
a. Telling the child is an important aspect of their parental responsibilities.
A means of controlling the birth of the fetal head with a vertex presentation is: a. The Ritgen maneuver. c. The lithotomy position. b. Fundal pressure. d. The De Lee apparatus.
a. The Ritgen maneuver.
When assessing a multiparous woman who has just given birth to an 8-pound boy, the nurse notes that the woman's fundus is firm and has become globular in shape. A gush of dark red blood comes from her vagina. The nurse concludes that: a. The placenta has separated. b. A cervical tear occurred during the birth. c. The woman is beginning to hemorrhage. d. Clots have formed in the upper uterine segment.
a. The placenta has separated.
With regard to a woman's intake and output during labor, nurses should be aware that: a. The tradition of restricting the laboring woman to clear liquids and ice chips is being challenged because regional anesthesia is used more often than general anesthesia. b. Intravenous (IV) fluids usually are necessary to ensure that the laboring woman stays hydrated. c. Routine use of an enema empties the rectum and is very helpful for producing a clean, clear delivery. d. When a nulliparous woman experiences the urge to defecate, it often means birth will follow quickly.
a. The tradition of restricting the laboring woman to clear liquids and ice chips is being challenged because regional anesthesia is used more often than general anesthesia.
A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. The nurse's best response is: a. "Don't worry about it. You'll do fine." b. "It's normal to be anxious about labor. Let's discuss what makes you afraid." c. "Labor is scary to think about, but the actual experience isn't." d. "You can have an epidural. You won't feel anything."
b. "It's normal to be anxious about labor. Let's discuss what makes you afraid."
The nurse discovers welts on the back of a Vietnamese child during a home health visit. The child's mother says that she has rubbed the edge of a coin on her child's oiled skin. The nurse should recognize that this is: a. Child abuse. b. A cultural practice to rid the body of disease. c. A cultural practice to treat enuresis or temper tantrums. d. A child discipline measure common in the Vietnamese culture.
b. A cultural practice to rid the body of disease.
A patient whose cervix is dilated to 5 cm is considered to be in which phase of labor? a. Latent phase b. Active phase c. Second stage d. Third stage
b. Active phase
Nurses can help their clients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate? a. Latent: Mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours b. Active: Moderate, regular contractions; 4- to 7-cm dilation; duration of 3 to 6 hours c. Lull: No contractions; dilation stable; duration of 20 to 60 minutes d. Transition: Very strong but irregular contractions; 8- to 10-cm dilation; duration of 1 to 2 hours
b. Active: Moderate, regular contractions; 4- to 7-cm dilation; duration of 3 to 6 hours
Concerning the third stage of labor, nurses should be aware that: a. The placenta eventually detaches itself from a flaccid uterus. b. An expectant or active approach to managing this stage of labor reduces the risk of complications. c. It is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface. d. The major risk for women during the third stage is a rapid heart rate.
b. An expectant or active approach to managing this stage of labor reduces the risk of complications.
The mother of a school-age child tells the school nurse that she and her spouse are going through a divorce. The child has not been doing well in school and sometimes has trouble sleeping. The nurse should recognize this as: a. Indicative of maladjustment. b. Common reaction to divorce. c. Suggestive of lack of adequate parenting. d. Unusual response that indicates need for referral.
b. Common reaction to divorce.
Which term best describes a group of people who share a set of values, beliefs, practices, social relationships, law, politics, economics, and norms of behavior? a. Race b. Culture c. Ethnicity d. Social group
b. Culture
The type of injury a child is especially susceptible to at a specific age is most closely related to: a. Physical health of the child. b. Developmental level of the child.
b. Developmental level of the child.
A woman who is gravida 3 para 2 enters the intrapartum unit. The most important nursing assessments are: a. Contraction pattern, amount of discomfort, and pregnancy history. b. Fetal heart rate, maternal vital signs, and the woman's nearness to birth. c. Identification of ruptured membranes, the woman's gravida and para, and her support person. d. Last food intake, when labor began, and cultural practices the couple desires.
b. Fetal heart rate, maternal vital signs, and the woman's nearness to birth.
Through vaginal examination the nurse determines that a woman is 4 cm dilated, and the external fetal monitor shows uterine contractions every 3.5 to 4 minutes. The nurse would report this as: a. First stage, latent phase. b. First stage, active phase. c. First stage, transition phase. d. Second stage, latent phase.
b. First stage, active phase.
