Exam 1 - All Cards Class Combined

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A client newly diagnosed with multiple sclerosis asks the nurse, "Will I experience pain?" Which response would the nurse give? A. Tell me about your fears regarding pain B. Analgesics will be prescribed to control the pain C. Pain is not a characteristic symptoms of this condition D. Let's make a list of things to ask your primary health care provider

Which clinical indicators would the nurse expect to find when assessing a patient with Parkinson disease? Select all that apply A. Resting tremors B. Flattened affect C. Muscle flaccidity D. Tonic-clonic seizures E. Slow voluntary movements

A., B., E.

Which clinical manifestations would the nurse expect to find in a client who has acute human immunodeficiency virus? Select all that apply A. Malaise B. Confusion C. Constipation D. swollen lymph nodes E. oropharyngeal candidiasis

A., D. (Think flu symptoms)

In which settings would the nurse prepare to administer developmental assessment for pediatric clients? Select all that apply. One, some, or all responses may be correct. 1 Home 2 School 3 Hospital 4 Daycare center 5 Assisted living center

ALL EXCEPT ASSISTED LIVING CENTER

Which statement is true regarding varicoceles? 1 Varicoceles are commonly seen in prepubertal children. 2 Varicoceles result in a partial or complete venous occlusion. 3 Varicoceles result in a red, warm, and edematous scrotum. 4 Varicoceles cause an elongation of the veins of the spermatic cord.

4 Varicocele is characterized by a dilation and elongation of the veins of the spermatic cord that is presently superior to a testicle. This condition is rarely seen in prepubertal children. Testicular torsion results in partial or complete venous occlusion. In cases of severe torsion, the scrotum becomes red, warm, and edematous.

Which nursing intervention would the nurse provide for a 6-month-old infant with bronchiolitis? o Discouraging parental visits to conserve energy o Monitoring skin color, anterior fontanel, and vital signs o Wearing gown and gloves when providing care o Promoting stimulating activities to meet developmental needs

o Monitoring skin color, anterior fontanel, and vital signs · Continuous assessments, including monitoring skin color and anterior fontanel as well as vital signs, are vital in determining the infant's oxygenation and hydration status and responses to the disease process. The infant needs the parents' presence to fulfill the developmental goal of infancy, the establishment of trust. Respiratory syncytial virus is the most common cause of bronchiolitis in an infant. Droplet precautions are recommended for an infant with bronchiolitis. The infant is too ill to be involved in stimulating activities; energy should be conserved and oxygen demands kept to a minimum.

According to Erikson's psychosocial stages of development, mastery of which task increases a child's ability to cope with separation or pending separation from significant others? 1 Trust 2 Identity 3 Initiative 4 Autonomy

1 Trust

At which age does the anterior fontanel of the skull close? 1 12 to 18 months 2 20 to 24 months 3 26 to 30 months 4 32 to 36 months

12 to 18 months

Which event is considered as the hallmark of late puberty in young girls? 1 Breast enlargement 2 Adult type sexual hair 3 First menstrual period 4 Physiologic leukorrhea

3 First menstrual period is considered the hallmark of late puberty in young girls. Breast enlargement along with change in pubic hair to adult type sexual hair covering the mons pubis and labia majora occurs during mid-puberty stage. Physiologic leukorrhea (increased normal vaginal discharge) marks the uterine development early in puberty.

Which substance is released in response to low serum levels of calcium? 1 Renin 2 Erythropoietin 3 Parathyroid hormone 4 Atrial natriuretic peptide

3 Parathyroid Hormone

Which gonadotropin-releasing hormone agonists are used to treat endometriosis? Select all that apply. 1 Trazodone 2 Diclofenac 3 Leuprolide 4 Isotretinoin 5 Nafarelin acetate

35 Leuprolide and nafarelin acetate are gonadotropin-releasing hormone (GnRH) agonists used to treat endometriosis. Trazodone is used in cases of erectile dysfunction. Diclofenac is a nonsteroidal antiinflammatory drug used to relieve pain in endometriosis. Isotretinoin is an oral agent that is effective against severe cystic acne.

A 50-year-old male client has difficulty communicating because of expressive aphasia after a cerebrovascular accident (CVA, also known as a "brain attack"). When the nurse asks the client how he is feeling, his wife answers for him. How should the nurse address this behavior? 1 Ask the wife how she knows how the client feels. 2 Instruct the wife to let the client answer for himself. 3 When the wife leaves return to speak with the client. 4 Acknowledge the wife but look at the client for a response.

An 18-year-old adolescent who was diagnosed with new-onset type 1 diabetes mellitus has stress and reports not having a menstrual cycle for a long time. Which condition is the adolescent experiencing? 1 Amenorrhea 2 Primary amenorrhea 3 Female athlete triad 4 Hypogonadotropic amenorrhea

4 Hypogonadotropic amenorrhea may occur in type 1 diabetic adolescents experiencing stress. This condition can also result from sudden and severe weight loss, eating disorders, strenuous exercise, and mental illness.

Which characteristic change is observed during late adolescence stage? 1 Changes in puberty 2 Changes in dressing 3 Dominant peer orientation 4 Develops adult relationships

4 The characteristic change observed during the late adolescence stage is developing adult relationships. Early adolescence is characterized primarily by the changes of puberty. Middle adolescence is characterized by changes in dressing and dominant peer orientation.

Under which type of health care services would the student nurse include sports medicine? 1 Primary care 2 Tertiary care 3 Preventive care 4 Restorative care

4 Restorative care

Which average daily caloric intake is appropriate in preschoolers? 1 400 2 700 3 1000 4 1800

Which range of heart rate is acceptable for a preschooler? 1 60 to 100 2 80 to 110 3 75 to 100 4 90 to 140

80-110

Which fine motor developmental milestone emerges in 4-year-olds? 1 Uses scissors well 2 Builds a tower of 9 to 10 cubes 3 Can lace shoes but may not be able to tie the bow 4 Cannot draw a stick figure but may make a circle with facial features

A 4 year old can lace shoes but may not be able to tie the bow. A 5 year old uses scissors well. A 3 year old can build a tower of 9 to 10 cubes. Four year olds are usually unable to draw a stick figure, but they may make a circle with facial features.

when caring for clients with the diagnosis of anorexia nervosa or bulimia nervosa, it is important that the nurse understand the sociolcultural influences related to eating disorders in the US. what are these influences? select all that apply A) diet industry B) fashion trends C) fast food industry D) over the counter meds E) competitive women's athletics

A, B & E

A client exposed to pollen reports a runny, stuffy nose and itchy, watery eyes. The nasal examination reveals swollen and pink nasal mucosa. Which laboratory finding would the nurse expect to identify? A. IgE level of 150 IU/mL B. Eosinophil count of 2% C. Percentage of neutrophils of 80% D. total WBC of 3 billion

When assisting a client with Parkinson disease to ambulate, which instruction would the nurse provide the client? A. Avoid leaning forward B. hesitate between steps C. Rest when tremors are experienced D. Keep arms close to the center of gravity

Which action would the nurse perform immediately according to priority of care for a client with tonic-clonic seizures? A. Ensuring patent airway B. Administering IV fluids C. Monitoring level of consciousness D. Protecting the client from injury during seizures

Which client has an increased risk of developing IgE antibodies? A. client with pollen allergy B. client undergoing poison ivy reaction C. client with a bacterial infection D. client undergoing a blood transfusion

Which first-line medication would the nurse use to treat anaphylactic reactions? A. Epinephrine B. Norepinephrine C. Dexamethasone D. Diphenhydramine

A. Dexamethasone and Diphenhydramine are second line for anaphylactic reactions

Which findings would the nurse expect when completing an admission physical for a client with a diagnosis of Parkinson disease? Select all that apply A. Muscle rigidity B. Blank facial expression C. Leaning toward affected side D. Intention tremors with movement E. Hyperextension of the affected extremity

A., B. (nonintention tremors w/ Parkinsons)

According to current statistics, what percent of adolescents try marijuana by the end of high school? Record your answer using a whole number. ________

Current statistics show that by the end of high school, 49% of adolescents experiment with marijuana.

A client asks the nurse what causes sudden loss of vision common in persons with multiple sclerosis? A. Virus-induced iritis B. Intracranial pressure C. Closed-angle glaucoma D. Optic nerve inflammation

A client with Guillain-Barré syndrome has been hospitalized for 3 days. Which assessment data would the nurse plan to monitor frequently for this client? A. Localized seizures B. Skin desquamation C. Hyperactive reflexes D. Ascending weakness

Which nursing interventions is the priority for a client on an IV medication who is experiencing an anaphylactic reaction? A. Elevate the lower extremities B. Start a normal saline infusion C. Report to primary care provider immediately D. Stop IV medication and administer epinephrine

Which is a complication that may develop in the child with hypospadias with chordee? A. Renal failure B. Testicular cancer C. Testicular torsion D. Sexual difficulties

D. Sexual difficulties Chordee can affect the child's future reproductive capabilities, which are related to the inability to inseminate directly. Kidney function is not affected by hypospadias with chordee. The incidence of testicular cancer is not increased; nor is the risk for testicular torsion.

The nurse reviews the history to find that an adolescent has a tattoo on the neck and piercings on the ear and eyebrow. During the next visit, the nurse finds a new tattoo on the upper right arm and another piercing on the nose. Which would be priority nursing interventions? Select all that apply A. Prepare a proper diet plan for the adolescent B. Instruct the adolescent to get an electrocardiogram C. Instruct the adolescent to perform regular exercises D. Screen the adolescent for HIV E. Schedule the adolescent for administering the hepatitis vaccine

D., E.

The nurse is teaching a class about nutrition to a group of adolescents. Taking into consideration the prevalence of overweight teenagers, which is the best recommendation? 1 "Join a gym." 2 "Drink fewer diet sodas." 3 "Decrease fast-food intake." 4 "Take a multivitamin daily."

Decrease fast-food intake

Which preventive and primary care service provided by a community health center is most expensive? 1 Running errands 2 Health education 3 Disease management 4 Routine physical examinations

Disease management is the most expensive service provided by community health centers. Running errands is relatively inexpensive, because the cost is the merely the cost of transportation. Health education and routine physical examinations are inexpensive and can usually stop complications of diseases, which prevents from having to "manage" diseases, leading to costly and expensive treatment.

Which domain of the nursing intervention phase includes electrolyte and acid-base management? 1 Domain 1 2 Domain 2 3 Domain 3 4 Domain 4

Domain 2 Domain 2 of the nursing intervention phase includes electrolyte and acid-base management. Domain 2, or the physiological complex, includes care that supports homeostatic regulation. Domain 1 includes care that supports physical functioning. Domain 3 incorporates care that supports psychosocial functioning and facilitates lifestyle changes. Domain 4 involves care that supports protection against harm.

Which are examples of health promotion activities? Select all that apply. One, some, or all responses may be correct. 1 Good nutrition 2 Regular exercise 3 Physical awareness 4 Immunization against measles 5 Education about stress management

Health promotion activities enable clients to enhance or maintain their current health levels. Good nutrition and regular exercise are examples of such activities. Immunization against measles is an example of an illness prevention activity. Education about stress management and physical awareness are examples of a wellness education activity.

What is the maximum recommended length for enema tube insertion in an adolescent? Record your answer using a whole number. _____ cm

In adolescents, the maximum length for insertion of an enema tube is 10 cm.

Which nursing action is most accurate when assessing the chest circumference of a newborn? 1 Measuring during expiration only 2 Taking 3 measurements and recording the average 3 Measuring during inspiration and plotting this data on the growth chart 4 Placing the measuring tape around the rib cage at the nipple line

Placing the measuring tape around the rib cage at the nipple line

Which is the most important nursing intervention when working with an older adult client? 1 Encouraging frequent naps 2 Strengthening the concept of ageism 3 Reinforcing the client's strengths and promoting reminiscing 4 Teaching the client to increase calories and focusing on a high-carbohydrate diet

Reinforcing strengths promotes self-esteem; reminiscing is a therapeutic tool that provides a life review that assists adaptation and helps achieve the task of integrity associated with older adulthood. Frequent naps may interfere with adequate sleep at night. Reinforcing ageism may enhance devaluation of the older adult. A well-balanced diet that includes protein and fiber should be encouraged; increasing calories may cause obesity.

Which point is included in the World Professional Association for Transgender Health (WPATH) document regarding core principles of care for transgender clients?

Seeking informed consent before providing treatment

What is the average diastolic pressure recorded in a 16 year old? Record your answer using a whole number. ________________ mm Hg

The average diastolic pressure recorded in a 16 year old is 75 mm Hg.

The nurse speaking in support of the best interest of a vulnerable client reflects which nursing duty? a) Caring b) Veracity c) Advocacy d) Confidentiality

c) Advocacy

Which guideline is useful for reducing disparity when caring for transgender clients? a) Learning about health care needs of homosexual clients b) Always referring to transgender clients using pronouns of the sex to which they transition c) Always referring to transgender clients using pronouns of the sex with which they were born d) Learning about the treatment options for transgender clients and requirements of follow-up care

d) Learning about the treatment options for transgender clients and requirements of follow-up care

An African-American woman is diagnosed with primary hypertension. She asks, "Is hypertension a disease of African-American people?" What is the nurse's best response? "The prevalence of hypertension is about equal for women of all races." "The higher-risk population is composed of African-American men and women." "The highest-risk population consists of older Caucasian-American men and women." "The prevalence of hypertension is greater for African-American men than for African-American women."

"The higher-risk population is composed of African-American men and women." Rationale African-Americans represent a higher-risk population than Caucasian-Americans for hypertension; the reason is unknown. African-American women are more frequently affected by hypertension than are Caucasian women. African-Americans of both sexes have a higher prevalence than Caucasian-Americans of both sexes. African-American women have a higher risk than African-American men.

A client is diagnosed as having expressive aphasia. Which type of impairment does the nurse expect the client to exhibit? 1 Speaking or writing 2 Following specific instructions 3 Understanding speech or writing 4 Recognizing words for familiar objects

The nurse finds that a client with a urinary disorder has very pale-yellow-colored urine. What is the significance of this abnormal finding? 1 It indicates dilute urine. 2 It indicates blood in the urine. 3 It indicates concentrated urine. 4 It indicates the presence of myoglobin.

The nurse is reviewing a client's current medication therapy and suspects hematuria. Which medication is responsible for the client's condition? 1 Warfarin 2 Cimetidine 3 Phenazopyridine 4 Nitrofurantoin

To help prevent a cycle of recurring urinary tract infections in a female client, which instruction should the nurse share? 1 "Urinate as soon as possible after intercourse." 2 "Increase your daily intake of citrus juice." 3 "Douche regularly with alkaline agents." 4 "Take bubble baths regularly."

What is the cup-like structure that collects a client's urine and is located at the end of each papilla? 1 Calyx 2 Capsule 3 Renal cortex 4 Renal columns

What is the nurse's first action when developing a teaching plan for self-administration of insulin to a school-aged child? 1 Assessing the child's developmental level 2 Determining the family's understanding of the procedure 3 Discussing community resources for the child in the future 4 Collaborating with the school nurse to ensure continuity of care in school

When performing a neurologic assessment of a client, a nurse identifies that the client has a dilated right pupil. The nurse concludes that this suggests a problem with which cranial nerve? 1 Third 2 Fourth 3 Second 4 Seventh

According to Erikson's theory, which of these actions can predispose an adolescent to being in a state of confusion? 1 If an adolescent fails to establish a sense of identity 2 If an adolescent has a feeling of isolation and rejection 3 If an adolescent's parents fail to establish a sense of trust in him or her 4 If an adolescent's parents try to control him or her and limit his or her choices

1 Acquiring a sense of identity is essential for making adult decisions. If an adolescent fails to develop a sense of identity, they may end up in a state of confusion. If a young adult is not able to establish a companionship, isolation results due to rejection and disappointment. If the parents fail to establish a sense of trust with an infant, the child may develop feelings of mistrust. Controlling a child and limiting his or her choices may lead to a child developing a sense of shame and doubt.

The parents of a 15-year-old adolescent who is being treated for allergies privately tell a nurse that they suspect that their child is a hypochondriac. What is the most therapeutic response by the nurse? 1 Discussing developmental behaviors of adolescents 2 Explaining potentially serious complications of allergies 3 Discussing some of the underlying causes of hypochondriasis 4 Explaining that the parents may be transferring their fears to their adolescent

1 Adolescents are very aware of their changing bodies and become especially concerned with any alteration resulting from illness or injury. Explaining the complications of allergies does not address concepts related to growth and development of the adolescent and may cause unnecessary concern about the child's physical condition. A discussion about hypochondriasis may reinforce the parents' concern. Indicating that the parents may be engaging in transference is accusatory and is not supported by adequate data; this response may precipitate such feelings as anger and guilt.

Which scenario is a perfect example of primary prevention? 1 An infant receives the rotavirus vaccination in the hospital setting. 2 An adult in the early stages of Parkinson disease is advised to perform adequate exercise. 3 An older adult permanently paralyzed due to brain hemorrhage is transferred to a long-term care facility. 4 An older adult with Parkinson disease is administered carbidopa-levodopa to slow the progression of the disease.

1 An infant receives the rotavirus vaccination in the hospital setting. Primary prevention consists of all health promotion efforts and wellness education activities. An infant receiving the rotavirus vaccination is an example of primary prevention. An adult in the early stages of Parkinson disease is advised to perform adequate exercises; this is an example of secondary prevention. An older adult permanently paralyzed due to brain hemorrhage is transferred to a long-term care facility. This is an example of tertiary prevention. An older adult with Parkinson disease is administered carbidopa-levodopa to slow the progression of the disease. This is an example of secondary prevention.

An 18-year-old high school student arrives at the local blood drive center to donate blood for the first time. As the site is being prepared for needle insertion, the student becomes agitated, starts to hyperventilate, and complains of dizziness and tingling of the hands. What should the nurse instruct the student to do? 1 Breathe into cupped hands. 2 Pant using rapid, shallow breaths. 3 Use a rapid deep-breathing pattern. 4 Hold the breath for as long as possible.

1 Breathing into cupped hands allows carbon dioxide to reenter the lungs, which will increase the serum bicarbonate level, relieving the respiratory alkalosis that is occurring as a result of hyperventilation. A rapid breathing pattern will exacerbate the respiratory alkalosis because excess carbon dioxide will continue to be expelled with rapid breathing, lowering the serum bicarbonate level. A fast deep-breathing pattern will exacerbate the respiratory alkalosis because excess carbon dioxide will continue to be expelled with rapid breathing, lowering the serum bicarbonate level. A person who is experiencing a panic attack will not be able to hold his or her breath.

A nurse concludes that the teaching about sickle cell anemia has been understood when an adolescent with the disorder makes which statement? 1 "I'll start to have symptoms when I drink less fluid." 2 "I'll start to have symptoms when I have fewer platelets." 3 "I'll start to have symptoms when I decrease the iron in my diet." 4 "I'll start to have symptoms when I have fewer white blood cells."

1 Dehydration precipitates sickling of red blood cells and therefore is a major causative factor for painful episodes associated with sickle cell anemia. An inadequate number of platelets (thrombocytes) is unrelated to painful episodes associated with sickle cell anemia. Iron intake is unrelated to the sickling phenomenon. An inadequate number of white blood cells is unrelated to painful episodes associated with sickle cell anemia.

The parents of an adolescent treated for allergies privately tell the nurse that they suspect that their child is a hypochondriac. Which therapeutic response would the nurse provide? 1 Discussing developmental behaviors of adolescents 2 Explaining potentially serious complications of allergies 3 Discussing some of the underlying causes of hypochondriasis 4 Explaining that the parents may be transferring their fears to their adolescent

1 Discussing developmental behaviors of adolescents

At which age would the nurse anticipate the appearance of an imaginary friend for a preschool-age client? 1 3 years old 2 4 years old 3 5 years old 4 6 years old

1 Imaginary friends typically appear by 3 years of age and can last throughout the preschool stage of development. If an imaginary friend has not appeared by this age, it is unlikely to expect this to surface at 4, 5, or 6 years of age.

Which medication treatment in the client during her gestation may cause a single-lobed brain and neural tube defects? 1 Simvastatin 2 Isotretinoin 3 Carbamazepine 4 Cyclophosphamide

1 Neural tube defects and single-lobed brains are teratogenic effects in a newborn associated with simvastatin, an HMG-CoA reductase inhibitor. Isotretinoin may cause central nervous system (CNS) defects. Carbamazepine exposure may cause neural tube defects. Cyclophosphamide may cause CNS malformation as a teratogenic effect.

