RNCM 109_Mid

3. Monitoring for increased temperature.

Which action should the nurse take when providing postoperative nursing care to a child after insertion of a ventriculoperitoneal shun 1. Administer narcotics for pain control. 2. Check the urine for glucose and protein. 3. Monitoring for increased temperature. 4. Test cerebrospinal fluid leakage for protein. ​

1. The adolescent gives away a DVD and a cherished autographed picture of a performer

Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal? 1. The adolescent gives away a DVD and a cherished autographed picture of a performer. 2. The adolescent runs out of the therapy group, swearing at the group leader, and to her room. 3. The adolescent becomes angry while speaking on the telephone and slams down the receiver. 4. The adolescent gets angry with her roommate when the roommate borrows the client's clothes

"About one-third have an intellectual disability, but it's too early to tell about your child." ​

"About one-third have an intellectual disability, but it's too early to tell about your child." 2. "About two-thirds have an intellectual disability significantly retarded, and you'll know soon if this will occur." 3. Your child will probably be of normal intelligence since he demonstrates signs of it now." 4. "You'll need to talk with the doctor about that, but you can ask later 21. The parents of an infant with myelomeningocele ask the nurse about their child's future mental ability. What is the nurse's best response?

Encouraging the parents to hold their infant.

1. Explaining to the parents that they can visit at any time. Encouraging the parents to hold their infant. 3. Asking the parents to help monitor the infant's intake and output. 4. Helping the parents plan for their infant's discharge. 17. When developing the plan of care for a neonate who was diagnosed with an anorectal malformation anu subsequently underwent surgery, which of the following would be most helpful in facilitating parent- infant bonding?

2. Giving the infant small, frequent feedings.

1. Feeding the infant just before doing any procedures. 2. Giving the infant small, frequent feedings. 3. Feeding the infant in a horizontal position. 4. Scheduling the feedings for every 6 hours. 22. Before placement of a ventriculoperitoneal shunt for hydrocephalus, an infant is imitable, lethargic, and difficult to feed. To maintain the infant's nutritional status, which of the following actions would be most appropriate?

4. They are best planned in conjunction with observations of the infant's behavine

13. A newborn who had a surgical repair of a tracheoesophageal fistula (TEF) is started on oral feedings. Which of the following should the nurse include in the teaching plan for the mother about oral feedings? 1. They are better tolerated when larger, but less frequent feedings are offered. 2. They should be offered on a feeding schedule to help the infant accept the feedings more readily. 3. They are best accepted by the infant when offered by the same nurse or by the infant's mother. They are best planned in conjunction with observations of the infant's behavine

4. My child has a good chance of being potty trained."

15. After teaching the mother of a neonate who has successfully undergone surgery to repair a low anorectal anomaly, the mother indicates that she understands her child's prognosis when she states which of the following? 1. "My child will need to wear protective pads until puberty." 2. "My child will need extra fluids to prevent constipation." 3. "My child will probably always need a high-fiber diet." 4. My child has a good chance of being potty trained."

3. Lying on the side with the hips elevated.

6. When the infant returns to the unit after imperforate anus repair, the nurse should place the infant in which of the following positions? 1. On the abdomen, with legs pulled up under the body. 2. On the back, with legs extended straight out. 3. Lying on the side with the hips elevated. 4. Lying on the back in a position of comfort.

4. I am concerned about you. Are you now or have you ever been abused?"

A 10-year-old referred for evaluation after drawing sexually explicit scenes says to the psychiatric nurse, "I just felt like it." Which response by the nurse is focused on assessing for abuse-related symptoms? 1. "Well, a picture paints a thousand words. 2. "You just felt like destroying your takbooks? 3. "Your parents and teachers are very concerned about your drawings." 4. I am concerned about you. Are you now or have you ever been abused?"

