Module 10 Saunders ?'s

A 4-year old child is diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention should be implemented to alleviate the child's fears? 1. Encourage the child's parents to stay with the child 2. Encourage play with other children of the same age 3. Advise the family to visit only during the scheduled visiting hours 4. Provide a private room, allowing the child to bring favorite toys from home

1 Illness adds a stressor that makes separation more diffucult

The mother of a 3-year-old is concerned because her child still is insisting on a bottle at nap time and bedtime. Which is the most appropriate suggestion to the mother? 1. Allow the bottle if it contains juice 2. Allow the bottle if it contains water 3. Do not allow the child to have the bottle 4. Allow the bottle during naps but not at bedtime

2

The nurse is evaluating the developmental level of a 2-year-old. Which does the nurse expect to observe in this child? 1. Uses a fork to eat 2. Uses a cup to drink 3. Pours milk into a cup 4. Uses a knife for cutting food

2

Which car safety device should be used for a child which is 8 years old and is 4 feet tall? 1. Seat belt 2. Booster seat 3. Rear-facing convertible seat 4. Front-facing convertible seat

2

A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention should be implemented to alleviate the child's fears. 1. Encourage the child's parents to stay with the child 2. Encourage play with other children of the same age 3. Advise the family to visit only during the scheduled visiting hours 4. Provide a private room, allowing the child to bring favorite toys from home

1

A mother of a 3-year-old asks a clinic nurse about appropriate and safe toys for the child. The nurse should tell the mother that the most appropriate toy for a 3-year-old is which? 1. A wagon 2. A golf set 3. A farm set 4. A jack set with marbles

1

The nurse is caring for a child with a diagnosis of neutropenia. Which nursing interventions are most appropriate for a child placed in protective isolation for neutropenia? Select all that apply. 1. Place the child on a low-bacteria diet. 2. Change dressings using sterile technique. 3. Put flowers in a vase with water before placing in the room. 4. Peel fruits and vegetables before allowing the child to eat them. 5. Allow individuals who are ill to visit as long as they wear a mask.

1. Place the child on a low-bacteria diet. 2. Change dressings using sterile technique. 4. Peel fruits and vegetables before allowing the child to eat them. Rationale: For the hospitalized neutropenic child, flowers or plants should not be kept in the room because standing water and damp soil harbor Aspergillus and Pseudomonas species, to which these children are very susceptible. Fruits and vegetables not peeled before being eaten harbor molds and should be avoided until the white blood cell count rises. The child is placed on a low-bacteria diet. Dressings are always changed using sterile technique. Individuals who are ill are not allowed to visit the client.

A child is admitted to the pediatric unit with a diagnosis of acute stage Kawasaki disease. Which assessment findings by the nurse are characteristic of this disorder? Select all that apply. 1. Red throat 2. Cracking lips 3. Conjunctival hyperemia 4. Desquamation of the skin 5. Enlargement of the cervical lymph nodes

1. Red throat 3. Conjunctival hyperemia 5. Enlargement of the cervical lymph nodes Rationale: Kawasaki disease is known as mucocutaneous lymph node syndrome and is an acute systemic inflammatory disease. Assessment findings in the acute stage include fever, conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of the cervical lymph nodes. Desquamation of the skin, cracking lips, joint pain, cardiac manifestations, and thrombocytosis are characteristics of the subacute stage.

A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client? 1. Providing sitz baths 2. Encouraging fluid intake 3. Placing ice on the perineum 4. Monitoring hemoglobin and hematocrit levels

2. Encouraging fluid intake

The nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery? 1. Encourage ambulation hourly. 2. Assess vital signs every 4 hours. 3. Measure fundal height every 4 hours. 4. Prepare an ice pack for application to the area.