Which of these statements about pregnancy in the adolescent population are true? Select all that apply. One, some, or all responses may be correct. 1 Pregnant adolescents often seek out less prenatal care. 2 Infants of teen mothers are at risk of delivering babies late. 3 Adolescent mothers need competent daycare for their infants. 4 Infants of adolescent mothers are at increased risk for prematurity. 5 Fetuses of adolescent mothers are at higher risk for chromosomal defects

1 Pregnant adolescents often seek out less prenatal care. 3 Adolescent mothers need competent daycare for their infants. 4 Infants of adolescent mothers are at increased risk for prematurity.

The clinic nurse is teaching an adolescent about lifestyle modifications to prevent hyperlipidemia. Which statement by the adolescent indicates a need for further teaching? 1 "I'll start eating more red meat." 2 "I'm going to eat a lot of low-fat yogurt." 3 "I'll try to stop eating so much processed food." 4 "I'll start eating whole-grain bread instead of white."

1 Red meats are high in fat. The monounsaturated and polyunsaturated fats can increase high density lipoprotein and decrease low density lipoprotein cholesterol. For this reason, an increase in the consumption of red meat is not advisable. Most whole grains, breads, pastas, and cereals are naturally low in fat. Adolescents should be taught to choose lean meats, beans, and low-fat dairy products and to limit their intake of processed foods such as crackers, cookies, cakes, and higher fat snacks.

After her child's visit to the pediatrician a mother tells the nurse that she is concerned that an antidepressant has been prescribed for her adolescent son. What is the best response by the nurse? 1 "Tell me more about what's bothering you." 2 "You need to speak with the primary healthcare provider about your concern." 3 "Are you sure it's not a medication for attention deficit disorder?" 4 "Didn't the primary healthcare provider tell you why your son needs an antidepressant?"

1 Reflecting the parent's feelings provides an opportunity for further exploration. It is the nurse's responsibility to assess the mother's concerns before planning further interventions. Implying that either the primary healthcare provider or the mother is wrong is a nontherapeutic response. Implying that the mother didn't listen or understand is a judgmental, nontherapeutic response.

A 16-year-old single mother of a 1-year-old infant and the infant's grandmother bring the baby to the emergency department and report that the infant accidentally fell down the stairs. The nurse knows that a consent form for treatment should be signed. Who has the responsibility for signing the consent? 1 The mother, despite her age 2 No one, because this is an emergency 3 The grandmother, because she is a relative 4 Family court, because the mother is a minor

1 The client is an emancipated minor, meaning that she has adult status. In most states the age of majority is 18 years; however, parents younger than 18 years are considered emancipated minors and may sign consents for themselves and their children. Consent always is needed when a parent is present and capable of providing it. The grandmother does not have the legal right to give consent. Family court is unnecessary.

A nurse concludes that the teaching about sickle cell anemia has been understood when an adolescent with the disorder makes which statement? 1. I'll start to have symptoms when I drink less fluid 2. I'll start to have symptoms when I have fewer platelets 3. I'll start to have symptoms when I decrease the iron in my diet 4. I'll start to have symptoms when I have fewer white blood cells

1, Dehydration precipitates sickling of red blood cells and therefore is a major causative factor for painful episodes associated with sickle cell anemia

Which fine motor skills may be observed in an 8- to 10-month-old infant? Select all that apply. One, some, or all responses may be correct. 1 Using pincer grasp well 2 Picking up small objects 3 Showing hand preference 4 Crawling on the hands and knees 5 Pulling oneself to standing or sitting

1,2,3 The fine motor skills evident in 8- to 10-month-old infants include the accurate use of the pincer grasp and picking up small objects. At this stage, infants may also demonstrate a hand preference. Crawling on the hands and knees and pulling oneself to a standing or sitting position are considered gross motor skills.

Which would be common characteristics of a relationship between a middle adolescent and parents? Select all that apply. One, some, or all responses may be correct. 1 Great push for emancipation 2 Low point in the parent-child relationship 3 Desire to remain dependent on parents 4 Major conflicts over independence and control 5 Emotional and physical separation from parents

1,2,4 A child in middle adolescence will have a great push for emancipation, a low point in the parent-child relationship, and major conflicts over independence and control. A younger child will have a desire to remain dependent on his or her parents. A child in late adolescence will have an emotional and physical separation from his or her parents.

Which behaviors would the nurse anticipate when conducting a developmental assessment for a newborn? Select all that apply. One, some, or all responses may be correct. 1 Sucking on a pacifier 2 Grasping a parent's finger 3 Discovering hands and feet 4 Swallowing while breast-feeding 5 Rooting when the cheek is stroked

1,2,4,5

How does exercise help relieve menstrual discomfort in adolescents? Select all that apply. One, some, or all responses may be correct. 1 By reducing ischemia 2 By decreasing vasodilation 3 By increasing prostaglandins 4 By reducing pelvic discomfort 5 By releasing endogenous opiates

1,4,5 Exercise helps relieve menstrual discomfort through increased vasodilation followed by a subsequent decrease in ischemia. Exercise reduces congestion in the pelvis and minimizes the discomfort in the pelvis. Exercise promotes the release of endogenous opiates and suppresses prostaglandin production.

The nurse is differentiating between cephalhematoma and caput succedaneum. Which finding is unique to caput succedaneum? 1 Edema that crosses the suture line 2 Scalp tenderness over the affected area 3 Edema that increases during the first day 4 Scalp over the area becomes ecchymosed

According to Erikson's psychosocial stages of development, which outcome will occur if an individual fails to master the maturational crisis of adolescence? 1 Role confusion 2 Feelings of inferiority 3 Interpersonal isolation 4 Difficulties with intimacy

1. According to Erikson, adolescents are struggling to find out who they are; this is identity versus role confusion. If an adolescent is unsuccessful in this task, role confusion may result. Industry versus inferiority is the developmental struggle of the school-aged child. This reflects part of the struggle for autonomy. Adolescents tend to be group oriented, not isolated. Developing intimacy is the developmental task for the young adult. STUDY TIP: Becoming a nursing student automatically increases stress levels because of the complexity of the information to be learned and applied and because of new constraints on time. One way to decrease stress associated with school is to become very organized so that assignment deadlines or tests do not come as sudden surprises. By following a consistent plan for studying and completing assignments, you can stay on top of requirements and thereby prevent added stress.

1. Adolescents are very aware of their changing bodies and become especially concerned with any alteration resulting from illness or injury. Explaining the complications of allergies does not address concepts related to growth and development of the adolescent and may cause unnecessary concern about the child's physical condition. A discussion about hypochondriasis may reinforce the parents' concern. Indicating that the parents may be engaging in transference is accusatory and is not supported by adequate data; this response may precipitate such feelings as anger and guilt.

The nurse is teaching a high school student about scoliosis treatment options. On which priority information would the nurse focus? 1 Effect on body image 2 Least invasive treatment 3 Continuation with schooling 4 Maintenance of contact with peers

1. Establishing an identity, the major developmental task of the adolescent, is related to the affirmation of self-image. To achieve this task there is a need to conform to group norms, one of which is appearance. The type of treatment is not an issue. Although it is important to continue schooling and to maintain contact with peers, the effect on body image is more important. Test-Taking Tip: Have confidence in your initial response to an item because it more than likely is the correct answer.

According to Erikson's psychosocial stages of development, which developmental conflict affects a 4-year-old child? 1 Initiative versus guilt 2 Industry versus inferiority 3 Trust versus mistrust 4 Autonomy versus shame

1. Initiative versus guilt is the developmental conflict that faces the preschool child; the child will feel guilty if initiative is stifled by others. Industry versus inferiority is the conflict of the school-aged child. Trust versus mistrust is the conflict of infants aged 0 to 18 months. Autonomy versus shame is the conflict for children aged 18 months to 3 years. STUDY TIP: Determine whether you are a "lark" or an "owl." Larks, day people, do best getting up early and studying during daylight hours. Owls, night people, are more alert after dark and can remain up late at night studying, catching up on needed sleep during daylight hours. It is better to work with natural biorhythms than to try to conform to an arbitrary schedule. You will absorb material more quickly and retain it better if you use your most alert periods of each day for study. Of course, it is necessary to work around class and clinical schedules. Owls should attempt to register in afternoon or evening lectures and clinical sections; larks do better with morning lectures and day clinical sections.

Which stage is a part of postconventional reasoning? 1 Social contract orientation 2 Society-maintaining orientation 3 Instrumental relativist orientation 4 Punishment and obedience orientation

1. The social contract orientation stage is a part of postconventional reasoning. Society-maintaining orientation is part of the conventional/role conformity reasoning level. The instrumental relativist orientation stage and the punishment and obedience orientation stage are parts of the preconventional reasoning level. Test-Taking Tip: Have confidence in your initial response to an item because it more than likely is the correct answer.

A new mother is concerned that her 1-month-old infant is nursing every 2 hours. Which response by the nurse is most appropriate? 1. "It's common for newborns to nurse this often. Let's talk about how you're adjusting with the new baby." 2. "Breast milk is easily digested; giving your infant a little rice cereal will keep him full longer." 3. "It sounds as though your baby is a little spoiled; try to resist feeding more often than every 4 hours." 4. "You may not be producing enough milk; it'll be important for you to supplement feedings with formula."

1. "It's common for newborns to nurse this often. Let's talk about how you're adjusting with the new baby." Newborns typically nurse every 2 to 3 hours. Although breast milk is easily digested, feeding solids to an infant is not recommended at this age. Feeding satisfies a fundamental need; one does not spoil an infant by nursing as needed. Adequate intake is evidenced in infant weight gain and adequate urinary and bowel elimination. Supplementing feedings with formula may lead to decreased milk production.

Which refers to the professional obligation of the nurse to assume responsibility for actions? 1 Accountability 2 Individuality 3 Responsibility 4 Bioethics

1. Accountability Nurses have an obligation to uphold the highest standards of practice, assume full responsibility for actions, and maintain quality in the knowledge base and skill of the profession; this is referred to as accountability. Individuality and responsibility are positive characteristics of the nurse but are not necessarily professional obligations. Bioethics is a field of study concerned with the ethics and philosophical implications of certain biological and medical procedures and treatments.

Which population would the nurse include in a community education session on sexually transmitted infections (STIs)? Select all that apply. One, some, or all responses may be correct. a) Adolescents b)Homosexual men c) Transgender clients d) Multiple sex partners e) Intravenous drug users

1. Adolescents 2. Homosexual men 3. Transgender clients 4. Multiple sex partners 5. Intravenous drug users

The nurse is working with parents in the community to decrease the incidence of poisonings in children younger than 5 years of age. Which information would the nurse include to meet this goal? Select all that apply. One, some, or all responses may be correct. a) Clean fruits and vegetables. b) Place locks on medicine cabinets. c) Use child-resistant medication caps. d) Keep the poison control center number near the phone. e) Store cleaning products in a locked cabinet.

1. Clean fruits and vegetables. 2. Place locks on medicine cabinets. 3. Use child-resistant medication caps. 4. Keep the poison control center number near the phone. 5. Store cleaning products in a locked cabinet.

A couple asks a community health nurse about using condoms as a method of contraception. Arrange the steps of using a condom in sequential order. 1. Throw the condom away. 2. The condom is unrolled on the erected penis. 3. Leave 0.5 inch of space at the tip of the condom. 4. Hold the rim of the condom in place when withdrawing. 5. Contraceptive jelly is squeezed onto the tip of the condom. 6. Open the package to remove the condom and check for breaks or holes.

1. Open the package to remove the condom and check for breaks or holes. 2. Contraceptive jelly is squeezed onto the tip of the condom. 3. The condom is unrolled on the erected penis. 4. Leave 0.5 inch of space at the tip of the condom. 5. Hold the rim of the condom in place when withdrawing. 6. Throw the condom away.

A client with diabetes mellitus experiences a sudden fall in blood glucose levels while traveling by air. The client is not carrying any medications or a copy of a personal medical record. Which type of health information technology would be beneficial for this client? 1 Personal health record (PHR) 2 Clinical health care informatics 3 Electronic medical record (EMR) 4 Regional health information organization (RHIO)

1. Personal health record (PHR) The PHR is an electronic health record that consists of health data and the treatment provided for the client. The client can enter the data and maintain these health records. It is easy to carry and helps health care providers provide treatment in emergency conditions. Health care facilities maintain an EMR for each client. The client does not have access to these records in the air. Clinical health care informatics seeks to transform client health by educating and training health care professionals. It does not help provide emergency treatment to the client while traveling. RHIO oversees the exchange of the client's information among the client's health care providers and across geographic areas.

How are profits used in a for-profit health care organization? 1 Profits are paid out to shareholders. 2 Profits are used to buy new equipment. 3 Profits are used to build additional facilities. 4 Profits are invested in improving health care services.

1. Profits are paid out to shareholders. Health care organizations can be classified as for-profit and not-for-profit based on how the profits are distributed. In a for-profit organization, the profits are generated for the shareholders. In a not-for-profit organization, the profits are used to buy new equipment, build additional facilities, and improve health care services.

In clients with human immunodeficiency virus (HIV), which potential complication is most important for the nurse to teach prevention strategies? 1 Infection 2 Depression 3 Social isolation 4 Kaposi sarcoma

1. The client has a weakened immune response. Instructions regarding rest, nutrition, and avoidance of unnecessary exposure to people with infections help reduce the risk for infection. Clients can be taught cognitive strategies to cope with depression, but the strategies will not prevent depression. The client may experience social isolation as a result of society's fears and misconceptions; these are beyond the client's control. Although Kaposi sarcoma is related to HIV infection, there are no specific measures to prevent its occurrence.

During testing of the neurological reflexes of an infant, which reflex would the nurse expect to appear at 3 months and persist until 24 to 36 months of age? 1 Neck righting 2 Body righting 3 Otolith righting 4 Labyrinth righting

1. While the infant is supine, if the head is turned to one side, the shoulder, trunk, and finally the pelvis will turn toward that side. This reflex appears at 3 months, and persists until 24 to 36 months of age. Body righting is a modification of the neck-righting reflex in which turning hips and shoulders to one side causes all other body parts to follow; it appears at 6 months and persists until 24 to 36 months of age. When the body of an erect infant is tilted, the head is returned to an upright, erect position; this is known as otolith righting, which appears at 7 to 12 months of age, and persists indefinitely. When an infant in prone or supine position is able to raise his or her head, it is known as labyrinth righting. It appears at 2 months and is strongest at 10 months of age.

What is the correct order of the different stages in Piaget's theory of cognitive development?

1.Sensorimotor 2.Preoperational 3.Concrete operations 4.Formal operations

What are the common characteristics of a relationship between a middle adolescent and his or her parents? Select all that apply. 1 Great push for emancipation 2 Low point in the parent-child relationship 3 Desire to remain dependent on parents 4 Major conflicts over independence and control 5 Emotional and physical separation from parents

124 A child in middle adolescence will have a great push for emancipation, a low point in the parent-child relationship, and major conflicts over independence and control. A younger child will have a desire to remain dependent on his or her parents. A child in late adolescence will have an emotional and physical separation from his or her parents.

Which behavior patterns may be exhibited by teenagers in their late adolescence? Select all that apply. 1 Concealed temper 2 Introspective nature 3 Consistent emotions 4 Feeling of inadequacy 5 Intense daydreaming

13 Psychologically, teenagers in their late adolescence exhibit a consistency of emotions and are more likely to conceal their feelings and anger. An introspective nature and feelings of inadequacy are expressed by teenagers in their middle adolescence. Intense daydreaming is associated with teenagers in their early adolescence.

A school nurse is planning a class on injury prevention for a group of high school students. What guidelines should the nurse include? Select all that apply. 1 Swim with a buddy. 2 Drink beer instead of wine. 3 Use well-traveled walkways. 4 Smoke only in designated areas. 5 Refuse to play "chicken" with others.

135 Developmentally, adolescents have a drive for independence, an inclination for risk-taking, and a feeling of indestructibility. These traits increase the risk for injury. If one develops problems in the water, the buddy can secure help. Using well-traveled walkways reduces the risk for being alone and overcome by an individual who wishes to do harm. Refusing to play "chicken" helps the student prevent dangerous situations from which the student cannot retreat. Beer is alcohol, and its intake, and that of all types of alcohol, should be discouraged; when one is under the influence of alcohol, reaction time and judgment decrease and the risk for injury increases. Smoking should be discouraged to decrease the risk for respiratory disease.

What are the medical concerns in adolescent pregnancies? Select all that apply. 1 Anemia 2 Fetal obesity 3 Poor maternal weight gain 4 Pregnancy-induced diabetes 5 Pregnancy-induced hypertension

135 Medical concerns in adolescent pregnancies include maternal anemia, poor weight gain, and pregnancy-induced hypertension. Adolescents often receive delayed or inadequate prenatal care, increasing the risk of a low-birthweight infant, not an obese one. Pregnancy-induced diabetes is a risk factor associated with pregnancies involving maternal obesity and maternal age greater than 25 years.

A nurse is educating a group of adolescent girls about the risk of pregnancy. Which statements does the nurse include to help ensure adequate teaching? Select all that apply. 1 Infants born to adolescent mothers have low birth weights. 2 Pregnant adolescents are more likely to seek out prenatal care. 3 Infants born to adolescent mothers are more likely to be premature. 4 Pregnant adolescent girls should avoid participating in prenatal classes. 5 Infants born to adolescent girls have an increased risk of alcohol and drug exposure.

135 The nurse should explain to the adolescent girls that pregnancy at this age results in low birth weight infants. Infants born to adolescent mothers are at increased risk of prematurity and increased risk of exposure to alcohol and drugs. Pregnant adolescents are less likely to seek out prenatal care. Adolescents who participate in prenatal classes have improved nutrition and healthier babies.

Which physical or behavioral signs of substance abuse should a nurse look for in an adolescent? Select all that apply. 1 Worrying about being addicted 2 Showing a high performance in social activities 3 Experiencing an overdose or withdrawal symptoms 4 Worrying about a friend or family member who is addicted 5 Manifesting bizarre behavior or confusion

135 Worrying of being addicted, experiencing overdose or withdrawal symptoms, and manifesting bizarre behavior may be earliest signs of substance abuse. Showing high performance in social activities and worry about a friend or family member's substance abuse are not with a manifestation of substance abuse.

Which statements are true regarding primary dysmenorrhea? Select all that apply. 1 During the luteal phase, F2-alpha is secreted 2 Anovulatory bleeding that occurs after menarche is painful 3 Primary dysmenorrhea usually appears 2 to 5 months after menarche 4 Pain usually begins at the onset of menstruation and lasts for 8 to 48 hours 5 Excessive release of prostaglandin F2-alpha decreases the frequency of uterine contractions

14 Primary dysmenorrhea is a condition associated with the ovulatory cycle. During the luteal phase and subsequent menstrual flow, F2-alpha is secreted. The pain usually begins at the onset of menstruation and lasts for 8 to 48 hours. Anovulatory bleeding, which is common in the few months or years after menarche, is painless. Primary dysmenorrhea usually appears 6 to 12 months after menarche when ovulation is established. Excessive release of prostaglandin F2-alpha increases the amplitude and frequency of uterine contractions.

A young pregnant adolescent reports bleeding and abdominal pain and is diagnosed with an ectopic pregnancy. Which risk factors should the nurse look for in the client? Select all that apply. 1 Habit of smoking 2 Irregular menses 3 Use of contraceptive pills 4 Damage to the fallopian tubes 5 History of pelvic inflammatory disease

145 Adolescents who smoke experience a higher risk for ectopic pregnancy. Inflammation of the fallopian tubes and ovaries and a history of pelvic inflammatory disease are risk factors. The use of contraceptive pills and a history of irregular menses are not associated with ectopic pregnancy.

How does exercise help relieve menstrual discomfort in adolescents? Select all that apply. 1 By reducing ischemia 2 By decreasing vasodilation 3 By increasing prostaglandins 4 By reducing pelvic discomfort 5 By releasing endogenous opiates

145 Exercise helps to relieve menstrual discomfort through increased vasodilation followed by a subsequent decrease in ischemia. Exercise reduces congestion in the pelvis and minimizes the discomfort in the pelvis. Exercise promotes the release of endogenous opiates and suppresses prostaglandin production.

