Child Health

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Kawasaki disease

(inflammation of blood vessles, hence the strawberry tongue) causes coronary artery aneurysms.

Hemoglobin lab values

*Male:* 14-18 g/dl *Female:* 12.0-16.0 g/dl

Isoniazid (INH)

-antiTB - take daily for 6-12 months and most likely with other meds too -worked if 3 neg. sputum cultures, no temp. - Liver toxicity (hepato) check liver fxn - Don't take with alcohol (liver fxn remember?) - Take on empty stomach

A nurse is caring for a child with acute glomerulonephritis. Frequent monitoring of which of the following is a priority? 1. Blood pressure [20%] 2. Hematuria [14%] 3. Intake and output [48%] 4. Peripheral edema [17%]

1 / Acute glomerulonephritis is most often caused by recent streptococcal infection. Nursing care is focused on monitoring vital signs (particularly blood pressure) and fluid status, avoiding salt in the diet, and conserving energy.

The nurse is observing a pregnant client receiving an oxytocin infusion for induction of labor. The baseline fetal heart rate is 140/min; the strip is shown in the exhibit. What is the nurse's best course of action? Click on the exhibit button for additional information. 1. Apply oxygen 10 L/min by facemask [7%] 2. Continue to monitor the client [46%] 3. Discontinue oxytocin infusion [31%] 4. Notify the registered nurse [14%]

1 / An acceleration is a reassuring finding most often indicating fetal movement. Moderate variability is considered "good" and "normal" and fluctuates off baseline from 6-25/min.

Quickening, the awareness of fetal movements, occurs around

18-20 weeks gestation in primigravidas

Which infant should be the nurse's priority for monitoring and intervention? 1. Infant born 6 hours ago after 38 weeks gestation who has a respiratory rate of 52/min [14%] 2. Infant born 12 hours ago who is jittery and has a blood glucose level of 40 mg/dL(2.2 mmol/L) [50%] 3. Infant delivered vaginally 30 minutes ago who has bilateral crackles [32%] 4. Infant wrapped in a warm blanket 15 minutes ago due to a temperature of 97.7 F (36.5 C) [2%]

2 / An infant's blood glucose level should be ≥40 mg/dL within the first 24 hours after delivery. A level <40 mg/dL (2.2 mmol/L) indicates hypoglycemia. Symptoms of hypoglycemia include jitters, cyanosis, tremors, pallor, poor feeding, retractions, lethargy, low oxygen saturation, and seizures. This infant with borderline low glucose level is symptomatic and should be assessed first.

INR lab values

2-3, critical value if off, potential for patient to bleed. Use default order for order ?'s (hold all coumadin, assess for bleeding, prepare Vit K (antidote for Coumadin), Call or notify

The white blood cell count is normally elevated during the first

24 hours postpartum (up to 30,000/mm3 [30.0 x 109/L]). Leukocyte levels that are not decreasing require further evaluation.

A nurse is reinforcing teaching to the parent of a child who has a new diagnosis of absence seizures. Which statement by the parent indicates understanding of the teaching? 1. "My child may experience incontinence." [3%] 2. "My child may seem confused afterwards." [13%] 3. "My child may stare and seem inattentive." [75%] 4. "My child will notice unusual odors prior to the event." [7%]

3 / Absence seizures are characterized by a brief loss of consciousness and the appearance of inattention or daydreaming without loss of postural tone. Most absence seizures occur in children age 4-12, last less than 10 seconds, and may occur multiple times daily.

PTT (partial thromboplastin time)

60-70 seconds

predictor of a successful induction

Bishop score

A client in labor with a history of a previous cesarean birth has chosen to attempt a vaginal birth. During labor, which finding would be most concerning to the nurse? 1. Cessation of contractions and maternal tachycardia [51%] 2. Fetal tachycardia with moderate variability [35%] 3. Increased anxiety and discomfort with contractions [7%] 4. Painful, strong contractions every 3-4 minutes [4%]

Clients attempting vaginal birth after cesarean have a slightly increased risk for uterine rupture. Signs of uterine rupture may include abnormal fetal heart rate pattern (ie, decelerations, decreased variability, bradycardia), loss of fetal station, constant abdominal pain, cessation of uterine contractions, and maternal tachycardia.

congenital hypothyroidism

Initially normal at birth Symptoms develop after maternal T4 wanes: Lethargy Enlarged fontanelle Protruding tongue Umbilical hernia Poor feeding Constipation Dry skin Jaundice Diagnosis ↑ TSH & ↓ free T4 levels Newborn screening Treatment Levothyroxine

are used as a systematic approach to palpating the pregnant abdomen to identify fetal presentation

Leopold maneuvers

Hematocrit lab values

Male: 42%-52% Female: 37%-47%

used for shoulder dystocia

McRoberts maneuver consists of sharply flexing the thigh onto the maternal abdomen to straighten the sacrum

Agoraphobic individuals most typically fear being in the following situations:

Outside the home alone In a crowd or standing in line Traveling in a bus, train, car, ship, or airplane On a bridge or in a tunnel Open spaces (eg, parking lots, marketplaces) Enclosed spaces (eg, theaters, concert halls, stores)

Epilepticus (medical emergency)

Patient has a "string" of seizures with no respite. Usually caused by discontinuation of prescribed seizure medications

Magnesium Sulfate

Seizure activity

Symptoms of hypoglycemia

Sweating & pallor Irritability Tremors & weakness Tachycardia Drowsiness Hunger

Terazosin (Hytrin)

alpha 1 blocker

sentinel event

an accident or incident that results in grave physical or psychological injury or death

tetralogy of Fallot, transposition of the great vessels)

and cause cyanosis, which is evident shortly after birth and during periods of physical exertion.

insulin and dextrose

beta blockers, calcium channel antagonists

Infants with bacterial meningitis may have

bulging fontanelles due to an increase in intracranial pressure

Good evidence that intravenous immunoglobulin treatment within the first 10 days of symptoms reduces

coronary artery abnormalities (heart damage) in children with Kawasaki disease. Kawasaki disease is a disease that primarily affects children under five years old. The cause of Kawasaki disease is not known.

Depressed fontanelles indicate

dehydration

Sucrose

glucose + fructose

peritonitis

inflammation of the peritoneal cavity

compensation

involves experiencing a perceived deficit in one area and making up for it by overachieving in another. An example is someone not doing well academically who focuses on doing well in sports.

Projection

involves feeling uncomfortable with an impulse or feeling and easing the anxiety by assigning it to another person. An example is a husband with thoughts of infidelity who then accuses his wife of being unfaithful.

reaction formation

involves transforming an unacceptable feeling or impulse into its opposite. An example is a client with cancer who fears dying but behaves in an overly optimistic and fearless manner about his treatment and prognosis.

The Babinski reflex can be present up to 1-2 years and is a normal expected finding; it does not indicate

meningitis

A diastolic murmur is heard in

mitral stenosis and aortic regurgitation

Severe pain experienced with direct pressure on the tragus or with pulling on the pinna is a manifestation of

otitis externa, an infection of the outer ear.

Acute Otitis Media (AOM)

pus/fluid inside the ear produces bulging and red membranes.

autonomy

self-government

hyperemesis gravidarum

severe nausea and vomiting in pregnancy that can cause severe dehydration in the mother and fetus

peritoneal cavity contains

small intestine

veracity

truthfulness, honesty

A harsh systolic murmur is heard in the setting of

ventricular septal defect

A newborn is being evaluated for possible esophageal atresia with tracheoesophageal fistula. Which finding is the nurse most likely to observe? 1. Choking and cyanosis during feeding [64%] 2. Concave (scaphoid) abdomen [3%] 3. Diminished lung sounds [4%] 4. Projectile vomiting after feeding [26%]g

1 / Clinical manifestations of EA/TEF include frothy saliva, coughing, choking, drooling, and a distended abdomen. Clients may also develop apnea and cyanosis while feeding. These findings must be reported to the health care provider for further evaluation.

The nurse is reinforcing education to the parents of an adopted 5-year-old about how best to share details of the child's adoption. Which developmentally appropriate thought process does the nurse counsel the parents to anticipate? 1. Feelings of responsibility for being placed for adoption [34%] 2. Imagining what life would be like with a different family [15%] 3. Inability to conceptualize adoptive and biological parents [41%] 4. Worrying about what peers will say or think [7%]

1 / Children age 3-6 (preschool) are in Piaget's preoperational stage of cognitive development. Children in the preoperational stage are developmentally capable of understanding adoption on a basic level; however, it may be difficult for them to understand the concept of having another family. At age 5, children may be unable to fully understand cause and effect and therefore ascribe inappropriate causes to phenomena (eg, scraped knee was caused by earlier misbehavior). Preschoolers who are adopted may believe they are responsible for being adopted and can develop separation anxiety and a fear of abandonment. (Option 2) School-aged children who are adopted may imagine how life would be different with their biological parents. They may be sensitive to physical differences between themselves and their adoptive family and feel a sense of loss when thinking of their biological family. (Option 3) Toddlers are in the preoperational stage of cognitive development and can generally think about only one idea at a time. They cannot think about all parts of an idea in terms of the whole, making it difficult to understand the difference between adoptive and biological parents. (Option 4) Adolescents have abstract thinking abilities that enable introspection about their adoption. Open and honest communication is important at this age.

1 / Clients attempting vaginal birth after cesarean have a slightly increased risk for uterine rupture. Signs of uterine rupture may include abnormal fetal heart rate pattern (ie, decelerations, decreased variability, bradycardia), loss of fetal station, constant abdominal pain, cessation of uterine contractions, and maternal tachycardia.

The unit secretary notifies the nurse that 4 clients called the nurses' station reporting pain. Which client should the nurse assess first? 1. Client who had a foot amputation today reporting left shoulder pain radiating down the arm [45%] 2. Client who has acute pancreatitis reporting severe, continuous, penetrating abdominal pain [19%] 3. Client who has multiple myeloma reporting deep pelvic pain after walking down the hall [1%] 4. Client who has sickle cell disease reporting severe pain in the arms and upper back [33%]

1 / Clients undergoing lower-extremity amputation may experience surgical site pain or phantom limb pain. However, shoulder pain radiating down the arm is an unexpected finding following an extremity amputation and may indicate myocardial ischemia. Women, older adults, or clients with diabetes may have atypical presentations (eg, indigestion, jaw/shoulder pain, dyspnea, diaphoresis, nausea/vomiting) other than chest pain during a myocardial infarction (Option 1). (Option 2) In clients with pancreatitis, autodigestion of the pancreas by pancreatic enzymes causes severe, continuous, piercing, or penetrating abdominal pain. (Option 3) Multiple myeloma is a cancer of the bone marrow that causes bone degeneration and skeletal pain. Clients commonly report spinal, pelvic, and rib pain with physical activity. (Option 4) Clients with sickle cell disease experience acute painful episodes (sickle cell crisis) from exacerbation of red blood cell sickling and vasoocclusion. Vasoocclusion can cause severe pain, most often in the upper back, arms, or legs. Educational objective: Women, older adults, or clients with diabetes may have atypical presentations (eg, indigestion, jaw/shoulder pain, dyspnea, diaphoresis, nausea/vomiting) other than chest pain during a myocardial infarction. Additional Information Coordinated Care NCSBN Client Need

A client with borderline personality disorder says to the nurse, "You're the only one I trust around here. The others don't know what they are doing, and they don't care about anyone except themselves. I only want to talk with you." What priority action should the nurse advocate to be included in the client's nursing care plan? 1. Assign different staff members to care for the client each day [17%] 2. Continue assigning the client's stated preferred nurse to care for the client [20%] 3. Frequently reassure the client that all staff members are competent in their jobs [48%] 4. Reinforce unit rules and consequences of inappropriate behaviors [12%]

1 / Clients with borderline personality disorder, in an attempt to prevent abandonment and control their environment, may flatter and cling to one staff member while making derogatory remarks about others. The best nursing action is to rotate staff members assigned to care for the client.

The nurse is reviewing discharge instructions with the parents of a child who just had a tracheostomy. Which statement made by the parents indicates teaching has been effective? 1. "I will always travel with two tracheostomy tubes, one of the same size and one a size smaller." [42%] 2. "I will immediately change the tracheostomy tube if my child has difficulty breathing." [8%] 3. "I will provide deep suctioning frequently to prevent any airway obstruction." [36%] 4. "I will remove the humidifier if my child starts developing more secretions." [12%]

1 / Educational objective: Clients with a tracheostomy should always carry two spare tubes, one the same size and one a size smaller, to ensure that the tube can be replaced quickly and effectively.

The nurse is reinforcing information to a client in preparation for discharge from the hospital when the client breaks down crying, saying "the health care provider thinks I am crazy because I was diagnosed with a functional disorder." Which statement would be the best reply to this client? 1. "Functional disorder is a diagnosis for a genuine medical issue that medical science does not yet fully understand." [37%] 2. "I am very sorry to hear this, but are you sure that's what the health care provider (HCP) meant?" [27%] 3. "The HCP gave you the wrong information. I'll give you the information my HCP used." [0%] 4. "Why do you think you were diagnosed with a functional disorder?" [34%]

1 / Functional disorders are currently undiagnosable medical issues and should not be confused with physical disorders caused by emotional factors (psychosomatic illness), attention-seeking behavior, or malingering.