4. Prepare an ice pack for application to the area.

The 2-year-old is treated in the emergency department for a burn to the chest and abdomen. The child sustained the burn by grabbing a cup of hot coffee that was left on the kitchen counter. The nurse reviews safety principles with the parents before discharge. Which statement by the parents indicates an understanding of measures to provide safety in the home? 1. "We will be sure not to leave hot liquid unattended." 2. "I guess my children need to understand what the word hot means." 3. "We will be sure that the children stay in their rooms when we work in the kitchen." 4. "We will install a safety gate as soon as we get home so the children cannot get into the kitchen."

1

The mother of a 3 year old asks a clinic nurse about appriate and safe toys for the child. The nurse should tell the mother that the most appropriate toy for a 3-year-old is which? 1. a wagon 2. a golf set 3. a farm set 4. a jack set with marbles

1. a wagon, everything else may contain small choking hazards

The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? 1. Changes in vital signs 2. Signs of heavy bruising 3. Complaints of intense pain 4. Complaints of a tearing sensation

1. Changes in vital signs

338. The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? 1. Changes in vital signs 2. Signs of heavy bruising 3. Complaints of intense pain 4. Complaints of a tearing sensation

1. Changes in vital signs Because the client has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation. Changes in vital signs indicate hypovolemia in an anesthetized postpartum client with vulvar hematoma. Option 2 (heavy bruising) may be seen, but vital sign changes indicate hematoma caused by blood collection in the perineal tissues.

An infant of a mother infected with human immunodeficiency virus (HIV) is seen in the clinic each month and is being monitored for symptoms indicative of HIV infection. With knowledge of the most common opportunistic infection of children infected with HIV, the nurse assesses the infant for which sign? 1. Cough 2. Liver failure 3. Watery stool 4. Nuchal rigidity

1. Cough Rationale: Acquired immunodeficiency syndrome (AIDS) is a disorder caused by HIV and characterized by generalized dysfunction of the immune system. The most common opportunistic infection of children infected with HIV is Pneumocystis jiroveci pneumonia, which occurs most frequently between the ages of 3 and 6 months, when HIV status may be indeterminate. Cough is a common sign of this opportunistic infection. Cytomegalovirus infection is also characteristic of HIV infection; however, it is not the most common opportunistic infection. Liver failure is a common sign of this complication. Although gastrointestinal disturbances and neurological abnormalities may occur in a child with HIV infection, options 3 and 4 are not specific opportunistic infections noted in the HIV-infected child. Watery stool is noted with gastroenteritis and nuchal rigidity is seen in meningitis.

The nurse assesses the vital of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/minutes. On the basis of this finding , which action is most appropriate? 1. Administer oxygen 2. Document the findings 3. Notify the health care provider 4. Reassess the respiratory rate in 15 minutes

2

The nurse is monitoring a 3-month-old infant for signs of increased intracranial pressure. On palpation of the fontanels, the nurse notes that the anterior fontanels is soft and flat. One the basis of this finding, which nursing action is most appropriate? 1. Increase oral fluids 2. Document the finding 3. Notify the health care provider (HCP) 4. Elevate the head of the bed to 90 degrees

2

The nurse assess the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/minute. One the basis of this finding, which action is most appropriate? 1. Administer oxygen 2. Document the finding 3. Notify the health care provider 4. Reassess the respiratory rate in 15 mintues

2 respiratory rate in a 12 month old infant is 20-40 breaths a minute normal finding

The mother of a 3 year old is concerned because her child still insisting on a bottle at nap time and at bed time. Which is the most appropriate suggestion to the mother? 1. allow the bottle if it contains juice 2. allow the bottle if it contains water 3. do not allow the child to have the bottle 4. allow the bottle during naps but not bed time

2 if a bottle is allowed at nap time or bed time it should only contain water

Which car safety device should be used for a child who is 8 years old and is 4 feet tall? 1. Seat belt 2. Booster seat 3. Rear-facing convertible seat 4. Front-facing convertible seat

2 - booster seat

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? 1. A temperature of 100.4 °F (38 °C) 2. An increase in the pulse rate from 88 to 102 beats/minute 3. A blood pressure change from 130/88 to 124/80 mm Hg 4. An increase in the respiratory rate from 18 to 22 breaths/minute

2. An increase in the pulse rate from 88 to 102 beats/minute

The clinic nurse is instructing the parent of a child with human immunodeficiency virus (HIV) infection regarding immunizations. The nurse should provide which instruction to the parent? 1. The hepatitis B vaccine will not be given to the child. 2. The inactivated influenza vaccine will be given yearly. 3. The varicella vaccine will be given before 6 months of age. 4. A Western blot test needs to be performed and the results evaluated before immunizations.