How do adolescents establish health identity during psychosocial development? Select all that apply. 1 By evaluating their own health with a feeling of well-being 2 By fostering their independence within a balanced family structure 3 By building close peer relationships to achieve acceptance in the society 4 By achieving marked physical changes with masculine and feminine behaviors 5 By having the ability to function normally in the absence of any disease or infirmity

15 Adolescents establish health identity by evaluating their own health with a feeling of well-being. They also establish health identity by being able to function normally in the absence of any disease or infirmity. An individual establishes family identity by fostering their independence within balanced family structure. By building close peer relationships, an adolescent establishes a group identity. The sound and healthy growth of adolescents, characterized by marked physical changes, helps to build sexual identity.

A client has expressive aphasia. The client's family members ask how they can help the client regain as much speech function as possible. Which information should the nurse share with the family? 1 Speak louder than usual during visits while looking directly at the client. 2 Encourage the client to speak while allowing time to respond. 3 Give positive reinforcement for correct communication. 4 Tell the client to use the correct words when speaking.

A client is scheduled for a transurethral resection of the prostate. What should the nurse tell the client to expect after surgery? 1 "Urinary control may be permanently lost to some degree." 2 "An indwelling urinary catheter is required for at least a day." 3 "Your ability to perform sexually will be impaired permanently." 4 "Burning on urination will last while the cystostomy tube is in place."

A client is to have hemodialysis. What must the nurse do before this treatment? 1 Obtain a urine specimen to evaluate kidney function. 2 Weigh the client to establish a baseline for later comparison. 3 Administer medications that are scheduled to be given within the next hour. 4 Explain that the peritoneum serves as a semipermeable membrane to remove wastes.

A male client reports dysuria, nocturia, and difficulty starting the urinary stream. A cystoscopy and biopsy of the prostate gland have been scheduled. After the procedure the client reports an inability to void. Which action should the nurse take? 1 Insert a urinary retention catheter. 2 Palpate above the pubic symphysis. 3 Limit oral fluids until the client voids. 4 Assure the client that this is expected.

A registered nurse assesses a client's electronic medical record (EMR) and observes increased blood pressure, severe myopia, and blood glucose levels. Which type of eye disorder will the nurse most likely observe written in the EMR? 1 Cataract 2 Glaucoma 3 Corneal abrasions 4 Keratoconjunctivitis sicca

Immediately after cataract surgery a client reports feeling nauseated. What should the nurse do? 1 Provide some dry crackers to eat 2 Administer the prescribed antiemetic 3 Explain that this is expected after surgery 4 Encourage deep breathing until the nausea subsides

Which test helps a primary healthcare provider distinguish between conductive and sensorineural hearing loss? 1 Whisper test 2 Weber test 3 Tympanometry 4 Electrocochleography

An adolescent displaying low self-esteem complains of inflamed, red, and painful lesions on his forehead. What condition does he have? 1 Varicoceles 2 Acne vulgaris 3 Open comedones 4 Closed comedones

2 Acne vulgaris is a common skin problem that adolescents experience. It is an inflammatory manifestation to the proliferation of Propionibacterium acnes. A varicocele is a collection of elongated and twisted superficial veins near the spermatic cord, superior to the testicle. Comedones are noninflammatory lesions.

What should a nurse emphasize when teaching lifelong management of type 1 diabetes to an adolescent? 1 Soaking the feet in hot water each day 2 Inspecting both feet frequently for signs of trauma 3 Drying the feet thoroughly after a bath by rubbing with a towel 4 Treating minor cuts on the feet with an antiseptic such as iodine

2 Adequate inspection of the feet should become a habit; it is the quickest and easiest means of identifying pressure sites and preventing infection. Hot water should never be used, because it may cause burn injury of the skin. The feet should be patted dry, not rubbed; rubbing may cause abrasions and injure the skin. Strong antiseptics are too harsh and should not be used because they may cause injury to the skin.

Which activity by the community nurse is an illness prevention strategy? 1 Encouraging the client to exercise daily 2 Arranging an immunization program for chickenpox 3 Teaching the community about stress management 4 Teaching the client about maintaining a nutritious diet

2 An illness prevention program protects people from actual or potential threats to health. A chickenpox immunization program is an illness prevention program. It motivates the community to prevent a decline in health or functional levels. A health promotion program encourages the client to maintain his or her present levels of health. The nurse promotes the health of the client by encouraging the client to exercise daily. Wellness education teaches people how to care for themselves in a healthy manner. The nurse provides wellness education by teaching about stress management. The nurse promotes the health of the client by teaching the client to maintain a nutritious diet.

Which would be included in the plan of care for an obstetrical client who has been taking carbamazepine throughout the first trimester of pregnancy? 1 Evaluation for fetal hydramnios 2 Evaluation for a neural tube defect 3 Evaluation for cardiac malformation 4 Chromosomal assessment for Down syndrome

2 Carbamazepine is associated with neural tube defects. Fetal hydramnios, cardiac malformation, and Down syndrome are not related to the use of carbamazepine.

According to Kohlberg's theory of moral development, which stage is a part of conventional reasoning? 1 Social contract orientation 2 Society-maintaining orientation 3 Instrument relativist orientation 4 Universal ethical principle orientation

2 In Kohlberg's theory, the society-maintaining orientation is stage 4 of conventional reasoning. Social contract orientation is stage 5 of postconventional reasoning. Instrument relativist orientation is stage 2 of preconventional reasoning. Universal ethical principle orientation is stage 6 of postconventional reasoning.

An unconscious 16-year-old adolescent with type 1 diabetes is brought to the emergency department. The blood glucose level is 742 mg/dL (41.2 mmol/L). What finding does the nurse expect during the initial assessment? 1 Pyrexia 2 Hyperpnea 3 Bradycardia 4 Hypertension

2 Rapid breathing is an attempt by the respiratory system to eliminate excess carbon dioxide; it is a characteristic compensatory mechanism for correcting metabolic acidosis. An increase in temperature will occur if an infection is present; it is not a response to hyperglycemia. Tachycardia, not bradycardia, results from the hypovolemia of dehydration. Hypotension, not hypertension, may result from the decreased vascular volume associated with hyperglycemia.

Which is a common attribute that the nurse assesses in an "easy" child? 1 Passive resistance 2 Predictable habits 3 Intense mood expressions 4 Slow adaptation to change

2 The nurse anticipates that the "easy" child will have predictable habits. Passive resistance is a trait assessed in the "slow to warm up" child. Intense mood expressions and slow adaptation to change are characteristics of the "difficult" child.

According to Erikson, which would the nurse anticipate when assessing an adolescent? 1 Being engaged in tasks 2 Questioning sexual identity 3 Having highly imaginative thoughts 4 Wanting to participate in organized activities

2 The nurse would anticipate the adolescent to question sexual identity, according to Erikson. Being engaged in tasks and wanting to participate in organized activities is expected for the school-age child. The nurse would anticipate that a preschool-age child would have highly imaginative thoughts.

A 10-year-old child has been working on earning all of the scouting badges. Which of Erikson's stages of psychosocial development is this child achieving? 1 Identity 2 Industry 3 Intimacy 4 Initiative

2 The school-aged child is working on industry versus inferiority. A sense of accomplishment is an important part of this stage. Erikson classifies the adolescent as working on the development of identity versus confusion. It occurs as the child becomes independent from parents, creates a sense of self, and develops relationships with others. Intimacy versus isolation is the psychosocial developmental stage of young adulthood, when the security of self-identity changes to the insecurity of trying to establish a close relationship with another person. Initiative versus guilt is the psychosocial developmental stage of preschool children, who strive to seek out new experiences and discover their capabilities.

Which type of play do 2-year-old toddlers engage in? 1 Group 2 Parallel 3 Dramatic 4 Cooperative

2 Toddlers play independently but beside other children; they are aware of the other children, often grabbing toys from them, but do not socially interact with them. Group play is characteristic of older children. Dramatic play or acting is characteristic of older children; starting at the preschool age, they assume and act out roles. Cooperative play is also characteristic of older children; starting at the preschool age; they learn to share, wait their turn, and become sensitive to their peers' needs.

Which statements regarding acne are correct? Select all that apply. 1. Acne is a hormonal disease 2. Acne may be caused by stress 3. Family hx could be a reason for it 4. Propionibacterium acnes causes acne 5. Acne is commonly found on the face, chest, lower back, and neck

2, 3, 4

The nurse is obtaining consent from an unemancipated minor to perform an abortion. When would the nurse consider the consent-giving process to be appropriately completed? Select all that apply. One, some, or all responses may be correct. 1 Consent has been obtained from the spouse. 2 Consent has been given specifically by a court. 3 Self-consent has been granted by a court order. 4 Consent has been given by a grandparent. 5 Consent has been obtained from at least one parent of the minor.

2, 3, 5 An unemancipated minor is allowed to consent to an abortion if one of three conditions is fulfilled. The minor may give consent if consent has been obtained from at least one parent. The minor may also give consent if consent has been given specifically by a court or self-consent has been granted by a court order. The spouse or grandparents of unemancipated minors are not allowed to give consent for abortions.

Which qualities would an effective leader exhibit? Select all that apply. One, some, or all responses may be correct. 1. Born with the right stuff 2. Elicit a vision from people 3. Bring out the best in people 4. Engender discipline and obedience 5. Inspire people to bring the vision into reality

2, 3, 5 Leadership is the ability to elicit a vision from people and to inspire and empower those people to do what it takes to bring the vision into reality. A leadership quality is to bring out the best in people. Leaders are not born with the right stuff; rather they develop these qualities gradually over time when they perform with the right kind of attitude and determination. Leaders must possess the ability to inspire the commitment of followers and allow them to achieve goals autonomously rather than simply engendering discipline and obedience.

What over-the-counter drugs are used to treat vulvovaginal candidiases? Select all that apply. 1. Tinidazole 2. Miconazole 3. Clotrimazole 4. Azithromycin 5. Metronidazole

2, 3, Miconazole and clotrimazole are standard over-the-counter drugs used to treat candidiasis

The nurse is gathering a client's health history. Which information would the nurse classify as biographical information? Select all that apply. One, some, or all responses may be correct. 1 Symptoms 2 Client's age 3 Family structure 4 Type of insurance 5 Occupation status

2, 4, 5 Biographical information is factual demographic data about the client usually obtained by the admitting office staff. The client's age, types of insurance, and occupation status are considered biographical information. If the client presents with an illness, the nurse gathers details about the symptoms of the illness, which is descriptive information, not biographical information. The nurse obtains information about family structure while assessing the family history of the client. It is not biographical information.

Which psychophysiological factors influence communication between the nurse and a client? Select all that apply. One, some, or all responses may be correct. 1. Privacy level 2. Emotional status 3. Information exchange 4. Level of caring expressed 5. Growth and development

2, 5 Growth and development and emotional status are two psychophysiological factors that influence communication between the nurse and a client. Privacy level is an environmental factor. Information exchange is a situational factor. Level of caring expressed is a relational factor.

Which genetic syndromes are mostly recognized in adolescence? Select all that apply. One, some, or all responses may be correct. 1 Down syndrome 2 Turner syndrome 3 Edwards syndrome 4 Angelman syndrome 5 Klinefelter syndrome

2, 5 Turner syndrome and Klinefelter syndrome are genetic disorders most commonly recognized in adolescence. Although these syndromes are associated with genetic abnormalities, they may not be detected until adolescence because abnormalities may not become apparent until the client reaches this growth stage. Down syndrome, Edwards syndrome, and Angelman syndrome are recognized in the prenatal to newborn periods.

Which bones are examples of a client's flat bones? Select all that apply. One, some, or all responses may be correct. 1 Sacrum 2 Scapula 3 Sternum 4 Humerus 5 Mandible

2,3 Flat bones such as the scapula and sternum are compact bones separated by a layer of cancellous bone that contains bone marrow. Bones such as the sacrum and mandible are irregular bones; they appear in a variety of shapes and sizes. The humerus is a long bone with a central shaft and two widened ends.

Identify factors associated with an increased incidence of abuse within a family. Select all that apply. One, some, or all responses may be correct. 1 Acute illness 2 Pregnancy 3 Drug abuse 4 Chronic illness 5 Sexual orientation

2,3,5 Pregnancy, drug abuse, and sexual orientation are associated with an increased incidence of abuse within a family. Acute and chronic illness may place stress on the family, but these factors are not specifically linked to a higher incidence of violence.

Which safeguards would the school nurse teach parents to assess for before allowing school-age clients to participate in athletic programs? Select all that apply. One, some, or all responses may be correct. 1 A life-long enjoyment of fitness 2 The use of appropriate equipment 3 The development of basic motor skills 4 A physical examination every year 5 Participation in warm-up exercises before physical activity

2,4,5 Safeguards before participation in athletic programs include a physical examination every year, the use of appropriate equipment, and participating in warm-up exercise before physical activity. A life-long enjoyment of fitness and the development of basic motor skills are goals related to the participation in athletic programs, not safeguards.

Arrange the stages of the menstrual cycle in sequential order. 1. Ovulation 2. Follicular phase 3. Feedback mechanism 4. Follicular involution

2-1-4-3 The menstrual cycle begins with the follicular phase. During this phase, one ovarian follicle becomes dominant and produces a large amount of estrogen. After this phase is ovulation; this occurs when the dominant follicle releases an ovum around day 14 of the cycle. After the ovum is released, the follicle involutes with the decreased production of estrogen and thus progesterone in blood. As a feedback response to this decrease, the pituitary gland increases the production of follicle stimulating hormone, which initiates a new menstrual cycle.

A 55-year-old client reports cessation of menstrual periods for a year. Which term describes the client's condition? 1 Menarche 2 Menopause 3 Dyspareunia 4 Menorrhagia

2. Cessation of menstruation is called menopause; this is an aging process and occurs due to functional decline of the ovaries. The first episode of menstrual bleeding is called menarche. Dyspareunia refers to painful sexual intercourse. Menorrhagia is excessive vaginal bleeding.

A client who is at 20 weeks' gestation visits the prenatal clinic for the first time. Assessment reveals temperature of 98.8°F (37.1°C), pulse of 80 beats per minute, blood pressure of 128/80 mm Hg, weight of 142 lb (64.4 kg) (prepregnancy weight was 132 lb [59.9 kg]), fetal heart rate (FHR) of 140 beats per minute, urine that is negative for protein, and fasting blood glucose level of 92 mg/dL (5.2 mmol/L). Which would the nurse do after making these assessments? 1 Report the findings because the client needs immediate intervention. 2 Document the results because they are expected at 20 weeks' gestation. 3 Record the findings in the medical record because they are not within the norm but are not critical. 4 Prepare the client for an emergency admission because these findings may represent jeopardy to the client and fetus.

2. Document the results because they are expected at 20 weeks' gestation. All data presented are expected for a client at 20 weeks' gestation and should be documented. There is no need for immediate intervention or an emergency admission because all findings are expected.

Which statement describes the latency stage of Freud's psychoanalytic model of personality development? 1 During this stage, genital organs are the focus of pleasure. 2 During this stage, sexual urges are repressed and channeled into productive activities. 3 During this stage, an infant begins to think that his or her parent is separate from the self. 4 During this stage, sexual urges reawaken and are directed to an individual outside the family circle.

2. During the latency stage, Freud believed that sexual urges from the earlier Oedipal stage are repressed and channeled into productive activities that are socially acceptable. During the phallic stage, the genital organs are the focus of pleasure. During the oral stage, infants begin to think that the parent is something separate from the self. During the genital stage, sexual urges reawaken and are directed to an individual outside the family circle. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

Arrange in order the steps involved in the changes that occur during puberty. 1. Stimulation of the gonadal response 2. Triggering of GnRH by the hypothalamus 3. Movement of GnRH through a network of capillaries to the anterior pituitary gland 4. Stimulation of production and secretion of FSH and LH

2. Some events trigger the production of gonadotropin-releasing hormone (GnRH) by the hypothalamus. GnRH travels through a network of capillaries to the anterior pituitary gland and stimulates the production and secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). When the levels of these hormones increase, they in turn stimulate the gonadal response.

After surgery, an adolescent has a patient-controlled analgesia (PCA) pump that is set to allow morphine delivery every 6 minutes. Which statement indicates to the nurse that the family understand instructions about the PCA pump? 1. "I'll make sure that she pushes the PCA button every 6 minutes." 2. "She needs to push the PCA button whenever she needs pain medication." 3. "I'll have to wake her up on a regular basis so she can push the PCA button." 4. "I'll press the PCA button every 6 minutes so she gets enough pain medication while she's sleeping."

2. "She needs to push the PCA button whenever she needs pain medication." Morphine, an opioid analgesic, relieves pain; when control of pain is given to the adolescent, anxiety and pain are usually diminished, resulting in a decreased need for the analgesic; only the adolescent should press the PCA button. Having the adolescent press the PCA button every 6 minutes is unnecessary. Although pain medication can be delivered as often as every 6 minutes, it should be used only if necessary. If the adolescent is sleeping, the pain is under control; waking the adolescent will interfere with rest. If the adolescent is sleeping, the pain is under control; also, this will result in an unnecessary and excessive dosage of the opioid.

How much additional daily protein intake is required by the lactating client? 1 10 g 2 25 g 3 30 g 4 45 g

2. 25 g is the necessary amount of increased daily protein intake recommended for lactating women. 10 g of added protein will not meet the needs of the lactating client. 30 and 45 g are all more than the additional recommended amount, although most women in developed countries exceed this requirement.

Which is the expected color and consistency of amniotic fluid at 36 weeks' gestation? 1 Clear, dark amber colored, and containing shreds of mucus 2 Straw colored, clear, and containing little white specks 3 Milky, greenish yellow, and containing shreds of mucus 4 Greenish yellow, cloudy, and containing little white specks

2. By 36 weeks' gestation, amniotic fluid should be pale yellow or straw-colored with small particles of vernix caseosa present. Dark amber-colored fluid suggests the presence of bilirubin, an ominous sign. Greenish-yellow fluid may indicate the presence of meconium and suggests fetal compromise. Cloudy fluid suggests the presence of purulent material.

Arrange the pathophysiologic events of acne in the correct sequence. 1. Immune response and inflammation 2. Excessive sebum production 3. Alterations in follicular growth and differentiation 4. Colonization of Propionibacterium acnes

2. Excessive sebum production occurs with the maturation of adrenocortical glands. This action is followed by alterations in follicular growth and differentiation. Propionibacterium acnes proliferate and increase in number. This proliferation leads to an accumulation of neutrophils, which causes the formation of papules, pustules, nodules, and cysts and subsequent inflammation.

The nurse tells a client undergoing diuretic therapy to avoid working in the garden on hot summer days. Which condition is the nurse trying to prevent in this client? 1. Frostbite 2. Heatstroke 3. Hypothermia 4. Hyperthermia

2. Heatstroke Clients undergoing diuretic therapy are at risk of heatstroke when exposed to temperatures higher than 104°F (40°C). Frostbite occurs when the body is exposed to ice-cold temperatures. Hypothermia is a condition in which the skin temperature drops below 96.8°F (36°C). Hyperthermia occurs when the body is exposed to temperatures higher than 101.3°F (38.5°C).

Which statement indicates that the nurse is in the advanced beginner stage of Benner? 1 Learns about the profession through a specific set of rules and procedures 2 Identifies the basic principles of nursing care through careful observation 3 Understands the organization and specific care required by certain clients 4 Assesses the entire situation and transfers knowledge gained from multiple previous experiences

2. Identifies the basic principles of nursing care through careful observation According to the levels of proficiency set forth by Benner, the nurse in the advanced beginner stage is able to identify basic principles of nursing care through careful observation. The nurse in the novice stage learns about the profession through a specific set of rules and procedures. After reaching the competent stage, the nurse will be able to understand the organization and specific care required by certain clients. The nurse who has reached the proficient stage is able to assess an entire situation and transfer knowledge gained from multiple previous experiences.

Which disease is caused by the virus that causes chickenpox? 1 Athlete's foot 2 Herpes zoster 3 German measles 4 Infectious hepatitis Invasion of the post

2. Invasion of the posterior (dorsal) root ganglia by the same virus that causes chickenpox can result in herpes zoster, or shingles. This may be caused by reactivation of a previous chickenpox virus that has lain dormant in the body or by recent contact with an individual who has chickenpox. Athlete's foot is caused by a fungus. German measles is caused by a virus, but not the herpes virus. Hepatitis type A is caused by a virus, but not the herpes virus.

Ingestion of which chemicals may cause chemical pneumonia? 1 Bleach 2 Lighter fluid 3 Toilet cleaner 4 Mildew remover

2. Lighter Fluid Certain hydrocarbons, like lighter fluid, can cause severe pneumonia on ingestion. Bleach, toilet cleaner, and mildew remover are corrosives that are not associated with chemical pneumonia.