Four clients arrive in the urgent care clinic. Which does the nurse anticipate to be the priority for intervention? 1. Child who is confused and irritable and whose parent claims 2 glyburide pills are missing [57%] 2. Child with an abscess on the buttock that is red, swollen, and warm to the touch [3%] 3. Child with immune thrombocytopenia who fell off a bike and reports shoulder pain [22%] 4. Child with low-grade fever, barking cough, and runny nose who has mild retractions [16%]

1 / Glyburide is used to treat diabetes mellitus, and it can cause significantly low blood sugar if ingested by a client who does not have diabetes, especially a child. Based on the symptoms the child is exhibiting (irritability, confusion), hypoglycemia is likely. This client requires immediate intervention as severe hypoglycemia can result in coma and/or death. (Option 2) Buttock abscess, although painful, is not an emergency. Incision and drainage are needed. (Option 3) Immune thrombocytopenia (idiopathic thrombocytopenic purpura) can be a serious condition due to the risk for bleeding. A client with this condition should be assessed for internal bleeding following an injury, especially to the head. Shoulder pain is not a symptom associated with life-threatening bleeding; therefore, this client is not the top priority. (Option 4) This child with brassy (barking) cough most likely has croup, which can be life threatening and needs urgent assessment. However, because this client seems to be stable, the child with possible glyburide ingestion should be seen first. This child has mild retractions, a sign that the child is still moving air but work of breathing has increased. The presence of stridor or severe suprasternal, subcostal, and intercostal retractions would make this client a higher priority. Educational objective: Ingestion of antidiabetic drugs (eg, glyburide, glipizide, glimepiride) by a nondiabetic client (eg, child) is an emergency as severe hypoglycemia can result in coma and/or death.

While collecting data from pregnant clients in the obstetric clinic, the nurse should alert the health care provider to see which client first? 1. First-trimester client who reports frequent nausea and vomiting [1%] 2. Second-trimester client with dysuria and urinary frequency [5%] 3. Second-trimester client with obesity who reports decrease in fetal movement [49%] 4. Third-trimester client with right upper quadrant pain and nausea [44%]

1 / HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count) is a severe form of preeclampsia. Its clinical presentation can be quite variable and may include nonspecific symptoms such as right upper quadrant/epigastric pain, nausea, vomiting, and malaise. Complications, including placental abruption, stroke, and death, may occur if HELLP syndrome is not treated immediately.

The practical nurse is caring for a client with newly diagnosed infective endocarditis. Which assessment finding by the nurse is the highest priority to report to the registered nurse? 1. Pain and pallor in one foot [25%] 2. Pain in both knees [1%] 3. Splinter hemorrhages in the nail beds [16%] 4. Temperature of 102.2 F (39 C) [57%]

1 / Infective endocarditis causes the formation of vegetations on valve and endocardial surfaces. Embolization to various organ sites can occur. The onset of hemiplegia or painful, pale, cold foot/leg could indicate embolization and should be reported immediately

The nurse assesses a child with intussusception. Which assessment findings require priority intervention? 1. Abdominal rigidity with guarding [27%] 2. Absence of tears in crying child with IV start [10%] 3. Blood-streaked mucous stool in diaper [23%] 4. Sausage-shaped right-sided mass on palpation [38%]

1 / Intestinal perforation and peritonitis are common complications of intestinal obstruction (eg, intussusception). Peritonitis is characterized by fever, abdominal rigidity, guarding, and rebound tenderness and is a surgical emergency

A client at 20 weeks gestation states that she started consuming an increased amount of cornstarch about 3 weeks ago. Based on this assessment, the nurse should anticipate that the health care provider will order which laboratory test(s)? 1. Hemoglobin and hematocrit levels [35%] 2. Human chorionic gonadotropin level [17%] 3. Serum folate level [42%] 4. White blood cell count [3%]

1 / Pica is the constant craving for and consumption of nonfood and/or nonnutritive food substances that may occur in pregnancy. It may be accompanied by iron deficiency anemia. Hemoglobin and hematocrit levels are useful in these clients to screen for anemia

The post-anesthesia care unit nurse is caring for 4 clients during the immediate postoperative period. Which client would be the priority for the nurse to see first? 1. A client post cholecystectomy reporting increased nausea [33%] 2. A client post myomectomy with mild oozing of blood from the surgical site [31%] 3. A client post spinal surgery requesting additional pain medication [24%] 4. A client post transurethral resection of the prostate with reddish-pink drainage [11%]

1 / Postoperative clients are at an increased risk for vomit aspiration due to nausea and an altered level of consciousness (caused by anesthesia). These clients should be placed on their side and should receive antiemetics to prevent potential airway and breathing complications.

The nurse has received report on the following clients. Which client should be seen first? 1. Client 4 hours postoperative colon resection who has a blood pressure of 90/74 mm Hg [22%] 2. Client receiving hospice care who has Cheyne-Stokes respiration with 20-second periods of apnea [12%] 3. Client with anemia and hemoglobin level of 7 g/dL (70 g/L) who has a pulse of 110/min after ambulation [11%] 4. Client with diabetic ketoacidosis who has rapid, deep respirations at a rate of 32/min [53%]

1 / Postoperative hypotension can be a manifestation of bleeding, hypovolemia, and sepsis. Changes in vital signs (eg, decreased systolic pressure, tachycardia, tachypnea) and cool, pale skin can indicate decreased cardiac output and altered tissue perfusion.

The registered nurse (RN) teaches the parents of a hospitalized 3-month-old about separation anxiety. The practical nurse notices that the parents still seem concerned about leaving the infant while they work and so reinforces the information provided by the RN. Which statement by one of the parents indicates that the teaching has been effective? 1. "At this age, my baby will not cry because we are leaving." [35%] 2. "I know my baby will feel abandoned when we leave." [21%] 3. "My baby is too young to sense my anxiety about leaving." [35%] 4. "My baby understands that we will return later in the day." [7%]

1 / Separation anxiety starts around age 6 months, peaks at age 10-18 months, and can last until age 3 years. It produces more stress than any other factor (eg, pain, injury, change in surroundings) for children in this age range. However, separation anxiety is normal and resolves by age 3 years.

A client with a ventriculoperitoneal shunt has a dazed appearance and grunting and has not responded to the caregiver for 10 minutes. Status epilepticus is suspected. Which nursing intervention should be performed first? 1. Administer rectal diazepam [16%] 2. Assess for neck stiffness and Brudzinski sign [64%] 3. Draw blood for laboratory studies [2%] 4. Transport the client to CT for assessment of shunt malfunction [16%]

1 / Status epilepticus is a serious condition that could result in brain damage and death. Quickly stopping the seizure is the first nursing priority as long as there is an adequate airway and the client is breathing. IV or rectal benzodiazepines (lorazepam or diazepam) are used to rapidly control seizures

The nurse is preparing to assess a client visiting the women's health clinic. The client's obstetric history is documented as G5T1P2A1L2. Which interpretation of this notation is correct? 1. The client had 1 birth at 37 wk 0 d gestation or beyond [47%] 2. The client had 3 births between 20 wk 0 d and 36 wk 6 d gestation [27%] 3. The client has 3 currently living children [14%] 4. The client is currently not pregnant [10%]

1 / The GTPAL system notational components are G - gravida (number of pregnancies, regardless of outcome and including current pregnancies), T - term (37 wk 0 d gestation and beyond), P - preterm (20 wk 0 d through 36 wk 6 d gestation), A - abortions (before 20 wk 0 d gestation; spontaneous or induced), and L - currently living children.

A woman who had a cesarean delivery 5 hours ago now appears anxious and reports shortness of breath. The practical nurse should assess for which priority problem before notifying the registered nurse? 1. Calf warmth and redness [58%] 2. Elevated temperature [20%] 3. Elevated white blood cell count [6%] 4. Incisional discomfort [13%]

1 / The hypercoagulable state during pregnancy increases the risk for thrombus formation. The practical nurse should report any signs of deep venous thrombosis (eg, redness, swelling, warmth in the calf area) or pulmonary embolus (eg, anxiety, shortness of breath) to the registered nurse. Elevated white blood cell count and temperature are expected findings during the first 24 hours after childbirth.

A client at 20 weeks gestation reports "running to the bathroom all the time," pain with urination, and foul-smelling urine. Which question is most important for the nurse to ask when assessing the client? 1. "Are you having any pain in your lower back or flank area?" [40%] 2. "Do you wipe from front to back after urinating?" [19%] 3. "Have you found that you urinate more frequently since becoming pregnant?" [2%] 4. "Have you had a urinary tract infection in the past?" [38%]

1 / Urinary tract infections are common during pregnancy. If the client reports signs and symptoms of cystitis, the nurse's priority is to rule out ascending infection (ie, pyelonephritis), which would require hospitalization and IV antibiotics.

The nurse is monitoring a client who is in active labor with a cervical dilation of 6 cm. Which uterine assessment finding requires an intervention by the nurse? 1. Contraction duration of 95 seconds [44%] 2. Contraction frequency of every 3 minutes [22%] 3. Contraction intensity of 45 mm Hg [12%] 4. Uterine resting tone of 10 mm Hg [19%]

1 / Uterine contractions during labor dilate and efface the cervix and cause descent of the fetus. The contraction duration should not exceed 90 seconds or occur less than 2 minutes apart. Excess resting tone, contraction duration, and frequency result in uteroplacental insufficiency.

1 / Warning signs of a PE include sudden anxiety and shortness of breath

The nurse in a clinic is obtaining a developmental history of an 18-month-old during a well-child visit. Which activities should the child be expected to perform? Select all that apply. 1. Goes up stairs while holding a hand 2. Knows approximately 350 words 3. Runs without falling 4. Stacks 6 blocks in a tower 5. Turns 2 pages in a book at a time

1,2 / A toddler's development centers on both fine and gross motor skills. By 18 months, the toddler should be able to manage stairs while holding a hand and turn 2 or 3 pages in a book. The direction of development is toward improving locomotion skills (Options 1 and 5). (Options 2, 3, and 4) A 24-month-old should be able to build a tower of 6 or 7 blocks, run without falling, and have a vocabulary containing over 300 words. Educational objective: An 18-month-old typically is developing both fine and gross motor skills, which include going up stairs while holding a hand and turning 2 or 3 pages in a book

A client at 34 weeks gestation has constipation. The client has been taking 325 mg ferrous sulfate tid for anemia since the last appointment 4 weeks ago. Which instructions should the nurse reinforce for this client? Select all that apply. 1. Decrease total daily dairy intake 2. Increase intake of fruits and vegetables 3. Moderate-intensity regular exercise 4. One laxative twice daily for a week 5. Two cups of hot coffee each morning

1,2 / Constipation in pregnancy may be caused by increased progesterone levels and iron supplementation. It is best treated with 10-12 cups of fluid daily, a high-fiber diet/supplementation, and regular exercise. Clients should not take laxatives without first discussing this with the health care provider.

The home health nurse visits a 75-year-old client with mild Alzheimer dementia who recently moved in with a caregiver. Which observations would cause the nurse to suspect neglect? Select all that apply. 1. Client breaks eye contact when discussing caregiver 2. Client has lost 8 lb (3.63 kg) in the previous 4 weeks 3. Client is wearing clothing that is out of style 4. Client's eyeglasses have been visibly broken for 1 month 5. Client's prescription medication is expired

1,2,,4,5 / Manifestations of abuse or neglect in an older adult may include development of pressure ulcers, poor hygiene, dehydration, malnutrition, weight loss, soiled bedding/clothing, missing/broken assistive devices, and missing or expired medications.

Which assessment findings should the nurse anticipate in a child with suspected acute otitis media (AOM)? Select all that apply. 1. Frequent pulling on the affected ear 2. Refusal to eat 3. Restlessness and irritability 4. Retracted tympanic membranes 5. Severe pain with pressure on the tragus

1,2,3 / Clinical manifestations of AOM include high fever; ear pain; irritability; pulling on the affected ear; and bulging, red tympanic membranes.

The practical nurse is assisting the registered nurse in creating a care plan for a 3-year-old who was admitted with suspected pertussis infection. Which interventions should be included? Select all that apply. 1. Institute droplet precautions 2. Monitor for signs of airway obstruction 3. Offer small amounts of fluids frequently 4. Place the child in a negative-pressure isolation room 5. Request a prescription for cough suppressant

1,2,3 / Pertussis can occur despite vaccination. Initial manifestations include cold-like symptoms with a mild fever, followed by the characteristic violent, spasmodic cough; inspiratory whooping sound; and posttussive vomiting. Treatment consists of oral antibiotics, droplet precautions, and supportive measures (humidified oxygen and oral fluids)

The nurse is reviewing the records of an adolescent client. Which findings suggest that the client may need referral for depression screening? Select all that apply. 1. Client has had school disciplinary issues due to absenteeism and angry outbursts 2. Client has lost approximately 8 lb (3.64 kg) over the last 3 weeks without trying 3. Client is often found sleeping during class or activities 4. Client quit sports despite receiving previous athletic awards and trophies 5. Client voices concern about appearance related to facial acne

1,2,3,4 / Adolescent clients with depression frequently report vague somatic symptoms (eg, headache, stomachache) and may exhibit an irritable or cranky mood rather than a sad or dejected mood. In addition, changes in sleep patterns; low-self esteem; withdrawal from previously enjoyable activities; outbursts of aggressive or delinquent behavior; and precipitous weight changes may indicate the onset of a depressive disorder.

The medical-surgical nurse cares for a group of clients. Which client situations would prompt the nurse to notify the health care provider during the middle of the night? Select all that apply. 1. Client develops right-sided upper and lower extremity drift 2. Client found lying unconscious on the floor 3. Client has order for heparin with surgery planned for the morning 4. Client has serum sodium of 124 mEq/L (124 mmol/L) 5. Client refuses a prescribed, routine pain medication

1,2,3,4 / The nurse should notify the health care provider, regardless of the time, for acute client deterioration (eg, neurological changes), critical laboratory values, falls, or death. Other reasons include prescription clarification and the client leaving against medical advice or refusing a key treatment.

