Health and illness 2 exam 1 quiz questions

Give that the family is experiencing the sudden critical illness of one of its members, which action would be the most appropriate initially when working with this family? A. Assessing how the family views the illness of the family member B. Teaching the family about their family members illness C. Recognize that the nurses role is to be the person in charge D. Partnering with the leader of the family

A. Assessing how the family views the illness of the family member

A nurse is caring for a family who has recently lost their home and belongings in a fire. The family is staying with extended family in the area. Which of the following would be the most appropriate nursing diagnosis for the family? A. Compromised family coping B. Ineffective individual coping C. Dysfunctional family processes D. Readiness for enhanced family processes

A. Compromised family coping

Which of the following laboratory findings would the nurse expect in a child with an excess of water? A. Decrease hematocrit B. High serum osmolality C. High urine specific gravity D. increase blood urea nitrogen BUN

A. Decrease hematocrit Rationale; The excess water in the circulatory system results in hemodilution. Thus, the laboratory test shows falsely decreased hematocrit. Laboratory analysis of blood that is hemodilution will have a decreased serum osmolality and BUN.

Which of the following are risk factors for fluid imbalance? Select all that apply. A. Diuretic medication B. Renal impairment C. Allergy to penicillin D. Younger than two years of age E. Infection

A. Diuretic medication B. Renal impairment D. Younger than two years of age

Which statement below is accurate for a second-degree burn? A. Entire epidermidis and varying areas of the dermis are involved in the injury B. Deep tissue, muscle, and bone are often involved in the injury C. Total destruction of the dermis and epidermidis are involved in injury D. Patient is expected to have a complete recovery within 3 to 5 days

A. Entire epidermidis and varying areas of the dermis are involved in the injury

When assessing an older adult patient for dehydration, which of the following would be true? A. Expect decrease skin turgor on sternum or forehead. B. Expect distended neck veins (JVD) when lying flat C. Expect a bounding pulse D. Expect CBC to show decreased hematocrit

A. Expect decrease skin turgor on sternum or forehead. Rationale; dehydration in the elder adult would be flat neck veins but they should always be assessed with a patient at a 30 to 45° angle. Skin turgor would be decreased but this would be more reliable when tested on the sternum or forehead given the skin changes that occur in the elderly due to normal aging. The CBC would show increased hematocrit indicating hemoconcentration with dehydration. The pulse will have less amplitude with dehydration so it might be weak or thready.

A mother complains to the nurse at the pediatric clinic that her four-year-old child always talks to her toys and makes up stories. The mother wants her child to have a psychological evaluation. The nurses best initial response is to; A. Explain that playing make-believe is normal at this age. B. Separate the child from the mother to get more information. C. Refer the child to a psychologist immediately. D. Complete a developmental screening using a validated tool.

A. Explain that playing make-believe is normal at this age.

The nurse is admitting an older adult with decompensated congestive heart failure. The nursing assessment reveals crackles when ausculating lung sounds, dyspnea, and othopnea. Which physician order should the nurse question? A. IV 500 ml of 0.9% NaCl at 125 ml/hr B. Furosemide (lasix) 20 mg PO now C. Oxygen via face mask at 8 l/min D. KCI 20 mEq PO two times a day

A. IV 500 ml of 0.9% NaCl at 125 ml/hr

Every child is different, but there are still developmental milestones that children reach by certain age. These developmental milestones along with at what age they should be reached were developed by the centers of disease control and prevention. There are five groups of skills that children develop. Select them from the group below (select all that apply.) A. Language skills include speaking and understanding. B. Fine motor skills involve smaller muscle coordination needed for skills like drawing and writing. C. Athletic skills include sports and games. D. Cognitive skills include learning, reasoning, and remembering. E. Gross motor skills involve the use of bigger muscle groups needed for crawling, walking, or running. F. Musical skills include singing and dancing. G. Literacy skills include letter recognition and reading. H. Social skills include developing relationships and interacting with others.

A. Language skills include speaking and understanding. B. Fine motor skills involve smaller muscle coordination needed for skills like drawing and writing D. Cognitive skills include learning, reasoning, and remembering. E. Gross motor skills involve the use of bigger muscle groups needed for crawling, walking, or running. H. Social skills include developing relationships and interacting with others.