Which individual completes the developmental questionnaire for an infant using the Developmental (ASQ-3) screening? 1 Child 2 Parent 3 Nurse 4 Primary health care provider

2. The parent completes the questionnaire portion of the Development (ASQ-3) assessment. A health care professional, such as the nurse or primary health care provider, scores the assessment. The child's stage of development is assessed using this process.

Which is the best way for the nurse to promote adherence to the restrictions after colorectal surgery? 1 Limit restrictions to nonessential foods. 2 Handle dietary changes in a matter-of-fact way. 3 Have the dietitian explain the restrictions to the parents. 4 Arrange to have an adult other than a parent stay at mealtime.

2. Toddlers are ritualistic and do not tolerate change well; therefore any change in diet should be done in a matter-of-fact way. Limited restrictions on nonessential foods are not always possible. Although the parents could consult with the dietitian, this action will not change the toddler's response to the dietary restrictions. The toddler is still dependent on the parents and therefore will respond better to them than to a stranger.

Due to the immature immune systems of a toddler, which would the nurse anticipate when the child attends daycare? 1 Poor appetite 2 Minor infections 3 Temper tantrums 4 Bumps and bruises

2. minor infections Due to a continued immature immune system, the nurse anticipates that the toddler-age client who attends daycare will experience an increase in infection due to exposure to new antigens. A poor appetite and temper tantrums are common during the toddler stage of development; however, these are not due to an immature immune system. The toddler client is at risk for injury (bumps and bruises) due to a lack of motor coordination, not an immature immune system.

Which statement describes stage 4 of Kohlberg's theory? Select all that apply. 1 Child recognizes that there is more than one right view. 2 Child shows respect for authority and maintains the social order. 3 Adolescents choose to avoid a party where they know beer will be served. 4 Individual wants to win approval and maintain the expectations of one's immediate group. 5 Child's response to a moral dilemma is in terms of absolute obedience to authority and rules.

23 According to stage 4 of Kohlberg's theory, adolescents show respect for authority and maintain the social order. They choose not to attend a party where beer will be served because they know this is wrong. During stage 2, the child recognizes that there is more than one right view. Stage 3 states that an individual wants to win approval and maintain the expectations of one's immediate group. During stage 1, the child's response to a moral dilemma is in terms of absolute obedience to authority and rules.

What over-the-counter drugs are used to treat vulvovaginal candidiases? Select all that apply. 1 Tinidazole 2 Miconazole 3 Clotrimazole 4 Azithromycin 5 Metronidazole

23 Miconazole and clotrimazole are standard over-the-counter drugs used to treat candidiasis. Tinidazole is used to treat trichomoniasis. Azithromycin is used to treat chlamydia. Metronidazole is used to treat bacterial vaginosis and trichomoniasis.

Which herbal therapies can be recommended to a client with breast pain? Select all that apply. 1 Dong quai 2 Chamomile 3 Bugleweed 4 Chaste tree fruit 5 Black cohosh root

234 Herbal therapies for breast pain include chamomile, bugleweed, and chaste tree fruit. Dong quai is recommended for menstrual cramping and dysmenorrhea. Black cohosh root eases premenstrual discomfort and tension.

The client reports excessive bleeding during the menstruation. Which herbal therapies are unlikely to be prescribed by the primary healthcare provider? Select all that apply. 1 Raspberry 2 Chamomile 3 Lady's mantle 4 Chaste tree fruit 5 Shepherd's purse

24 Chamomile is an antispasmodic agent that helps to reduce breast pain. Chaste tree fruit is used to reduce breast pain by reducing the prolactin levels. Raspberry, lady's mantle, and shepherd's purse are uterotonic drugs used to treat menorrhea.

Which genetically inherited syndromes are mostly recognized in adolescence? Select all that apply. 1 Down syndrome 2 Turner syndrome 3 Edwards syndrome 4 Angelman syndrome 5 Klinefelter syndrome

25 Turner syndrome and Klinefelter syndrome are the genetic disorders most commonly recognized in adolescence. Although these syndromes are associated with genetic abnormalities, they may not be detected until adolescence because abnormalities may not become apparent until the client reaches this growth stage. Down syndrome, Edwards syndrome, and Angelman syndrome are recognized in the prenatal to newborn periods.

A client with chronic renal failure has been on hemodialysis for 2 years. The client communicates with the nurse in the dialysis unit in an angry, critical manner and is frequently noncompliant with medications and diet. The nurse can best intervene by first considering that the client's behavior is most likely for which reason? 1 An attempt to punish the nursing staff 2 A constructive method of accepting reality 3 A defense against underlying depression and fear 4 An effort to maintain life and to live it as fully as possible

A nurse is caring for a 13-year-old child who has an external fixation device on the leg. What is the nurse's priority goal when providing pin care? 1 Easing pain 2 Minimizing scarring 3 Preventing infection 4 Preventing skin breakdown

During a home visit, a nurse discovers that a child in the household has a disability and has been experiencing seizures. In addition, the child's parent is indifferent to the child's physical, emotional, or medical needs and seems to provoke seizure episodes by harsh verbal exchanges with the child. The nurse believes that an intervention by an appropriate community resource is indicated. Where should the nurse direct the referral? 1 Outpatient clinic 2 Hospital pediatric unit 3 Child Protective Services 4 Bureau of the handicapped

The nurse is performing an assessment of a female client's reproductive system. Which action should the nurse take? 1 Maintain friendly demeanor with the client during assessment 2 Ask about sexual practices at the beginning of assessment 3 Ask about menstrual history at the beginning of assessment 4 Maintain gender-specific terms while questioning during assessment

Which hearing disorder is most common in women? 1 Tinnitus 2 Hyperacusis 3 Otosclerosis 4 Meniere's disease

Which school-age client would the nurse anticipate will experience sibling rivalry as a source of stress? 1 A 9-year-old male 2 A 7-year-old male 3 A 6-year-old female 4 An 8-year-old female

3 A 6-year-old school-age client is most likely to experience sibling rivalry as a source of stress. The 9-year-old, 7-year-old, and 8-year-old are not as likely to experience sibling rivalry as a source of stress.

By which age should an infant have had his or her first dental examination? 1 3 months 2 9 months 3 12 months 4 18 months

3 A child will have completed an initial dental visit by the age of 12 months. The initial examination should be completed by age 6 months or within 6 months of the first tooth erupting, which averages at around the age of 12 months.

Which of these behaviors does an adolescent exhibit? 1 Temper tantrums 2 Attempts to control situations 3 Synchronization of moral skills 4 Eagerness for formal education

3 Adolescents refine and synchronize physical, psychosocial, cognitive, and moral skills to become an accepted member of society. Toddlers tend to have temper tantrums. Toddlers also learn about how to control situations. Preschoolers refine the mastery of their bodies and eagerly await the beginning of formal education.

When teaching an adolescent with type 1 diabetes about dietary management, what instruction should the nurse include? 1 Meals should be eaten at home. 2 Foods should be weighed on a gram scale. 3 A ready source of glucose should be available. 4 Specific foods should be cooked for the adolescent.

3 An adolescent with type 1 diabetes must carry a source of simple sugar (e.g., glucose tablets, Insta-Glucose, sugar-containing candy such as LifeSavers) to rapidly counteract the effects of hypoglycemia. This should be followed by a complex carbohydrate and a protein. Stating that meals should be eaten at home is an unrealistic and unnatural instruction for an adolescent. Stating that foods should be weighed on a gram scale is an unnecessary and time-consuming procedure. The adolescent should be made to feel a part of the family; the recommended diet is nutritious and no different from that of the rest of the family.

How do adolescents establish group identity during psychosocial development? 1 By evaluating their own health with a feeling of well-being 2 By fostering their independence with balanced family structure 3 By building close peer relationships in order to achieve acceptance in the society 4 By achieving marked physical changes with masculine and feminine behaviors

3 By building close peer relationships, adolescents develop a sense of belonging, approval, and the opportunity to learn acceptable behavior. This action establishes group identity. An adolescent establishes health identity by evaluating his or her own health with a feeling of well-being. An individual establishes family identity by fostering his or her independence within a balanced family structure. The sound and healthy growth of an adolescent, with marked physical changes, helps the adolescent build sexual identity.

Which nutrient deficiency in the pregnant adolescent may result in decreased birth weight as a consequence of low bone mineral density in the fetus? 1 Zinc 2 Iron 3 Calcium 4 Folic acid

3 Calcium and vitamin deficiency may result in decreased birth weight as a consequence of low bone mineral density. Zinc deficiency may not lead to a decrease in bone mineral density. Iron deficiency may lead to anemia. Folic acid deficiency may result in neural tube defects.

The nurse is teaching a class about nutrition to a group of adolescents. Taking into consideration the prevalence of overweight teenagers, what is the best recommendation the nurse can make? 1 "Join a gym." 2 "Drink fewer diet sodas." 3 "Decrease fast food intake." 4 "Take a multivitamin daily."

3 Eating a variety of healthful foods instead of a fast-food diet that is high in fat and carbohydrates helps decrease excess weight and increase energy with which to engage in physical activities. Joining a gym is expensive and unnecessary. Physical activity can be achieved in the schoolyard or at home. A multivitamin will not promote weight loss. Vitamins and minerals are best obtained in a balanced diet. Diet soft drinks do not contribute to obesity.

An 18-year-old adolescent male complains of painful urination and yellow-green mucosal discharge from urethra not associated with abdominal pain. What condition is the client likely to have? 1 Varicocele 2 Testicular torsion 3 Epididymitis 4 Gynecomastia

3 Epididymitis is a condition characterized by dysuria, pyuria, scrotal pain, redness, and swelling. Epididymitis is not associated with gastrointestinal symptoms as in testicular torsion. Varicocele is a condition characterized by elongation, dilation, and tortuosity of the veins of the spermatic cord superior to the testicle which is not associated with urethral discharge. Gynecomastia has no symptoms of abnormal urethral discharge.

Which statement is accurate regarding erythropoietin? 1 Erythropoietin is released by the pancreas. 2 An erythropoietin deficiency causes diabetes. 3 An erythropoietin deficiency is associated with renal failure. 4 Erythropoietin is released only when there is adequate blood flow.

3 Erythropoietin is produced by the kidneys; its deficiency occurs in renal failure. Erythropoietin is released by the kidneys, not the pancreas. Erythropoietin deficiency causes anemia. Erythropoietin is secreted in response to hypoxia, which results in decreased oxygenated blood flow to the tissue

Which gestational period would the nurse identify as appropriate for the administration of corticosteroids during preterm labor? 1 Less than 20 weeks 2 20 to 24 weeks 3 24 to 34 weeks 4 More than 34 weeks

3 If preterm labor occurs during 24 to 34 weeks of gestation and if labor is unavoidable, corticosteroids should be administered to promote lung maturity. Labor occurring before 20 weeks of gestation usually results in a nonviable fetus; corticosteroids would not need to be administered. Corticosteroids do not promote lung maturation during 20 to 24 weeks of gestation. Fetal lungs mature at 34 weeks of gestation. A fetus in this period of gestation would not require the administration of corticosteroids if labor is unavoidable.

In which stage of Kohlberg's theory of moral development would the nurse anticipate a client who wants to maintain expectations with his or her immediate group? 1 Stage 1 2 Stage 2 3 Stage 3 4 Stage 4

3 In level II, conventional reasoning, stage 3, the nurse anticipates a client who wants to win approval and maintain expectations of his or her immediate group. In level I, preconventional reasoning, stage 1, the nurse anticipates absolute obedience to authority and rules. In level I, stage 2, the nurse anticipates that the child will realize there is more than one right view. In level II, stage 4, the client expands focus from the relationship with others to societal concerns.

In which period of Piaget's theory does the adolescent feel a sense of invulnerability? 1 Sensorimotor 2 Preoperational 3 Formal operations 4 Concrete operations

3 In the formal operation period, the fourth period of Piaget's theory, the adolescent feels a sense of invulnerability. This leads to risk-taking behaviors. In the sensorimotor period, the first period of Piaget's theory, the infant develops a schema or action pattern for dealing with the environment. Period II is the preoperational period. During this time, a child learns to think with the use of symbols and mental images. The period of concrete operations is the third period of Piaget's theory. At this time, the child is able to coordinate two concrete perspectives in social and scientific thinking.

An adolescent who has had a leg amputated because of bone cancer begins to experience phantom limb sensations. How should the nurse respond when the client complains of pain and requests medication? 1 By withholding the medication to help prevent addiction 2 By stating that the limb has been removed and that the pain is psychological 3 By acknowledging that the pain is real and administering medication to relieve it 4 By explaining that the phantom limb sensation will subside within a few more days

3 Pain medication is required, along with intensive supportive nursing care. To the client the pain is real, requiring pain medication; addiction is not a concern at this time. Explaining that the pain is psychological in origin does not help relieve the pain; medication and emotional support are required. The pain may not recede within a few days; pain medication should be administered.

An adolescent with terminal cancer tells the home care nurse, "I'd really like to get my general education development (GED) certificate. Do you think that's possible?" What is the best approach for the nurse to take in response to the adolescent's question? 1 Refocusing the conversation on things the adolescent has already accomplished in life 2 Trying to help the adolescent understand that this goal is too taxing and slightly unrealistic 3 Arranging a conference with the school and encouraging the adolescent to prepare for the test 4 Suggesting to the adolescent that this energy should be directed toward expressing feelings about the illness

3 Passing the high school equivalency test is the client's desire, and the nurse should do everything possible to help the client fulfill the goal. Refocusing the conversation on things that the adolescent has already accomplished in life is not therapeutic; the client has an unmet need, and the nurse should not try to refocus the client away from the stated objective. The client should be encouraged, not discouraged; mental activity is not too taxing and is not unrealistic if the client wishes to engage in it. There are no data supporting the conclusion that the client needs to work through feelings about the illness.

Which drug used to treat syphilis is contraindicated in pregnancy? 1 Miconazole 2 Clotrimazole 3 Tetracycline 4 Metronidazole

3 Tetracycline can be administered to clients with syphilis who are allergic to penicillin G. This drug is contraindicated in pregnant women, as it can cause birth defects or staining/discoloration to the fetus' developing teeth if given during the second trimester. Miconazole and clotrimazole are used to treat candidiasis. Metronidazole is used to treat bacterial vaginosis.

Which medication treatment may have been given during gestation to a mother whose baby was born with shortened limbs? 1 Phenytoin 2 Topiramate 3 Thalidomide 4 Carbamazepine

3 Thalidomide is an anticancer medication that may cause shortening of the limbs as a teratogenic effect. Phenytoin, topiramate, and carbamazepine are antiseizure medications that may cause growth delays and neural tube defects.

The nurse is teaching crutch-walking to a 12-year-old adolescent. What does the child do that indicates the need for more teaching? 1 Takes short steps of equal length 2 Looks forward to maintain balance 3 Looks down when placing the crutches 4 Assumes an erect posture when walking

3 The child should maintain an erect walking posture, without looking down, to ensure equilibrium and prevent loss of balance. Taking short steps is the correct technique for safe ambulation while crutch-walking. Looking forward is the correct technique for safe ambulation while crutch-walking; it keeps the body's center of gravity over the hips. Maintaining an erect posture is the correct technique for safe ambulation during crutch-walking; it keeps the body's center of gravity over the hips.

Which statement regarding the teenage diet is true? 1 Adolescents are fond of healthy food 2 Adolescents need vitamin supplements 3 Adolescents need high amounts of calories 4 Adolescents require low amounts of protein

3 The energy needs of teenagers increase to meet the greater metabolic demands of growth. Adolescents are fond of eating fast food at restaurants. Vitamin supplements are not required for teenagers. The daily requirement of protein increases in teenagers.

Which action would the nurse take for an older client with Alzheimer disease who sleeps very little and becomes more disoriented from sleep deprivation? 1 Shut the client's door during the night. 2 Apply a vest restraint when the client is in bed. 3 Leave a dim light on in the client's room at night. 4 Administer the client's prescribed as-needed sedative medication.

3 The nurse would leave a dim light on in the client's room at night. A small light in the room may prevent misinterpretation of shadows, which can heighten fear and alter the client's perception of the environment. A disoriented and confused client should be closely observed, not isolated by closing the door. Restraints are a last resort; less restrictive interventions should be used first. Sedatives should be used sparingly in older adults, because they may cause further confusion and agitation.

Which hormone aids in regulating intestinal calcium and phosphorous absorption? 1 Insulin 2 Thyroxine 3 Glucocorticoids 4 Parathyroid hormone

3 Adrenal glucocorticoids aid in regulating intestinal calcium and phosphorous absorption by increasing or decreasing protein metabolism. Insulin acts together with growth hormone to build and maintain healthy bone tissue. Thyroxine increases the rate of protein synthesis in all types of tissues. Parathyroid hormone secretion increases in response to decreased serum calcium concentration and stimulates the bones to promote osteoclastic activity.

The nurse observes that an 18-month-old toddler is crawling up stairs but needs assistance when climbing the stairs upright. Which would this indicate to the nurse? 1 Presence of talipes equinovarus 2 Presence of neurological damage 3 Expected behavior in a toddler of this age 4 Existence of developmental dysplasia of the hip

3 It is not until 2 years of age that toddlers are able to use their feet to walk up stairs instead of crawling. Talipes equinovarus is identified with the use of other criteria. At 18 months of age the inability of the toddler to use the feet to go up stairs is not a problem; it is expected and does not indicate neurological damage. Developmental dysplasia of the hip is identified with the use of other criteria.

If hearing loss is detected early, proper intervention can help a child achieve normal language development. Which should be the latest age that hearing loss should be detected to ensure that a child achieves normal language development? Record your answer using a whole number. ______________ months

3 months If a health care provider detects hearing loss before the child is 3 months old and an intervention is initiated within 6 months, the child can achieve normal language development.

Which activities can a child perform at 3 years of age? Select all that apply. One, some, or all responses may be correct. 1 Jumping rope 2 Drawing triangles 3 Turning doorknobs 4 Holding crayons with fingers 5 Eating with a spoon without rotating it 6 Classifying objects based on size and color

3,4,5 At the age of 3 years, a child can turn the pages of a book one at a time and can easily turn doorknobs. The child can now hold crayons with the fingers. A 3-year-old child can manage to eat with a spoon without rotating it. A preschooler by the age of 5 years is able to jump rope and can easily draw triangles and diamond shapes. By the age of 3 years, a child is able to drink from a cup without spilling it. A preschooler, not a toddler, is able to classify objects according to their size or color. Test-Taking Tip: On a test day, eat a normal meal before going to school. If the test is late in the morning, take a high-powered snack with you to eat 20 minutes before the examination. The brain works best when it has the glucose necessary for cellular function.

Which physiological changes should be noticed in an adolescent during puberty? Select all that apply. One, some, or all responses may be correct. 1 Increase in the respiratory rate 2 Increase in the number of neurons 3 Increase in number of neural connections 4 Decrease in the basal body temperature gradually 5 Increase in serum iron, hemoglobin, and hematocrit

3,4,5 During puberty, as a part of normal physiological growth, there is proliferation of support cells that nourish the neurons along with increase in number of neural connections in the brain. The basal body temperature decreases gradually and reaches adult value by 12 years of age. The size and strength of heart, blood volume, systolic blood pressure, serum iron levels, hemoglobin, and hematocrit values increase whereas heart rate decreases and reaches adult value. The diameter and length of the lungs increase, but respiratory rate decreases gradually to reach the adult value by adolescence. The growth of neurons does not increase but slows to a more gradual rate by adolescence.

Which instruction would the nurse include when teaching episiotomy care? 1 Rest with legs elevated at least 2 times a day. 2 Avoid stair climbing for several days after discharge. 3 Perform perineal care after toileting until healing occurs. 4 Continue sitz baths 3 times a day if they provide comfort.

3. Performing perineal care after toileting until the episiotomy is healed is critical to the prevention of infection, which is at the core of episiotomy care. Resting is encouraged to promote involution and general recovery from childbirth. Stair climbing may cause some discomfort but is not detrimental to healing. There is no limit to the number of sitz baths per day that the client may take if they provide comfort. Test-Taking Tip: Calm yourself by closing your eyes, putting down your pencil (or computer mouse), and relaxing. Deep-breathe for a few minutes (or as needed, if you feel especially tense) to relax your body and to relieve tension.

