S3 U4 test questions 1

A nurse should plan to implement which interventions for a child admitted with inorganic failure to thrive? Select all that apply. Observation of parent-child interactions Assignment of different nurses to care for the child from day to day Use of 28 calorie per ounce concentrated formulas Administration of daily multivitamin supplements Role modeling appropriate adult-child interactions

Observation of parent-child interactions Administration of daily multivitamin supplements Role modeling appropriate adult-child interactions

organic failure to thrive

Occurs when there is an underlying medical cause to low weight/height

A nurse assesses a client with diabetes mellitus. Which assessment finding would alert the nurse to decreased kidney function in this client? Urine specific gravity of 1.033 Presence of protein in the urine Elevated capillary blood glucose level Presence of ketone bodies in the urine

Presence of protein in the urine Renal dysfunction often occurs in the client with diabetes. Proteinuria is a result of renal dysfunction. Specific gravity is elevated with dehydration

The long-term treatment plan for an adolescent with an eating disorder focuses on Managing the effects of malnutrition Establishing sufficient caloric intake Improving family dynamics Restructuring perception of body image

Restructuring perception of body image The treatment of eating disorders is initially focused on reestablishing physiologic homeostasis. Once body systems are stabilized, the next goal of treatment for eating disorders is maintaining adequate caloric intake. Although family therapy is indicated when dysfunctional family relationships exist, the primary focus of therapy for eating disorders is to help the adolescent cope with complex issues. The focus of treatment in individual therapy for an eating disorder involves restructuring cognitive perceptions about the individuals body image.

A nurse is assessing a newborn for facial feature characteristics associated with fetal alcohol syndrome: Which characteristics should the nurse expect to assess? Select all that apply. Short palpebral fissures Smooth philtrum Low set ears Inner epicanthal folds Thin upper lip

Short palpebral fissures Smooth philtrum thin upper lip Infants with fetal alcohol syndrome may have characteristic facial features, including short palpebral fissures, a smooth philtrum (the vertical groove in the median portion of the upper lip), and a thin upper lip.

An emergency department nurse moves to a new city where heat-related illnesses are common. Which clients does the nurse anticipate being at highest risk for heat-related illnesses? (Select all that apply.) Homeless individuals People with substance abuse disorders Caucasians Hockey players Older adults Obese individuals

Homeless individuals People with substance abuse disorders Older adults Obese individuals

In general, healthy families are able to adapt to changes within the family unit; however, some factors add to the usual stress experienced by any family. The nurse is in a unique position to assess the child for symptoms of neglect. Which high-risk family situation places the child at the greatest risk for being neglected? Marital conflict and divorce Adolescent parenting Substance abuse A child with special needs

Substance abuse

what is a chronic, multisystem, autoimmune disease characterized by inflammation of the connective tissue.

Systemic lupus erythematosus

what stage of hypothermia do you expect when A client presents to the emergency department after prolonged exposure to the cold. The client is difficult to arouse and speech is incoherent. they also have muscle weakness, increased loss of coordination, acute confusion, apathy, incoherence, stupor, and impaired clotting.

moderate hypothermia

Persistent tachycardia in infants can indicate

more than 150 bpm RDS

VS for heat stroke

temp above 104 tachycardia fast RR low BP

A nurse teaches a client with type 1 diabetes mellitus. Which statement would the nurse include in this client's teaching to decrease the client's insulin needs? a. "Limit your fluid intake to 2 L a day." "Animal organ meat is high in insulin." "Limit your carbohydrate intake to 80 g a day." "Walk at a moderate pace for 1 mile daily."

"Walk at a moderate pace for 1 mile daily." Moderate exercise such as walking helps regulate blood glucose levels on a daily basis and results in lowered insulin requirements for patients with type 1 diabetes mellitus. Restricting fluids and eating organ meats will not reduce insulin needs.

A nurse is teaching a wilderness survival class. Which statements would the nurse include about the prevention of hypothermia and frostbite? (Select all that apply.) "Wear synthetic clothing instead of cotton to keep your skin dry." "Drink plenty of fluids. Brandy can be used to keep your body warm." "Remove your hat when exercising to prevent overheating." "Wear sunglasses to protect skin and eyes from harmful rays." "Know your physical limits. Come in out of the cold when limits are reached." "Change your gloves and socks if they become wet."

"Wear synthetic clothing instead of cotton to keep your skin dry." "Wear sunglasses to protect skin and eyes from harmful rays." "Know your physical limits. Come in out of the cold when limits are reached." "Change your gloves and socks if they become wet." To prevent hypothermia and frostbite, the nurse would teach patients to wear synthetic clothing (which moves moisture away from the body and dries quickly), layer clothing, and a hat, facemask, sunscreen, and sunglasses. The client would also be taught to drink plenty of fluids, but to avoid alcohol when participating in winter activities.