2. The inactivated influenza vaccine will be given yearly. Rationale: Immunizations against common childhood illnesses are recommended for all children exposed to or infected with HIV. The inactivated influenza vaccine that is given intramuscularly will be administered (influenza vaccine should be given yearly). The hepatitis B vaccine is administered according to the recommended immunization schedule. Varicella-zoster virus vaccine should not be given because it is a live virus vaccine; varicella-zoster immunoglobulin may be prescribed after chickenpox exposure. Option 4 is unnecessary and inaccurate.

The nurse is providing instructions to the mother of a child with human immunodeficiency virus infection regarding immunizations. Which statement by the mother indicates an understanding of the immunization schedule? 1. "The hepatitis B vaccine is not to be given to my child." 2. "My child will receive all the vaccines like any other child." 3. "Family members in the household need to receive the influenza vaccine." 4. "Blood tests are needed before any immunizations are given to my child."

3. "Family members in the household need to receive the influenza vaccine." Rationale: Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. A child with human immunodeficiency virus (HIV) infection will receive the same immunizations as other children, except for live vaccines. All household members receive the influenza vaccine. Blood tests prior to immunizations are unnecessary and inaccurate.

A 6-year-old child with human immunodeficiency virus (HIV) infection has been admitted to the hospital for pain management. The child asks the nurse if the pain will ever go away. The nurse should make which best response to the child? 1. "The pain will go away if you lie still and let the medicine work." 2. "Try not to think about it. The more you think it hurts, the more it will hurt." 3. "I know it must hurt, but if you tell me when it does, I will try to make it hurt a little less." 4. "Every time it hurts, press on the call button and I will give you something to make the pain go all away."

3. "I know it must hurt, but if you tell me when it does, I will try to make it hurt a little less." Rationale: The multiple complications associated with HIV are accompanied by a high level of pain. Aggressive pain management is essential for the child to have an acceptable quality of life. The nurse must acknowledge the child's pain and let the child know that everything will be done to decrease the pain. Telling the child that movement or lack thereof would eliminate the pain is inaccurate. Allowing a child to think that he or she can control the pain simply by thinking or not thinking about it oversimplifies the pain cycle associated with HIV. Giving false hope by telling the child that the pain will be taken "all away" is neither truthful nor realistic.

The nurse is caring for a child with acquired immunodeficiency syndrome (AIDS) and notes the presence of mouth sores. The nurse provides instructions to the mother regarding maintaining adequate nutritional intake in the child. Which statement by the mother indicates a need for further teaching? 1. "I should weigh my child each morning." 2. "I will offer an iced pop to lick before meals." 3. "Salty foods are very important to maintain an appropriate sodium level in the child." 4. "Milk, juice, or water should really be offered after a meal rather than before a meal."

3. "Salty foods are very important to maintain an appropriate sodium level in the child." Rationale: Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Salty or spicy foods should be avoided because they irritate mouth sores. The child should be weighed each morning, and calorie intake should be reviewed every 24 hours. If mouth sores are present, the child should be offered an iced pop to lick or ice before meals to numb the mouth. The mother should be instructed to offer foods high in protein and calories and to give vitamin and mineral supplements if prescribed. Milk, juice, and water should be administered to the child after meals because children can fill up on liquids before eating.

335. The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action? 1. Record the findings. 2. Massage the fundus. 3. Notify the health care provider (HCP). 4. Place the client in Trendelenburg's position.