In which stage of Erikson's theory does the child initiate self-care activities? 1 Initiative versus guilt 2 Integrity versus despair 3 Autonomy versus sense of shame and doubt 4 Generativity versus self-absorption and stagnation

3. The development of self-care activities in a toddler occurs at the stage of autonomy versus a sense of shame and doubt; this is the second stage of Erikson's theory. The initiative versus guilt stage is the third stage of Erikson's theory. During this stage, children like to pretend and try out new roles. Integrity versus despair is the eighth stage of Erikson's theory. At this stage, many older adults view their lives with a sense of satisfaction. Middle-age adults achieve success at the stage of generativity versus self-absorption and stagnation. Individuals contribute to future generations through parenthood, teaching, and community involvement. Test-Taking Tip: Sometimes the reading of a question in the middle or toward the end of an exam may trigger your mind with the answer or provide an important clue to an earlier question.

How would the nurse prevent footdrop in a client with a leg cast? 1 Encourage complete bed rest to promote healing of the foot. 2 Place the foot in traction. 3 Support the foot with 90 degrees of flexion. 4 Place an elastic stocking on the foot to provide support.

3. To prevent footdrop (plantar flexion of the foot because of weakness or paralysis of the anterior muscles of the lower leg) in a client with a cast, the foot should be supported with 90 degrees of flexion. Bed rest can cause footdrop, and 45 degrees is not enough flexion to prevent footdrop. Application of an elastic stocking for support also will not prevent footdrop; a firmer support is required.

The parents of a 2-year-old child are watching the nurse administer the Denver II Developmental Screening Test to their child. They ask, "Why did you make our child draw on paper? We don't let our child draw at home." Which is the best response by the nurse? 1. "I should have asked you about drawing first." 2. "These drawings help us determine your child's intelligence." 3. "It lets us test the child's ability to perform tasks requiring the hands." 4."I don't understand why drawing is forbidden in your home."

3. "It lets us test the child's ability to perform tasks requiring the hands." The Denver II Developmental Screening Test is one of the tests used to evaluate young children whose development appears to be behind the norm. It involves the use of a variety of methods to determine the level of development. The parents gave their consent to have the test done and were told that a variety of skills would be tested. A developmental screening test is designed not to test intelligence, but rather to test the child's ability to perform specific age-appropriate developmental tasks. It is inappropriate to question the parents' childrearing ability.

Which point listed by the nursing student is accurate regarding the loss of a client's medication records? 1 "Loss of medical records may lead to libel charges." 2 "The registered nurse would maintain accurate nursing records." 3 "There is an assumption that the care provided to the client was negligent." 4 "The health care facility needs to demonstrate why the medical records were lost."

3. "There is an assumption that the care provided to the client was negligent." In case a client's medical record is lost, there is an assumption that the care provided to the client was negligent. Loss of medical records may lead to a malpractice claim. The entire institution is responsible for maintaining medical records. Primary health care providers need to demonstrate why the medical records were lost.

Which is the range of heart rate for a healthy, alert neonate? 1 120 to 180 beats/min 2 130 to 170 beats/min 3 110 to 160 beats/min 4 100 to 130 beats/min

3. 110 to 160

Which organization assists in establishing policies related to Medicare and Medicaid payment for meaningful use of electronic health records (EHRs)? 1 National Institutes of Health (NIH) 2 American Medical Informatics Association (AMIA) 3 Center for Medicare and Medicaid Services (CMS) 4 Health Information Management Systems Society (HIMSS)

3. Center for Medicare and Medicaid Services (CMS) CMS rules specify how health care facilities and providers make meaningful use of the EHRs and technologies to receive payment from Medicare and Medicaid. The NIH uses translational bioinformatics for medical research. The AMIA and the HIMSS have been involved in identifying nursing informatics competencies.

Which defines assessment? 1 Coordinating care delivery 2 Analyzing assessment data to determine diagnoses or issues 3 Collecting comprehensive data pertinent to the client's health and/or situation 4 Registered nurse provides consultation to influence an identified plan

3. Collecting comprehensive data pertinent to the client's health and/or situation Assessment is the process of collection of comprehensive data pertinent to the client's health and/or situation. Coordination of care refers to delivering care to the client. Diagnosis refers to analyzing the assessment data to determine the diagnoses or issues. Consultation is the process where a registered nurse discusses with other health care providers to influence the identified plan, enhance the abilities of other caregivers, and effect change.

Which preventive and primary care service provided by a community health center is most expensive? 1 Running errands 2 Health education 3 Disease management 4 Routine physical examinations

3. Disease management Disease management is the most expensive service provided by community health centers. Running errands is relatively inexpensive, because the cost is the merely the cost of transportation. Health education and routine physical examinations are inexpensive and can usually stop complications of diseases, which prevents from having to "manage" diseases, leading to costly and expensive treatment.

What is gynecomastia? Select all that apply. 1 Inflammation of epididymis of testis 2 Suspended testis from its vascular structures 3 Bilateral or unilateral enlargement of breast in adolescent boys 4 Elongation and dilation of the veins of the spermatic cord superior to the testicle 5 An unusual physical change during the growth and development of sexual organs

35 Gynecomastia is a bilateral or unilateral enlargement of breast seen in adolescent boys. It is an unusual change during growth and development and subsides on its own. Gynecomastia is caused by a hormone imbalance of testosterone and estrogen. Epididymitis is inflammation of epididymis of testis. Intravaginal torsion of the testicle is a condition in which the tunica vaginalis, which normally encases the testicle, fails to do so and the testis hangs free from its vascular structures. A varicocele is characterized by elongation, dilation, and tortuosity of the veins of the spermatic cord superior to the testicle.

Which of these statements regarding adolescents are true? Select all that apply. 1 Homicide is infrequent among adolescents. 2 Suicide is the leading cause of death in adolescents. 3 The United States has the highest rate of teenage pregnancy. 4 Half of all adolescents have use alcohol by the end of the high school. 5 Anorexia nervosa and bulimia are two eating disorders found in adolescence.

35 The United States has the highest annual rates of teenage pregnancy and childbearing among the industrialized nations. Anorexia nervosa and bulimia are two eating disorders found in adolescents. Homicide is not infrequent; it is the second leading cause of death among adolescents. Motor vehicle accidents, not suicide, are the leading cause of death among adolescents. Eighty-five percent of adolescents, not 50%, have used alcohol by the end of high school.

A client with parkinsonism is taking an anticholinergic medication for morning stiffness and tremors in the right arm. During a visit to the clinic, the client complains of some numbness in the left hand. What is the nurse's priority intervention? 1 Refer the client to the primary healthcare provider only if other neurologic deficits are present. 2 Ask the primary healthcare provider to increase the client's dosage of the anticholinergic medication. 3 Stress the importance of having the client call the primary healthcare provider as soon as possible. 4 Make arrangements immediately for further medical evaluation by the client's primary healthcare provider.

The nurse provides discharge teaching to a client who had a transurethral vaporization of the prostate. Which statement by the client indicates successful learning? 1 "I should sit for several hours daily." 2 "I should attempt to void every 2 hours when I'm awake." 3 "I should avoid vigorous exercise for 6 months after surgery." 4 "I should notify my primary healthcare provider if my urinary stream decreases."

The nurse recognizes which mental process is associated with deterioration that accompanies aging? 1 Judgment 2 Intelligence 3 Creative thinking 4 Short-term memory

Which education would the nurse provide the parents of a 6-week-old immunocompromised infant about why their baby is still so healthy? 1 Exposure to pathogens during this time can be limited. 2 Some antibodies are produced by the infant's colonic bacteria. 3 Bottle feeding with soy formula has boosted the immune system. 4 Antibodies are passively received from the mother through the placenta and breast milk

Which stage of Kohlberg's theory of moral development defines "right" by the decision of the conscience? 1 Social contract orientation 2 Society-maintaining orientation 3 Instrumental relativist orientation 4 Universal ethical principle orientation

Which type of joint is present in the client's shoulders? 1 Pivotal 2 Saddle 3 Condyloid 4 Spheroidal

While assessing a client the nurse observes abnormal rigidity with pronation of the arms. Which condition should the nurse record in the assessment findings? 1 Decortication 2 Pronator drift 3 Babinski's sign 4 Decerebration

A 14-year-old teenager with type 1 diabetes wants to go out to eat with friends after a volleyball game. The teenager asks the school nurse whether this is permissible on the insulin/diet/exercise regimen that has prescribed. How should the nurse respond? 1 "Fast foods are unhealthy, especially for teenagers with diabetes." 2 "It would be best if you ate at home, where you can control your diet." 3 "Go with your friends but make an effort to eat something other than pizza." 4 "I'll teach you how to determine the amount of carbohydrates in different fast foods."

4 A fast food exchange list allows the diabetic teenager to participate in postgame activities without feeling different from peers; this is important to the adolescent. The nutritional benefits of fast foods are not the issue. The adolescent needs to learn how to select appropriate foods when away from the home environment; this will promote social interaction with peers. Eating a different food when all of the friends are eating pizza will make the adolescent feel different from the peers; the temptation not to adhere to the diet may be too great to resist.

Which tissue connects the client's tibia to the femur at the knee joint? 1 Fascia 2 Bursae 3 Tendons 4 Ligaments

4 A ligament is a dense, fibrous connective tissue that connects bone to bone, such as the tibia to the femur at the knee joint. Ligaments provide stability while permitting controlled movement at the joint. Fascia is a connective tissue that can withstand limited stretching; it provides strength to muscle tissues. Bursae are small sacs of connective tissue lined with synovial membrane and synovial fluid that are located at bony prominences and joints to relieve pressure. A tendon is a dense, fibrous connective tissue that attaches muscle to bone.

At which stage of Kohlberg's theory does an individual show societal concerns? 1 Stage I 2 Stage II 3 Stage III 4 Stage IV

4 According to Kohlberg's theory of moral development, at stage IV the individual expands focus from a relationship with others towards societal concerns. At stage I, the child is afraid of punishment. A child in this stage reasons, "I must follow the rules; otherwise I will be punished." At stage II, the child recognizes that there is more than one right view. At stage III, the child wants to win approval and maintains the expectations of one's immediate group.

An adolescent with Duchenne muscular dystrophy has received care at the pediatric clinic since early childhood. Of which body system should the nurse perform a focused assessment to identify life-threatening complications as the child ages? 1 Neurologic 2 Gastrointestinal 3 Musculoskeletal 4 Cardiopulmonary

4 As muscular degeneration advances in the adolescent, the diaphragm, auxiliary muscles of respiration, and heart are affected, resulting in life-threatening respiratory infections and heart failure. Central nervous system functioning is not affected by Duchenne muscular dystrophy. Nutritional problems are less of a priority than cardiopulmonary problems. Although the musculoskeletal system will exhibit marked degeneration, it is second in priority to the cardiopulmonary changes.

What is the most major cause of acne in adolescent women? 1 Stress 2 Dietary intake 3 Family history 4 Hormonal imbalance

4 Hormonal imbalances cause premenstrual flares of acne in nearly 70% of women. A clear association between stress and acne has not been demonstrated. A research study showed that 45% of adolescent men have a family history of acne. Studies show some evidence of an association between the intake of dairy products and high glycemic-index foods and acne.

A full-term infant who is large for gestational age (LGA) should be monitored for which risk? 1 Hypotension 2 Hypothermia 3 Hypocalcemia 4 Hypoglycemia

4 Infants that are LGA are considered at risk for hypoglycemia, and their glucose should be monitored following a protocol. LGA infants are not at an increased risk for hypotension, hypothermia, or hypocalcemia.

A nurse teaches a teenager who is undergoing chemotherapy about the need for special mouth care because of the potential for lesions. What statement by the teenager leads the nurse to conclude that the instructions have been understood? 1 "I'll brush my teeth with baking soda." 2 "I'll use mouthwash to rinse my mouth." 3 "I'll swish my mouth out with hydrogen peroxide." 4 "I'll use a soft-bristled toothbrush to clean my teeth."

4 Soft bristles are less irritating to the oral mucosa and less likely to cause trauma than irritating substances are. Baking soda, mouthwash, and hydrogen peroxide are all caustic substances that may irritate the mucosa.

Which would evidence of the Babinski reflex indicate during a newborn assessment? 1 Hypoxia during labor 2 Neurological injury during birth 3 Hyperreflexia of the muscular system 4 Immaturity of the central nervous system (CNS)

4 Stimulation of the newborn's immature neuromuscular system causes dorsiflexion of the big toe and fanning of the remaining toes (Babinski sign). CNS damage resulting from hypoxia may manifest as a lack of Babinski sign. The newborn would not elicit the Babinski reflex if there were neurological injury during birth. Hyperreflexia is an abnormal increase in reflexes; it is not related to the Babinski reflex.

At which age is a toddler physiologically and psychologically prepared for toilet training? 1 13 months 2 16 months 3 19 months Correct 4 22 months

4 The 22-month-old toddler is both physiologically and psychologically prepared for toilet training. The 13-month-old, 16-month old, and 19-month old are not yet physiologically and psychologically prepared for toilet training.

An auditory screening reveals that a child has mild hearing loss. Which statement would the nurse use to explain this degree of hearing loss? 1 "A severe hearing deficit may develop." 2 "It will not interfere with progress in school." 3 "An immediate follow-up visit is not necessary." 4 "Speech therapy and hearing aids may be required."

4. A mild degree of hearing loss causes the child to miss 25% to 40% of conversations; it may result in speech deficits and interfere with the child's educational progress if it is not corrected. Hearing aids usually help improve function. There is no evidence that this child's hearing loss is progressive. The significance of the hearing loss requires further analysis and intervention.

Which order should parents introduce new foods to a 5-month-old who is now eating fortified cereal mixed with formula? 1 Meats and fish 2 Eggs and cheeses 3 Citrus fruits and bread 4 Vegetables and non-citrus fruits

4. Generally it is recommended that vegetables and non-citrus fruits be introduced after cereals because they are easily digested. The introduction of meats and fish, eggs and cheeses, and citrus fruit and bread should be delayed until after 6 months of age.

Client-Medication A-Isoniazid B-Rifampin C-Pyrazinamide D-Ethambutol Which tuberculosis client is at risk for developing optic neuritis? 1. Client A 2. Client B 3. Client C 4. Client D

4. Client D Ethambutol is an antitubercular medication that causes optic neuritis. Client D is at risk for optic neuritis. Client A is at risk for vitamin B deficiency. Client B is at risk for liver toxicity. Client C is at risk for sunburn.

what does the professional nurse consider to be the center of decision-making when providing client care? A) ethics of care B) nursing skills C) analytical skills D) research based practice

The nurse teaches a pregnant client regarding the necessity for a folic acid supplement. Folic acid taken in the first trimester of pregnancy helps reduce the risk for which neonatal disorder? 1 Phenylketonuria 2 Down syndrome 3 Neural tube defects 4 Erythroblastosis fetalis

A folic acid supplement (0.4 mg/day) greatly reduces the incidence of fetal neural tube defects. Phenylketonuria is a genetic disorder that cannot be prevented by the action of folic acid. Down syndrome is a genetic disorder that also cannot be prevented by the action of folic acid. Erythroblastosis fetalis is related to the Rh factor and is not prevented by the action of folic acid.

A client is admitted to the hospital after having a tonic-clonic seizure and is diagnosed with a seizure disorder. Which is most important for the nurse to include in a teaching program? A. Explain strategies a client might use to prevent physical trauma from occurring during a seizure B. Teach the client to take anticonvulsant medications on an empty stomach C. Teach the client that the symptoms and treatment of seizure disorders are similar, regardless of the cause D. Explain that sharing the knowledge of their illness with others is not necessary, because the medications will control the seizures

A client with Parkinson disease is admitted to the hospital. Which medication is prescribed to improve the physical manifestations of Parkinson disease? A. Carbidopa-Levodopa B. Isocarboxazid C. Dopamine D. Pyridoxine

A client suspected of having myasthenia gravis is scheduled for an edrophonium chloride test. To treat a common complication associated with the test, the nurse will have which medication available? A. Atropine B. Phenytoin C. Neostigmine D. Diphenhydramine

A. Atropine treats sudden muscle weakness that can cause respiratory distress

A client is admitted to the hospital with a tentative diagnosis of Guillain-Barré syndrome. Which question by the nurse will elicit information consistent with this diagnosis? A. Have you experienced an infection recently? B. Is there a history of the disorder in your family? C. Did you receive a head injury in the past year? D. What medications have you taken in the past year?

A. it's linked to several other diseases and comes a few weeks laters

A client reports nasal discharge, sneezing, lacrimation, and itching all over the body. During an assessment, the client reports exposure to dusts and molds. The nurse observes swelling and a pink color at the itching site. Which class of medications would the nurse anticipate administering to treat this client's condition? A. Medications containing antihistamines B. Antipruritic medications C. Mast cell-stabilizing medications D. Leukotriene receptor antagonists

A. ! Mast-cell stabilizing are used to manage not treat allergic rhinitis !

A diagnosis of myasthenia gravis is suspected for a client who sees the primary health care provider because of fatigue, double vision, and muscle weakness. Which information would the nurse expect the client to report? A. Muscle weakness improving after a period of rest B. Symptoms worse in the morning upon awakening C. Intermittent periods of hyperactivity D. Slow, insidious onset of muscle weakness

A. weakness and fatigue come quickly and fade with rest

The nurse is assessing an adolescent after the administration of epinephrine. Which side effect is most important for the nurse to identify? A. Tachycardia B. Hypoglycemia C. Constricted pupils D. Decreased blood pressure

A. Tachycardia

Which consistent approach would the nurse use for a client with an antisocial personality disorder? A. Warm and firm without being punitive B. Indifferent and detached but nonjudgmental C. Conditionally acquiescent to client demands D. Clearly communicative of personal disapproval

A. Warm and firm without being punitive The nurse would be warm and firm without being punitive. The client needs positive relationships with other adults, but clear, consistent limits must be presented to minimize attempts at manipulation. Acting indifferent and detached but nonjudgmental is not a therapeutic approach. Being indifferent and detached gives the impression that the nurse does not care. Being conditionally acquiescent to client demands is not a therapeutic approach because clear, consistent limits are necessary to prevent manipulation. Being clearly communicative of personal disapproval is a judgmental attitude that should be avoided.

Which would the nurse identify as increasing the risk of human immunodeficiency virus (HIV) transmission? Select all that apply A. Childbirth B. Monogamy C. Breast-feeding D. Needle sharing E. Sharing plates and utensils

A., C., D.

According to Kohlberg's theory, which stage comes before the society-maintaining orientation stage? 1 Social contract orientation 2 Good boy-nice girl orientation 3 Instrumental relativist orientation 4 Punishment and obedience orientation

According to Kohlberg's theory, the good boy-nice girl orientation phase (stage 3) occurs before the society-maintaining orientation phase (stage 4). Social contract orientation is the fifth stage. Instrumental relativist orientation is the second stage.

Which information about nausea and vomiting in the first trimester would the nurse provide to the pregnant client? 1 It is always present during early pregnancy. 2 It will disappear when lightening occurs. 3 It is a common response to an unwanted pregnancy. 4 It may be related to an increased human chorionic gonadotropin level.

An increased level of human chorionic gonadotropin, or hCG, may cause nausea and vomiting, but the exact reason is unknown. Some pregnant women do not experience nausea and vomiting. Lightening occurs at the end of the third trimester; nausea and vomiting usually cease at the end of the first trimester. Nausea and vomiting are unrelated to whether a pregnancy is desired or unwanted.

Which of these cultural groups adopts a combination of dietary, herbal, and other naturalistic therapies to prevent and treat illness? 1 East Asian 2 Hispanic 3 Asian Indian 4 Native American

Asian Indian

A nurse is counseling a client with amyotrophic lateral sclerosis (ALS) about management of this disorder. What important suggestion should the nurse make to the client? A. Eye surgery may improve your vision B. Activities should be spaced throughout the day C. Opioids may be necessary for the pain in your legs D. Leg restraints will decrease the chance of physical injury

B. Conserve energy and space activities because a progressive disease

Which procedure would the nurse expect as a treatment option for a client newly diagnosed with Guillain-Barré syndrome? A. Hemodialysis B. Plasmapheresis C. Thrombolytic therapy D. Immunosuppression therapy

B. its like fixing the plasma

Which term would a nurse use to document observing the characteristic gait associated with Parkinson's disease? A. Ataxic B. Shuffling C. Scissoring D. Asymmetric

B. Shuffling

Which actions transmit the human immunodeficiency virus (HIV)? Select all that apply A. Multiple mosquito bites B. Sharing syringe needles C. Breast-feeding a newborn D. Dry kissing an infected individual E. Anal intercourse F. Sharing drinking glasses

B., C., E.