The nurse is planning education for clients in group prenatal care who are entering the second trimester of pregnancy. Which of the following are appropriate for the nurse to include in second-trimester teaching? Select all that apply. 1. Anticipate light fetal movements around 16-20 weeks gestation 2. Expect to have an abdominal ultrasound for fetal anatomy evaluation 3. Gain about 1 lb (0.5 kg) per week if pre-pregnancy BMI was normal 4. Increase consumption of iron-rich foods like meat and dried fruit 5. Plan for gestational diabetes screening near the end of the second trimester

1,2,3,4,5 / Educational objective: During the second trimester, the nurse should provide guidance regarding fetal movements, weight gain, screening/diagnostic tests (eg, fetal anatomy ultrasound, 1-hour glucose challenge test), and increased requirements for iron to maintain maternal and fetal health.

After a recent outbreak of varicella in an elementary school, the practical nurse is assisting with the development of an informative letter to parents. Which of the following instructions are appropriate to include? Select all that apply. 1. Apply calamine lotion to soothe lesions 2. Clip your child's fingernails short 3. Ensure that your child's vaccinations are up to date 4. Keep your child home until lesions have crusted 5. Place mittens on your child's hands when sleeping

1,2,3,4,5 / Varicella (chickenpox) is highly contagious and clients should remain at home until all lesions have crusted. Ensuring that vaccinations are up to date is the best way to prevent varicella infection and other communicable diseases. Applying soothing lotion (eg, calamine), clipping fingernails short, and wearing mittens during sleep may prevent secondary bacterial infections caused by intense scratching.

A practical nurse is collaborating with a registered nurse educator to develop materials for a hospital-wide campaign about zero tolerance for lateral violence and bullying among staff. Which actions should staff members be encouraged to perform if they experience workplace violence? Select all that apply. 1. Document the interactions with the bully 2. Ignore the bully's comments, remarks, and allegations 3. Observe interactions between the bully and other colleagues 4. Report the violent incidents to the hospital administrator 5. Tell the bully you will not tolerate the unprofessional behavior

1,2,4 / Clients who are immunosuppressed from chemotherapy should not be cared for by a health care provider who is infectious.

The nurse is reviewing anticipatory guidance with the parents of a 6-month-old infant with phenylketonuria. Which statements by the nurse are appropriate? Select all that apply. 1. "A low-phenylalanine diet is required." 2. "Meat and dairy products should not be introduced into the diet." 3. "Phenylketonuria is self-limiting and usually resolves by adulthood." 4. "Special infant formula is required." 5. "Tyrosine should be removed from the diet."

1,2,4 / Management of the client with PKU includes: Monitoring serum levels of phenylalanine Including synthetic proteins and special formulas (eg, Lofenalac, Phenyl-Free) in the diet (Option 4) Eliminating high-phenylalanine foods (eg, meats, eggs, milk) from the diet (Option 2) Encouraging the consumption of natural foods low in phenylalanine (most fruits and vegetables)

Which findings support a diagnosis of post-traumatic stress disorder? Select all that apply. 1. Difficulty concentrating 2. Feeling detached from others 3. Feeling lethargic and apathetic 4. Flashbacks of the traumatic event 5. Persistent angry, fearful mood

1,2,4,5 / A person suffering from post-traumatic stress disorder experiences 3 categories of symptoms: reexperiencing the traumatic event, avoiding reminders of the trauma, and hyperarousal.

The nurse is caring for a child admitted with measles. Which of the following interventions will the nurse anticipate for this client? Select all that apply. 1. Administering prescribed vitamin A supplements 2. Advising measles vaccination for susceptible family members 3. Monitoring for swelling of the parotid glands 4. Placing the client in a negative-pressure isolation room 5. Using a N95 respirator mask during client contact

1,2,4,5 / Clients with measles are highly contagious and require airborne precautions (eg, negative-pressure isolation room, N95 respirator). Susceptible (eg, unvaccinated) family members should receive postexposure prophylaxis (eg, measles, mumps, and rubella [MMR] vaccine). Administering vitamin A supplements prevents vitamin A deficiency which, if severe, can cause blindness.

Which of the following tasks can the practical nurse (PN) safely assign to an experienced unlicensed assistive personnel (UAP)? Select all that apply. 1. Ambulate an oxygen-dependent client to the bathroom 2. Check pulse oximetry for a client with respiratory rate 12/min 3. Instruct a client with pneumonia on usage of the incentive spirometer 4. Provide oral hygiene to a client with chronic obstructive pulmonary disease (COPD) 5. Turn and reposition a client with pneumonia

1,2,4,5 / Experienced UAP can assist stable clients with activities of daily living, hygiene needs, ambulation, transfer, and repositioning. They can also take vital signs (eg, pulse oximetry), assist with treatments, and prevent aspiration (eg, repositioning). However, the PN is responsible for ensuring the client's safety, supervision of the UAP, and evaluation of the care rendered by the UAP.

The nurse is caring for a full-term newborn following vaginal delivery. Which nursing interventions should be implemented? Select all that apply. 1. Always wear gloves when handling the newborn before bathing 2. Cover the newborn to maintain a body temperature of 97.5-99 F (36.4-37.2 C) 3. During the initial bath, remove as much vernix caseosa as possible 4. Give a single dose of vitamin K intramuscularly 5. Suction the pharynx first, then the nasal passages

1,2,4,5 / Nursing management of a newborn includes using standard precautions when in contact with blood or body fluids (eg, bathing), maintaining the infant's airway (suction the pharynx before the nose), thermoregulation, and administering vitamin K and prophylactic ophthalmic ointment

Which tasks can the licensed practical nurse appropriately assign to unlicensed assistive personnel? Select all that apply. 1. Assist the nurse in ambulating a client 1 day post abdominal surgery 2. Measure and empty drainage output into a bulb drain 3. Monitor for redness and swelling at a client's IV insertion site 4. Provide extra blankets at the client's request 5. Take family members to the waiting room after a client goes into surgery

1,2,4,5 / Unlicensed assistive personnel may perform noncomplex tasks (eg, escorting family members, providing additional blankets) and clinical tasks (eg, emptying, measuring, and recording output) related to the care of clients under the direction of the licensed practical nurse.

A nurse is participating in an obstetrical emergency simulation in which the health care provider announces a shoulder dystocia. As the assisting nurse, which of the following interventions should the nurse implement? Select all that apply. 1. Document the time the fetal head was born 2. Flex the client's legs back against the abdomen and apply downward pressure above the symphysis pubis 3. Prepare for a forceps-assisted birth 4. Provide newborn suction bulb to the health care provider for suctioning fetal mouth and nose 5. Request additional assistance from other nurses immediately

1,2,5 / Documenting the exact time of events (eg, birth of fetal head, shoulder dystocia maneuvers) (Option 1) Verbalizing passing time to guide health care provider decision-making (eg, "two minutes have passed") Performing maneuvers to relieve shoulder impaction (eg, McRoberts maneuver, suprapubic pressure) (Option 2) Requesting additional help from staff (eg, nurses, neonatologist) immediately

A client comes to the clinic indicating that a home pregnancy test was positive. The client's last menstrual period was September 7. Today is December 7. Which are true statements for this client? Select all that apply. 1. According to Naegele's rule, the expected date of delivery is June 14 2. Detection of the fetal heart rate via Doppler is possible 3. Fundal height should be 24 cm above the symphysis pubis 4. The client should be feeling fetal movement 5. Urinary frequency is a common symptom

1,2,5 / Naegele's rule for estimating date of delivery is the last menstrual period minus 3 months plus 7 days. Fetal heart rate is detectable by Doppler at 10-12 weeks gestation. Urinary frequency is a presumptive sign of pregnancy in the first trimester.

A pregnant client at 30 weeks gestation comes to the prenatal clinic. Which vaccines may be administered safely at this prenatal visit? Select all that apply. 1. Influenza injection 2. Influenza nasal spray 3. Measles, mumps, and rubella 4. Tetanus, diphtheria, and pertussis 5. Varicella

1,4 / Inactivated vaccines (eg, inactivated influenza; tetanus, diphtheria, and pertussis) may be given during pregnancy to protect pregnant clients from illness and provide the fetus with passive immunity. Live virus vaccines are contraindicated in pregnancy.

The parents of a 2-year-old client ask how they can help their child cope with hospitalization. Which of the following suggestions should the nurse give the parents? Select all that apply. 1. Follow as many home routines as possible 2. Organize a visit from a playgroup friend 3. Sleep in the child's hospital room at night 4. Take child on regular visits to the playroom 5. Tell the child they did not cause the illness

1,3,4 / Hospitalization for toddlers (ie, 12-36 months) is particularly difficult due to separation anxiety and a limited ability to cope with stress. Toddlers thrive on home rituals and routines, which bring stability and reassurance. Hospitalization can severely disrupt these routines, triggering frustration and temper tantrums. Caregivers should maintain as many home routines as possible (eg, sleeping, eating) to help the child cope with unfamiliar hospital surroundings and procedures (Option 1). Parents should also stay with the child as much as possible, including overnight (ie, rooming-in), to provide consistency and alleviate separation anxiety (Option 3). Play, an important part of a child's emotional and social well-being, is an effective coping mechanism for children of all ages to deal with the stress of being away from home. The playroom is a safe place for children to act out their fears and anxieties related to illness and hospitalization (Option 4). (Option 2) A visit from friends is not likely to provide much comfort to a toddler and may actually cause additional stress. Adolescents, who are driven by peer interaction, would be more likely to benefit from this strategy. (Option 5) Preschool-aged children (3-5 years) have egocentric and magical thinking, which may cause them to think that their illness is due to something they have done or thought. Toddlers do not think this way. Educational objective: Coping mechanisms used by hospitalized toddlers include following homes rituals and routines, having parents stay with the child (including overnight), and using the playroom for relief of anxiety and fear.

A nurse is caring for a school-age client who has fever, somnolence, and a skin rash from suspected meningococcal meningitis. Which interventions should be implemented for this client? Select all that apply. 1. Allow the client to self-position for comfort 2. Have the client wear a mask at all times for 24 hours 3. Keep the client on NPO status 4. Minimize the environmental stimuli 5. Place the client in a negative airflow room

1,3,4 / Nursing care for a child with known or suspected meningococcal meningitis includes key safety and comfort measures. Droplet precautions are initiated because this form of meningitis is easily transferred through secretions. Precautions should be continued for 24 hours after initiation of antibiotic therapy. Clients with somnolence or other altered level of consciousness should be kept on NPO status to prevent aspiration (Option 3). Comfort measures include promoting a quiet environment, minimizing stimuli in the room, and allowing the client to self-position (Options 1 and 4). Due to nuchal rigidity, most clients prefer to lie with the head of the bed slightly raised and without a pillow, or in a side-lying position. (Option 2) Under droplet precautions, the nurse should wear a mask when caring for the client. However, the client does not need to wear a mask unless transportation outside the room (eg, to perform an imaging study) is necessary. (Option 5) A negative airflow room would be used for a client under airborne precautions (eg, active tuberculosis). A client with known or suspected meningitis requires droplet precautions. Educational objective: Nursing care for a client with suspected meningococcal meningitis includes implementing safety measures such as droplet precautions and NPO status (for somnolence), and promoting comfort by minimizing stimuli, raising the head of the bed slightly, and removing the pillow. Droplet precautions should continue for 24 hours after initiation of antibiotic therapy.

The nurse is monitoring a 12-month-old diagnosed with intussusception. Which findings should the nurse expect? Select all that apply. 1. Palpable olive-shaped mass in epigastrium 2. Palpable sausage-shaped mass in upper right quadrant 3. Projectile vomiting containing blood 4. Screaming and drawing the knees up to the chest 5. Stool mixed with blood and mucus

1,3,4 / The classic clinical triad of intussusception is intermittent, severe, crampy abdominal pain; a palpable sausage-shaped mass on the right side of the abdomen; and currant jelly stools

The nurse is monitoring a neonate 1 hour after spontaneous vaginal delivery. Which of the following are expected findings? Select all that apply. 1. Capillary glucose of 60 mg/dL (3.3 mmol/L) 2. Holosystolic murmur auscultated at fourth intercostal space 3. Respirations of 56 breaths per minute 4. Single transverse crease across palm of the hand 5. White papules on bridge of the nose

1,3,5 / Expected findings for a neonate at 1-3 hours postpartum include respirations between 30-60 breaths per minute, milia, and glucose levels <70-100 mg/dL (3.9-5.6 mmol/L) but ≥40 mg/dL (2.2 mmol/L).

A nurse is discussing the fine motor abilities of a 10-month-old infant with the infant's parent. Which are developmentally appropriate skills for an infant of this age? Select all that apply. 1. Grasps a small doll by the arm 2. Stacks 3 wooden blocks 3. Transfers small objects from hand to hand 4. Turns single pages in a book 5. Uses a basic pincer grasp

1,3,5 / Fine motor skills of infants develop around the ability to grasp and pick up objects. By 3 months, infants will reflexively grasp a rattle placed in their hand. At 5 months, they are able to voluntarily clasp it with their palm. Around 7 months, infants are able to transfer an object from one hand to the other. By 8-10 months, infants have replaced the palmar grasp with a crude pincer grasp (use of thumb, index, and other fingers) to pick up round oat cereal and other finger foods. By 11 months, this develops into a neat pincer grasp (use of thumb and index finger). (Options 2 and 4) By 12 months, infants may attempt to turn multiple book pages at once, and they also begin attempts to stack 2 blocks. These skills require finer muscle control than is expected of a 10-month-old. Educational objective: Fine motor skills of infants develop around the ability to grasp objects. Voluntary grasping with the palm begins around 5 months, followed by the ability to transfer an object between hands by 7 months and the development of a crude pincer grasp (using the thumb, index, and other fingers) around 8-10 months

The nurse is collecting data on a 2-day-old infant with suspected Hirschsprung disease. Which findings should the nurse anticipate? Select all that apply. 1. Bright red bleeding from anus 2. Distended abdomen 3. Has not passed stool (meconium) 4. Nonbilious vomiting 5. Refuses to feed

1,3,5 / Hirschsprung disease is caused by a lack of specialized nerve cells in portions of the distal large intestine; this renders the internal sphincter unable to relax. An infant with Hirschsprung disease will not pass meconium but will have a distended abdomen and bilious emesis.