3. Notify the health care provider (HCP). If bleeding is excessive, the cause may be laceration of the cervix or birth canal. Massaging the fundus if it is firm would not assist in controlling the bleeding. Trendelenburg's position should be avoided because it may interfere with cardiac and respiratory function. Although the nurse would record the findings, the initial nursing action would be to notify the HCP.

339. The nurse is developing a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery? 1. Assess vital signs every 4 hours. 2. Measure fundal height every 4 hours. 3. Prepare an ice pack for application to the area. 4. Inform the health care provider of assessment findings.

3. Prepare an ice pack for application to the area. A hematoma is a localized collection of blood into the tissues of the reproductive sac after delivery. Vulvar hematoma is the most common. Application of ice reduces swelling caused by hematoma formation in the vulvar area. Options 1, 2, and 4 are not interventions that are specific to the plan of care for a client with a small vulvar hematoma.

The nurse provides home care instructions to the parent of a child with acquired immunodeficiency syndrome (AIDS). Which statement by the parent indicates the need for further teaching? 1. "I will wash my hands frequently." 2. "I will keep my child's immunizations up to date." 3. "I will avoid direct unprotected contact with my child's body fluids." 4. "I can send my child to day care if he has a fever, as long as it is a low-grade fever."

4. "I can send my child to day care if he has a fever, as long as it is a low-grade fever." Rationale: AIDS is a disorder caused by human immunodeficiency virus (HIV) and characterized by generalized dysfunction of the immune system. A child with AIDS who is sick or has a fever should be kept home and not brought to a day care center. Options 1, 2, and 3 are correct statements and would be actions a caregiver should take when the child has AIDS.

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction? 1. "I should breast-feed every 2 to 3 hours." 2. "I should change the breast pads frequently." 3. "I should wash my hands well before breastfeeding." 4. "I should wash my nipples daily with soap and water."

4. "I should wash my nipples daily with soap and water."

A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action? 1. Initiate an intravenous line. 2. Assess the client's blood pressure. 3. Prepare to administer morphine sulfate. 4. Administer oxygen, 8 to 10 L/minute, by face mask.

4. Administer oxygen, 8 to 10 L/minute, by face mask.

A child was seen in the health care clinic and received an immunization of DPT (diphtheria, pertussis, tetanus) vaccine. One hour later, the mother calls the clinic and tells the nurse that the injection site is painful and red. Which instruction should the nurse provide to the mother? 1. Call the health care provider. 2. Monitor the child for a fever. 3. Return to the health care clinic immediately. 4. Apply cold compresses for 24 hours for 20 minutes at a time.

4. Apply cold compresses for 24 hours for 20 minutes at a time. Rationale: For painful or red injection sites, the nurse should instruct the mother to apply cold compresses for the first 24 hours for 20 minutes at a time and then to use warm or cold compresses as long as needed. The instructions in the remaining options are incorrect. It is not necessary for the mother to bring the child to the clinic immediately, and it is not necessary for the mother to contact the health care provider. Although it may be appropriate to monitor the child for a fever, this action is not associated with the information in the question.

The nurse is providing instructions to the mother of a child who has been exposed to human immunodeficiency virus infection. The nurse should include notifying the health care provider if which symptom occurs in the child? 1. Fussiness 2. Lethargy 3. Irritability 4. Coughing

4. Coughing Rationale: Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. The mother should be instructed to call the health care provider (HCP) if the child develops a fever higher than 101°F (38.3°C); has vomiting and diarrhea, a decreased appetite, difficulty in swallowing, or drooling; develops rashes or sores on the skin; or has coughing or chest congestion. The mother should also notify the HCP if ear pain, ear pulling, or drainage from the ears occurs; if wounds appear that do not heal; or if the child is exposed to chickenpox. Fussiness, lethargy and irritability are vague symptoms that are nonspecific to the subject of the question.

The student nurse is presenting a clinical conference regarding human immunodeficiency virus (HIV) in children. Which information should the student include? 1. HIV cannot be spread by hugging, holding, or touching other people. 2. HIV can be transmitted from open wounds but only if there is skin-to-skin contact. 3. HIV is only able to be transmitted from an infected mother to her baby through breast milk. 4. HIV infection cannot be transmitted if a female uses an intrauterine device as birth control.