In addition to injuries, the leading causes of death in adolescents ages 15 to 19 years are: a. Suicide, cancer. b. Homicide, suicide c. Homicide, heart disease. d. Drowning, cancer.
b. Homicide, suicide
Which statement best describes the process of critical thinking? a. It is a simple developmental process. b. It is purposeful and goal directed.
b. It is purposeful and goal directed.
From a worldwide perspective, infant mortality in the United States: a. Is the highest of the other developed nations. b. Lags behind five other developed nations. c. Is the lowest infant death rate of developed nations. d. Lags behind most other developed nations.
b. Lags behind five other developed nations.
For women who have a history of sexual abuse, a number of traumatic memories may be triggered during labor. The woman may fight the labor process and react with pain or anger. Alternately, she may become a passive player and emotionally absent herself from the process. The nurse is in a unique position of being able to assist the client to associate the sensations of labor with the process of childbirth and not the past abuse. The nurse can implement a number of care measures to help the client view the childbirth experience in a positive manner. Which intervention would be key for the nurse to use while providing care? a. Telling the client to relax and that it won't hurt much b. Limiting the number of procedures that invade her body c. Reassuring the client that as the nurse you know what is best d. Allowing unlimited care providers to be with the client
b. Limiting the number of procedures that invade her body
Which statement regarding childhood morbidity is the most accurate? a. Morbidity does not vary with age. b. Morbidity is not distributed randomly.
b. Morbidity is not distributed randomly.
What is an expected characteristic of amniotic fluid? a. Deep yellow color b. Pale, straw color with small white particles c. Acidic result on a Nitrazine test d. Absence of ferning
b. Pale, straw color with small white particles
The nurse is preparing staff in-service education about atraumatic care for pediatric patients. Which intervention should the nurse include? a. Prepare the child for separation from parents during hospitalization by reviewing a video. b. Prepare the child before any unfamiliar treatment or procedure by demonstrating on a stuffed animal.
b. Prepare the child before any unfamiliar treatment or procedure by demonstrating on a stuffed animal.
After an emergency birth, the nurse encourages the woman to breastfeed her newborn. The primary purpose of this activity is to: a. Facilitate maternal-newborn interaction. b. Stimulate the uterus to contract. c. Prevent neonatal hypoglycemia. d. Initiate the lactation cycle.
b. Stimulate the uterus to contract.
Nurses alert to signs of the onset of the second stage of labor can be certain that this stage has begun when: a. The woman has a sudden episode of vomiting. b. The nurse is unable to feel the cervix during a vaginal examination. c. Bloody show increases. d. The woman involuntarily bears down.
b. The nurse is unable to feel the cervix during a vaginal examination.
A Hispanic toddler has pneumonia. The nurse notices that the parent consistently feeds the child only the broth that comes on the clear liquid tray. Food items such as Jell-O, Popsicles, and juices are left. What would best explain this? a. The parent is trying to feed child only what child likes most. b. The parent is trying to restore normal balance through appropriate "hot" remedies. c. Hispanics believe that the "evil eye" enters when a person gets cold. d. Hispanics believe that an innate energy called chi is strengthened by eating soup.
b. The parent is trying to restore normal balance through appropriate "hot" remedies.
The primary difference between the labor of a nullipara and that of a multipara is the: a. Amount of cervical dilation. b. Total duration of labor. c. Level of pain experienced. d. Sequence of labor mechanisms.
b. Total duration of labor.
Under which circumstance would it be unnecessary for the nurse to perform a vaginal examination? a. An admission to the hospital at the start of labor b. When accelerations of the fetal heart rate (FHR) are noted c. On maternal perception of perineal pressure or the urge to bear down d. When membranes rupture
b. When accelerations of the fetal heart rate (FHR) are noted
The nurse expects to administer an oxytocic (e.g., Pitocin, Methergine) to a woman after expulsion of her placenta to: a. Relieve pain. b.Stimulate uterine contraction. c.Prevent infection. d. Facilitate rest and relaxation.
b.Stimulate uterine contraction.
The nurse recognizes that a woman is in true labor when she states: a. "I passed some thick, pink mucus when I urinated this morning." b. "My bag of waters just broke." c. "The contractions in my uterus are getting stronger and closer together." d. "My baby dropped, and I have to urinate more frequently now."
c. "The contractions in my uterus are getting stronger and closer together."