Which clinical manifestation are found in the client diagnosed with stage 3 Parkinson Disease? Select all that apply A. Akinesia B. Mask-like face C. Postural Instability D. Unilateral limb involvement E. Increased gait disturbances

B., C., E. Akinesia is in Stage 4 and Unilateral in stage 1 because turns to bilateral later Stage 3 characterized by posture and gait Mask face starts in stage 2 and continues into stage 3

A client on antipsychotic medication therapy develops parkinsonism. Which medications would the nurse anticipate being beneficial for the client? Select all that apply A. Levodopa B. Benztropine C. Amantadine D. Bromocriptine E. Diphenhydramine

B., C., E. Levodopa is for non-drug-induced-Parkinsons

The nurse is conducting a client interview. Which response by the nurse is an example of back channeling? 1 "All right, go on... " 2 "What else is bothering you?" 3 "Tell me what brought you here." 4 "How would you rate your pain on a scale of 0 to 10?"

Back channeling involves the use of active listening prompts such as "Go on... ," "all right," and "uh-huh." Such prompts encourage the client to complete the full story. The nurse uses probing by asking the client, "What else is bothering you?" Such open-ended questions help obtain more information until the client has nothing more to say. The statement, "Tell me what brought you here" is an open-ended statement that allows the client to explain his or her health concerns in his or her own words. Closed-ended questions such as, "How would you rate your pain on a scale of 0 to 10?" are used to obtain a definite answer. The client answers by stating a number to describe the severity of pain.

A nurse understands that value clarification is a technique useful in therapeutic communication because initially it helps clients do what? Become aware of their personal values Gain information related to their needs Make correct decisions related to their health Alter their value systems to make them more socially acceptable

Become aware of their personal values Rationale Value clarification is a technique that reveals individuals' values so the individuals become more aware of them and their effect on others. Gaining information, making correct health decisions, and altering value systems to make them more socially acceptable are not outcomes of value clarification.

Which clinical finding is associated with high-dose lead exposure? 1 Blindness 2 Hyperactivity 3 Hearing impairment 4 Mild intellectual deficit

Blindness could indicate that the client is suffering from encephalopathy as a result of high-dose exposure to lead. Hyperactivity, hearing impairment, and mild intellectual deficit are clinical signs of low-dose exposure to lead.

How can the lines of communication be improved in a healthcare organization during the process of delegation? By considering all aspects of client care By selecting experienced nursing assistants as delegatees By appreciating and valuing each other's cultural perspectives By selecting a delegatee having similar strengths as that of the delegator

By appreciating and valuing each other's cultural perspectives Rationale The lines of communication in a healthcare organization can be improved by appreciating and valuing each other's cultural perspectives, which balances strengths between the delegator and delegatee and improves client care outcomes. Considering all aspects of client care ensures that all of the client care needs are addressed. Selecting experienced nursing assistants as delegatees increases the chances of the delegatee to adapt to changing situations. Selecting a delegatee having similar strengths as that of the delegator may decrease the lines of communication because the delegatee might do the task of the delegator.

A resident in a nursing home recently immigrated to the United States (Canada) from Italy. How does the nurse plan to provide emotional support? By offering choices consistent with the client's heritage By assisting the client in adjusting to American culture By ensuring that the client understands American beliefs By correcting the client's misconceptions about appropriate health practices

By offering choices consistent with the client's heritage Rationale Adherence to a plan of care is enhanced by the nurse's providing choices consistent with the client's cultural beliefs and practices. The nurse's cultural or personal beliefs and biases should not influence or interfere with the implementation of appropriate care. Helping the client adjust to American culture is not the priority at this time; care should be adapted to the client's needs and culture. The person's cultural practices should not be addressed unless they are detrimental to the person's health.

a client who has a hemoglobin of 6 gm/dL is refusing blood because of religious reasons. what is the most appropriate action by the nurse? A) call the chaplain to convince the client to receive the blood transfusion B) discuss the case with coworkers C) notify the primary healthcare provider of the clients's refusal of blood products D) explain to the client that they will die without the blood transfusion

a nurse hired to work in a metropolitan hospital provides services for a culturally diverse population. one of the nurses on the unit says it is the nurses' responsibility to discourage "these people" from bringing all that "home medicine stuff" to their family members. which response by the recently hired nurse is most appropriate? A) hospital policies should put a stop to this B) everyone should conform to the prevailing culture C) nontraditional approaches to health care can be beneficial D) you are right because they may have a negative impact on people's health

as the nurse is discussing psychiatric care with an older adult client, the client says, when i was growing up i was taught to accept my lot in life and not complain. i'm proud of the fact that despite my issues i can still function independently. i dont want to be just put away. the nurse understands that the factors that influence the client's mental health are examples of? A) setting of care B) anxiety disorder C) attitudes and beliefs D) cultural and ethnic disparities

the mother of a preschool age child tells the school nurse that her husband is dying of cancer and that she is worried about how her child will cope. as part of their discussion, what does the school nurse include that preschool-age children view death as? A) universal B) irreversible C) a form of sleep D) a frightening ghost

what should a nurse consider about the past experiences of clients who have immigrated to this country? A) it affects all of their inherited traits B) there will be a little impact on their lives today C) it is important that their values be assessed first D) how they will interact is permanently established

which ethnic group has a greater incidence of osteoporosis due to musculoskeletal differences? A) irish american B) african am. C) chinese am. D) egyptian am.

A client is diagnosed with Parkinson disease and receives a prescription for Levodopa therapy. Which mechanism of action would the nurse identify for this medication? A. Blocks the effects of acetylcholine B. Increases the production of dopamine C. Restores the dopamine levels in the brain D. Promotes the production of acetylcholine

A client tells the nursing assistant "I am so worried about the results of the biopsy they took today." The nurse overhears the nursing assistant reply, "Don't worry. I'm sure everything will come out all right." Which conclusion would the nurse make about the nursing assistant's answer? A. It shows empathy. B. It uses distraction. C. It gives false reassurance. D. It makes a value judgement

C. It gives false reassurance A person cannot know the results of the biopsy until it is examined under a microscope. The response does not allow the client to voice concerns, shuts off communication, and provides reassurance that may not be accurate. This answer does not empathize with the client; it minimizes the client's concerns. This response is not a form of distraction; it minimizes the client's concern and shuts off communication. This response does not contain any value statements.

Which relationship is the most important to the formation of personality? 1 Peer relationships 2 Sibling relationships 3 Spousal relationships 4 Parent-child relationships

Children base their own worth on the feedback they receive from their parents. This sense of worth sets the basic ego strengths and is vital to the formation of the personality. Peer groups and sibling relationships are important; however, the parent-child relationship is the most important. Spousal relationships come later in life, after the basic personality has been formed. STUDY TIP: A helpful method for decreasing test stress is to practice self-affirmation. After you have adequately studied and really know the material, start looking in the mirror each time you pass one and say to yourself—preferably out loud—"I know this material, and I will do well on the test." After several times of watching and hearing yourself reaffirm your knowledge, you will gain inner confidence and be able to perform much better during the test period. This technique really works for students who are adventurous enough to use it. It may feel silly at first, but if it works, who cares? It will work for performing skills in clinical as well, as long as you have practiced the skill sufficiently.

The nurse leader states, "The people in rural America dress and act differently from those in urban centers." What concept describes this statement? Acculturation Ethnocentrism Cultural imposition Cultural marginality

Cultural marginality Rationale Cultural marginality is defined as situations and feelings of passive betweenness when people exist between two different cultures. refers to adapting to a particular culture. It is a process by which a person becomes a competent participant in the dominant culture. Ethnocentrism refers to the belief that one's own ways are the best, most superior, or preferred ways to act, believe, or behave. Cultural imposition is defined as the tendency of an individual or group to impose their values, beliefs, and practices on another culture for varied reasons.

An Asian client arrives at the mental health clinic with symptoms of anxiety and panic. While speaking with the client, the nurse notes that the client makes very little eye contact. What does this assessment data suggest? Shyness Cultural variation Symptom of depression Shame regarding treatment

Cultural variation Rationale As a show of respect, people in Asian cultures tend to make little eye contact, particularly with people perceived as authority figures. A lack of eye contact may connote shyness in some clients, but further assessment is needed. A lack of eye contact may suggest a depressed mood; however, there is no indication of depression in this client. A lack of eye contact may indicate shame or low self-esteem in the American culture; however, it is important not to make this same interpretation of behavior for someone from another culture.

A 5-year-old child who is newly arrived from Latin America attends a nursery school where everyone speaks English. The child's mother tells the nurse that her child is no longer outgoing and has become very passive in the classroom. What is the probable reason for the child's behavior? Culture shock Social immaturity Experience of discrimination Lack of interest in school activities

Culture shock Rationale The child learned to think and solve problems in a different culture and language and may feel helpless in the new classroom. There are no data to indicate that social immaturity, discrimination, or lack of interest is the precipitating factor for the child's behavior.

a nurse manager works on a unit where the nursing staff members are uncomfortable taking care of clients form cultures that are different from their own. how should the nurse manager address this situation? A) assign articles about various cultures so that they can become more knowledgeable B) relocate the nurses to units where they will not have to care for clients form a variety of cultures C) rotate the nurses' assignments so they have an equal opportunity to care for clients from other cultures D) plan a workshop that offers opportunities to learn about the cultures they might encounter while at work.

after determining that the nurses on the psych unit are uncomfortable caring for clients who are form different cultures than their own, the nurse manager establishes a unit goal that by the next annual review the unit will have achieved what? A) increased cultural sensitivity B) decreased cultural imposition C) decreased cultural dissonance D) increased cultural competence

which theory proposes that older adults experience a shift from a materialistic to cosmic view of the world? A) activity theory B) continuity theory C) disengagement theory D) gerotranscendence theory

Corticosteroid therapy is prescribed for a patient with multiple sclerosis. In response to the therapy, which symptom would a nurse expect to decrease? A. Emotional lability B. Muscular Contractions C. Pain in the extremities D. Visual impairment

D. Corticosteroids decrease inflammation around the optic nerve !Visual impairment is the most common physiological manifestation of MS!

Which domain of the Nursing Interventions Classification (NIC) taxonomy includes care that supports homeostatic regulation? 1 Domain 1 2 Domain 2 3 Domain 3 4 Domain 4

Domain 2 of the NIC taxonomy includes care that supports homeostatic regulation. Domain 1 includes care that supports physical functioning. Domain 3 includes care that supports psychosocial functioning and facilitates life style changes. Domain 4 includes care that supports protection against harm.

A multigravida of Asian descent weighs 104 lb (47.2 kg), having gained 14 pounds (6.4 kg) during the pregnancy. On her second postpartum day, the client is withdrawn and eating very little from the meals provided. Which intervention is most important for the nurse to implement? Report these findings to the healthcare provider. Encourage the family to bring in special foods preferred in their culture. Order a high-protein milkshake to supplement between meals. Call the dietitian to work with client to plan high calorie meals for the client to eat.

Encourage the family to bring in special foods preferred in their culture. Rationale In family-centered childbearing, care should be adapted to the client's cultural needs and preferences whenever possible. Discussing the problem with the healthcare provider is the nurse's responsibility but will not address the client's preferences. Ordering a high-protein milkshake as a between-meal snack may offer the client an option but is unlikely to meet the cultural preferences. Having the dietitian assist with planning meals does not address the underlying problem.

What does the professional nurse consider to be the center of decision-making when providing client care? Ethics of care Nursing skills Analytical skills Research based practice

Ethics of care Rationale A professional nurse always follows the ethics of care and considers caring to be the center of decision-making. The nurse must know what behavior is ethically appropriate while caring for a client. A nurse's effectiveness in performing tasks is important to client care; however, client satisfaction comes from the effective dimension of care. Because ethics of care are unique to each client, the nurse should not base decision-making only on analytical skills. The nurse should not provide client care based only on intellectual principles or research knowledge. Caring is the most important factor because it considers client preferences and values.

Excessive sebum production occurs with the maturation of adrenocortical glands. This action is followed by alterations in follicular growth and differentiation. Propionibacterium acnes proliferate and increase in number. This proliferation leads to an accumulation of neutrophils, which causes the formation of papules, pustules, nodules, and cysts and subsequent inflammation.

During a survey, the community nurse meets a client who has not visited a gynecologist after the birth of her second child. The client says that her mother or sister never had annual gynecologic examinations. Which factor is influencing the client's health practice? Spiritual belief Family practices Emotional factors Cultural background

Family practices Rationale Family practices influence the client's perception of the seriousness of diseases. The client does not feel the need to seek preventive care measures because no family member practices preventive care. The client is not influenced by spiritual beliefs in this instance. An individual's spiritual beliefs and religious practices may restrict the use of certain forms of medical treatment. Emotional factors such as stress, depression, or fear may influence an individual's health practice; however, this client does not show signs of being affected by emotional factors. The client is said to be influenced by cultural background if he or she follows certain beliefs about the causes of illness and uses customary practices to restore health.

Which is a characteristic of the glands that secrete a thick substance in response to emotional stimulation and become odoriferous because of bacterial action? 1 Highly active in childhood 2 Absent around the umbilicus 3 Widely distributed throughout the body 4 Grow in conjunction with axillary hair follicles

Grow in conjunction with axillary hair follicles The apocrine sweat glands secrete a thick substance in response to emotional stimulation and become odoriferous because of bacterial action. These glands grow in conjunction with hair follicles around the axillae. The apocrine glands are inactive during childhood and reach their secretory potential at the time of puberty. The apocrine glands are situated around the umbilicus. They have limited distribution and are found only around the axillae, areolae, external auditory canal, and anal and genital regions. Eccrine sweat glands, not the apocrine glands, have wide distribution throughout the body.

A child watches an older sibling playing with a ball but makes no effort to participate in the play. Which social character is the child exhibiting? 1 Parallel play 2 Pretend play 3 Onlooker play 4 Associative play

In onlooker play a child actively observes other children playing and does not attempt to enter into the activity; the child is interested only in observation and not in participation. In parallel play children play independently among other children. In pretend play children act out any event of daily life and practice the roles and identities as established in their surroundings. In associative play children play together and are engaged in a similar or identical activity.

After determining that the nurses on the psychiatric unit are uncomfortable caring for clients who are from different cultures than their own, the nurse manager establishes a unit goal that by the next annual review the unit will have achieved what? Increased cultural sensitivity Decreased cultural imposition Decreased cultural dissonance Increased cultural competence

Increased cultural competence Rationale Cultural competence encompasses sensitivity as well as knowledge, desire, and skill in caring for those who are different from one's self. The nurses are already somewhat sensitive to those from different cultures and now must move forward in their ability to care for these clients. The nurses are not imposing their culture on the clients; they are avoiding them. There is no clashing of cultures in this situation.

Which activity can be performed by infants aged 6 to 8 months? 1 Holding a pencil 2 Showing hand preference 3 Placing objects into containers 4 Transferring objects from hand to hand

Infants aged 6 to 8 months may be able to transfer objects from hand to hand. Infants aged 10 to 12 months may be able to hold a pencil. Infants aged 8 to 10 months may show a hand preference. Infants aged 10 to 12 months may be able to place objects into a container. STUDY TIP: A word of warning: do not expect to achieve the maximum benefits of this review tool by cramming a few days before the examination. It doesn't work! Instead, organize planned study sessions in an environment that you find relaxing, free of stress, and supportive of the learning process.

Which method would the nurse use to best elicit the Moro reflex in a full-term newborn? 1 Touching the infant's cheek 2 Striking the surface of the infant's crib suddenly 3 Allowing the infant's feet to touch the surface of the crib 4 Stroking the sole of the foot along the outer edge from the heel to the toe

Jarring the crib produces a startle response (Moro reflex); the legs and arms extend, and the fingers fan out, while the thumb and forefinger form a C. When the cheek is touched, the head turns toward the side that was touched; this is the rooting reflex. When the feet touch the crib surface the stepping reflex is elicited; one foot is placed before the other in a simulated walk with the weight on the toes. When the bottom of the foot is stroked along the outer edge of the sole from the heel to the toe, the toes flare out. This is the Babinski reflex, which is expected because of the newborn's immature nervous system. In an adult, this reflex is a sign of neurological damage.

The nurse knows that jaundice first becomes visible in a newborn when serum bilirubin reaches which level? 1 1 to 3 mg/dL (17.1-51.3 µmol/L) 2 2 to 4 mg/dL (34.2-68.4 µmol/L) 3 5 to 7 mg/dL (85.5-119.7 µmol/L) 4 8 to 10 mg/dL (136.8-171 µmol/L)

Jaundice in a newborn first becomes visible when the serum bilirubin level reaches 5 to 7 mg/dL (85.5-119.7 µmol/L). Jaundice will not be visible at a serum bilirubin level of less than 5 mg/dL (85.5 µmol/L).

The nurse is caring for an African American client with renal failure. The client states that the illness is a punishment for sins. Which cultural health belief does the client communicate? Yin/Yang balance Biomedical belief Determinism belief Magicoreligious belief

Magicoreligious belief Rationale An African American client may have magicoreligious beliefs, which focuses on hexes or supernatural forces that cause illness. Such clients may believe that illness is a punishment for sins. The yin/yang belief system does not consider illness as a punishment. The biomedical belief system maintains that health and illness are related to physical and biochemical processes with disease being a breakdown of the processes. The belief of determinism focuses on outcomes that are externally preordained and cannot be changed.

Which dietary modifications help improve the nutritional status of a client with acquired immunodeficiency syndrome (AIDS)? 1 Refraining from consuming fatty foods 2 Refraining from consuming frequent meals 3 Refraining from consuming high-calorie foods 4 Refraining from consuming high-protein foods

Many clients with AIDS become intolerant to fat due to the disease and the antiretroviral medications. The client should be instructed to refrain from consuming fatty foods. The client should be encouraged to eat small and frequent meals to improve nutritional status. High-calorie and high-protein foods are beneficial to clients with AIDS because they provide energy and build immunity.

The nurse teaches a client with a diagnosis of emphysema about the importance of preventing infections. The nurse would include which information in the education? 1 Purpose of bronchodilators t2 Importance of meticulous oral hygiene 3 Technique used in pursed-lip breathing 4 Methods used to maintain a dust-free environment

Microorganisms in the mouth are transferred easily to the tracheobronchial tree and are a source of potential infection; meticulous oral hygiene is essential to reduce the risk of respiratory infection. Bronchodilators will not prevent infection; they dilate the bronchi. Pursed-lip breathing will not prevent infection; it promotes gas exchange in the alveoli and facilitates more effective exhalation. It is impossible to maintain a dust-free environment. Test-Taking Tip: Attempt to select the answer that is most complete and includes the other answers within it. For example, a stem might read, "A child's intelligence is influenced by what?" and three options might be genetic inheritance, environmental factors, and past experiences. The fourth option might be multiple factors, which is a more inclusive choice and therefore the correct answer.

The nurse is caring for an Asian client who had a laparoscopic cholecystectomy six hours ago. When asked whether there is pain, the client smiles and says, "No." What should the nurse do? Monitor for nonverbal cues of pain Check the pressure dressing for bleeding Assist the client to ambulate around his room Irrigate the client's nasogastric tube with sterile water

Monitor for nonverbal cues of pain Rationale Asian clients tend to be stoic regarding pain and usually do not acknowledge pain; therefore, the nurse should assess these clients further. This type of surgery does not require pressure dressings. First, the client must be assessed further for pain. If there is pain, the client should ambulate after, not before, receiving pain medication. Postoperatively, nasogastric tubes are irrigated when needed, not routinely.

Which hormone is crucial in maintaining the implanted ovum at its site? 1 Inhibin 2 Estrogen 3 Progesterone 4 Testosterone

Progesterone is necessary to maintain an implanted egg. Inhibin regulates the release of follicle-stimulating hormone and gonadotropin-releasing hormone. Estrogen plays a vital role in the development and maintenance of secondary sexual characteristics. Testosterone is important for bone strength and development of muscle mass.

The nurse is caring for an Asian-American client with a diagnosis of depression. While interviewing this client the nurse notes that the client maintains traditional cultural beliefs and values. What is the most important information for the nurse to obtain about the client? Dietary practices Concept of space Immigration status Role within the family

Role within the family Rationale If an Asian-American client adheres to traditional Asian practices, the nurse must recognize that the family is the central and most important social force acting on the individual. Dietary practices, concept of space, and immigration status are not as significant as family dynamics.