1. HIV cannot be spread by hugging, holding, or touching other people. Rationale: Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. HIV cannot be spread by using the same toilet seat, bathtub, or shower; coughing or sneezing; or hugging, holding, or touching people. HIV can be spread from unprotected sexual intercourse regardless of birth control, from sharing of needles, from an infected mother to her baby through breast milk and vaginal secretions during the birth process, or from open wounds if there is blood-to-blood contact.

The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. 1. Wear a supportive bra. 2. Rest during the acute phase. 3. Maintain a fluid intake of at least 3000 mL/day. 4. Continue to breast-feed if the breasts are not too sore. 5. Take the prescribed antibiotics until the soreness subsides. 6. Avoid decompression of the breasts by breast-feeding or breast pump.

1. Wear a supportive bra. 2. Rest during the acute phase. 3. Maintain a fluid intake of at least 3000 mL/day. 4. Continue to breast-feed if the breasts are not too sore.

The nurse is evaluating the developmental level of a 2-year-old. Which does the nurse expect to observe in this child? 1. Uses a fork to eat 2. Uses a cup to drink 3. Pours own milk into a cup 4. Uses a knife for cutting food

2 - use a cup to drink by age 2 the child can use a cup and spoon by age 3 they can use forks

A CD4+ count has been prescribed for a child with human immunodeficiency virus (HIV) infection. The nurse has explained to the mother the purpose of the blood test. Which comment by the mother indicates the need for further explanation? 1. "This test is used to determine the child's immune status." 2. "This test identifies the specific diagnosis of HIV infection." 3. "This test is a blood test that is used to identify the risk for disease progression." 4. "This test assesses the need for Pneumocystis jiroveci pneumonia prophylaxis after 1 year of age."

2. "This test identifies the specific diagnosis of HIV infection." Rationale: Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. CD4+ counts are used to assess a young child's immune status, risk for disease progression, and need for P. jiroveci pneumonia prophylaxis after 1 year of age. These counts are measured at 1 and 3 months, every 3 months until the age of 2 years, and at least every 6 months thereafter. More frequent monitoring of CD4+ counts is indicated when P. jiroveci pneumonia prophylaxis and antiretroviral therapy are recommended. The CD4+ count is not diagnostic of HIV infection.

330. The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? 1. A temperature of 100.4 ° F 2. An increase in the pulse rate from 88 to 102 beats/ minute 3. A blood pressure change from 130/ 88 to 124/ 80 mm Hg 4. An increase in the respiratory rate from 18 to 22 breaths/ minute

2. An increase in the pulse rate from 88 to 102 beats/ minute During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. An increasing pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. A slight increase in temperature is normal. The blood pressure decreases as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. The respiratory rate is slightly increased from normal.

337. A postpartum client is diagnosed with cystitis. The nurse should plan for which priority nursing action in the care of the client? 1. Providing sitz baths 2. Encouraging fluid intake 3. Placing ice on the perineum 4. Monitoring hemoglobin and hematocrit levels

2. Encouraging fluid intake Cystitis is an infection of the bladder. The client should consume 3000 mL of fluids per day if not contraindicated. Sitz baths and ice would be appropriate interventions for perineal discomfort. Hemoglobin and hematocrit levels would be monitored with hemorrhage.

The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply. 1. Discourage reminiscing 2. Make the decisions for the family 3. Encourage expression of feelings, concerns, and fears 4. Explain everything that is happening to all family members 5. Touch and hold the client's or family member's hand if appropriate 6. Be honest and let the client and family know that they will not be abandoned by the nurse

3,5,6

The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage? 1. A primiparous client who delivered 4 hours ago 2. A multiparous client who delivered 6 hours ago 3. A multiparous client who delivered a large baby after oxytocin induction 4. A primiparous client who delivered 6 hours ago and had epidural anesthesia

3. A multiparous client who delivered a large baby after oxytocin induction

The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign should the nurse note if superficial venous thrombosis were present? 1. Paleness of the calf area 2. Coolness of the calf area 3. Enlarged, hardened veins 4. Palpable dorsalis pedis pulses

3. Enlarged, hardened veins

On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action? 1. Document the findings. 2. Elevate the client's legs. 3. Massage the fundus until it is firm. 4. Push on the uterus to assist in expressing clots.