At 1 minute after birth, the nurse assesses the newborn to assign an Apgar score. The apical heart rate is 110 bpm, and the infant is crying vigorously with the limbs flexed. The infant's trunk is pink, but the hands and feet are blue. What is the correct Apgar score for this infant? a. 7 b. 8 c. 9 d. 10
c. 9
The nurse teaches a pregnant woman about the characteristics of true labor contractions. The nurse evaluates the woman's understanding of the instructions when she states, "True labor contractions will: a. Subside when I walk around." b. Cause discomfort over the top of my uterus." c. Continue and get stronger even if I relax and take a shower." d. Remain irregular but become stronger."
c. Continue and get stronger even if I relax and take a shower."
Which description of the phases of the second stage of labor is accurate? a. Latent phase: Feeling sleepy, fetal station 2+ to 4+, duration 30 to 45 minutes b. Active phase: Overwhelmingly strong contractions, Ferguson reflux activated, duration 5 to 15 minutes c. Descent phase: Significant increase in contractions, Ferguson reflux activated, average duration varied d. Transitional phase: Woman "laboring down," fetal station 0, duration 15 minutes
c. Descent phase: Significant increase in contractions, Ferguson reflux activated, average duration varied
Which action is correct when palpation is used to assess the characteristics and pattern of uterine contractions? a. Place the hand on the abdomen below the umbilicus and palpate uterine tone with the fingertips. b. Determine the frequency by timing from the end of one contraction to the end of the next contraction. c. Evaluate the intensity by pressing the fingertips into the uterine fundus. d. Assess uterine contractions every 30 minutes throughout the first stage of labor.
c. Evaluate the intensity by pressing the fingertips into the uterine fundus.
A nulliparous woman who has just begun the second stage of her labor would most likely: a. Experience a strong urge to bear down. b. Show perineal bulging. c. Feel tired yet relieved that the worst is over. d. Show an increase in bright red bloody show.
c. Feel tired yet relieved that the worst is over.
Because the risk for childbirth complications may be revealed, nurses should know that the point of maximal intensity (PMI) of the fetal heart tone (FHT) is: a. Usually directly over the fetal abdomen. b. In a vertex position heard above the mother's umbilicus. c. Heard lower and closer to the midline of the mother's abdomen as the fetus descends and rotates internally. d. In a breech position heard below the mother's umbilicus. ANS: C
c. Heard lower and closer to the midline of the mother's abdomen as the fetus descends and rotates internally.
Which statement is most descriptive of pediatric family-centered care? c. It recognizes that the family is the constant in a child's life. d. It avoids expecting families to be part of the decision-making process.
c. It recognizes that the family is the constant in a child's life.
The leading cause of death from unintentional injuries in children is: a. Poisoning. . b. Drowning. c. Motor vehicle-related fatalities. d. Fire- and burn-related fatalities.
c. Motor vehicle-related fatalities.
Health beliefs vary among the cultural groups living in the United States. The belief that health is "a state of harmony with nature and the universe" is common in which culture? a. Japanese b. African-American c. Native American d. Hispanic American
c. Native American
Which action by the nurse demonstrates use of evidence-based practice (EBP)? a. Gathering equipment for a procedure b. Documenting changes in a patient's status c. Questioning the use of daily central line dressing changes d. Clarifying a physician's prescription for morphine
c. Questioning the use of daily central line dressing changes
The nurse thoroughly dries the infant immediately after birth primarily to: a. Stimulate crying and lung expansion. b. Remove maternal blood from the skin surface. c. Reduce heat loss from evaporation. d. Increase blood supply to the hands and feet.
c. Reduce heat loss from evaporation.
It is paramount for the obstetric nurse to understand the regulatory procedures and criteria for admitting a woman to the hospital labor unit. Which guideline is an important legal requirement of maternity care? a. The patient is not considered to be in true labor (according to the Emergency Medical Treatment and Active Labor Act [EMTALA]) until a qualified health care provider says she is. b. The woman can have only her male partner or predesignated "doula" with her at assessment. c. The patient's weight gain is calculated to determine whether she is at greater risk for cephalopelvic disproportion (CPD) and cesarean birth. d. The nurse may exchange information about the patient with family members.
c. The patient's weight gain is calculated to determine whether she is at greater risk for cephalopelvic disproportion (CPD) and cesarean birth.
Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth? a. The fetal head is felt at 0 station during vaginal examination. b. Bloody mucus discharge increases. c. The vulva bulges and encircles the fetal head. d. The membranes rupture during a contraction.
c. The vulva bulges and encircles the fetal head.
The nurse knows that the second stage of labor, the descent phase, has begun when: a. The amniotic membranes rupture. b. The cervix cannot be felt during a vaginal examination. c. The woman experiences a strong urge to bear down. d. The presenting part is below the ischial spines.
c. The woman experiences a strong urge to bear down.
The major cause of death for children older than 1 year is: a. Cancer. b. Infection. c. Unintentional injuries. d. Congenital abnormalities.
c. Unintentional injuries.
In documenting labor experiences, nurses should know that a uterine contraction is described according to all these characteristics except: a. Frequency (how often contractions occur). b. Intensity (the strength of the contraction at its peak). c. Resting tone (the tension in the uterine muscle). d. Appearance (shape and height).
d. Appearance (shape and height).
A mother brings 6-month-old Eric to the clinic for a well-baby checkup. She comments, "I want to go back to work, but I don't want Eric to suffer because I'll have less time with him." The nurse's most appropriate answer is: a. "I'm sure he'll be fine if you get a good babysitter." b. "You will need to stay home until Eric starts school." c. "You should go back to work so Eric will get used to being with others." d. "Let's talk about the child care options that will be best for Eric."
d. "Let's talk about the child care options that will be best for Eric."
Which collection of risk factors most likely would result in damaging lacerations (including episiotomies)? a. A dark-skinned woman who has had more than one pregnancy, who is going through prolonged second-stage labor, and who is attended by a midwife b. A reddish-haired mother of two who is going through a breech birth c. A dark-skinned, first-time mother who is going through a long labor d. A first-time mother with reddish hair whose rapid labor was overseen by an obstetrician
d. A first-time mother with reddish hair whose rapid labor was overseen by an obstetrician
When a nulliparous woman telephones the hospital to report that she is in labor, the nurse initially should: a. Tell the woman to stay home until her membranes rupture. b. Emphasize that food and fluid intake should stop. c. Arrange for the woman to come to the hospital for labor evaluation. d. Ask the woman to describe why she believes she is in labor.
d. Ask the woman to describe why she believes she is in labor.
A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. The nurse's initial response would be to: a. Prepare the woman for imminent birth. b. Notify the woman's primary health care provider. c. Document the characteristics of the fluid. d. Assess the fetal heart rate and pattern.
d. Assess the fetal heart rate and pattern.
Which is now referred to as the "new morbidity"? a. Limitations in the major activities of daily living b. Unintentional injuries that cause chronic health problems c. Discoveries of new therapies to treat health problems d. Behavioral, social, and educational problems that alter health
d. Behavioral, social, and educational problems that alter health
A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact. The nurse should expect the woman to be: a. Admitted and prepared for a cesarean birth. b. Admitted for extended observation. c. Discharged home with a sedative. d. Discharged home to await the onset of true labor.
d. Discharged home to await the onset of true labor.
The nurse who performs vaginal examinations to assess a woman's progress in labor should: a. Perform an examination at least once every hour during the active phase of labor. b. Perform the examination with the woman in the supine position. c. Wear two clean gloves for each examination. d. Discuss the findings with the woman and her partner.
d. Discuss the findings with the woman and her partner.
Which term best describes the emotional attitude that one's own ethnic group is superior to others? a. Culture b. Ethnicity c. Superiority d. Ethnocentrism
d. Ethnocentrism
For the labor nurse, care of the expectant mother begins with any or all of these situations, with the exception of: a. The onset of progressive, regular contractions. b. The bloody, or pink, show. c. The spontaneous rupture of membranes. d. Formulation of the woman's plan of care for labor.
d. Formulation of the woman's plan of care for labor.
The Vietnamese mother of a child being seen in the clinic avoids eye contact with the nurse. Considering cultural differences, the best explanation for this is that the parent: a. Feels responsible for her child's illness. b. Feels inferior to nurse. c. Is embarrassed to seek health care. d. Is showing respect for nurse.
d. Is showing respect for nurse.
A clinic nurse is planning a teaching session about childhood obesity prevention for parents of school-age children. The nurse should include which associated risk of obesity in the teaching plan? a. Type I diabetes b. Respiratory disease c. Celiac disease d. Type II diabetes
d. Type II diabetes