A foreign language-speaking client needs to undergo chemotherapy; a signed consent form is required. What should the nurse do to explain the terms of the consent to the client? Seek the help of an official interpreter. Seek the help of the primary healthcare provider to assist the client. Seek help from the client's family friend who speaks the client's language. Seek help from the client's caregiver who speaks the same language as the client.

Seek the help of an official interpreter. Rationale The nurse should seek the help of an official interpreter to explain the terms of consent to the client. The nurse should not ask for the primary healthcare provider's assistance because he or she might not know the language. The nurse should not seek help from the client's family friend who speaks the language because he or she is not authorized to interpret health information. The nurse should not seek help from the client's caregiver who speaks the same language because he or she should not interpret health information.

Which education would the nurse provide parents about the side effects of the Haemophilus influenzae (Hib) vaccine? 1 Lethargy 2 Urticaria Incorrect3 Generalized rash Correct4 Low-grade fever TheHib vaccine may cause a low-grade fever. Lethargy is not expected. Urticaria is more likely to occur with the tetanus and pertussis vaccines. There may be a mild reaction at the injection site, but a generalized rash is not expected.

The Hib vaccine may cause a low-grade fever. Lethargy is not expected. Urticaria is more likely to occur with the tetanus and pertussis vaccines. There may be a mild reaction at the injection site, but a generalized rash is not expected.

Which is the average annual increase in the height of preschoolers? 1 2 inches (5 cm) 2 2 to 8 inches (5-20 cm) 3 4 to 8 inches (10-30 cm) 4 2.5 to 3 inches (6.2-7.5 cm)

The average increase in the height of preschoolers per year is 2.5 to 3 inches (6.2-7.5 cm). The average increase in the height of school-aged children per year is 2 inches (5 cm). The average increase in the height of adolescent girls is 2 to 8 inches (5-20 cm). The average increase in the height of adolescent boys is 4 to 8 inches (10-30 cm).

What is the average systolic blood pressure in a 15 year old? Record your answer using a whole number ______________________ mm Hg

The average systolic blood pressure in a 15 year old is 119 mm Hg.

The preschool-age client is learning sociocultural mores. What should this imply to the nurse regarding this client? The child is developing a conscience. The child is learning about gender roles. The child is developing a sense of security. The child is learning about the political process.

The child is developing a conscience. Rationale Learning the sociocultural mores of the family implies that the child is developing a conscience. This does not imply that the child is learning gender roles, developing a sense of security, or learning about the political process.

According to Erikson's psychosocial stages of development, which developmental conflict is a college student attempting to resolve as he struggles with indecision about an academic major? 1 Initiative versus guilt 2 Integrity versus despair 3 Industry versus inferiority 4 Identity versus role confusion

The client is demonstrating a search for self and has not resolved the developmental conflict of adolescence, identity versus role confusion. Initiative versus guilt is the developmental conflict of early childhood. Integrity versus despair is the developmental conflict of old age. Industry versus inferiority is the developmental conflict of middle childhood. Test-Taking Tip: Answer every question. A question without an answer is always a wrong answer, so go ahead and guess.

According to Piaget's theory of cognitive development, which milestone would the nurse expect a 6-month-old infant to demonstrate? 1 Early traces of memory 2 Beginning sense of time 3 Repetitious reflex responses 4 Beginning of object permanence

The concept of object permanence begins to develop around 6 months of age. Early traces of memory and beginning sense of time occur at between 13 and 24 months. Repetitious reflex responses occur during the first several months of life. These diminish as the newborn grows.

What size of induration after a tuberculin test signifies a positive result in a 16-year-old client? Record your answer using a whole number. _________________ mm

The nurse should consider an induration of 15 mm (1.5 cm) a positive sign of tuberculin testing in a 16-year-old client.

The school nurse would teach the students that the ovum is no longer viable at which time interval after ovulation? 1 12 hours 2 24 hours 3 48 hours 4 72 hours

The ovum is viable for about 24 hours after ovulation; if not fertilized before this time, it degenerates. For this reason, 12 hours, 48 hours, and 72 hours are all incorrect answers.

On a routine prenatal visit, which is the sign or symptom that a healthy primigravida at 20 weeks' gestation will most likely report for the first time? 1 Quickening 2 Palpitations 3 Pedal edema 4 Vaginal spotting

The recognition of fetal movement or quickening commonly occurs in primigravidas at 18 to 20 weeks' gestation; it is felt about 2 weeks earlier in multigravidas. Palpitations should not occur in the healthy primigravidas. Pedal edema may occur at the end of the pregnancy as the gravid uterus presses on the femoral arteries, impeding circulation. Immediate follow-up care is required when it occurs this early in the pregnancy. Vaginal spotting is abnormal and requires immediate follow-up care.

Which stage of Piaget's theory of cognitive development would the nurse observe in a preschooler? 1 Sensorimotor 2 Preoperational 3 Formal operations 4 Concrete operations

The second stage of Piaget's theory of cognitive development is the preoperational stage. It is observed from 2 to 7 years. During this stage, the child may learn to think with the use of symbols and mental images. The first stage is the sensorimotor stage, observed from birth to 2 years. During this stage, the child learns about her- or himself and her or his environment through motor and reflex actions. The fourth stage is formal operations, characterized by a prevalence of egocentric thought. The concrete operations stage is stage 3, which signifies that the child is able to perform mental operations.

Which stage of Kohlberg's theory can be seen in an individual seeking to modify a law if it is not fair to a particular group? 1 Social contract orientation 2 Society-maintaining orientation 3 Instrument relativist orientation 4 Universal ethical principle orientation

The universal ethical principle orientation stage is associated with a person who wants to modify a law if it does not seem just. According to the social contract orientation stage, a person tends to follow a law even if it is not fair. During the society-maintaining stage, an individual shows concerns for his or her society and makes decisions in accordance to his or her society. During the instrument relativist orientation stage, a child recognizes that there is more than 1 correct view. Test-Taking Tip: After you have eliminated 1 or more choices, you may discover that 2 of the options are very similar. This can be very helpful because it may mean that 1 of these look-alike answers is the best choice and the other is a very good distractor. Test both of these options against the stem. Ask yourself which one completes the incomplete statement grammatically and which one answers the question more fully and completely. The option that best completes or answers the stem is the one you should choose. Here, too, pause for a few seconds, give your brain time to reflect, and recall may occur.

Which is the best way for a school nurse to determine a young child's readiness to learn? 1 By assessing the child's vision and hearing 2 By making a referral for psychological and intelligence testing 3 By ensuring that the teacher has an understanding of the child's needs 4 By confirming that the parents understand the importance of homework

Vision and hearing are vital to the child's ability to learn because they provide pathways for stimuli to reach and be interpreted by the brain. Neither psychological nor intelligence testing is necessary for all children. Although important in the learning process, ensuring that the teacher understands the child's needs and confirming that the parents understand the importance of homework are not related to a child's readiness to learn. STUDY TIP: Establish your study priorities and the goals by which to achieve these priorities. Write them out and review the goals during each of your study periods to ensure focused preparation efforts.

Which characteristic can be observed in abusive parents? Select all that apply. One, some, or all responses may be correct. a) Social isolation b) Poor coping skills c) Family authoritarianism d) Feeling of no control over life e) Inability to seek help from others f) Expects child to satisfy needs for love

a) Social isolation b) Poor coping skills c) Family authoritarianism d) Feeling of no control over life e) Inability to seek help from others f) Expects child to satisfy needs for love

Which topic is most important for the nurse to teach in a community health promotion class for middle-aged adults? a) Tobacco cessation b) Infection prevention c) Alcohol abstinence d) Pain management

a) Tobacco cessation

The nurse has instructed the client about effective ways of reducing burn injury. Which statement made by the client shows ineffective learning? a) "I will refrain from smoking when lying in bed." b) "I will set the bathing water temperature below 160°F (71°C)." c) "I will use a potholder when taking the food from an oven." d) "I will keep the screens and doors closed on the front of any fireplace."

b) "I will set the bathing water temperature below 160°F (71°C)."

The community nurse is assessing an older adult client who lives alone at home. The nurse finds that the client refrains from physical activity for fear of falling when walking. Which intervention(s) by the nurse are beneficial to promote a healthy lifestyle? Select all that apply. One, some, or all responses may be correct. a) Instruct the client to apply bedside rails. b) Encourage the client to wear nonskid shoes. c) Suggest that the client use an assistive device. d) Ask the client to install handrails in the bathroom. e) Help the client rearrange furniture in the house

b) Encourage the client to wear nonskid shoes. c) Suggest that the client use an assistive device. e) Help the client rearrange furniture in the house

The nurse is teaching campfire safety to a group of community members and includes information about what to do if a person catches on fire. The nurse teaches the most effective method for putting out the flames. Which information from the group members indicates successful learning? a)Wrap hand with towel and slap at the flames. b) Instruct the victim to roll on the ground. c) Pour cold liquid over the flames. d) Remove the victim's burning clothes.

b) Instruct the victim to roll on the ground.

A 16-year-old high school student comes to a community health center because of the fear of having contracted herpes. The teenager is upset and shares this information with the community health center nurse. Which response would the nurse provide? a) "Let me get a brief health history now." b) "Try not to worry until you know whether you have herpes." c) "You sound worried. Let me make arrangements to have you examined." d) "Herpes has received too much attention in the media; let's be realistic."

c) "You sound worried. Let me make arrangements to have you examined."

Which clients are ideal candidates for interpreter service to prevent contributing health disparities? Select all that apply. One, some, or all responses may be correct. a) An English-speaking client with a speech disorder b) An African American client with a hearing impairment c) A non-English-speaking client in the emergency department d) A Spanish-speaking client ready to be discharged from the facility e) An Indian American who does not speak the language used at the facility

c) A non-English-speaking client in the emergency department d) A Spanish-speaking client ready to be discharged from the facility e) An Indian American who does not speak the language used at the facility

Which is the most highly sensitive time within the developing embryo for the risk of malformation related to environmental teratogens? a) Heart at 32 weeks' gestation b) Cleft lip at 18 weeks' gestation c) Cleft palate at 8 weeks' gestation d) Upper limbs at 24 weeks' gestation

c) Cleft palate at 8 weeks' gestation

Which role is the nurse expected to have in a community-based nursing practice if there is a sudden spread of malaria? a) Educator b) Collaborator c) Epidemiologist d) Client advocate

c) Epidemiologist

The nurse in an emergency department is assessing a young child with a head injury. The child is accompanied by a parent. Which observation would prompt the nurse to assess the child for abuse? a) The child has Mongolian spots on the back. b) The child belongs to a single-parent family. c) The child has received care for injuries twice earlier. d) The child and parent narrate the same story about the injury.

c) The child has received care for injuries twice earlier.

Which statement describes the step followed to provide competent care for vulnerable populations? a) "Refrain from giving priority to cultural practices and values of the vulnerable populations." b) "Provide financial and legal advice to the vulnerable people as this may be more important to them." c) "Evaluate the clients' beliefs and values about health in terms of the nurse's own culture, beliefs, and values." d) "Understand the clients' cultural beliefs, values, and practices to determine their specific needs and interventions."

d) "Understand the clients' cultural beliefs, values, and practices to determine their specific needs and interventions."

A client who does not understand English requires an interpreter. Which action by the student nurse may exacerbate health disparities? a) The student expects the interpreter to act as the client's advocate. b) The student expects the interpreter to have a health care background. c) The student maintains steady eye contact with the client. d) The student talks only to the interpreter about the client

d) The student talks only to the interpreter about the client

A community health care nurse is conducting a survey about homeless children in the community. Which finding helps the nurse distinguish absolute homelessness from relative homelessness? a) The children are under-immunized and at risk for childhood illnesses. c) The children are more likely to drop out of school and become unemployable. d) The children have access to health care only through the emergency department. e) The children do not have a physical shelter and may sleep outdoors or in vehicles.

e) The children do not have a physical shelter and may sleep outdoors or in vehicles.

Which structure is a component of the auditory ossicles? 1 Malleus 2 Vestibule 3 Tympanic membrane 4 External acoustic meatus

The nurse reviews the laboratory reports of four clients. Which client would the nurse suspect as having type I-mediated asthma? o Client A o Client B o Client C o Client D

o Client A · Asthma is a type I or IgE-mediated hypersensitivity reaction. Client A, with IgE antibodies in the blood, has type 1-mediated asthma. Client B, with no antibodies, may not have humoral allergy or may have a humoral deficiency. Client C and client D may have either type II or type III hypersensitivity reactions.

A client with chronic obstructive pulmonary disease prepares to take a medication that is delivered via a nebulizer. Which instruction would the nurse provide when teaching about use of the nebulizer? o "Hold your breath, spray the medication into your mouth, then inhale deeply." o "Depress the canister as you inhale deeply, then hold your breath for at least 10 seconds." o "Seal your lips around the mouthpiece and breathe in and out, taking slow, deep breaths." o "Inhale the medication from the nebulizer, remove the mouthpiece to exhale and then repeat."

o "Seal your lips around the mouthpiece and breathe in and out, taking slow, deep breaths." · Sealing the lips around the mouthpiece ensures that medication is delivered on inspiration; slow, deep breaths promote better deposition and efficacy of medication deep into the lungs. The breath should not be held during administration. A nebulizer treatment delivers medication by inhaling it into the mouth through a mouthpiece, not a canister. Removing the mouthpiece from the mouth to exhale allows valuable aerosolized medication to be deposited into the air; therefore the client will not receive the full dose of aerosolized medication.

A client with asthma is pregnant. Which nursing intervention is advisable to ensure the safe delivery of the baby? o Have the client stop taking her medication. o Advise the client to abort the pregnancy. o Have the client continue the asthma treatment. o Have the client reduce the dose of the medication.

o Have the client continue the asthma treatment. · Untreated maternal asthma poses a high risk to the fetus. The client should continue the medication. The medication should not be stopped because this action may have harmful effects on both the fetus and the mother. The pregnancy does not need to be aborted. A reduction in the dose may not give the desired therapeutic action.

Which diagnostic testing is most useful in evaluating the effectiveness of treatment for asthma? o Chest x-ray o Pulmonary function tests o Serum eosinophil counts o Immunoglobulin E levels

o Pulmonary function tests · The most useful test when evaluating the effectiveness of asthma treatment is pulmonary function testing, which measures airflow. A chest x-ray might be used to check for complications of asthma such as respiratory infection, but is not used to evaluate the effectiveness of asthma treatment. Serum eosinophil counts might be used to determine whether a client's asthma was caused by allergies, but eosinophil counts will not be commonly used to check for effectiveness of treatment. Immunoglobulin E levels might be checked to determine if a client had allergic asthma, but would not be used to check for whether treatment was effective.

The nurse is providing hygiene care to a immobile client who was admitted for exacerbation of chronic obstructive pulmonary disease (COPD). Which nursing intervention is correct when the client becomes short of breath during the care? o Obtain a pulse oximeter to determine the client's oxygen saturation level. o Put the client in a high Fowler position. o Darken the lights and provide a rest period of at least 15 minutes. o Continue the hygiene activities while reassuring the client.

o Put the client in a high Fowler position. · Putting the client in the high Fowler position will help expand the lungs and decrease the severity of shortness of breath. Leaving the client to obtain a pulse oximeter while the client is experiencing shortness of breath places the client in danger. Providing a rest period of at least 15 minutes may be appropriate but is not the priority. The nurse needs to acknowledge the change in the client's condition, such as shortness of breath, and take care of this immediate client need before continuing the hygiene activities.

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a partial pressure of carbon dioxide (PCO2) of 60 mm Hg. Which complication would the nurse suspect the client is experiencing? o Metabolic acidosis o Metabolic alkalosis o Respiratory acidosis o Respiratory alkalosis

o Respiratory acidosis · The pH indicates acidosis; the PCO2 level is the parameter for respiratory function. The expected PCO2 is 40 mm Hg. These results do not indicate a metabolic disorder or indicate respiratory alkalosis.

When assessing the breath sounds of a client with chronic obstructive pulmonary disease (COPD), the nurse hears moist rumbling sounds that improve after the client coughs. How will the nurse document the lung sounds? o Rhonchi o Wheezes o Fine crackles o Vesicular sounds

o Rhonchi · Rhonchi are coarse and moist sounds caused by obstruction of the airway with thick mucus, and they usually clear or change with coughing as the mucus moves or is expectorated. Wheezes are high-pitched, continuous sounds. Fine crackles are high-pitched popping noises. Vesicular sounds are the normal breath sounds.

Which is the primary focus of nursing care in the "family as context" approach? 1 The relationship among family members 2 The health and development of an individual 3 The ability of the family to meet its basic needs 4 The family's process of caregiving for a sick member

Which parent education would the nurse provide the parents of a 6-month-old about how to introduce their infant to pureed foods? 1 "Introduce 1 food at a time every 4 to 7 days." 2 "Mix the pureed food with the formula 2 or 3 times a day." 3 "Try to maintain the formula intake regardless of solid food intake." 4 "Offer pureed foods by spoon after the bottle of formula is finished.

When completing a neurologic assessment, the nurse determines that a client has a positive Romberg test. Which finding supports the nurse's conclusion? 1 Inability to stand with feet together when eyes are closed 2 Fanning of toes when the sole of the foot is firmly stroked 3 Dilation of pupils when focusing on an object in the distance 4 Movement of eyes toward the opposite side when head is turned

Which synovial joint movement is described as turning the sole away from the midline of the body? 1 Pronation 2 Eversion 3 Adduction 4 Supination

A client with myasthenia gravis experiences dysphagia. What is the priority risk associated with dysphagia that must be considered when planning nursing care? 1 Aspiration 2 Dehydration 3 Nutritional imbalance 4 Impaired communication

A nurse is caring for a client with Guillain-Barré syndrome. The nurse should prepare the client for what essential care related to rehabilitation? 1 Physical therapy 2 Speech exercises 3 Fitting with a vertebral brace 4 Follow-up on cataract progression

An adolescent girl is concerned about her body image after amputation of a leg for bone cancer. After the nurse has obtained the girl's consent, what nursing action is most therapeutic? 1 Encouraging her peers to visit 2 Keeping her lower body covered 3 Placing her in a room by herself 4 Limiting her visitors to the family

A parent is worried about the infant's excessive dependence on nonnutritive sucking. Which intervention will help decrease this dependence? 1 Prolonging the feeding time 2 Using infant formulas frequently 3 Offering pacifier as soon as the crying begins 4 Wrapping the infant snugly most of the time

1 An infant's dependence on nonnutritive sucking can be reduced by prolonging the feeding time, so that the sucking pleasure is increased. Using infant formulas will not help prevent nonnutritive sucking, because the child needs the pleasure of sucking. Using a pacifier as soon as the crying begins increases the child's dependence on nonnutritive sucking, because it reinforces a pattern of distress-relief. Wrapping the infant snugly most of the time may not be possible, because it may cause the infant to feel uncomfortable.

Which source of stress would the nurse anticipate in a 4-year-old child? 1 Attention 2 Confusion 3 Stranger anxiety 4 Separation anxiety

1 Attention is a particular source of stress in 4-year-olds. A child in this age group likes to talk and is frustrated if ignored or put off. Confusion and stranger anxiety are sources of stress in 3-year-olds. Separation anxiety is a source of stress to 3-year-olds and 5-year-olds as well.

The nurse finds that an adolescent has episodes of binge eating followed by self-induced vomiting and strenuous exercise. Which condition is the adolescent likely to have? 1 Bulimia 2 Anorexia 3 Orthorexia 4 Binge behavior

1 Bulimia is a disorder characterized by repeated episodes of binge eating followed by inappropriate compensatory behavior, such as self-induced vomiting and/or strenuous exercise. Anorexia is an eating disorder characterized by low body weight. Orthorexia is a disorder in which the individual avoids certain foods, believing them to be harmful. Binge behavior is consumption of large amounts of foods in a brief time but without the subsequent compensatory behavior.

Which factor is associated with the aging process? Correct1 Slowing of responses 2 Change of personality 3 Loss of intelligence 4 Loss of long-term memor

1 Neurological responses are slowed because of reduced sensory-receptor sensitivity. Excluding pathological processes, the personality will be consistent with that of earlier years. There is no loss of intellectual ability unless there is a pathological problem. Short-term, not long-term, memory is reduced because of a shortened attention span, delayed transmission of information to the brain, and perceptual deficits.