A patient at risk for fluid volume overload is put on a 2 g sodium diet. He ask you why he has to be on this diet because the food does not taste good. Which reply by the nurse is the most appropriate to this patient? A. Taking too much salt in your diet increases your risk for retaining fluids because it attracts water. B. Salt increases your risk of hypernatremia which is bad for your muscles and heart. C. Sodium levels in the extra cellular fluid influence whether water is retained or excreted D. You can add salt substitute to your food to make it taste better

A. Taking too much salt in your diet increases your risk for retaining fluids because it attracts water.

A patient is being discharged after successful treatment for hyperphosphatemia. The nurse would know that the teaching has been affective when the client says, "I need to limit how much —- are in my diet" A. Bananas B. Dairy products C. Fatty foods D. Green leafy vegetables

B. Dairy products

A 30 year old pregnant woman with gestational hypertension is on the maternity unit receiving magnesium sulfate. Her lab levels are high and show hypermagnesemia. which one of the following would the nurse expect to find with hypermagnesemia? A. Respiratory rate of 16 B. Decrease deep tendon reflexes C. Urine output at 45 mL per hour D. Blood pressure of 138/85

B. Decrease deep tendon reflexes Rationale; absent or decrease deep tendon reflexes would indicate hypermagnesium. Absent DTR indicates an emergency due to high levels of magnesium in the blood. The nurse should monitor for respiratory depression with magnesium sulfate. Minimum urine output an adult should be greater than 30 mL per hour.

The nurse is caring for an infant with severe diarrhea that has lasted three days. The child has poor skin turgor and dry mucous membranes. What is the priority nursing diagnosis for the nurse to use when planning care for this child? A. Impaired mucous membranes B. Fluid volume deficit C. Alteration in nutrition D. Risk for infection

B. Fluid volume deficit

The nurse is concerned the patient may develop hyperkalemia. Which of the following questions with the nurse want to include in their assessment? A. Have you experienced a feeling of sudden warmth to the skin? B. Have you noticed any changes in your muscle strength? C. Do you have an increase in your thirst? D. Have you noticed any confusion?

B. Have you noticed any changes in your muscle strength?

Patients that use thiazide diuretic's such as hydrochlorothiazide can experience low serum potassium levels. As a nurse, which of the following signs and symptoms would indicate hypokalemia? A. Increase urinary output B. Irregular pulse C. Sticky mucous membrane D. Diarrhea

B. Irregular pulse

When doing a physical assessment of a patient, the nurse should expect which of these findings related to fluid volume overload? A. Postural hypotension B. Orthopnea (difficulty breathing when supine) C. Wheezing D. Decrease skin turgor

B. Orthopnea (difficulty breathing when supine)

The nurse preparing a teaching plan for a preschooler knows that, according to Piaget, the expected stage of development for a preschooler (age 3 to 5 years) is; A. Concrete operational B. Preoperational C. Sensorimotor D. Formal operational

B. Preoperational

Client is admitted with full thickness burns to 30% of the body, including both legs. After establishing a patent airway which intervention is a priority? A. Covering the wounds with antibacterial dressings B. Replacing fluid and electrolytes C. Supporting the lower extremities in normal anatomic position D. Evaluating the presence and quality of pulses distal to the burn injury

B. Replacing fluid and electrolytes

A patient has completed treatment for an addiction to prescription pain medication's. As part of the clients therapy, the family participates in a family therapy program. Which reason would best explain the need for a family system approach to therapy? A. The family has unresolved issues toward the client. B. The dynamics of the entire family have and will continue to shift to accommodate a change. C. The family needs to learn signs of relapse if the client begins taking pills again D. The family needs to focus on helping the client until equilibrium is regained.

B. The dynamics of the entire family have and will continue to shift to accommodate a change.

You are working as a community nurse and working with a family struggling to communicate with each other. The family is interested in building their relationship with each other. As a first step in understanding The family dynamics you work to construct an eco-map. Which statement would accurately describe one of the relationships between a family member to interactions outside of the household? Use the eco-map to answer these questions. A. The maternal grandparents have a positive relationship with their daughter. B. The maternal grandparents have a positive relationship with their grandchildren. C. Sue has a strong relationship with John's parents. D. Carol and Britney have a strong relationship with her paternal grandparents.

B. The maternal grandparents have a positive relationship with their grandchildren.

In a dysfunctional family a nurse notes that two people in the family are having a stressful relationship. One of these individuals has talked to another individual outside of the family unit about the stressful relationship to try to get this person to approach the family member about the stress they are causing. This type of behavior is called; A. Double bind B. Triangulation C. Scapegoating D. Sibling rivalry

B. Triangulation

Nurses utilize an eco-map to assess families. Which of the following statements best describes the purpose of designing an eco-map? A. Used a graphic presentation to represent the relationships and roles within the family unit. B. Used to document the family units relationship to outside systems. C. Used to observe the relevant events experienced by the family over time. D. Comprehensive interview tool to discern family strengths and weaknesses.