3. Massage the fundus until it is firm.

340. On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action? 1. Elevate the client's legs. 2. Document the findings. 3. Massage the fundus until it is firm. 4. Push on the uterus to assist in expressing clots.

3. Massage the fundus until it is firm. If the uterus is not contracted firmly (i.e., it is soft and boggy), the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Elevating the client's legs would not assist in managing uterine atony. Documenting the findings is an appropriate action but is not the initial action. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage.

The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action? 1. Record the findings. 2. Massage the fundus. 3. Notify the health care provider (HCP). 4. Place the client in Trendelenburg's position.

3. Notify the health care provider (HCP).

The nurse is reviewing the immunization schedule for a child with human immunodeficiency virus (HIV) infection with the mother. Which instruction should the nurse provide to the mother? 1. Immunizations will not be given to the child with HIV infection. 2. The immunization schedule is altered because of the HIV infection. 3. The child and the siblings will need to receive inactivated polio vaccine. 4. The child with HIV infection will start immunizations when 3 years old.

3. The child and the siblings will need to receive inactivated polio vaccine. Rationale: Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. The mother should be instructed that the child with HIV infection should keep immunizations up to date. The child with HIV infection and the siblings will receive an inactivated polio vaccine because the child with HIV infection is immunocompromised. All household members will receive the influenza vaccine. The immunization schedule would not be altered in any other way, and it is important for the mother to understand clearly the immunization schedule.

A mother arrives at a clinic with her toddler and tells the nurse she has a difficult time getting the child to go bed at night. What measure is most appropriate for the nurse to suggest to the mother? 1. Allow the child to set bedtime limits 2. Allow the child to have temper tantrums 3. Avoid letting the child nap during the day 4. Inform the child of bedtime a few minutes before it is time for bed

4

331. The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. 1. Wear a supportive bra. ** 2. Rest during the acute phase. ** 3. Maintain a fluid intake of at least 3000 mL. ** 4. Continue to breast-feed if the breasts are not too sore. *** 5. Take the prescribed antibiotics until the soreness subsides. 6. Avoid decompression of the breasts by breast-feeding or breast pump.

331. 1, 2, 3, 4 Rationale: Mastitis is an infection of the lactating breast. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3000 mL/ day (if not contraindicated), and taking analgesics to relieve discomfort. Antibiotics may be prescribed and are taken until the complete prescribed course is finished. They are not stopped when the soreness subsides. Additional supportive measures include the use of moist heat or ice packs and wearing a supportive bra. Continued decompression of the breast by breast-feeding or breast pump is important to empty the breast and prevent the formation of an abscess.

A 16-year-old is admitted to the hospital for acute appendicitis and an appendectomy is performed. Which nursing intervention is most appropriate to facilitate normal growth and development postoperatively? 1. Encourage the child to rest and read 2. Encourage the parents to room in with the child 3. Allow the family to bring in the child's favorite computer games 4. Allow the child to interact with others in his or her same age group

4

The nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing that which is the most appropriate activity for this child? 1. A radio 2. A sports video 3. Large picture books 4. Crayons and a coloring book

4

The nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing which is the most appropriate? 1. a radio 2. a sports video 3. large picture books 4. crayons and a coloring book

4 eliminate 1 and 2 knowing they are for adolescents LARGE gives you a clue it should be younger than 5 so this leaves you with 4

The nurse is reviewing the laboratory results of studies on a 4-month-old infant and notes that the human immunodeficiency virus (HIV) antibody test is positive. How should the nurse interpret this test result? 1. The infant has HIV. 2. Repeat the test in 1 month. 3. The infant is infected with the HIV virus. 4. The mother is infected with the HIV virus.