People with diabetes need at least ___ g of carbohydrates each day.

130

what does A1C have to be for a diagnosis of DM

6.5 or higher

What is the primary nursing concern for a child having an anaphylactic reaction? Identifying the offending allergen Ineffective breathing pattern Increased cardiac output Positioning to facilitate comfort

Ineffective breathing pattern The primary action is to assess airway patency, respiratory rate and effort, level of consciousness, oxygen saturation, and urine output.

Developmental delays, self-injury, fecal smearing, and severe temper tantrums in a preschool child are symptoms of Down syndrome Intellectual disability Psychosocial deprivation Separation anxiety

Intellectual disability

what factors could be responsible for SLE

Although the etiology is unknown, genetic, hormonal, environmental, and immune response factors are likely to be responsible.

A nurse is teaching parents about the importance of immunizations for infants because of immaturity of the immune system. The parents demonstrate that they understand the teaching if they make which statement? The spleen reaches full size by 1 year of age. IgM, IgE, and IgD levels are high at birth. IgG levels in the newborn infant are low at birth. Absolute lymphocyte counts reach a peak during the first year.

Absolute lymphocyte counts reach a peak during the first year.

An emergency department nurse cares for a middle-age mountain climber who is confused, ataxic, and exhibits impaired judgement. After administering oxygen, which intervention would the nurse implement next? Administer dexamethasone. Complete a mini mental state examination. Prepare the client for computed tomography of the brain. Request a psychiatric consult.

Administer dexamethasone. The client is exhibiting signs of mountain sickness and high-altitude cerebral edema (HACE). Dexamethasone reduces cerebral edema by acting as an anti-inflammatory in the central nervous system.

A primary health care provider prescribes a rewarming bath for a client who presents with Grade 3 frostbite. What action would the nurse take prior to starting this treatment? Administer intravenous morphine. Wrap the limb with a compression dressing. Massage the frostbitten areas. Assess the limb for compartment syndrome.

Administer intravenous morphine. Rapid rewarming in a water bath is recommended for all instances of partial-thickness and full-thickness frostbite. Patients experience severe pain during the rewarming process and nurses would administer intravenous analgesics.

An emergency department nurse plans care for a client who is admitted with heat stroke. Which interventions does the nurse include in this patient's plan of care? (Select all that apply.) Administer oxygen via mask or nasal cannula. Administer ibuprofen, an antipyretic medication. c. Apply cooling techniques until core body temperature is less than 101° F (38.3° C). Infuse 0.9% sodium chloride via a large-bore intravenous cannula. Obtain baseline serum electrolytes and cardiac enzymes. Insert an indwelling urinary catheter for urine output measurements.

Administer oxygen via mask or nasal cannula. Infuse 0.9% sodium chloride via a large-bore intravenous cannula. Obtain baseline serum electrolytes and cardiac enzymes. Insert an indwelling urinary catheter for urine output measurements. Heat stroke is a medical emergency. Oxygen therapy and intravenous fluids would be provided, and baseline laboratory tests would be performed as quickly as possible. Urinary output is measured via an indwelling urinary catheter. The client would be cooled until core body temperature is reduced to 102° F (38.9° C). Antipyretics would not be administered.

A client presents to the emergency department after prolonged exposure to the cold. The client is difficult to arouse and speech is incoherent. What action would the nurse take first? Reposition the client into a prone position. Administer warmed intravenous fluids to the client. c. Wrap the client's extremities in warm blankets.d. Initiate extracorporeal rewarming via hemodialysis.

Administer warmed intravenous fluids to the client. Moderate hypothermia manifests with muscle weakness, increased loss of coordination, acute confusion, apathy, incoherence, stupor, and impaired clotting. Moderate hypothermia is treated by core rewarming methods, which include administration of warm IV fluids; heated oxygen; and heated peritoneal, pleural, gastric, or bladder lavage. The client's trunk would be warmed prior to the extremities to prevent peripheral vasodilation. Extracorporeal warming with cardiopulmonary bypass or hemodialysis is a treatment for severe hypothermia.

A client is receiving total parenteral nutrition (TPN). On assessment, the nurse notes that the client's pulse is 128 beats/min, blood pressure is 98/56 mm Hg, skin is dry, and skin turgor is poor. What action should the nurse perform next? Assess the 24-hour intake and output. Assess the client's oral cavity. Prepare to hang a normal saline bolus. Increase the infusion rate of the TPN.

