NRS 104 Midterm Review

A major dental problem among very young children is bottle mouth caries. What is a preventive measure the nurse should suggest? a. Juice at bedtime b. Milk at bedtime c. A sugar-coated pacifier d. Water at bedtime

D. Water at bedtime

What is the best description of personality? a. The level of mental health that a person attains in life b. The relativity consistent set of attitudes and behaviors particular to an individual c. The result if a positive self-concept and acceptable behavior d. The ability to manage stress

b. The relativity consistent set of attitudes and behaviors particular to an individual

A client with delirium becomes agitated and confused at night. The Best initial intervention by the nurse is which action? a. Move the client next to the nurse's station b. Use a night light and turn off the television c. Keep the television and a soft light on during the night d. Play soft music during the night and maintain a well-lit room

b. Use a night light and turn off the television

The nurse is collecting data on a client who is actively hallucinating. Which nursing statement would be therapeutic at this time? a. "I know you feel 'they are out to get you,' but it's not true" b. "I can hear the voice, and she wants you to come to dinner" c. "Sometimes people hear things or voices others can't hear" d. "I talked to the voices you're hearing, and they won't hurt you"

c. "Sometimes people hear things or voices others can't hear"

A client taking lithium carbonate reports vomiting, abdominal pain diarrhea, blurred vision, tinnitus, and tremors. The lithium level is checked as a part of routine follow-up, and the level is 3.0 mEq/L. The nurse knows that this is which level? a. Toxic b. Normal c. Slightly above normal d. Excessively below normal

A. Toxic

A young mother asks the nurse how long she should wait before introducing solid food to her infant. The nurse explains that breast milk will provide all the nutrition her infant needs for how many months? a. 2 to 3 months b. 4 to 6 months c. 7 to 9 months d. 10 to 12 months

B. 4 to 6 months

What is the leading cause of death in young adults? a. Diabetes b. Accidents c. Hypertension d. Testicular cancer

B. Accidents

Which finding should the nurse suspect as abnormal in the newborn during the initial assessment? a. Eyes crossed at times b. Persistent high-pitched cry c. Arms and legs flexed d. Slight bluish tinge of the extremities

B. Persistent high-pitched cry

Following delivery of the newborn, which nursing intervention should be carried out immediately? a. Weigh the infant. b. Warm the infant. c. Bathe the infant. d. Inoculate the infant.

B. Warm the infant

Why is vitamin K given by injection to the newborn? a. Most mothers have a vitamin K deficiency that develops during pregnancy. b. Bacteria that synthesize vitamin K are not present in newborns. c. Vitamin K prevents the synthesis of prothrombin. d. The newborn does not store vitamin K.

Bacteria that synthesize vitamin K are not present in newborns.

A newborn baby weighs 7 lb at birth. What does the nurse anticipate the baby's weight will be at 1 year of age? a. 14 lb b. 17 lb c. 21 lb d. 25 lb

C. 21 lb

When the pediatric nurse is attempting to establish a trusting relationship with a child, what is the most important and lasting thing to do? a. Convey respect. b. Talk with the child. c. Be honest. d. Talk with family.

C. Be honest

Where would acrocyanosis be assessed on a newborn? a. Circumoral area b. Brow c. Feet d. Mucous membrane

C. Feet

What is a major complication of gestational diabetes that affects the infant? a. Lack of nutrition b. Dehydration c. Hypoglycemia d. Hyperglycemia

C. Hypoglycemia

To prevent accidental poisoning of a child, where should medications be placed in the home? a. In a dresser drawer b. In the medicine cabinet c. In a locked cupboard d. On a high shelf

C. In a locked cupboard

Why is the fetus dependent on the mother for glucose control? a. The insulin requirements are higher. b. Insulin is destroyed by the placenta. c. Insulin does not cross the placenta. d. Insulin is absorbed by the fetus

C. Insulin does not cross the placenta

What is a characteristic of a normal breast-fed infant's stool? a. Green and loose b. Dark green and sticky c. Pale yellow and frequent d. Light brown and pasty

C. Pale yellow and frequent

The nurse identifies that the newborn is jaundiced within the first 24 hours of birth, with jaundice occurring over bony prominences of the face and the mucous membrane. What type of jaundice does this represent? a. Physiologic b. Normal c. Pathologic d. Transitory

C. Pathologic

The nurse is assessing the newborn and discovers a yellowing of the skin. What is true for jaundice that appears at birth? a. Within normal limits b. Pathologic c. A result of iron deficiency d. Indicating possible hepatitis

C. Pathologic

The nurse assures a patient who has become sensitized to the Rh antigen that she can be protected for future pregnancies by receiving what injection? a. Iron b. Vitamin B12 c. RhoGAM d. Type O blood