1,3,5 / The chain of command should be followed when reporting incidents of lateral violence. If the immediate supervisor takes no action, the employee can move up the chain.

Which statements involve acceptable use of an abbreviation, symbol, or dose designation in documentation? Select all that apply. 1. "2 cm × 3 cm × 1 cm stage II decubitus noted on left shin." 2. "4.0 u SSRI administered to cover capillary glucose of 160 mg/dL." 3. "Dose of .5 mg hydromorphone administered and the client feels 'better.'" 4. "Maalox 5 mL PO administered pc as requested for c/o heartburn." 5. "Spouse voiced understanding of home urinary catheterization QID."

1,4,5 / Acceptable abbreviations include "ac," "pc," "QID," and "cm." Unacceptable abbreviations include "qd," "q1d," and "qod"; "SSRI" for insulin; and "u" for units. There must be a zero before a decimal dose and no trailing zero after a decimal point.

A client denies illicit drug use but has some suspicious behaviors. The client's neonate has a low birth weight. What other signs would lead the nurse to suspect neonatal abstinence syndrome? Select all that apply. 1. Irritability and restlessness 2. Meconium ileus and floppy tone 3. Microencephaly and cleft palate 4. Poor feeding and loose stools 5. Stuffy nose and frequent sneezing

1,4,5 / Prenatal exposure to maternal illicit drug use results in abstinence syndrome in the neonate. Neonatal abstinence syndrome affects the autonomic nervous system (stuffy nose, frequent yawning), gastrointestinal tract (poor feeding, diarrhea), and central nervous system (irritability, restlessness, high-pitched cry)

The charge nurse in a long-term memory care facility is making assignments for the Alzheimer unit. Which tasks may be delegated to experienced unlicensed assistive personnel? Select all that apply. 1. Assisting clients with bathing and hair care 2. Evaluating safety hazards in clients' rooms 3. Monitoring clients for behavioral changes 4. Placing bed alarms at night for clients at risk for wandering 5. Reporting a client's swallowing difficulties during mealtime

1,4,5 / The role of UAP includes the following: Assisting with activities of daily living (eg, toileting, bathing, skin care, oral care, personal hygiene) (Option 1) Assisting with feeding Reporting changes in ability to eat or difficulty swallowing (Option 5) Reporting changes in behavior Placing bed alarms to reduce risk of falls (Option 4)

While caring for a client in skeletal traction, which tasks can the nurse assign to experienced unlicensed assistive personnel to help prevent immobility hazards? Select all that apply. 1. Assist with active and passive range of motion exercises 2. Change bed linens while logrolling the client from side to side 3. Check the color and temperature of the affected extremity 4. Reapply pneumatic compression device after bathing the client 5. Remind the client to use the incentive spirometer

1,4,5 / Unlicensed assistive personnel (UAP) have the skills and knowledge to perform standard procedures to prevent immobility hazards for a client in traction (eg, pneumonia, pressure ulcers, foot drop, thromboembolism). When providing care for a stable client, the nurse can safely assign the following tasks to UAP: Assist with active and passive range of motion exercises after the client has been taught how to perform them by the registered nurse (RN) or physical therapist (Option 1) Notify the nurse of client reports of pain, tingling, or decreased sensation in the affected extremity Remind clients to use the incentive spirometer after they have been taught proper use by the RN or respiratory therapist (Option 5) Maintain proper use of pneumatic compression devices (Option 4) Remind the client to move frequently using the overhead trapeze (Option 2) UAP change the linens from the top to the bottom of the bed with assistance while clients lift themselves using the overhead trapeze. This approach maintains immobilization of the injured extremity. Logrolling the client will require multiple staff members, including one person to stabilize weights. (Option 3) The nurse is responsible for peripheral circulation, neurovascular, and skin assessments. Educational objective: To prevent immobility hazards for a client in skeletal traction, the nurse can assign the following tasks to unlicensed assistive personnel: Assist with active and passive range of motion exercises Notify the nurse of client reports of pain, tingling, or decreased sensation in the affected extremity Remind the client to use the incentive spirometer Maintain proper use of pneumatic compression devices

The night nurse reports that the client hospitalized with major depressive disorder has been unable to go to sleep until late at night. The client gets up, paces the hallway, wrings the hands, and appears teary. Which interventions does the nurse advocate adding to the care plan? Select all that apply. 1. Arrange for the client to receive 20 minutes of natural sunlight each day 2. Encourage the client to take naps during the day to make up for lost sleep 3. Have the client engage in strenuous physical exercise just before bedtime 4. Serve the client a glass of warm milk in the evening 5. Spend time with the client in a quiet environment just before bedtime 6. Tell the client to take a warm bath before going to bed

1,4,5,6 / Nonpharmacological strategies for improving sleep hygiene include exercising during the day, engaging in a relaxing activity before bedtime, dealing with worries at a set time of day, providing a relaxing sleep environment, avoiding naps during the day, avoiding caffeine after noon, and drinking a warm cup of milk before bedtime.

The Bishop score is a system for the assessment and rating of cervical favorability and readiness for induction of labor.

A higher Bishop score indicates an increased likelihood of successful induction that results in vaginal birth. For nulliparous women, a score ≥8 usually indicates that induction will be successful

The nurse is reinforcing teaching to a client, gravida 1 para 0, at 8 weeks gestation about expected weight gain during pregnancy. The client's prepregnancy BMI is 21 kg/m2. Which statement made by the client indicates an appropriate understanding about weight gain? 1. "I should gain 10 pounds during the first trimester." [12%] 2. "I should gain about 30 pounds during the entire pregnancy." [63%] 3. "I should gain no more than half a pound per week during the third trimester." [18%] 4. "If I gain no more than 20 pounds during pregnancy, it will be easier to lose weight postpartum." [5%]

2 / Appropriate weight gain during pregnancy decreases risks to the client and fetus. Weight gain in the first trimester should be 1.1-4.4 lb (0.5-2.0 kg), regardless of BMI. The optimal total weight gain during pregnancy is determined by the client's prepregnancy BMI.

The nurse makes a home visit to a client with Alzheimer disease. While reviewing the client's home care needs, the client's spouse states, "It's hard to see my spouse worsen each day. I'm not sure I can keep doing this alone anymore." Which response by the nurse is best? 1. "Perhaps finding a caregiver to care for your spouse at night might be helpful." [4%] 2. "Tell me about the care you provide in a typical day and its challenges." [62%] 3. "Try not to worry. It's normal to feel overwhelmed when you are stressed." [0%] 4. "You seem worried that you won't be able to provide the care that your spouse needs." [32%]

2 / Caregiver role strain is a caregiver's perception of multifactorial difficulties associated with providing care to another person. The nurse should routinely monitor for signs of caregiver role strain (eg, fatigue, depression, isolation) because it can have a significant negative impact on a caregiver's health and well-being

The pediatric nurse receives report on 4 clients. Which client should the nurse see first? 1. A 2-month-old awaiting evaluation for possible hip dislocation; parents are at the bedside [14%] 2. A 6-year-old just returned from a bronchoscopy; a parent is at the bedside [42%] 3. A 7-year-old just returned from a noncontrast abdominal CT scan; no parents are at the bedside [18%] 4. An 11-year-old scheduled for ear surgery today; no parents are at the bedside [24%]

2 / When deciding which client to see first, the nurse should apply the "ABC" (airway, breathing, circulation) guideline to problems that clients may have or could develop.

The nurse is reinforcing teaching for parents of a child diagnosed with fifth disease. Which statement by a parent indicates a need for further teaching? 1. "Our child should be feeling much better in 7-10 days." [19%] 2. "Our child's condition is communicable until the rash disappears." [34%] 3. "We will ensure our child covers the mouth and nose when coughing or sneezing." [11%] 4. "We will give our child ibuprofen to treat the joint pain." [35%]

2 / Children with fifth disease are communicable only prior to onset of symptoms (eg, rash, joint pains). The causative agent, human parvovirus, spreads via respiratory secretions. Fifth disease is self-limiting and short-lived; treatment is given to alleviate symptoms. Isolation is not usually required for a non-hospitalized child.

The practical nurse is collecting data on several clients in the antepartum unit. Which client should the practical nurse report to the registered nurse for further assessment? 1. 24 weeks gestation, 1-hour glucose screen is 120 mg/dL [7%] 2. 25 weeks gestation, hemoglobin is 9 g/dL [40%] 3. 30 weeks gestation, nonstress test is reactive [12%] 4. 36 weeks gestation, white blood cell count is 13,000/mm3 [39%]

2 / Clients are diagnosed with iron deficiency anemia when hemoglobin is <11 g/dL in the first and third trimesters and <10.5 g/dL in the second trimester.

The nurse is caring for a client newly admitted with an acute manic episode of bipolar disorder. The nurse identifies which dinner selection as the most appropriate to promote client nutrition? 1. Baked sweet potato, kale, yeast roll, water [27%] 2. Cheeseburger, apple, vanilla milkshake [36%] 3. Spaghetti with meatballs, fruit salad, milk [21%] 4. Vegetable soup, salad, dinner roll, iced tea [14%]

2 / Clients with acute mania often have elevated activity levels that increase their risk for malnutrition and dehydration. Nurses should provide easily carried and consumed foods high in energy and protein (eg, burgers, sandwiches, shakes) to promote adequate nutritional intake.

The nurse has just received report on 4 clients. Which reported information is the most concerning? 1. Client on a heparin drip with an activated partial thromboplastin time of 60 seconds [31%] 2. Client reporting back pain 1 hour following coronary angiography [34%] 3. Client with a head injury and a Glasgow Coma Scale score of 14 [20%] 4. Client with incisional pain rated 6/10 on day 2 post coronary artery bypass graft [13%]

2 / Clients with any indication of compromised airway, breathing, or circulation always take priority. The onset of back pain after angiography always requires further assessment to monitor for retroperitoneal bleeding

The nurse on the mental health unit received report on 4 clients. Which client should the nurse see first? 1. Client diagnosed with major depressive disorder who has consumed no food from the past 3 meal trays [27%] 2. Client diagnosed with post-traumatic stress disorder who reports an anxiety level of 8/10 and is pacing in the room [64%] 3. Client newly admitted with bipolar mania who reports sleeping only 4 hours last night [5%] 4. Client newly admitted with obsessive-compulsive disorder who has spent the last hour counting socks [1%]

2 / Clients with post-traumatic stress disorder have periods of extreme anxiety and emotional arousal during which they can be a danger to themselves or others.

The nurse on the mental health unit recognizes the use of which defense mechanism when a client leaves a stressful family meeting and immediately begins to verbally abuse a roommate? 1. Compensation [3%] 2. Displacement [46%] 3. Projection [33%] 4. Reaction formation [15%]

2 / Displacement is an ego defense mechanism that involves transferring uncomfortable feelings, emotions, or impulses about one person or situation to a substitute person or situation.

The clinic nurse supervises a graduate nurse who is reinforcing teaching about home management to the parents of a 2-year-old with acute diarrhea. The nurse would need to intervene when the graduate nurse reinforces which instruction? 1. "Do not give your child antidiarrheal medications." [30%] 2. "Follow the bananas, rice, applesauce, and toast diet for the next few days." [28%] 3. "Record the number of wet diapers and return to the clinic if you notice a decrease." [27%] 4. "Use a skin barrier cream such as zinc oxide in the diaper area until diarrhea subsides." [13%]

2 / During bouts of acute diarrhea and dehydration, treatment focuses on maintaining adequate fluid and electrolyte balance. The first-line treatment is oral rehydration therapy, which involves using oral rehydration solutions (ORS) to increase reabsorption of water and sodium. Even if the diarrhea is accompanied by vomiting, ORS should still be offered in small amounts at frequent intervals. Continuing the child's normal diet (solid foods) is encouraged as it shortens the duration and severity of diarrhea. The BRAT (bananas, rice, applesauce, and toast) diet is not recommended as it does not provide sufficient protein or energy.

The nurse is attending an end-of-year school family picnic. Which situation needs an immediate intervention? 1. A 2-year-old eating a hot dog unsupervised [49%] 2. A 3-year-old playing alone in a wading pool [48%] 3. A 4-year-old tossing a beach ball [0%] 4. A 5-year-old climbing on monkey bars [1%]

2 / Foreign body aspiration is a leading cause of accidental injury and death in small children due to tracheal anatomy and underdeveloped swallowing mechanisms. Food items that are particularly risky for a toddler include those that are round and slippery, sticky, or hard and rough

A nurse is assessing a 1-month-old infant with an atrial septal defect (ASD). Which assessment finding does the nurse expect? 1. Muffled heart tones [24%] 2. Murmur [49%] 3. Cyanosis [15%] 4. Weak femoral pulses [10%]

2 / In a child with atrial septal defect, the nurse would expect to hear a heart murmur on auscultation of heart sounds.

The practical nurse is collecting data on 4 infants in the pediatric unit. Which assessment finding would the practical nurse report to the registered nurse? 1. 3-week-old whose anterior fontanelle bulges slightly with crying [31%] 2. 4-week-old whose posterior fontanelle is flat and soft [12%] 3. 6-month-old with birth weight of 7 lb 3 oz (3.3 kg) who now weighs 12 lb (5.4 kg) [38%] 4. 12-month-old with birth weight of 6 lb 4 oz (2.8 kg) who now weighs 20 lb (9.1 kg) [17%]

2 / Infants should double in birth weight by age 6 months and triple in birth weight by age 12 months. An infant who does not meet expected length or weight milestones should be reported to the registered nurse for further assessment. Fontanelles should be flat, but slight pulsation or temporary bulging of the anterior fontanelle when the infant cries, coughs, or is lying down is considered normal.