B. Used to document the family units relationship to outside systems.

In caring for a family who has a family member in the ICU, it is best practice for the nurse to; A. Not promote hope in the family because the pt is in critical condition B. Update the family about the pts condition every week C. Allow the family to see the pt frequently D. Give the family general information about the pts prognosis

C. Allow the family to see the pt frequently

A patient has Cushing's disease where the body holds onto sodium. Which of the following signs and symptoms are associated with high serum sodium? A. Soft spongy eyeballs B. Low back pain C. Altered LOC D. Diarrhea

C. Altered LOC

My mother ask the nurse for information about the denver II and ASQ-3. The most appropriate response by the nurse is that these; A. Can diagnose developmental disabilities B. Will identify a need for physical therapy C. Are developmental screening tools D. Provide a framework for health teaching

C. Are developmental screening tools

Tapping lightly over the facial nerve 2 cm anterior to the earlobes will yield facial muscle twitching. This best describes a positive result of which test? A. Homans sign. B. Romberg sign. C. Chvosteks sign D. Trousseau sign

C. Chvosteks sign

Which of the following statements is true regarding family systems theory? A. Change in one family member cannot create a change in other members. B. Families adjust to stress with either positive or negative coping strategies. C. Family is viewed as a unit that continuously interacts with its members and the environment. D. Focus is on the developmental stage of the family compared to norms.

C. Family is viewed as a unit that continuously interacts with its members and the environment. Rationale; Family systems theory views the family as a system whose members continuously interact with each other in the environment. Emphasis is on the interaction between the members; a change in one family member creates a change in other members, which in turn result in a new change in the original member. Family stress theory explains how families react to stressful events and suggest factors that promote adaptation to stress. Developmental theory addresses family change over time based on predictable changes or norms.

A patient begins to take stock of life and look into the future. The nurse assesses that this client is in which of Ericksons developmental stages? A. Identity vs role confusion B. Industry VS inferiority C. Integrity vs despair D. Generativity vs stagnation

C. Integrity vs despair

The nursing staff requires an accurate daily weight with intake and output for an adult patient who has renal failure and had his routine dialysis treatment yesterday. Why are these important? A. It is a reliable index of adequacy of electrolyte control B. It provides data for assessing cardiac function C. It serves as a basis for determining fluid retention D. It is a measure of nutritional status

C. It serves as a basis for determining fluid retention

The nurse is reviewing the health history of today's patients. Which of the following patients would be at risk for developing hypophosphatemia? A. Patient with lymphoma and currently receiving chemotherapy B. Patient with high levels of vitamin D C. Patient with a long history of alcoholism D. Patient with a low calcium level

C. Patient with a long history of alcoholism

A 17-year-old girl is hospitalized for appendicitis, and her mother asked the nurse why she is so needy and acting like a child. The best response of the nurse is that in the hospital, adolescents ... A. Rebel against rules. B. Want to know everything. C. Regress because of stress. D. Have separation anxiety

C. Regress because of stress.

A patient has a magnesium deficit. The highest priority nursing diagnosis for this patient would be A. Risk for bleeding B. Diarrhea C. Risk for decreased cardiac output D. Impaired skin integrity

C. Risk for decreased cardiac output

The nurse is interviewing a family about adding grandma who has Alzheimer's disease into their household. If the nurse utilizes the structural functional theory to interview the mother of this family, which one of the following questions would be characteristic of this theory? A. "can you utilize your past support resources to help you deal with change caused by the addition of grandma to the family?" B. "you are in the sandwich generation (caring for aging parents as well as raising children). How are you managing these tasks?" C. "bringing a new member into the family can be stressful, how do you plan on adapting to the stress question" D. " what is your role in caring for grandma now that she lives with you?"

D. " what is your role in caring for grandma now that she lives with you?" Rationale; The functional structural theory accents the roles of all the individuals in the family. These roles help to maintain family equilibrium through family dynamics. The nurse needs to examine the shared responsibilities of the family in the care of grandma to make sure the undue expectations are not placed upon one member.

The nurse is assessing a client with a burn injury using the rule of nines. Which information will this assessment contribute to future care planning and fluid replacement? A. Type of intravenous fluids required B. Respiratory needs C. Rehabilitation needs D. Amount of body surface area burned

D. Amount of body surface area burned

You continue to work with sues family and have created the eco-map. The family is looking at resources that provide support for the family. Use the eco map provided to determine the correct answer. A. Christy receives positive support from her boyfriends relationship. B. Christy is receiving positive support from her school as a resource. C. Christy receives support from her relationship with her basketball team D. Christy receives support from her friends relationship.

D. Christy receives support from her friends relationship.

Which of the following family theories is described as a series of tasks for the family though its life span? A. Family stress theory B. Structural functional theory C. Developmental theory D. Family systems theory

D. Family systems theory

To prevent laryngeal spasm and respiratory arrest in a patient who is at risk for hypocalcemia? An EARLY sign of hypocalcemia the nurse should assess for is: A. Weak hand grips B. Confusion C. Constipation D. Lip tingling

D. Lips tingling

Autism spectrum disorder is more common in boys than girls and is more likely to occur in children with an older sibling who has ASD. True or false

True

Pediatric clinicians are guided to perform developmental screening with a standard screening tool at the 9, 18, and 30 month well child visits. True or false

True

The school nurse talking with a high school class about the difference between growth and development would best describe growth as a. processes by which early cells specialize. b. psychosocial and cognitive changes. c. qualitative changes associated with aging. d. quantitative changes in size or weight.

d. quantitative changes in size or weight.