Assess the 24-hour intake and output. This client has clinical indicators of dehydration, so the nurse calculates the patient's 24-hour intake, output, and fluid balance. This information is then reported to the health care provider. The client's oral cavity assessment may or may not be consistent with dehydration. The nurse may need to give the client a fluid bolus, but not as an independent action. The client's dehydration is most likely due to fluid shifts from the TPN, so increasing the infusion rate would make the problem worse, and is not done as an independent action for clients receiving TPN.

A client is in the bariatric clinic 1 month after having gastric bypass surgery. The client is crying and says "I didn't know it would be this hard to live like this." What approach by the nurse is best? Assess the client's coping and support systems. Inform the client that things will get easier. Re-educate the client on needed dietary changes. Tell the client that lifestyle changes are always hard.

Assess the client's coping and support systems.

A client resuscitated after drowning is admitted to the emergency department. What assessment findings does the nurse recognize as symptoms of a drowning? (Select all that apply.) Bilateral crackles Bradycardia Cyanosis of the lips Hypotension Flushed, diaphoretic skin

Bilateral crackles Bradycardia Cyanosis of the lips Hypotension Drowning victims will exhibit signs of pulmonary edema which includes crackles in one or both lungs, persistent dry cough, and cyanosis of the lips and/or nail beds. The diving reflex as a response to asphyxia produces bradycardia, signs of decreased cardiac output with hypotension, and vasoconstriction of vessels in the intestine, skeletal muscles, and kidneys.

A nurse is reviewing laboratory values for several clients. Which value indicates a need for a nutritional assessment? Client with an albumin of 3.5 g/dL Client with a cholesterol of 142 mg/dL (3.7 mmol/L) Client with a hemoglobin of 9.8 mg/dL (98 mmol/L) Client with a prealbumin of 28 mg/dL

Client with a cholesterol of 142 mg/dL (3.7 mmol/L) A cholesterol level below 160 mg/dL (4 mmol/L) is a possible indicator of undernutrition, so this client would be at highest priority for a nutritional assessment. The albumin and prealbumin levels are normal.

While on a camping trip, a nurse cares for an adult client who had a drowning incident in a lake and is experiencing agonal breathing with a palpable pulse. What action would the nurse take first? Deliver rescue breaths. Wrap the client in dry blankets. Assess for signs of bleeding. Check for a carotid pulse.

Deliver rescue breaths. In this emergency situation, the nurse immediately initiates airway clearance and ventilator support measures, including delivering rescue breaths.

The parents of a teen suspect their child is using amphetamines. Manifestations of amphetamine use include (select all that apply) Weight gain Excessive talking and activity Excessive sleeping Insomnia Agitation

Excessive talking and activity Insomnia Agitation Euphoria, hyperactivity, agitation, irritability, insomnia, weight loss, tachycardia, and hypertension are expected behaviors and effects of amphetamine abuse.

Children receiving long-term systemic corticosteroid therapy are most at risk for Hypotension Dilation of blood vessels in the cheeks Growth delays Decreased appetite and weight loss

Growth delays

A nurse is caring for a client who is about to receive a bone marrow transplant. To best help the client cope with the long recovery period, what action by the nurse is best? Arrange a visitation schedule among friends and family. Explain that this process is difficult but must be endured. Help the client find things to hope for each day of recovery. Provide plenty of diversionary activities for this time.

Help the client find things to hope for each day of recovery. Providing hope is an essential nursing function during treatment for any disease process, but especially during the recovery period after bone marrow transplantation, which can take up to 3 weeks. The nurse can help the client look ahead to the recovery period and identify things to hope for during this time. Visitors are important to clients, but may pose an infection risk. Telling the client that the recovery period must be endured does not acknowledge his or her feelings.

A client receiving continuous tube feeding to provide total enteral nutrition begins vomiting. What action by the nurse is most appropriate? Administer an antiemetic. Check the patient's gastric residual. Hold the feeding until the vomiting subsides. Reduce the rate of the tube feeding by half.

Hold the feeding until the vomiting subsides. The nurse would stop the feeding until the vomiting subsides and consult with the registered dietitian nutritionist or primary health care provider about the rate at which to restart the feeding. Giving an antiemetic is not appropriate. After vomiting, a gastric residual will not be accurate.

The nurse is teaching participants in a family-oriented community center ways to prevent their older relatives and friends from getting heat-related illnesses. What information does the nurse include? (Select all that apply.) Use sunscreen with an SPF of at least 15 when outdoors. Take cool baths or showers after outdoor activities. Check on the older adult daily in hot weather. Drink plenty of liquids throughout the day.