The nurse is caring for a 7-year-old client diagnosed with nephrotic syndrome who will be discharged soon. Which statement by the parent indicates the need for further teaching? 1. "I'll provide a healthy diet without added salt for my child." [10%] 2. "I'll organize playdates to keep my child's spirits up during relapses." [31%] 3. "I'll restrict my child's fluids if I notice swelling or rapid weight gain." [40%] 4. "I'll test for protein in my child's urine every day." [18%]

2 / Nephrotic syndrome is characterized by massive proteinuria, edema, and hypoalbuminemia. Home management includes a low-sodium diet with attractive foods; infection prevention; fluid restriction for severe edema; and monitoring of weight gain and proteinuria to detect relapse.

The nurse is caring for a newborn with patent ductus arteriosus. Which assessment finding should the nurse expect? 1. Harsh systolic murmur [19%] 2. Loud machine-like murmur [39%] 3. Soft diastolic murmur [23%] 4. Systolic ejection murmur [17%]

2 / Patent ductus arteriosus (PDA) is an acyanotic congenital defect more common in premature infants. When fetal circulation changes to pulmonary circulation outside the womb, the ductus arteriosus should close spontaneously. This closure is caused by increased oxygenation after birth. If a PDA is present, blood will shunt from the aorta back to the pulmonary arteries via the opened ductus arteriosus. Many newborns are asymptomatic except for a loud, machine-like systolic and diastolic murmur. The PDA will be treated with surgical ligation or IV indomethacin to stimulate duct closure.

The nurse is caring for a postpartum client 36 hours after a cesarean birth who was just diagnosed with postpartum endometritis. Which prescription is priority for the nurse to administer? Click the exhibit button for additional information. 1. Acetaminophen PO PRN for fever [31%] 2. Clindamycin IV every 8 hours [40%] 3. Lactated Ringer IV bolus once [9%] 4. Methylergonovine PO every 4 hours [18%]

2 / Postpartum endometritis is an infection of the endometrium (uterine lining) and is characterized by fever, chills, tachycardia, uterine tenderness, and foul-smelling or purulent lochia. The nurse's priority intervention is initiation of broad-spectrum antibiotics to treat the infection and reduce the risk of complications (eg, abscess, peritonitis). Subsequent interventions include antipyretics, IV fluids, and (possibly) uterotonics for uterine subinvolution.

The practical nurse is monitoring a client 12 hours after the prolonged vaginal delivery of a term infant. Which finding should be reported to the registered nurse? 1. Discomfort during fundal palpation [8%] 2. Foul-smelling lochia [47%] 3. Oral temperature 100.1 F (37.8 C) [10%] 4. White blood cell count 24,000/mm3 (24.0 x 109/L) [33%]

2 / Signs of endometrial infection include elevated temperature, chills, malaise, excessive pain, and foul-smelling lochia. During the first 24 hours postpartum, temperature and white blood cell count are normally elevated. Fever and leukocyte counts that do not decrease require further evaluation

After talking to a client, the health care provider tells the nurse that the client's signature is needed on the consent form that has been completed. While the nurse is obtaining the signature, the client states, "I'm not clear on what is included in the low-fat diet that I'll be on after the cholecystectomy." What action should the nurse take? 1. Call the health care provider (HCP) to come and talk to the client [41%] 2. Provide educational materials about low-fat diet options [53%] 3. Refuse to witness the signature on the consent form [2%] 4. Tell the client that the HCP will explain the low-fat diet later [2%]

2 / The health care provider (HCP) performing the surgery should explain the risks, benefits, and alternatives of the specific procedure to the client. However, the nurse can witness the client's signing of the consent form; this differs from "obtaining consent." If the client has a question about the procedure or the risks, alternatives, or outcomes, the HCP should be contacted to provide additional teaching to the client. However, an ordinary question about general care or health care teaching can be answered by the nurse as this is part of the nurse's role. (Options 1, 3, and 4) Because the client is not asking about details related to the procedure, it is unnecessary for the HCP to return to talk to the client (unless the client specifically requests this). The client's question does not interfere with the ability to legitimately sign consent for the procedure or with the nurse's witnessing of the client signing the consent form. Educational objective: It is the responsibility of the health care provider (HCP) to obtain informed consent and explain a procedure's risks, benefits, and alternatives to the client. The nurse can witness the client's signature and provide normal teaching. If the client has a question about the proposed procedure/surgery, the HCP should return and provide additional teaching.

The home health aide reports to the practical nurse that the client has been trying to give away possessions. When the nurse asks the client about this behavior, the client says, "With my spouse dead, there's no reason for me to go on." What is the best priority response by the nurse? 1. "Do you have any friends in the building?" [0%] 2. "Have you thought of hurting yourself?" [47%] 3. "Tell me more about how you're feeling." [46%] 4. "You're not thinking of killing yourself, are you?" [5%]

2 / The priority nursing action for clients who express suicidal ideation (eg, thoughts about "not wanting to go on" or "wishing for death") or engage in potential suicidal indicators (eg, giving away possessions) is to determine suicidal intent. The nurse should ask clients direct questions about thoughts of hurting or killing themselves.

A nurse auscultates a loud cardiac murmur on a newborn with suspected trisomy 21 (Down syndrome). A genetic screen and an echocardiogram are scheduled that day. The neonate's vital signs are shown in the exhibit. What would be an appropriate action for the nurse to complete next? Click on the exhibit button for additional information. 1. Call the health care provider immediately [11%] 2. Document the finding [63%] 3. Place the neonate in a knee-chest position [14%] 4. Provide oxygen to the neonate [9%]

2 / Trisomy 21 (Down syndrome) is often associated with the cardiac anomaly AV canal defect. Findings typically include a loud murmur that requires no immediate action when vital signs are stable. After the neonate grows in size and can better tolerate the invasive procedure, surgery will correct the anomaly.

A nurse in a pediatric clinic is collecting data on a 30-month-old child. Which finding requires further evaluation? 1. Bladder and bowel control achieved [3%] 2. Current weight is 6 times greater than birth weight [39%] 3. Head circumference increased by 1 in (2.5 cm) in the past year [27%] 4. Resting heart rate is 120 beats per minute [29%]

2 / Weight gain slows during the toddler years with an average yearly weight gain of 4-6 lb (1.8-2.7 kg). By age 30 months, current weight should be approximately 4 times greater than birth weight. A toddler weighing 6 times the initial birth weight requires further evaluation. Family nutrition and meal habits should be discussed.

The registered nurse (RN) and licensed practical nurse (LPN) are caring for several clients. The RN delegates client positioning to the LPN. While evaluating the delegated task, the RN realizes that which client positions require intervention? Select all that apply. 1. High Fowler position in preparation for a paracentesis 2. Left side-lying position after percutaneous liver biopsy 3. Semi-Fowler after cardiac catheterization via femoral entry 4. Sims during soap-suds enema administration 5. Supine position after a lumbar puncture

2,3 / Clients undergoing paracentesis should be upright. After liver biopsy, clients should be in a right side-lying position to prevent hemorrhage. After femoral cardiac catheterization, clients should remain flat. After lumbar puncture, clients should be flat in bed to minimize risk of headache

The emergency department nurse cares for a client whose college roommate reports recent changes in the client's behavior. Which behaviors and clinical data meet the criteria for involuntary admission to the mental health unit? Select all that apply. 1. Client has been sleeping on the floor in the den rather than the bed 2. Client has refused food and water for 4 days and has poor skin turgor 3. Client repeatedly mumbles, "I must kill them before they get me" 4. Marijuana was found in the client's personal belongings 5. The health care provider makes a diagnosis of schizophrenia

2,3 / Clients with a mental illness have the right to refuse treatment, including inpatient hospitalization. Clients can be involuntarily admitted for psychiatric treatment if they pose an imminent danger to themselves or others or if they are gravely disabled and unable to meet their own basic needs.

The nurse on the mental health unit is collaborating with the registered nurse to develop the care plan for a newly admitted client with a diagnosis of schizophrenia with persecutory delusions. Which interventions should the nurse expect to include with regard to the delusional thinking? Select all that apply. 1. Explore the meaning behind the client's delusions 2. Focus on reality and verbally reinforce it 3. Focus on the client's feelings secondary to the delusions 4. Gently confront the client about the false beliefs 5. Present logical explanations to discredit the delusions

2,3 / When communicating with a delusional client, the nurse must focus on the client's feelings and reinforce reality rather than argue or present evidence that the delusion is false or irrational.

A practical nurse is collaborating with the registered nurse to form a care plan for a client diagnosed with placenta previa at 33 weeks gestation. What does the nurse anticipate being included in the plan of care? Select all that apply. 1. Activity as tolerated 2. Nonstress test 1 or 2 times a week 3. Prepare for cesarean birth at any time 4. Type and screen blood 5. Vaginal examinations twice weekly

2,3,4 / Clients with placenta previa are at risk for hemorrhage. Bed rest with bathroom privileges is recommended for clients at less than 36 weeks gestation. A nonstress test or biophysical profile should be performed once or twice a week to evaluate fetal well-being. Pelvic rest is instituted to prevent disruption of the cervix. A cesarean birth is planned prior to onset of labor.

The nurse is reinforcing education about home care to the parent of a 10-year-old with cystic fibrosis. Which of the following statements by the parent indicates that teaching has been effective? Select all that apply. 1. "Chest physiotherapy is administered only if respiratory symptoms worsen." 2. "I will give my child pancreatic enzymes with all meals and snacks." 3. "I will increase my child's salt intake during hot weather." 4. "Our child will need a high-carbohydrate, high-protein diet." 5. "We will limit our child's participation in sports activities."

2,3,4 / Cystic fibrosis causes increased viscosity of exocrine gland secretions. Clients require pancreatic enzyme supplements with all meals and snacks; a diet high in carbohydrates, protein, and fat; and increased salt intake during times of significant perspiration. Clients should also incorporate chest physiotherapy and exercise into their daily routine.

What socioeconomic indicators would the nurse identify as risk factors for a 2-month-old infant to develop failure to thrive (FTT)? Select all that apply. 1. Both caregivers work outside the home 2. Infant lives only with mother, who is currently unemployed 3. Infant's primary caregiver has cognitive disabilities 4. Parents are socially and emotionally isolated 5. Parents live together but are not married

2,3,4 / FTT, or growth failure, is a state of undernutrition and inadequate growth in infants and young children. Most cases of FTT are related to an inadequate intake of calories, which can be tied to many different etiologies. Physiologic risk factors for FTT include preterm birth, breastfeeding difficulties, gastroesophageal reflux, and cleft palate. Socioeconomic risk factors include: Poverty - most common Social or emotional isolation - parents may lack the support system needed to assist them with the problems of child rearing Cognitive disability or mental health disorder Lack of nutritional education - parents may not have knowledge of proper feeding techniques or appropriate calorie intake based on age and size of the child

The school nurse is discussing self-management of exercise-induced bronchoconstriction with a high school student who has asthma and just joined the football team. Which of the following actions are appropriate for the nurse to include during the discussion? Select all that apply. 1. Advise participation in a different, less strenuous sport 2. Ask the client to demonstrate use of the inhaler 3. Describe methods to warm inspired air during cold weather 4. Recommend using the inhaler 15-30 minutes before exercise 5. Reinforce that the inhaler is for personal use only

2,3,4,5 / Exercise-induced bronchoconstriction is characterized by swelling, spasms, and constriction of the airway during/after strenuous activity, primarily in clients diagnosed with asthma. This reaction is usually triggered by increased respiration of cool, dry air. The client should use the inhaler approximately 15-30 minutes before exercising to reduce bronchoconstriction during activity and warm inspired air by breathing through the nose or into a scarf or cupped hands (Options 3 and 4). The nurse should ensure proper use of the inhaler by having the client demonstrate inhaler administration; reinforcing personal use of the inhaler is also important due to the potential for abuse of inhaled bronchodilators to enhance performance, as seen in some athletes

A nurse is caring for a 3-month-old infant who has bacterial meningitis. Which clinical findings support this diagnosis? Select all that apply. 1. Depressed anterior fontanelle 2. Frequent seizures 3. High-pitched cry 4. Poor feeding 5. Presence of the Babinski sign 6. Vomiting

2,3,4,6 / Bacterial meningitis is an inflammation of the meninges in the brain and spinal cord that is caused by specific types of bacteria, including group B streptococcal, meningococcal, or pneumococcal pathogens. Clinical manifestations of bacterial meningitis in infants age <2 include: Fever or possible hypothermia Irritability, frequent seizures High-pitched cry Poor feeding and vomiting Nuchal rigidity Bulging fontanelle possible but not always present One of the most common acute complications of bacterial meningitis in children is hydrocephalus. Long-term complications include hearing loss, learning disabilities, and brain damage. Due to the severity of potential complications, prompt identification and immediate treatment are vital for any client with suspected bacterial meningitis

The school nurse creates a cafeteria menu for a newly enrolled child with celiac disease. Which lunches would be appropriate for this child? Select all that apply. 1. Beef barley soup with mixed vegetables and French bread 2. Grilled chicken, baked potato, and strawberry yogurt 3. Mexican corn tacos with ground beef and cheese 4. Peanut butter and jelly on rice cakes with an oatmeal cookie 5. Rice noodles with chicken and broccoli

2,3,5 / Celiac disease (celiac sprue) is an autoimmune disorder in which the body is unable to process gluten, a protein found in most grains. Gluten consumption will damage the villi of the small intestine; this results in malabsorption of fats (steatorrhea, foul-smelling stools) and other nutrients, which can lead to malnutrition and failure to thrive. The child will need to adhere to a gluten-free diet for life. Rice, corn, and potatoes are gluten free and are allowed in the diet (Options 2, 3, and 5). A child with celiac disease cannot eat barley, rye, oats, or wheat (mnemonic - BROW). (Option 1) A child with celiac disease cannot consume barley or French bread as both contain gluten. (Option 4) Peanut butter and jelly on rice cakes are permitted but not the oatmeal cookie.