3. Increasing the level of suicide ecautions

A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to nurse, "I'm finally cured. How should the nurse interpret this behavior as a cue to modify the treatment 1. Suggesting a reduction of medication 2. Allowing increased "in-room" activities 3. Increasing the level of suicide ecautions 4. Allowing the client off-unit privileges as needed

4. Bradycardia

A mother arrives at the emergency department with her 5- year-old child and states that the child fell off a bunk bed. A head injury is suspected. The nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP), Which is a late sign of increased ICP? 1. Nausea 2. Irritability 3. Headache 4. Bradycardia ​

1. Limited range of motion in the affected hip

A1-month-old infant is seen in a clinic and is diagnosed with developmental dysplasia of the hip. On assessment, the nurse understands which should be noted in this condition? 1. Limited range of motion in the affected hip 2. An apparent lengthened femur on the affected side 3. Asymmetrical adduction of the affected hip when the infant is placed supine with the knees and hips flexed 4. Symmetry of the gluteal skinfolds when the infant is placed prone and the legs are ​

1. Primary nocturnal enuresis does not respond to treatment.

A7-year-old child is seen in a clinic, and the health care provider documents a diagnosis of primary nocturnal enuresis. The nurse should provide which information to the parents? 1. Primary nocturnal enuresis does not respond to treatment. 2. Primary nocturnal enuresis is caused by a psychiatric problem. 3. Primary nocturnal enuresis requires surgical intervention to improve the problem. 4. Primary nocturnal enuresis is usually outgrown without therapeutic intervention. ​

4. Associate eating with a pleasurable experience.

After surgery to repair a tracheoesophageal fistula, an infant receives gastrostomy feedings. After feeding the by this method, the nurse cradles and rocks the infant for about 15 minutes, primarily to help accomplish which of the following? 1. Promote intestinal peristalsis 2. Prevent regurgitation of formula. 3. Relieve pressure on the surgical site. 4. Associate eating with a pleasurable experience.

Emphasizing the infant's normal and positive features.

Emphasizing the infant's normal and positive features. 2. Encouraging the parents to discuss their fears and concerns. 3. Reinforcing the doctor's explanation of the defect. 4. Having the parents feed their infant. O P 19. When developing the plan of care for an infant diagnosed with myelomeningocele and the parents who have just been informed of the infant's diagnosis, which action should the nurse include as the priority when the parents visit the infant for the first

2. Writing

The nurse is activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate this client? 1. Chess 2. Writing 3. Ping pong 4. Basketball

4. Edema resulting from bleeding below the periosteum of the

The nurse is reviewing the record of a newborn intant in the nursery and notes that the health care provider (HCP) has documented the presence of cephalohematoma. Based on this documentation what should the nurse expect to note on assessment of the infant? 1. A suture split greater than 1 cm 2. A hard, rigid, immobile suture line 3. Swelling of the soft tissues of the head and scalp 4. Edema resulting from bleeding below the periosteum of the cranium

3.Choking with feedings

The nurse reviews the record of a newborn infant and notes that a diagnosis of esophageal atresia with tracheoesophageal fistula is suspected. The nurse expects to note which mos kely sign of this condition documented in the record? 1. Incessant crying 2. Coughing at nighttime 3.Choking with feedings 4. Severe projectile vomiting ​

2. I can see that you are becoming upset.

What statement should the nurse make to a client diagnosed with posttraumatic stress disorder who appears to be experiencing anxiety? 1. "Try not to worry so much." 2. I can see that you are becoming upset." 3. "Everything is going to be all right; just relax." 4. Everything is going to be all right; just relax.

4.Helping the client to examine dysfunctional thoughts and beliefs

When a client is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa, a cognitive behavioral approach is used as part the treatment plan. nurse plans based on which purpose of this approach? 1. Providing a supportive environment 2. Examining intrapsychic conflicts and past issues 3. Emphasizing social interaction with clients who withdraw 4.Helping the client to examine dysfunctional thoughts and beliefs

4. Irritability and increasing difficulty with eating

A nurse evaluates discharge teaching as successful when the parents of a school-age child with a ventriculoperitoneal shunt insertion identify which sign as signaling a blocked shunt? 1. Decreased urine output with stable intake. 2. Tense fontanel and increased head circumference. 3. Elevated temperature and reddened incisional site. 4. Irritability and increasing difficulty with eating

2. Identifying anxiety-producing situations

When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoti a environment at home. Which is the most appropriate maintenance goal? 1. Suppressing feelings of anxiety 2. Identifying anxiety-producing situations 3. Continuing contact with a crisis counselor 4. all anxiety from daily situations

4. "I keep washing my hands over and over

Which piece of subjective data obtained during assessment of a severely anxious client would indicate the possibility of posttraumatic stress disorder? 1. "I'm always crying." 2. "I'm afraid to go outside." 3. "I keep reliving the abuse." 4. "I keep washing my hands over and over