Take cool baths or showers after outdoor activities. Check on the older adult daily in hot weather. Drink plenty of liquids throughout the day. To best prevent heat-related illnesses, the nurse would teach individuals to use sunscreen with at least an SPF of 30 for both UVA and UVB rays, to shower or bathe in cool water after being outdoors to reduce body heat, to remain hydrated, and to wear light-colored, loose-fitting clothes. Families and friends should check older adults at least twice a day during a heat wave; however, this may not prevent heat-related illness but could catch it quickly and limit its severity.

A client has glossitis What action by the nurse is most appropriate? Encourage the client to have genetic testing. Instruct the client on high-fiber foods. Place the client in protective precautions. Teach the client about cobalamin therapy.

Teach the client about cobalamin therapy. This condition is known as glossitis, and is characteristic of B12 anemia. If the anemia is a pernicious anemia, it is treated with cobalamin.

What goal has the highest priority for a child with malabsorption associated with lactose intolerance? The child will experience no abdominal spasms. The child will not experience constipation associated with malabsorption syndrome. The child will not experience diarrhea associated with malabsorption syndrome. The child will receive adequate nutrition as evidenced by a weight gain of 1 kg/day.

The child will not experience diarrhea associated with malabsorption syndrome.

A nurse in a well-child clinic is teaching parents about their childs immune system. Which statement by the nurse is correct? The immune system distinguishes and actively protects the bodys own cells from foreign substances. The immune system is fully developed by 1 year of age. The immune system protects the child against communicable diseases in the first 6 years of life. The immune system responds to an offending agent by producing antigens.

The immune system distinguishes and actively protects the bodys own cells from foreign substances. Intact skin, mucous membranes, and processes such as coughing, sneezing, and tearing help maintain internal homeostasis.

Which statement is true regarding how infants acquire immunity? The infant acquires humoral and cell-mediated immunity in response to infections and immunizations. The infant acquires maternal antibodies that ensure immunity up to 12 months age. Active immunity is acquired from the mother and lasts 6 to 7 months. Passive immunity develops in response to immunizations.

The infant acquires humoral and cell-mediated immunity in response to infections and immunizations. The term infants passive immunity is acquired from the mother and begins to dissipate during the first 6 to 8 months of life. Passive immunity is acquired from the mother. Active immunity develops in response to immunizations.

RR in hyperglycemia

The rate and depth of respiration are increased (Kussmaul respirations) in an attempt to excrete more acids by exhalation

Which organs and tissues control the two types of specific immune functions? The spleen and mucous membranes Upper and lower intestinal lymphoid tissue The skin and lymph nodes The thymus and bone marrow

The thymus and bone marrow The thymus controls cell-mediated immunity (cells that mature into T lymphocytes). The bone marrow controls humoral immunity (stem cells for B lymphocytes).

Which sign or symptom is likely to be manifested by an adolescent with a depressive disorder? Abuse of alcohol Impulsivity and distractibility Carelessness and inattention to details Refusal to leave the house

abuse of alcohol Depression often manifests in conjunction with substance abuse, so children who abuse substances should be evaluated for depression as well.

The nurse is assessing a client who has undernutrition. What signs and symptom(s) would the nurse expect? (Select all that apply.) Alopecia Stomatitis Muscle wasting Peripheral edema Anemia Dry, scaly skin

all

Elevated capillary blood glucose levels and ketones in the urine are consistent with

diabetes mellitus but are not specific to renal function.

inorganic failure to thrive

food shortage, incorrect mixing of formula, or neglect

Fat malabsorption is indicated by

foul-smelling, greasy, bulky stools.

what is indicated when a person playing football comes reporting a headache, weakness, and nausea. What actions would the nurse take

heat exhaustion Heat exhaustion manifests as flulike symptoms with headache, weakness, nausea, and/or vomiting.

prednisone does what to glucose levels

increases

glossitis is common with what

inflammation of the tongue b12 deficiency

Providing care for the neonate born to a mother who abuses substances can present a challenge for the health care team. Nursing care for this infant requires a multisystem approach. The first step in the provision of this care is a. Pharmacologic treatment b. Reduction of environmental stimuli c. Neonatal abstinence syndrome scoring d. Adequate nutrition and maintenance of fluid and electrolyte balance

c. Neonatal abstinence syndrome scoring Neonatal abstinence syndrome (NAS) is the term used to describe the cohort of symptoms associated with drug withdrawal in the neonate. The Neonatal Abstinence Scoring System evaluates CNS, metabolic, vasomotor, respiratory, and gastrointestinal disturbances. This evaluation tool enables the care team to develop an appropriate plan of care. The infant is scored throughout the length of stay and the treatment plan is adjusted accordingly.

malabsorption is what acid base imbalance

metabolic acidosis