The practical nurse is assisting the registered nurse during a physical assessment of a 10-year-old with abdominal discomfort. Which actions does the practical nurse anticipate during the assessment? Select all that apply. 1. Ask the accompanying parent to rate and describe the client's pain 2. Ask the client to describe the most concerning symptom 3. Conduct a head-to-toe examination in a manner similar to an adult examination 4. Explain the outcome of the examination to the parent without the client present 5. Honor the client's request to be examined without a parent present

2,3,5 / Factors to consider during the physical assessment of school-age children (age 6-12) include the following: Clients (even those as young as age 3) can tell and/or show the examiner where they hurt or how they feel in their own terms Clients are capable of understanding and assisting in their physical examination. In fact, school-age clients are usually quite interested in medical equipment and how it works. Clients develop modesty during this period and some do not want a parent, especially of the opposite sex, in the room with them during a physical examination. This request should be honored. A head-to-toe sequence is appropriate for this age group.

Which actions would the nurse expect to be included in the care plan for a client hospitalized for bipolar disorder, acute manic episode? Select all that apply. 1. Ask the client to plan an outing for the unit 2. Assign the client to a private room 3. Choose clothing for the client 4. Include the client in group therapy sessions 5. Schedule the client for physical activity with a staff member 6. Seat the client with other clients in the dining room for meals

2,3,5 / The nursing care plan for clients with acute mania should include providing a quiet, structured, non-stimulating environment; engaging the client in one-on-one and physical activities; limiting contact with other people; and providing foods of high nutritional value that are easy to eat.

The nurse reinforces teaching for the parents of a 6-year-old diagnosed with nocturnal enuresis. What instructions will the nurse include? Select all that apply. 1. "Allow your child to wear a diaper at bedtime for emotional security." 2. "Attach an enuresis alarm to your child's underwear." 3. "Prepare a calendar with your child for logging wet and dry nights." 4. "Restrict oral fluids to 8 ounces with each meal." 5. "Wake your child at a specified time each night to void."

2,3,5 Nocturnal enuresis, or involuntary bed-wetting at night, is managed with a variety of nonpharmacologic measures that nurses should teach parents. These include use of positive reinforcement and bed alarms, restricting fluids after the evening meal, avoiding scolding or ridiculing, awakening the child at a specified time to void, and keeping a log of wet and dry nights

The nurse is inspecting the legs of a client with a suspected lower-extremity deep venous thrombosis. Which of the following clinical manifestations should the nurse expect? Select all that apply. 1. Blue, cyanotic toes 2. Calf pain 3. Dry, shiny, hairless skin 4. Lower leg warmth and redness 5. Unilateral leg edema

2,4,5 / A deep venous thrombosis (DVT) is a blood clot formed in large veins, typically of the lower extremities, that occurs commonly from decreased activity or mobility. Clinical manifestations of a lower-extremity DVT include unilateral edema, calf pain or tenderness to touch, warmth, erythema, and low-grade fever.

The nurse is performing an assessment on a 39-week neonate an hour after a spontaneous vaginal delivery. What are common expected newborn findings? Select all that apply. 1. One artery and one vein in the umbilical cord 2. Plantar creases up the entire sole 3. Skin on the nose blanches to a yellowish hue 4. Toes fan outward when the lateral sole surface is stroked 5. White pearl-like cysts on gum margins

2,4,5 / Expected (normal) findings for a term newborn include plantar creases up the sole of the foot, presence of Babinski reflex, and Epstein's pearls

The nurse is returning the results of a urine pregnancy test to a client currently taking several medications. Which of the following prescriptions are contraindicated in pregnancy? Select all that apply. 1. Albuterol inhaler 2. Doxycycline 3. Insulin aspart 4. Isotretinoin 5. Levothyroxine 6. Lisinopril

2,4,6 / Commonly used medications that are absolutely contraindicated in pregnancy include doxycycline, isotretinoin, and ACE inhibitors

The nurse recognizes which factor as possibly contributing to a sentinel event? 1. Administered flumazenil to a client who overdosed on lorazepam [16%] 2. Administered insulin/dextrose to a client with potassium level of 7.2 mEq/L (7.2 mmol/L) [22%] 3. Administered warfarin to a client with International Normalized Ratio of 6 [34%] 4. Initiated nitroprusside infusion in a client with blood pressure of 210/112 mm Hg [26%]

3 / A sentinel event is any unanticipated event in a health care setting that results in death or serious physical/psychological injury. Warfarin is an anticoagulant often used in clients with the following: Atrial fibrillation (to prevent clot formation and reduce the risk for stroke) Deep venous thrombosis and pulmonary embolism (to prevent additional clots) Mechanical heart valves (to prevent clot formation on valves) The International Normalized Ratio (INR) is a blood test used to monitor the effectiveness of warfarin therapy. The typical target INR is 2-3. In some instances (eg, mechanical heart valves), the therapeutic INR target is as high as 3.5. The higher the INR, the higher the bleeding risk. The nurse should not administer warfarin if the INR is >4. (Option 1) Flumazenil is the appropriate antidote for a benzodiazepine (eg, lorazepam, alprazolam, diazepam) overdose. (Option 2) Insulin quickly lowers serum potassium by pushing it intracellularly. Dextrose is given to prevent hypoglycemia. This is an appropriate action. (Option 4) Nitroprusside is a potent vasodilator often used for hypertensive emergency or urgency. Educational objective: The target International Normalized Ratio (INR) for most conditions in which warfarin is used is normally 2-3 and occasionally is as high as 3.5. The risk of bleeding increases as the INR rises.

The nurse is caring for a 10-year-old diagnosed with osteomyelitis. What is the best activity the nurse can suggest to promote age-specific growth and development during hospitalization? 1. Fantasy play with puppets [8%] 2. Invite friends to come visit [38%] 3. Provide missed schoolwork [26%] 4. Watch favorite movies [27%]

3 / According to Erikson's stages of psychosocial development, school-age children deal with the conflict of industry versus inferiority. Attaining a sense of industry (competence) is the most significant developmental goal for children age 6-12. Parents should therefore be encouraged to provide a hospitalized child with missed school work on a regular basis. This will help the child keep up with school demands, learn new skills, cope with the stressors of hospitalization, and avoid a sense of inferiority. (Option 1) Fantasy play with puppets is more appropriate for a preschool-age child as imaginary play and magical thinking peak during this stage of development. (Option 2) Although school-age children enjoy spending time with friends, peer relationships are significantly more important during the adolescent period. (Option 4) Watching television is a good diversion for all hospitalized children, but it does not promote age-specific growth and development.

A 15-year-old client with type 1 diabetes mellitus is admitted to the hospital with a blood glucose of 460 mg/dL (25.6 mmol/L). Based on this information, the nurse understands that which factor is contributing to this client's noncompliant behavior? 1. Client has limited understanding of the disease process [43%] 2. Client is depressed and wants to die [5%] 3. Client's psychosocial developmental stage [36%] 4. Lack of supervision by the client's caregivers [13%]

3 / Adolescence in psychosocial development is marked by risk-taking behaviors, a sense of invincibility, the need for independence, and a strong connection to peers.

The nurse is caring for a 4-year-old who was hospitalized with influenza. Which nursing action would be most effective to maintain psychosocial integrity? 1. Encouraging use of puzzles for play [16%] 2. Offering the child stacking blocks for diversion [20%] 3. Providing crayons to draw noses on facemasks [47%] 4. Suggesting that playmates visit the child [14%]

3 / Clients with influenza are maintained on droplet precautions, and anyone entering the room must wear a facemask. Medical play during the preschool period (age 3-6 years) facilitates psychosocial integrity. Crayons are age-appropriate toys. Drawing noses on facemasks will help the child feel more comfortable with procedures and provides a developmentally appropriate diversion. (Option 1) Puzzles would be more appropriate for the school-age child (6-12 years). (Option 2) Stacking blocks would be more appropriate for the toddler (age 1-3 years). (Option 4) Maintaining contact with peers would be more appropriate for the adolescent (age 12-19 years).

The nurse on the mental health unit receives report about a client diagnosed with schizophrenia who is experiencing a delusion of reference. Which client statement supports this symptom? 1. "I need for you to get rid of these bugs that are crawling under my skin." [17%] 2. "Hear that? She told me to kill my father." [26%] 3. "That song is a message sent to me in secret code." [38%] 4. "Those Martians are trying to poison me with the tap water." [16%]

3 / Delusions are a positive symptom of schizophrenia. Delusions of reference cause clients to feel as if songs, newspaper articles, and other events are personal to them.

The nurse is caring for a child with Kawasaki disease who is receiving IV immunoglobulin. The nurse knows that this therapy is given to: 1. Fight the infection [50%] 2. Minimize rash [9%] 3. Prevent heart disease [27%] 4. Reduce spleen size [12%]

3 / IVIG along with aspirin is the recommended initial treatment for Kawasaki disease, with the primary goal of coronary disease prevention.

The nurse is reinforcing teaching about breastfeeding to a postpartum client. Which statement by the client indicates a correct understanding of teaching? 1. "I will feed my baby for 5-10 minutes on each breast." [20%] 2. "I will hold my baby on their back with the head turned toward my breast." [14%] 3. "If I need to reposition my baby's latch, I will use my finger to break the suction first." [57%] 4. "The baby's mouth should grasp only the nipple, not the areola." [7%]

3 / If the newborn latches incorrectly or needs to be removed from the breast, the client should insert a finger to break suction before unlatching. When removed from the breast incorrectly, nipple trauma may occur, leading to sore nipples and painful breastfeeding.

3 / Infants should double in birth weight by age 6 months and triple in birth weight by age 12 months. An infant who does not meet expected length or weight milestones should be reported to the registered nurse for further assessment. Fontanelles should be flat, but slight pulsation or temporary bulging of the anterior fontanelle when the infant cries, coughs, or is lying down is considered normal.

A 12-month-old is found to have a moderately elevated blood lead level. Which of the following is the most serious concern for this child? 1. Gastrointestinal bleeding [18%] 2. Growth retardation [10%] 3. Neurocognitive impairment [47%] 4. Severe liver injury [23%]

3 / Lead poisoning can lead to many severe complications of the neurological system (eg, developmental delays, cognitive impairment, seizures). Elevated blood lead levels are particularly dangerous in young children due to immature development of the brain and nervous system.

The nurse is floated from the obstetrical (OB) floor to the medical/surgical floor. Which client is the best assignment for the OB nurse? 1. Female client with a fractured pelvis who is 4 months pregnant [76%] 2. Female client with cytomegalovirus pneumonia [6%] 3. Male client with an open bowel resection with a Foley catheter [13%] 4. Male client with history of Billroth II surgery who is septic [2%]

3 / Nurses who are floated for a shift to areas different than their usual client population should be assigned clients who can be managed using skills similar to those used for their usual client population and not requiring specialized knowledge. An abdominal bowel surgery with a Foley catheter is similar to the type of care required with a cesarean section; therefore, this client should be assigned to the obstetrical (OB) nurse. (Option 1) An OB nurse would have limited experience in dealing with an early pregnancy and no experience with major orthopedic problems. (Option 2) Cytomegalovirus (CMV) is generally passed from infected individuals to others through direct contact with bodily fluids, such as urine, saliva, or breast milk. CMV infection can be transmitted from this client to the OB nurse and then to pregnant clients on return to the OB unit; this can result in serious fetal infection. (Option 4) An OB nurse would have limited experience in dealing with infectious clients because they are transferred out of the OB unit. Educational objective: Floating nurses should be assigned clients who require care that can be given using skills and knowledge similar to those used for their usual client population. Obstetrical nurses should not be assigned infectious clients.

The nurse on a pediatric unit is caring for a school-age child with suspected Reye syndrome. Which subjective client data is most consistent with this condition? 1. No history of varicella vaccine administration [13%] 2. Recent exposure to bats [8%] 3. Recent influenza infection [29%] 4. Recent use of acetaminophen for fever [48%]

3 / Reye syndrome in children is characterized by fever, acute encephalopathy, and altered hepatic function. It often develops following a viral infection, especially varicella or influenza. The risk of developing Reye syndrome increases if aspirin is used to treat varicella- or influenza-associated fever; acetaminophen or ibuprofen should be given instead.

The nurse is observing a student nurse care for a mother who has been unsuccessful with breastfeeding her newborn infant. Which action by the student would require the nurse to intervene? 1. Assesses the baby's position and sucking behavior during breastfeeding [14%] 2. Demonstrates to the mother how to use an electric breast pump [11%] 3. Provides supplemental formula feedings until improved breastfeeding occurs [54%] 4. Shows the mother how to hand express breast milk [19%]

3 / Supplemental formula feedings and the use of artificial nipples are avoided when ineffective breastfeeding is present, as they interfere with the mother's ability to breastfeed exclusively. Supplemental formula feeds are only used after a full assessment and if other techniques are unsuccessful.

The nurse is reinforcing teaching about infant safety to a class of expectant parents. Which statement by a participant indicates a need for further instruction? 1. "I will make sure there is a firm mattress in the crib." [3%] 2. "I will put my baby to bed with a pacifier." [19%] 3. "I will tie bumper pads to the sides of the crib to protect my baby's head." [33%] 4. "I will use a sleeping sack or a thin blanket that I tuck to cover my baby." [44%]

3 / The risk of sudden infant death syndrome can be reduced by following safe sleep practices and prevention guidelines. Infants should always be placed on their backs on a firm surface without loose bedding or toys. Preventive measures include maintaining a smoke-free environment, avoiding overheating, promoting breastfeeding, and having the infant use a pacifier.

The practical nurse collaborates with the registered nurse to develop a care plan for a client diagnosed with anorexia nervosa who is being admitted after failure of outpatient treatment. Which client outcome is the priority? 1. Acknowledges poor interpersonal skills [4%] 2. Identifies new coping mechanisms [24%] 3. Increases caloric intake to gain weight [60%] 4. Verbalizes sources of conflict and anger [10%]

3 / Treatment for a client requiring hospitalization for anorexia nervosa should focus on the short-term outcomes of increasing caloric intake, slow weight gain, and addressing medical conditions caused by starvation.