4. The mother is infected with the HIV virus. Rationale: Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. A positive HIV antibody test result in a child younger than 18 months indicates only that the mother is infected because maternal IgG antibodies persist in infants for 6 to 9 months and, in some cases, as long as 18 months. The other options are incorrect interpretations of this laboratory result.

A health care provider prescribes laboratory studies for an infant of a woman positive for human immunodeficiency virus (HIV). The nurse anticipates that which laboratory study will be prescribed for the infant? 1. Chest x-ray 2. Western blot 3. CD4+ cell count 4. p24 antigen assay

4. p24 antigen assay Rationale: Infants born to HIV-infected mothers need to be screened for the HIV antigen. The detection of HIV in infants is confirmed by a p24 antigen assay, virus culture of HIV, or polymerase chain reaction. A Western blot test confirms the presence of HIV antibodies. The CD4+ cell count indicates how well the immune system is working. A chest x-ray evaluates the presence of other manifestations of HIV infection, such as pneumonia.

Which intervention(s) are appropriate for the care of an infant? Select all that apply. 1. Provide swaddling 2. Talk in a loud voice 3. Provide the infant with a bottle of juice at nap time 4. Hang mobiles with black and white contrast designs 5. Caress the infant while bathing or during diaper changes 6. Allow the infant to cry for a least 10 minutes before responding

1,4,5

A 3-year-old child with human immunodeficiency virus infection is being discharged from the hospital. The nurse is providing discharge instructions to the mother regarding home care and infection control measures. Which statement by the mother indicates a need for further teaching? 1. "I should discard any unused food and formula immediately." 2. "I need to wash all vegetables carefully before preparing them." 3. "If the nipple becomes soft and sticky, I will discard the nipple." 4. "I will put the clean eating utensils, baby bottle, and dishes in the dishwasher."

1. "I should discard any unused food and formula immediately." Rationale: Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy.The parents should be instructed to cover unused food and formula and refrigerate. They should also be informed to discard unused refrigerated food or formula after 24 hours. The remaining options are accurate instructions related to basic infection control.

The nurse is preparing to administer an MMR (measles, mumps, and rubella) vaccine to a 15-month-old child. Before administering the vaccine, which question should the nurse ask the mother of the child? 1. "Has the child had any sore throats?" 2. "Has the child been eating properly?" 3. "Is the child allergic to any antibiotics?" 4. "Has the child been exposed to any infections?"

3. "Is the child allergic to any antibiotics?" Rationale: Before the administration of MMR vaccine, a thorough health history needs to be obtained. MMR is used with caution in a child with a history of an allergy to gelatin, eggs, or neomycin because the live measles vaccine is produced by chick embryo cell culture and because MMR also contains a small amount of the antibiotic neomycin. The questions in the remaining options are not directed at addressing contraindications to administering immunizations.

333. The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign would the nurse note if superficial venous thrombosis were present? 1. Paleness of the calf area 2. Coolness of the calf area 3. Enlarged, hardened veins 4. Palpable dorsalis pedis pulses

3. Enlarged, hardened veins Thrombosis of superficial veins usually is accompanied by signs and symptoms of inflammation, including swelling, redness, tenderness, and warmth of the involved extremity. It also may be possible to palpate the enlarged, hard vein. Clients sometimes experience pain when they walk. Palpable dorsalis pedis pulses is a normal finding.

A 16 year old is admitted to the hospital for acute appendicitis and an appendectomy is performed. Which nursing intervention is most appropriate to facilitate normal growth and development postoperatively? 1. Encourage the client to rest and read 2. Encourage the parents to room in with the client 3. Allow the family to bring the client's favorite video games 4. Allow the client to interact with others in his or her (adolescent) age group.