C. RhoGam

Compared to older infants of comparable weight, how much higher is the morbidity and mortality rate for preterm infants? a. One to two times b. Two to three times c. Three to four times d. Four to five times

C. Three to four times

When should the gestational age of the infant be determined? a. Within 5 to 10 minutes of delivery b. Within 1 to 2 hours of delivery c. Within 2 to 8 hours of delivery d. Within 12 to 24 hours of delivery

C. Within 2 to 8 hours of delivery

At what age does a child typically possess the physiologic, neuromuscular, and psychological maturity necessary to master toilet training? a. 6 to 10 months b. 10 to 14 months c. 14 to 18 months d. 18 to 24 months

D. 18 to 24 months

How can a family best assist a toddler who is attempting to feed himself? a. Encourage the child to use a fork. b. Feed the child themselves using a fork. c. Encourage large portions for easier handling. d. Offer the child finger foods.

D. Offer the child finger foods

What is the correct order for assessing vital signs in an infant to ensure the accuracy of measurements? a. Respiration, temperature, pulse b. Pulse, respiration, temperature c. Temperature, pulse, respiration d. Respiration, pulse, temperature

D. Respiration, pulse, temperature

Which newborn assessment finding can suggest a chromosomal disorder? a. Epstein pearls b. Gynecomastia c. Babinski reflex d. Simian crease

D. Simian crease

What is the term for the cream cheese-like substance that protects the infant's skin from amniotic fluid? a. Lanugo b. Meconium c. Desquamation d. Vernix caseosa

D. Vernix caseosa

A patients says the anchorwoman on the television news talks to him and told him that there was a car bombing in Israel today. What is the nurse's best response? a. "I don't think you understand how television projection works." b. "She is reporting the world news to everyone in the room. It appears she us looking at you but she is looking in a TV camera that sends a picture to the TV." c. "If you look in the back of the TV console, you will see there is no person inside." d. "You are delusional. That is only a projected image of a person reading the news to a camera far away."

She is reporting the world news to everyone in the room. It appears she us looking at you but she is looking in a TV camera that sends a picture to the TV."

Before initially feeding an infant, what reflex should the nurse assess? a. Moro reflex b. Rooting reflex c. Babinski reflex d. Swallow reflex

Swallow reflex

A 52-year-old patient experienced cardiac arrest from a myocardial infarction. During his acute care stay in the hospital, the patient flirts with all his female nurses. When he is asked to stop, he withdraws and later complains of chest heaviness. What is the possible explanation for the patient's behavior? a. Boredom from restricted activity b. Lack of motivation to recover c. Frustration from his illness d. Threatened self-concept

Threatened self-concept

The newborn infant has oxygenation problems and a lack of subcutaneous fat. What should the nurse determine as the gestational age of this infant? a. 20 to 37 completed weeks of pregnancy b. 38 to 41 completed weeks of pregnancy c. 14 to 36 completed weeks of pregnancy d. 42 or more completed weeks of pregnancy

a. 20 to 37 completed weeks of pregnancy

The nurse is caring for a patient who is currently voicing feelings of anxiety. The nurse correctly recognizes what as the best description of the feelings that the patient is experiencing? a. A vague feeling of apprehension b. Feelings of paranoia c. Emotional stability d. Concerns about the impressions that others have of her

a. A vague feeling of apprehension

A client is admitted to a psychiatric unit for treatment of a psychotic disorder. The client is at the locked exit door and is shouting, "Let me out! There's nothing wrong with me! I don't belong here!" The nurse identifies this behavior as which defense mechanism? a. Denial b. Projection c. Regression d. Rationalization

a. Denial

The nurse is assigned to care for a client experiencing disturbed thought process. The nurse is told that the client believes that their food is being poisoned. Which communication technique would the nurse plan to use to encourage the client to eat? a. Open-ended questions and silence b. Focusing on self-disclosure regarding food preferences c. Stating the reasons that the client may not want to eat d. Offering opinions about the necessity of adequate nutrition

a. Open-ended questions and silence

A 47-year-old patient is in the hospital for severe depression. She is unkept and has lost 15 pounds in the past 2 months. Her family states that she always keeps a knife in her purse. The nurse will consider which intervention for this patient? a. Suicide precautions to prevent self-injury b. Occupational therapy to build self-esteem c. Art psychotherapy to help her express feelings d. Large-portioned meals to improve nutritional status

a. Suicide precautions to prevent self-injury

Lab work is ordered for a client who has been experiencing delusions. When the lab tech approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The nurse present at the time would respond with which question or statement? a. "The tech is not going to hurt you but is going to help." b. "Are you fearful and think that others may want to hurt you?" c. "What makes you think that the tech wants to hurt you?" d. "The tech will leave and come back later for your blood."

b. "Are you fearful and think that others may want to hurt you?"