A 15-year-old parent brings a 4-month-old infant for a well-baby checkup. The parent tells the nurse that the baby cries all the time; the parent has tried everything to keep the infant quiet but nothing works. What is the priority nursing action? 1. Advise the parent to give a pacifier whenever the infant cries [1%] 2. Ask the parent to describe what is done to "keep the baby quiet" [40%] 3. Assess the infant's pattern and frequency of crying [45%] 4. Explore the parent's support system [12%]

3 / When a parent tells the nurse that an infant cries "all the time," the priority nursing action is to assess the pattern, quality, and frequency of the child's crying. This will help the nurse determine if the crying is normal infant behavior or a sign of a more serious condition that requires further evaluation and treatment

Which of the following are examples of medical battery? Select all that apply. 1. A child is placed in a papoose restraint for suturing of a facial laceration with the parent present 2. Application of soft wrist restraints to the arms of a confused, adult client with a nasogastric tube 3. The nurse administers 2 mg of morphine PRN to a difficult, alert client but tells the client it is saline 4. The nurse inserts a needed urinary catheter even though a competent client refuses it 5. The nurse threatens to put a client in restraints if the client does not stay in bed

3,4 / Battery is touching that is legally defined as unacceptable or occurs without consent. Examples include performing a procedure despite a competent client's refusal or without obtaining proper consent from a competent client (or parent/legal guardian when the client is a child). Assault is the threat of battery.

The practical nurse (PN) is assisting the registered nurse (RN) to care for a client receiving oxytocin for induction of labor. Which of the following actions by the PN are appropriate during oxytocin infusion? Select all that apply. 1. Assess deep tendon reflexes every hour 2. Assist RN to initiate intermittent fetal monitoring 3. Evaluate fluid intake and output every 4 hours 4. Notify RN if >5 contractions occur in 10 minutes 5. Obtain blood pressure with each oxytocin dose change

3,4,5 /

The nurse is reinforcing prior teaching for the parents of a child newly diagnosed with hemophilia A. Which statements by the parents indicate that teaching has been effective? Select all that apply. 1. "A high-calorie, high-protein diet is best for our child." 2. "It is extremely important that we do not allow our child to become dehydrated." 3. "Our child should wear a medical alert bracelet at all times." 4. "We should avoid giving our child over-the-counter medicine containing aspirin." 5. "We should encourage a noncontact sport such as swimming."

3,4,5 / Hemophilia is a hereditary bleeding disorder caused by a deficiency in coagulation proteins. Treatment consists of replacing the missing clotting factor and teaching the client about injury prevention, including: Avoid medications such as ibuprofen and aspirin that have platelet inhibition properties (Option 4). Avoid intramuscular injections; subcutaneous injections are preferred. Avoid contact sports and safety hazards; noncontact activities (eg, swimming, jogging, tennis) and use of protective equipment (eg, helmets, padding) are encouraged (Option 5). Dental hygiene is necessary to prevent gum bleeding, and soft toothbrushes should be used. MedicAlert bracelets should be worn at all times

When monitoring an infant with a left-to-right-sided heart shunt, which findings would the nurse expect during the physical assessment? Select all that apply. 1. Clubbing of fingertips 2. Cyanosis when crying 3. Diaphoresis during feedings 4. Heart murmur 5. Poor weight gain

3,4,5 / Left-to-right cardiac shunts (eg, patent ductus arteriosus, atrial septal defect, ventricular septal defect) result in excess blood flow to the lungs. Manifestations include heart murmur, poor weight gain, diaphoresis with exertion, and signs of heart failure.

Which tasks are appropriate for the nurse in a long-term care unit to delegate to unlicensed assistive personnel? Select all that apply. 1. Assign lunch times to other unlicensed assistive personnel on the unit 2. Assist a client with bathing and changing an ostomy appliance 3. Collect vital signs on a client newly arrived on the unit 4. Pick up a prescribed oral antibiotic from the pharmacy 5. Record intake and output for a client with chronic neurogenic bladder

3,4,5 / Unlicensed assistive personnel (UAP) can be delegated tasks that are not specific to the nursing process. Any task that involves assessment, coordination of care planning, or evaluation requires the attention of the nurse. The UAP may gather information (eg, vital signs, intake and output) about stable clients, assist stable clients with activities of daily living, and retrieve necessary supplies, but the nurse retains accountability for all of the delegated actions and outcomes (Options 3, 4, and 5). The nurse is also responsible for determining the competency level of the UAP prior to delegating tasks. (Option 1) Making staff lunch assignments is part of the management of the unit; therefore, the nurse cannot delegate this task. The nurse must ensure that there is adequate staff coverage to meet client needs during the assigned lunch times. (Option 2) UAP can give bed baths to stable, appropriate clients. However, it is necessary for the nurse to collect data about the stoma of a client with an ostomy; therefore, this task cannot be delegated to UAP. Educational objective: Client care that is specific to the nursing process (assessment, monitoring, assisting in planning, evaluation) cannot be delegated to unlicensed assistive personnel (UAP). UAP can assist with basic care activities, check routine vital signs, document intake and output, and assist with activities of daily living, hygiene, and positioning for stable clients. The nurse is ultimately accountable for the care provided by UAP.

The licensed practical nurse is working with a registered nurse to care for a client who has just returned to the cardiac unit after having a percutaneous coronary intervention. Which actions assigned by the registered nurse should the practical nurse question as outside of the practical nurse's scope of practice? Select all that apply. 1. Administering oral pain medication if client reports low back pain 2. Checking for bleeding at the catheter insertion site every 15 minutes 3. Performing post-procedure vital sign measurements 4. Reinforcing instructions to keep the involved extremity straight 5. Reviewing ECG for dysrhythmias

3,5 / After performing the initial assessment of the client post-procedure and comparing it to the pre-procedure baseline, the RN may assign the following tasks to the LPN: Administer medications (Option 1) Monitor neurovascular status of involved extremity Check for bleeding at catheter site every 15 minutes for the first hour, then according to institution policy (Option 2) Report any changes in neurovascular status or bleeding to the RN Reinforce important teaching (eg, keep affected extremity straight, maintain bedrest)

The nurse reinforces teaching to a client who was newly prescribed levothyroxine sodium after thyroid removal. Which instructions will the nurse include? Select all that apply. 1. Drowsiness is a common side effect; taking the dose at bedtime will make this less noticeable 2. Notify the health care provider if you become pregnant as the medication is harmful to the fetus 3. Notify the health care provider if you feel a fluttering or rapid heartbeat 4. Take the medication with a meal to prevent stomach upset 5. You will need to take this medication for the rest of your life

3,5 / Clients receiving thyroid hormone replacement therapy (levothyroxine sodium) should understand that treatment is lifelong and be taught the signs of excess hormone (eg, tachycardia/palpitations, weight loss, insomnia). The medication is best absorbed on an empty stomach and is safe to take during pregnancy.

The nurse is reinforcing teaching to the parents of a 6-month-old child who has been given a new prescription for a liquid iron supplement. Which statements by the parents indicate a need for further teaching? Select all that apply. 1. "Our child might become constipated while taking this medication." 2. "Our child's stools might become black and tarry." 3. "We can give the dose with milk to prevent gastric irritation." 4. "We will administer the dose into the back of our child's cheek." 5. "We will administer the dose with meals to increase absorption."

3,5 / Liquid iron supplements are best absorbed on an empty stomach. Consuming vitamin C with iron supplements increases iron absorption. Milk products and antacids should be avoided for 2 hours following oral iron administration. Iron may be given with meals to reduce gastric irritation; however, this will decrease absorption.

Phenytoin (Dilantin)

Anticonvulsant 10-20

Avoiding dehydration is important for those with

sickle cell anemia

A 4-year-old admitted with Wilms tumor is scheduled for a right nephrectomy in the morning. Which nursing action is a priority pre-operatively? 1. Assessment of the child's emotional maturity level [7%] 2. Auscultating for adventitious breath sounds [13%] 3. Monitoring blood pressure closely [22%] 4. Reinforcing instructions not to palpate the abdomen [56%]

4 / Wilms tumor is discovered when caregivers note an unusual bulging/swelling on one side of a child's abdomen. The abdomen should not be palpated once diagnosis is suspected or confirmed as this can disrupt the tumor and cause dissemination of tumor cells.

A school-age child is brought to the emergency department due to nausea, vomiting, and severe right lower quadrant pain. The child's white blood cell count is 17,000/mm3 (17.0 x 109/L). Which statement by the child is of most concern to the nurse? 1. "I am hungry and they will not let me eat." [12%] 2. "I don't like hospitals and I want to go home." [2%] 3. "I'm so tired." [29%] 4. "My belly doesn't hurt anymore." [54%]

4 / A child with acute-onset right lower quadrant abdominal pain, nausea, and vomiting and a high white blood cell count likely has acute appendicitis. Appendicitis is a serious condition that usually requires emergency surgery due to the risk of appendix rupture. The pain results from swelling and inflammation of the appendix. However, once the appendix ruptures, pain is relieved only temporarily and will return with full-blown peritonitis and sepsis.

A pregnant client comes to the labor and delivery unit stating the water just broke at home. On assessment of the client's perineal area, the nurse visualizes a loop of umbilical cord protruding from the vagina. Which nursing intervention would be appropriate? 1. Apply suprapubic pressure [16%] 2. Perform Leopold maneuvers [23%] 3. Perform the McRoberts maneuver [11%] 4. Position the client on hands and knees [48%]

4 / A client with a prolapsed umbilical cord should be placed on hands and knees (eg, knee-chest position) or Trendelenburg position to relieve pressure on the cord until emergency delivery.

A nurse is caring for a client at 12 weeks gestation who is admitted for hyperemesis gravidarum. Which clinical manifestation should the nurse expect? 1. Abdominal pain and low-grade fever [37%] 2. Blood pressure ≥140/90 mm Hg [20%] 3. High urine protein level [16%] 4. Moderate to high urine ketones [23%]

4 / Hyperemesis gravidarum (ie, excessive vomiting during pregnancy) leads to fluid and electrolyte imbalances (eg, hypokalemia, hypotension), weight loss of ≥5% of prepregnancy weight, nutritional deficiencies, and ketonuria. Urine ketones are expected because they are a by-product of fat breakdown, which occurs in starvation states.

The practical nurse is collecting data on several clients waiting to be seen in the prenatal clinic. Which client situation is most important to report to the registered nurse? 1. 18 weeks gestation client taking ceftriaxone and reporting mild diarrhea [14%] 2. 22 weeks gestation client with twins who is taking acetaminophen twice a day [24%] 3. 28 weeks gestation client taking metronidazole who has dark-colored urine [27%] 4. 32 weeks gestation client taking ibuprofen for moderate back pain [33%]

4 / Nonsteroidal anti-inflammatory drugs must be avoided starting at 30 weeks gestation due to the risk of causing premature closure of the ductus arteriosus in the fetus and prolonged labor in the client. Prior to 30 weeks gestation, they may be taken only under the close supervision of a health care provider.

The nurse is assigning client care tasks to unlicensed assistive personnel. Which statement by the nurse is appropriate? 1. "I need you to take vital signs on all clients in rooms 1 through 10 this morning." [26%] 2. "Mrs. Jones fell out of bed during the night while walking to the commode. Please monitor her closely." [14%] 3. "Please ensure that Mr. Garcia in room 8 ambulates several times." [15%] 4. "Please take Mr. Wu's vital signs in 10 minutes and let me know if his systolic blood pressure is <100." [44%]

4 / Nurses assigning client care to unlicensed assistive personnel must consider the five rights of delegation. Right direction/communication involves providing clear instructions about the assigned tasks, specific information needed for task completion, the time frame, and when to report back to the nurse.

4 / Right upper quadrant (RUQ) or epigastric pain can be an indicator of HELLP syndrome, a severe form of preeclampsia. HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count) is often mistaken for viral gastroenteritis due to its variable and nonspecific presentation. Misdiagnosis may lead to severe complications (eg, placental abruption, liver failure, stroke) and maternal/fetal death. Clients may have RUQ pain, nausea, vomiting, and malaise. Headache, visual changes, proteinuria, and hypertension may or may not be present.

A nurse is measuring the uterine fundal height of a client who is at 36 weeks gestation in supine position. The client suddenly reports dizziness and the nurse observes pallor and damp, cool skin. What should the nurse do first? 1. Auscultate for heart and lung sounds [4%] 2. Determine fetal heart rate and pattern [12%] 3. Notify the supervising registered nurse [4%] 4. Reposition client into a lateral position [78%]

4 / Supine hypotensive syndrome is usually seen in the third trimester of pregnancy when the weight of the uterine contents compresses the inferior vena cava. Resultant maternal hypotension is best treated initially by immediately turning the client to the right or left side to relieve pressure on the vena cava.

The nurse is caring for a 10-year-old diagnosed with attention-deficit hyperactivity disorder (ADHD). In addition to the 3 core symptoms of ADHD (hyperactivity, impulsiveness, and inattention), which of the following would the nurse expect to find? 1. Confusion and a learning disability [29%] 2. Delayed physical and emotional development [11%] 3. Disorientation and cognitive impairment [21%] 4. Low self-esteem and impaired social skills [37%]

4 / The diagnosis of attention-deficit hyperactivity disorder includes the presence of hyperactivity, impulsiveness, and inattention. The negative consequences of the core manifestations include impaired social skills, poor self-esteem, academic or work failure, increased risk for depression and anxiety, and increased risk for substance abuse.