4 the other options isolate the adolescent

A mother arrives at a clinic with her toddler and tells her nurse that she has a difficult time getting the child to go to bed at night. What is the most appropriate for the nurse to suggest to the mother? 1. Allow the child to set bedtime limits 2. Allow the child to have temper tantrums 3. Avoid letting the child nap during the day 4. Inform the child of bedtime a few minutes before it is time for bed

4 - toddlers often resist going to bed, make sure to inform them a few minutes prior

332. The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction? 1. "I should breast-feed every 2 to 3 hours." 2. "I should change the breast pads frequently." 3. "I should wash my hands well before breast- feeding." 4. "I should wash my nipples daily with soap and water."

4. "I should wash my nipples daily with soap and water." Mastitis is inflammation of the breast as a result of infection. It generally is caused by an organism that enters through an injured area of the nipples, such as a crack or blister. Measures to prevent the development of mastitis include changing nursing pads when they are wet and avoiding continuous pressure on the breasts. Soap is drying and could lead to cracking of the nipples, and the client should be instructed to avoid using soap on the nipples. The mother is taught about the importance of hand-washing and that she should breast-feed every 2 to 3 hours.

The mother with human immunodeficiency virus (HIV) infection brings her 10-month-old infant to the clinic for a routine checkup. The health care provider has documented that the infant is asymptomatic for HIV infection. After the checkup, the mother tells the nurse that she is so pleased that the infant will not get HIV infection. The nurse should make which most appropriate response to the mother? 1. "I am so pleased also that everything has turned out fine." 2. "Because symptoms have not developed, it is unlikely that your infant will develop HIV infection." 3. "Everything looks great, but be sure to return with your infant next month for the scheduled visit." 4. "Most children infected with HIV develop symptoms within the first 9 months of life, and some become symptomatic sometime before they are 3 years old."

4. "Most children infected with HIV develop symptoms within the first 9 months of life, and some become symptomatic sometime before they are 3 years old." Rationale: Acquired immunodeficiency syndrome (AIDS) is caused by HIV infection and characterized by generalized dysfunction of the immune system. Most children infected with HIV develop symptoms within the first 9 months of life. The remaining infected children become symptomatic sometime before age 3 years. With their immature immune systems, children have a much shorter incubation period than adults. Options 1, 2, and 3 are incorrect. Additionally, these options offer false reassurance.

336. The nurse is preparing to care for four assigned clients. Which client is at highest risk for hemorrhage? 1. A primiparous client who delivered 4 hours ago 2. A multiparous client who delivered 6 hours ago 3. A primiparous client who delivered 6 hours ago and had epidural anesthesia 4. A multiparous client who delivered a large baby after oxytocin (Pitocin) induction

4. A multiparous client who delivered a large baby after oxytocin (Pitocin) induction The causes of postpartum hemorrhage include uterine atony; laceration of the vagina; hematoma development in the cervix, perineum, or labia; and retained placental fragments. Predisposing factors for hemorrhage include a previous history of postpartum hemorrhage, placenta previa, abruptio placentae, overdistention of the uterus from polyhydramnios, multiple gestation, a large neonate, infection, multiparity, dystocia or labor that is prolonged, operative delivery such as a cesarean or forceps delivery, and intrauterine manipulation. The multiparous client who delivered a large fetus after oxytocin induction has more risk factors associated with postpartum hemorrhage than the other clients. In addition, there are no specific data in the client descriptions in options 1, 2, and 3 that present the risk for hemorrhage.

334. A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action? 1. Initiate an intravenous line. 2. Assess the client's blood pressure. 3. Prepare to administer morphine sulfate. 4. Administer oxygen, 8 to 10 L/ minute, by face mask.

4. Administer oxygen, 8 to 10 L/ minute, by face mask. If pulmonary embolism is suspected, oxygen should be administered, 8 to 10 L/ minute, by face mask. Oxygen is used to decrease hypoxia. The client also is kept on bed rest with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client, but this would not be the initial nursing action. An intravenous line also will be required, and vital signs need to be monitored, but these actions would follow the administration of oxygen.