The nurse is providing care for a client admitted to the hospital with a diagnosis of anxiety disorder. The nurse is talking with the client, and the client says, "I have a secret to tell you. You won't tell anyone about it will you?" Which is the appropriate nursing response? a. "No, I won't tell anyone" b. "I cannot promise to keep a secret" c. "If you tell me the secret, I will tell it to your doctor" d. "If you tell me the secret, I will need to document it in your record"

b. "I cannot promise to keep a secret"

When a mother asks the nurse about introducing solid foods into the child's diet, which of the following would be the best answer? a. "Introduce meat first." b. "Introduce one solid food at a time several days apart." c. "Introduce solid foods by mixing two or three foods together." d. "Introduce solid foods by adding strained food to the infant's bottle."

b. "Introduce one solid food at a time several days apart."

What should be included when discussing the care of a circumcised infant after discharge from the hospital? a. Gently remove the yellow exudate from the foreskin. b. Apply sterile petroleum gauze after each diaper change c. Wipe the circumcision with alcohol each day. d. Avoid the use of cloth diapers until the foreskin has healed

b. Apply sterile petroleum gauze after each diaper change

The nurse is caring for a female client who was recently admitted to the hospital for anorexia nervosa. The nurse enters the client's room and notes that the client is doing vigorous push-ups. Which nursing action is appropriate? a. Interrupt the client and weight her immediately b. Interrupt the client and offer to take her for a walk c. Allow the client to complete her exercise program d. Tell the client that she is not allowed to exercise vigorously

b. Interrupt the client and offer to take her for a walk

A nursery nurse is implementing phototherapy for a jaundiced infant. What is the purpose of the phototherapy? a. It is initiated when the bilirubin level reaches 5 mg/dL. b. It converts bilirubin to a water-soluble form to be excreted in the urine. c. It changes bilirubin to a bile salt to be excreted through the bowel. d. It requires eye patches to remain in place 24 hours a day.

b. It converts bilirubin to a water-soluble form to be excreted in the urine

What is the best therapy choice for bipolar, or manic-depressive disorder? a. Chlorpromazine b. Lithium Carbonate c. Electroconvulsive therapy d. Fluoxetine

b. Lithium Carbonate

A patient who was sexually abused as a child recently married but finds sexual intercourse painful. She confides in her friend, who is a nurse. What is the appropriate response from her friend? a. "You should see your gynecologist right away in case you have torn tissues." b. "It is normal to have pain at first, but you will adjust to your husband over time." c. "You should seek counseling and make sure to get a good physical exam." d. "Did you report this to the police."

c. "You should seek counseling and make sure to get a good physical exam."

Why do alcohol and illegal drugs endanger the fetus? a. Both are absorbed into the bloodstream. b. Both affect the mother. c. Both cross the placental barrier. d. Both increase the heart rate of the fetus.

c. Both cross the placental barrier.

An assembly line manager in a factory was told that he would be laid off if his line did not meet the hourly quota. He promptly went to his workers and threatened to fire anyone who was found taking even 1-minute extra on a break. What is the manager displaying? a. Denial b. Regression c. Displacement d. Identification

c. Displacement

The nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire, but despite the client's efforts, the neighbor died. Which action would the nurse take to enable the client to work through the meaning the crisis? a. Identifying the client's ability to function b. Identifying the client's potential for self-harm c. Inquiring about the client's feelings that may affect coping d. Inquiring about the client's perception of the causes of the neighbor's death

c. Inquiring about the client's feelings that may affect coping

During a crisis intervention what is the highest priority of nursing care? a. Managing anxiety b. identifying situational supports c. Patient safety d. Teaching specific coping skills that the patient lacks

c. Patient safety

The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the obtained data, the nurse would identify which as a priority concern? a. The client's report of not eating or sleeping b. The presence of bruises on the client's body c. The client's report of self-destructive thoughts d. The family member is disapproving of the treatment

c. The client's report of self-destructive thoughts

The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse would monitor for which symptoms? a. Hypotension, ataxia, vomiting b. Stupor, agitation, muscular rigidity c. Hypotension, bradycardia, agitation d. Hypertension, disorientation, hallucinations

d. Hypertension, disorientation, hallucinations

The nurse is caring for a newborn who was circumcised earlier in the day. What should be included in the plan of care? a. Administration of a topical anesthetic to the site b. Application of ice to stop bleeding c. Retraction of any remaining foreskin d. Observation for bleeding for the first 12 hours

d. Observation for bleeding for the first 12 hours