A 9-year-old with type 1 diabetes takes insulin glargine and NPH regularly. While at school, the client becomes shaky, diaphoretic, and pale. What is the most appropriate action by the nurse? 1. Administer scheduled dose of NPH insulin [9%] 2. Give emergency glucagon IM injection [12%] 3. Give peanut butter and crackers [33%] 4. Provide 4 oz (120 mL) of a regular soft drink [44%]

4 / The nurse should hold the client's scheduled NPH insulin until the client's BG is normal and symptoms resolve. (Option 2) An emergency glucagon IM injection is indicated if the client is somnolent, unconscious, seizing, or unable to swallow. (Option 3) After the client's BG improves, the client should eat a meal. However, if the next meal is more than an hour away, the nurse should give the client a serving of carbohydrate (eg, crackers) plus protein or fat (eg, peanut butter, cheese) to maintain glucose levels. Educational objective: Clients with diabetes mellitus should be monitored for signs of hypoglycemia (eg, shakiness, sweating, pallor, alterations in mental status). Conscious clients experiencing hypoglycemia should receive a snack of 15 g of a quick-acting carbohydrate.

The nurse assists with a community teaching program for parents and caregivers of infants. Which statement by a participant indicates that teaching has been successful? 1. "After age 6 months, it is safe to use honey to sweeten my infant's formula." [3%] 2. "I should wait until my infant is 1 year old to introduce egg products." [25%] 3. "I will switch my 1-year-old to low-fat milk instead of commercial formula." [17%] 4. "My infant should be able to pick up small finger foods by age 10 months." [54%]

4 / The pincer grasp, a thumb to forefinger movement, develops at age 8-10 months. This is the time to start offering small finger foods, such as crackers or cut-up pieces of nutritious foods. Caregivers should inform their health care provider if the infant does not achieve this significant milestone in fine motor development (Option 4). (Option 1) Formula should never be sweetened. Honey (especially raw or wild) should not be offered to children age <12 months because their immature gut systems are susceptible to Clostridium botulinum (botulism) infection. (Option 2) Common allergenic foods (eg, eggs, fish, peanut products) may be introduced along with other foods starting at age 4-6 months. Previous guidelines recommended delaying introduction of these foods until age 12 months. However, recent evidence suggests that delaying introduction of these foods may actually increase the risk for food allergy. (Option 3) Infants should be transitioned to whole milk, not low-fat milk, at age 12 months. Due to rapid growth, a child's brain requires the nutrition from the fat found in whole milk.

A client who was suddenly overwhelmed with an intense fear that something terrible was going to happen is brought to the emergency department by the spouse after they were out at dinner. The client is now shaking, hyperventilating, and having heart palpitations. What is the priority nursing action? 1. Encourage the client to perform deep breathing exercises [57%] 2. Explore possible reasons for the episode [5%] 3. Place the client in a private room and tell the client to relax [4%] 4. Remain in the room with the client [32%]

4 / The priority nursing action for the client experiencing symptoms of a panic attack is for the nurse to stay with the client in a calm environment, ensure the client's safety, and offer support.

The nurse in the pediatric clinic is planning to reinforce postoperative teaching to parents. The nurse should talk with the parent of which child first? 1. 2-year-old with bilateral tympanostomy tubes who has a small piece of plastic in the right outer ear [16%] 2. 4-year-old post adenotonsillectomy who is now reporting ear pain [51%] 3. 6-year-old with strep throat who needs a note to return to school 24 hours after starting antibiotics [6%] 4. 7-year-old 5 days post tonsillectomy who wants to return to soccer practice tomorrow [26%]

4 / The risk of post-tonsillectomy hemorrhage persists for up to 14 days after surgery, and resuming strenuous activity too early increases this risk. The potential for bleeding is higher 7-10 days postoperatively while sloughing occurs.

The nurse receives report on 4 clients. Which client should be seen first? 1. 10-month-old with audible congestion and mucus-producing cough [35%] 2. 10-year-old with an active nose bleed who is applying pressure [11%] 3. 12-year-old with urinary frequency and burning, and fever [10%] 4. 15-year-old with painful right hip, fever, and limited range of motion [41%]

4 / This client is exhibiting localized (eg, pain, limited range of motion) and systemic infection symptoms (eg, fever), which may indicate septic arthritis. Possible causes include recent surgery, injections, trauma, or spread from adjacent infection (eg, cellulitis). A septic hip is considered a surgical emergency. The hip joint is prone to develop avascular necrosis (eg, damage to the femoral head) from compromised blood supply due to infection or injury (eg, fracture). This can result in sequelae that are significant in both the short term (eg, sepsis, death) and long term (eg, joint destruction). Management includes culturing synovial fluid and blood, giving antibiotics, and debriding the infected joint.

Hypoglycemia treatment in a conscious client is administration of 15 g of a quick-acting carbohydrate. After treatment, the nurse should recheck BG every 15 minutes, repeating treatment if it remains low. Quick-acting carbohydrate options include:

4 oz (120 mL) of a regular soft drink or fruit juice (Option 4) 8 oz (240 mL) of low-fat milk 1 tablespoon (15 mL) of honey or syrup 6 hard candies Commercial dextrose products

A recently widowed client becomes tearful at a routine clinic visit and states, "I just can't get over my spouse's death." Which of the following responses by the nurse are appropriate? Select all that apply. 1. "A friend of mine passed away recently. I know how hard losses can be." 2. "I see that you're upset. I will step out while you process these feelings." 3. "It may take a while, but coming to terms with loss gets easier with time." 4. "This is a difficult time. Tell me about how you have been coping." 5. "What are your thoughts about attending a grief support group?"

4,5 / Nurses should use therapeutic communication techniques (eg, reflecting, asking open-ended questions, suggesting strategies or resources) to support clients' psychosocial needs and build the nurse-client relationship. Minimization, automatic responses, and leaving clients who are sharing strong emotions are nontherapeutic actions.

4,5 / The registered nurse (RN), not the licensed practical nurse (LPN), should perform initial assessments (including vital signs), review the ECG for any dysrhythmias, monitor the client for chest pain, and monitor any infusions of anticoagulants or antiplatelet drugs (Options 3 and 5). If the client is stable after the initial assessment, the RN may delegate routine vital sign measurements.

Major signs and symptoms of endometrial infection include temperature >100.4 F (38.0 C), chills, malaise, excessive uterine tenderness, and purulent, foul-smelling lochia. During the first 24 hours postpartum, temperature is normally elevated, but a reading of

>100.4 F (38 C) requires further evaluation.

functional disorder

A disorder in which there is no known physiologic reason for the abnormal functioning of an organ or organ system.

lactulose (Cephulac)

Category: Laxative, ammonia detoxicant, Use: Chronic constipation, portal-system encephalopathy, Precautions: nausea, vomiting, and cramps, Can give enema

Retracted tympanic membranes occur when there is negative pressure in the middle ear, which can occur with a blocked

Eustachian tube or as a complication of chronic infections

A primigravid client in early labor is admitted and reports intense back pain with contractions. The fetal position is determined to be right occiput posterior. Which action by the nurse would be most helpful for alleviating the client's back pain during early labor? 1. Applying counterpressure to the client's sacrum during contractions 2. Encouraging the client to remain in bed during early labor 3. Positioning the client on the left side with pillows for support 4. Requesting that the nurse anesthetist administer epidural anesthesia

Fetal occiput posterior (OP) position is a common fetal malposition that occurs when the fetal occiput rotates and faces the mother's posterior or sacrum. OP fetal position can cause increased back pain or "back labor." Many fetuses in OP position during early labor spontaneously rotate to occiput anterior position (occiput facing the mother's anterior or pubis).

The proper method of delivering a dose via metered-dose inhaler (MDI) includes the following:

First shake the MDI and attach it to the spacer. Exhale completely to optimize medication inhalation. Place lips tightly around the mouthpiece. Deliver a single puff of medication into spacer. Take a slow deep breath and hold it for 10 seconds to allow for effective medication distribution. Rinse mouth with water to remove any leftover medication from oral mucous membranes. Spit out the water to ensure no medication is swallowed.

pyloric stenosis

Infants with infantile hypertrophic pyloric stenosis often present with excessive hunger (frequent feeder), a palpable olive-shaped mass in the epigastrium to the right of the umbilicus, and projectile vomiting (can be up to 3 feet). (Option 3) Projectile vomiting (without blood) is seen with pyloric stenosis and elevated intracranial pressure. Bloody vomiting is seen with gastric ulcers and variceal bleed. Intussusception causes non-projectile vomiting that is usually non-bloody, but stools mixed with mucus and blood are seen

A systolic ejection murmur is heard in

pulmonic stenosis

lactose intolerance

The inability to completely digest the milk sugar lactose

most accurate indicator of fluid loss or gain and should therefore be included in the plan? 1. Blood pressure measurements [3%] 2. Daily weight measurements [74%] 3. Severity of pitting edema [2%] 4. Strict intake and output measurements [19%]

The most accurate indicator of fluid loss or gain in an acutely ill client is daily weight measurement

The nurse is caring for an 11-year-old admitted for surgical treatment of a fractured femur who also has attention-deficit hyperactivity disorder, predominantly inattentive type. What is the priority nursing action? 1. Encourage the child to keep up with school work [17%] 2. Give the child a written schedule of daily activities [36%] 3. Limit the number of visitors [7%] 4. Reinforce verbal explanations of what to expect during hospitalization [39%]

The most important nursing intervention in caring for a child with attention-deficit hyperactivity disorder is providing a structured, consistent, and organized environment. A written schedule of activities will remind the child what to expect at any given time.

The nurse reviews new laboratory results for assigned clients. Which finding is the highest priority for the nurse to report to the supervising registered nurse? 1. CD4+ cell count of 500/mm3 in a client with HIV and oral candidiasis who is receiving PO fluconazole [16%] 2. Hemoglobin A1c of 7.3% in a client with type 2 diabetes and pneumonia who is receiving IV levofloxacin [23%] 3. Platelet count of 152,000/mm3 in a client with a venous thrombosis who is receiving a continuous heparin infusion [15%] 4. Serum glucose of 65 mg/dL in a client with radiation enteritis who is receiving total parenteral nutrition [44%]

The target serum glucose level for clients receiving nutritional support (eg, total parenteral nutrition [TPN]) is 140-180 mg/dL. Hypoglycemia (serum glucose <70 mg/dL) may occur with an interruption or slowed rate of tube feedings or TPN infusion, insufficient dextrose in TPN formula, or excessive insulin administration. Although hyperglycemia (serum glucose of >180 mg/dL) is a more common adverse effect of nutritional support, hypoglycemia can occur and cause life-threatening complications (eg, seizures, nervous system dysfunction). If serum glucose is <70 mg/dL, the nurse should contact the registered nurse or health care provider and promptly administer supplemental glucose (eg, by mouth, IV dextrose) or IM glucagon per facility protocol (Option 4). (Option 1) A CD4+ cell count of 500/mm3 is within normal limits (500-1,200/mm3). (Option 2) A hemoglobin A1c of 7.3% in a client with type 2 diabetes is not exceptionally high; the recommended goal is <7%. Infection causes physiologic stress and increased serum glucose, but it would not affect the hemoglobin A1c level, which reflects glucose control over 2-3 months. (Option 3) A platelet count of 152,000/mm3 is within normal limits (150,000-400,000/mm3). The nurse should report a dramatic decrease (≥50%) or platelet level <150,000/mm3, which may indicate heparin-induced thrombocytopenia, a serious condition that causes paradoxical arterial or venous thrombosis. Educational objective: Hypoglycemia (serum glucose <70 mg/dL) can result in life-threatening complications (eg, seizures, nervous system dysfunction). It should be treated with supplemental glucose, and the health care provider should be notified.

The nurse is evaluating a client's understanding of postcircumcision care for a 24-hour-old newborn. Circumcision was performed using the clamp method. Which statement by the client demonstrates a need for further teaching? 1. "Bleeding should be no larger than the size of a quarter." [8%] 2. "I should cleanse the glans with warm water occasionally." [20%] 3. "I should expect at least 2 wet diapers in the next 24 hours." [35%] 4. "Yellow exudate on the glans penis indicates infection." [34%]

Yellow exudate on the glans penis indicates normal healing. Unusual swelling, increasing redness, odor, abnormal discharge, excessive bleeding, or absent/decreased urine output should be reported.

health care proxy

a durable power of attorney issued for purposes of health care decisions only

Clubbing of the fingertips is associated with

chronic hypoxia

Nonmaleficence

do no harm

zoophobia

fear of animals

placenta previa

implantation of the placenta over the cervical opening or in the lower region of the uterus

Fifth disease (erythema infectiosum)

is a childhood disease caused by the human parvovirus. This common community-acquired disease does not usually require treatment, but respiratory isolation is recommended for 7 days following the onset of symptoms. The initial stage of the disease presents as red cheeks that appear to be "slapped" or "slapped cheeks" with circumoral pallor

hyperthyroidism/ grave's disease

is an autoimmune condition related to increased production of TH. Neonatal Graves disease is uncommon and usually occurs secondary to maternal hyperthyroidism. Tachycardia and increased bowel motility (frequent or loose stools) are features of hyperthyroidism and are related to an increase in metabolic processes

Hyperemesis gravidarum (ie, excessive vomiting during pregnancy) leads to fluid and electrolyte imbalances (eg, hypokalemia, hypotension), weight loss of ≥5% of prepregnancy weight, nutritional deficiencies, and

ketonuria. Urine ketones are expected because they are a by-product of fat breakdown, which occurs in starvation states.

Clients with cystic fibrosis are at risk for

malnutrition and need a high-calorie diet.

Epitaxis

nosebleed

Displacement

one of many ego defense mechanisms, occurs when a person shifts uncomfortable feelings or impulses about one situation or person to a substitute situation or person deemed acceptable to receive these uncomfortable feelings or impulses.

Paternalism

the policy or practice on the part of people in positions of authority of restricting the freedom and responsibilities of those subordinate to them in the subordinates' supposed best interest.

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