What is the most common cause of ophthalmia neonatorum in infants born to adolescent mothers? 1 Chlamydia 2 Gonorrhea 3 Human papilloma virus 4 Herpes simplex virus

1 Ophthalmia neonatorum is a neonatal infection caused when the infant is born to a mother who has a chlamydia infection.

1 Peer acceptance is crucial during this period; friends must have the opportunity to accept the client with one leg. Concealment does not help the adolescent or others accept the loss. Isolating the adolescent will increase feelings of alienation and being different. An adolescent needs to relate to and be accepted by peers as well as family.

Prolonged labor is an incident very common in pregnant adolescents. Which age group of adolescents has the highest risk of prolonged labor? 1 12 to 13 years 2 14 to 15 years 3 16 to 18 years 4 19 to 21 years

1 The adolescents of age group 12 to 13 years are at the higher risk of prolonged labor because of cephalopelvic disproportion and underdevelopment. The age group of 14 to 15 will have moderate chances of prolonged labor as the transition between cephalopelvic disproportion and pelvic adequacy starts. For age group 16 to 21 the labor time shortens as the body completes transition.

Which gland secretes gonadotropin-releasing hormone (GnRH) to help control the events of puberty? 1 Hypothalamus 2 Thyroid 3 Anterior pituitary 4 Posterior pituitary

1 The hypothalamus releases gonadotropin-releasing hormone (GnRH), which stimulates the anterior pituitary gland. This gland exerts hormonal influence on the events of puberty. GnRH travels through a network of capillaries to the anterior pituitary gland, where it stimulates the production and secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), but the anterior pituitary itself does not secrete GnRH. The posterior pituitary and thyroid glands have no involvement in the neuroendocrine events of puberty.

Which information would the nurse base a response on to a mother who asks for guidance regarding who to tell of the diagnosis of diabetes of her child, who plays on the soccer team? 1 Children with diabetes who participate in active sports can have episodes of hypoglycemia. 2 Children may have to leave athletic teams if school authorities learn that they have diabetes. 3 The school nurse will treat the child if clinical findings of hypoglycemia are recognized early. 4 The coach might violate confidentiality by discussing the child's condition with other faculty members.

1 The people associated with the school who are interacting with the child should be told about the child's condition. Knowledgeable people can be alert for early signs of hypoglycemia and have snacks available for the child to help prevent a hypoglycemic episode. Forcing the child to leave the team is a form of discrimination; children with diabetes are allowed to engage in activities as long as their diabetes remains under control. The adult who is with the child when the signs of hypoglycemia first appear should be prepared to treat the child; this person may or may not be the nurse. Information about the child's health status is on a "need to know" basis; professionals are expected to honor confidentiality.

Which statement about varicocele is true? 1 Varicocele occurs most often on the left side. 2 The left testicle is larger when associated varicocele is present. 3 Testicular size increases with increasing duration of a varicocele. 4 Dihydrotestosterone level increases with the duration of a varicocele

1 Varicocele occurs most often on the left side. The left testicle is smaller when associated varicocele is present. Testicular size decreases with increasing duration of varicocele. Dihydrotestosterone levels decrease with increasing duration of a varicocele.

What is the maximum recommended length for enema tube insertion in an adolescent? Record your answer using a whole number.

10 cm

Which herbal therapies would be beneficial to a client with menstrual cramping? Select all that apply. 1 Catnip 2 Fennel 3 Black haw 4 Bugleweed 5 Chamomile

123 Herbal drugs such as catnip, fennel, and black haw are used to treat menstrual cramping and dysmenorrhea. Bugleweed and chamomile are used to treat breast pain.

What are the pathophysiologic factors of acne? Select all that apply. 1 Comedogenesis 2 Production of excessive sebum 3 Alteration in follicular growth 4 Consumption of dairy products 5 Colonization of Propionibacterium acnes

1235 Pathophysiologic factors of acne include comedogenesis (the formation of comedones), the production of excessive sebum, an alteration in follicular growth, and the proliferation of Propionibacterium acnes. Consuming dairy products may potentiate acne, but it is not a pathophysiologic factor.

Which language developmental milestone is seen in 4-year-olds? 1 Names four or more colors 2 Knows simple songs 3 Has a vocabulary of about 2100 words 4 Uses sentences of six to eight words, with all parts of speech

2 A 4 year old typically knows simple songs. A 5 year old typically can name four or more colors, has a vocabulary of about 2100 words, and uses sentences of six to eight words with all parts of speech.

Which of these stages is followed by the "society-maintaining orientation," according to the Kohlberg's theory? 1 "Social contract orientation" 2 "Good boy-nice girl orientation" 3 "Instrumental relativist orientation" 4 "Punishment and obedience orientation"

2 According to Kohlberg's theory, "good boy-nice girl orientation" (stage 3) is followed by "society-maintaining orientation" (stage 4). "Social contract orientation" is stage 5. "Instrumental relativist orientation" is stage 2. "Punishment and obedience orientation" is stage 1.

an african man presents to the emergency department to obtain pain medication. the nurse behaves judgmentally and labels the client a drug abuser. what is the nurse demonstrating? A) ethnocentrism B) multiculturalism C) culture encounter D) cultural imposition

A 13-year-old is found to have idiopathic scoliosis. She is upset about the treatment regimen and is worried about being different from her friends. What should the nurse do to help the child maintain a positive self-image during treatment? 1 Remind her how crooked her back will be if she refuses treatment. 2 Help her investigate appropriate clothing to enhance her appearance. 3 Disregard her negative characteristics and focus on her positive attributes. 4 Refer her for psychological counseling until the treatment program is completed.

2 Clothes can be selected to minimize the appearance of a brace, especially if an effort is made to wear current styles. Reminding the child how she will look without treatment has a negative connotation that emphasizes the problem. Focusing only on positive attributes may be misinterpreted as unqualified praise; adults should give honest appraisals of both positive and negative attributes. There are no data to indicate that the child will not adjust to the treatment regimen.

According to Erikson's theory of psychosocial development, which task does the nurse recognize as the chief psychosocial task of preschoolers? 1 Control over bodily functions 2 Development of a sense of initiative 3 Toleration of separation from parents 4 Ability to interact with others in a less egocentric manner

2 Development of a sense of initiative

Which stage of Kohlberg's theory explains the influence of moral values on an individual's thought? 1 Good boy-nice girl orientation 2 Society-maintaining orientation 3 Instrumental relativist orientation 4 Universal ethical principle orientation

2 During the society-maintaining orientation stage, an individual expands focus from a relationship with others to societal concerns. These individuals may be influenced by moral values. During the good boy-nice girl orientation stage, an individual wants to win the approval of and maintain the expectations of one's immediate group. When a child wants to be on time for dinner, this action explains the instrumental relativist orientation stage. The universal ethical principle orientation stage defines "right" in accordance with self-chosen ethical principles.

An adolescent visits the allergy clinic because of seasonal environmental allergies, and blood is drawn for testing. Which laboratory finding indicates to the nurse that an allergic response is in progress? 1 Decreased platelet count 2 Increased eosinophil level 3 Increased lymphocyte count 4 Decreased immunoglobulin level

2 Eosinophils increase to inhibit the inflammatory response to histamine, which is released in allergic reactions. Platelets and lymphocytes are unrelated to allergic reactions. Immunoglobulins increase, not decrease, in response to an allergic reaction.

2 In the "family as context" approach, the primary focus is the health and development of an individual in a specific environment. The relationship and family processes are the primary focus when the family is viewed as the client. When the family is viewed as the context, the focus is on the ability of the family to meet the basic needs of the individual, not its own needs. The process followed by the family when caring for the sick family member is assessed when the family is viewed as the client.

A 17-year-old mother is to sign the consent for her son's myringotomy. What should the nurse say to the mother about this procedure? 1 "This procedure may not help." 2 "Tell me what you know about this procedure." 3 "Your son will need to have this done again when he's older." 4 "One of your parents must also sign this because you're too young."

2 Informed consent requires that the responsible person understand the procedure. Predicting therapeutic outcomes is not within the role of the nurse. Predicting future surgical interventions is not within the role of the nurse. A 17-year-old mother is an emancipated minor who has the legal authority to sign her child's consent form.

A client's phenytoin level is 16 mcg/L. Which action will the nurse take? A. Hold the medication and notify the provider B. Administer the next dose as prescribed C. Hold the next dose and then resume administration D. Call the health care provider to obtain a higher dose

A 15-year-old with cystic fibrosis (CF) is admitted with a respiratory infection. The nurse determines that the adolescent is cyanotic, has a barrel-shaped chest, and is in the 10th percentile for both height and weight. What is the priority nursing intervention? 1 Increasing physical activities 2 Performing postural drainage 3 Maintaining dietary restrictions 4 Administering prescribed pancreatic enzymes

2 Postural drainage, including percussion and vibration, aids removal of respiratory secretions that provide a medium for further bacterial growth. Children with CF must cope with impaired gas exchange that results in intolerance to activity. Increasing activity at this time may be too taxing. There must be a balance between activity and rest within the child's limitations. There are no dietary restrictions. Children with CF should have a balanced nutritional intake that is high in calories. Although important, administration of prescribed pancreatic enzymes is not the priority.

Which term is used for the tip of a pyramid in the kidney? 1 Calyx 2 Papilla 3 Renal pelvis 4 Renal column

2 Pyramids are components of renal medulla, and the tip of each pyramid is called a papilla. A calyx is a structure that collects the urine at the end of each pyramid. The renal calices join together to form the renal pelvis. A renal column is a cortical tissue that separates the pyramids.

Which action would the nurse include in the plan of care for a client who just had a posterior lumbar laminectomy? A. Encourage the client to cough B. Reposition the client by log rolling C. Assess the client for indications of peritonitis D. Instruct the client to bend the knees when turning

A chronically ill, older client lives with their daughter. The client reports the daughter, who has three small children, seems run-down, coughs a lot, and sleeps all the time. Which statement supports the need for the nurse to pursue the daughter's condition as a potential case finding? 1 Tuberculosis has been rising dramatically in the general population. 2 Older adults with chronic illness are more susceptible to tuberculosis. 3 There is a high incidence of tuberculosis in children less than 12 years of age. 4 Death from tuberculosis has been decreasing in the United States and Canada.

2 The client's chronic illness and older age increase vulnerability; the daughter's condition should be explored in greater detail. Tuberculosis is only one of many potential causes of the daughter's clinical condition. Children who have not yet reached puberty and adolescence have the lowest incidence of tuberculosis. Morbidity and mortality resulting from tuberculosis are increasing, not decreasing.

The nurse is helping an adolescent with iron-deficiency anemia make breakfast meal choices. Which foods should the nurse suggest? 1 Apple fruit cup 2 Bowl of raisin bran 3 Cup of blueberry yogurt 4 Slice of wheat bread toast with butter

2 The iron content in the options is as follows: ¾ cup raisin bran, 13.5 mg; one slice of wheat bread, 0.9 mg; 1 cup of blueberry fruit yogurt, 0.2 mg; and apple fruit cup, 0.2 mg. The best choice is the bowl of raisin bran cereal, which has the highest iron content of all the choices.

According to the CDC, which stage of HIV is present in the client with 350 cells/mm3 of CD4+T-cell count? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

B. (Stage 1 is 500 Stage 2 is 499-201 Stage 3 is 200 Stage 4 is when there is no info)

A 15-year-old plans to go to a nightclub without informing his or her parents but is afraid of being caught. Which behavior does this indicate? 1 Seriation 2 Invulnerability 3 Personal fable 4 Imaginary audience

2 When an adolescent goes to a club but fears getting caught by his or her parents, this action shows a sense of invulnerability. Feelings of invulnerability frequently lead to risk-taking behaviors. Seriation is the ability to mentally classify objects according to their quantitative dimensions. Personal fable is when adolescents think that their thoughts and feelings are unique. Adolescents have a belief that an imaginary audience constantly scrutinizes their actions.

Identify the stage at which an adolescent develops abstract thinking. 1 Genital stage 2 Conventional reasoning 3 Formal operations period 4 Identity vs. role confusion

3 According to Piaget's moral development theory, an adolescent develops abstract thinking during the formal operations period. According to Freud's genital stage, sexual urges reawaken and are directed to an individual outside the family circle. During the conventional reasoning stage, a person establishes his or her morals based on his or her own personal internalization of societal expectations. According to the identity versus role confusion stage, there is a marked preoccupation with appearance and body image.

Which period of Piaget's theory marks the end of cognitive development? 1 Sensorimotor 2 Preoperational 3 Formal operations 4 Concrete operations

3 According to Piaget's theory, the formal operations period marks the end of cognitive development. During this period, adolescents have the capacity to reason with respect to possibilities. The sensorimotor period is the first period when a newborn develops a schema or pattern for dealing with the environment. The second period is the preoperational period when a child develops egocentrism and animism. During the concrete operations period, children are able to perform mental operations.

What transformations occur during the mid-puberty stage of a normally developing adolescent female? 1 Scanty and irregular menstrual periods 2 Appearance of pubic hair and an increase in normal vaginal discharge 3 Breast enlargement and the growth of pubic hair 4 Changes in the nipple and areola and the development of a small bud of breast tissue

3 During mid-puberty, the breast enlarges from a small bud of breast tissue, while pubic hair develops and covering the mons pubis and labia majora. Scanty and irregular menstrual periods are a characteristic feature of late-puberty. The first appearance of pubic hair, an increase in normal vaginal discharge, changes in the nipple and areola, and the development of a small bud of breast tissue occur during early-puberty.

Which quantity of iron would be considered mildly to moderately toxic in a preschool child? 1 8 mg/kg 2 15 mg/kg 3 35 mg/kg 4 65 mg/kg

3 Ingestions of 20 to 60 mg/kg of iron are considered mildly to moderately toxic in children. Ingestion of either 8 mg/kg or 15 mg/kg is not considered toxic. Ingestion of amounts greater than 60 mg/kg (here, 65 mg/kg) is severely toxic and possibly fatal.

Which statement about levonorgestrel requires correction? 1 Levonorgestrel is an over the counter drug. 2 Levonorgestrel is an emergency contraceptive. 3 Levonorgestrel is taken in combination with methotrexate. 4 Levonorgestrel should be taken within 120 hours of intercourse.

3 Methotrexate is a drug prescribed for inducing abortion; this drug is used in combination with misoprostol. Levonorgestrel is an over-the-counter medication that is given without a prescription. It is an emergency contraceptive that should be taken within 120 hours of intercourse.

A 13-year-old adolescent is found to have idiopathic scoliosis. Because exercise and avoidance of fatigue are essential components of care, which sport should the nurse suggest as the most therapeutic for this preadolescent? 1 Golf 2 Bowling 3 Swimming 4 Badminton

3 The hyperextension required in swimming helps strengthen back muscles and necessitates deeper respirations, both of which are necessary before surgery and before wearing a brace or cast. The other options involve twisting the back muscles, which is not therapeutic for a child with this condition.

A 16-year-old girl with sickle cell anemia is experiencing a painful episode (vaso-occlusive crisis) and has a patient-controlled analgesia (PCA) pump. She complains of pain (5 on a scale of 1 to 10) in her right elbow. The nurse observes that the pump is "locked out" for another 10 minutes. What action should the nurse implement? 1 Turning on the television for diversion 2 Calling the primary healthcare provider for another analgesic prescription 3 Placing the prescribed as-needed warm, wet compress on the elbow 4 Informing her gently that she must wait until the pump reactivates to get more medication

3 Vasodilation should help reduce pain from cellular clumping; applying a warm, wet compress will address the pain until the pump can be activated. Television may be an adequate distractor for mild pain, not moderate or severe pain. Nursing measures should be attempted first to relieve the pain before the primary healthcare provider is called. Telling the adolescent to wait provides no comfort.

A neonate weighing 5 lb 6 oz (2438 g) is born in a cesarean birth and admitted to the newborn nursery. Which range of resting respiratory rate would the nurse anticipate? 1 20 to 40 breaths/min 2 30 to 60 breaths/min 3 60 to 80 breaths/min 4 70 to 90 breaths/min

30-60 After respiration is established, the normal neonate respiratory rate ranges from 30 to 60 breaths/min with short periods of apnea. Twenty breaths per minute is bradypnea. A respiratory rate faster than 60 breaths/min is tachypnea.

What are the treatment goals in anorexia nervosa? Select all that apply. 1 The development of a calorie-restricted diet plan 2 The development of a regular exercise schedule 3 The repairing of family interactions 4 The reinstitution of normal nutrition to counteract a state of malnutrition 5 The correction of deficits and distortions in psychological functioning via psychotherapy

345 Clients with anorexia nervosa have a strong fear of becoming overweight. This is characterized by reduced nutritional food intake causing progressive weight loss and malnutrition. These clients usually have impaired family interactions due to low self-esteem. Therefore, the treatment goals should consist of repairing family interactions, reinstituting normal nutritional meals, and correcting deficits and distortions in psychological functioning.

Which medication is the first-line treatment for acne in adolescents? 1 Tretinoin 2 Doxycycline 3 Clindamycin 4 Benzoyl peroxide

4 Benzoyl peroxide is an effective first-line medication used to treat acne in adolescents; this medication is effective against inflammatory and noninflammatory acne. Tretinoin, doxycycline, and clindamycin are also used to treat acne, but they are not first-line agents.

Which period of Piaget's theory explains self-consciousness in an adolescent? 1 Period I 2 Period II 3 Period III 4 Period IV

4 In period IV of Piaget's theory, an adolescent demonstrates feelings and behaviors characterized by self-consciousness. During period I, an infant develops a schema or action pattern for dealing with the environment. During period II, the child demonstrates animism, in which he or she personifies objects. While going through period III, the child thinks about an action that earlier was performed physically.

Which identified clinical manifestation is a sign of allergic rhinitis? 1 Presence of high-grade fever 2 Reduced breathing through the mouth 3 Presence of pinkish nasal discharge 4 Reduced transillumination on the skin over the sinuses

4 Reduced transillumination on the skin overlying the sinuses indicates allergic rhinitis. This effect is caused by the sinuses becoming inflamed and blocked with thick mucoid secretions. Generally, fever does not accompany allergic rhinitis unless the client develops a secondary infection. In allergic rhinitis, the client is unable to breathe through the nose because it gets stuffy and blocked. Instead, the client will resort to mouth breathing. Clients with allergic rhinitis will have clear or white nasal discharge.

A nurse is caring for a 15-year-old client who is undergoing chemotherapy for leukemia. What does the nurse recognize that adolescents with health problems are most concerned about? 1 Missing time at school 2 Limiting social activities 3 Being dependent while enjoying the sick role 4 Feeling different regarding changes in body image

4 The 15-year-old is preoccupied with appearance. The side effects of the antineoplastics and prednisone may result in the adolescent feeling different, which affects body image. Although missing school may be a concern, it is typically not the primary concern. Although limitation of social activities is a concern, it is not the primary concern. Socialization can be facilitated. A 15-year-old enjoys and strives for independence and does not enjoy the sick role.

A nurse is reviewing the laboratory report of a 13-year-old adolescent with type 1 diabetes. What test is considered the most accurate in the evaluation of the effectiveness of diet and insulin therapy over time? 1 Blood pH 2 Serum protein level 3 Serum glucose level 4 Glycosylated hemoglobin

4 The glycosylated hemoglobin (GHb) test provides an accurate long-term index of the child's average blood glucose level for the 10- to 12-day period before the test; the more glucose the red blood cells were exposed to, the greater the GHb percentage. A high blood pH may indicate developing ketoacidosis, but it reflects short-term variations. Serum protein readings do not reflect the effectiveness of glucose management. Serum glucose readings reflect short-term (hours) variations.

Which method of contraception may provide adolescents with the longest duration of protection? 1 NuvaRing 2 Levonorgestrel implant 3 Spermicidal suppositories 4 Levonorgestrel intrauterine system

4 The levonorgestrel intrauterine system is a T-shaped intrauterine system which releases levonorgestrel. It must be placed within seven days of menses and provides protection up to five years. The NuvaRing, a flexible, soft, and transparent ring placed in the vagina, must be replaced every three weeks. The levonorgestrel implant is a small rod that provides protection for up to three years. Spermicidal suppositories are inserted into the vagina to kill sperm and provide protection for only a short duration.

Which client statement indicates understanding of teaching about a nonstress test? 1 "I'll need to have an intravenous (IV) line so the medication can be injected before the test." 2 "My baby may get very restless after I have this test." 3 "I hope this test doesn't cause my labor to start too early." 4 "If the heart reacts well, my baby should do OK when I give birth.

4 The nonstress test is used to evaluate the response of the fetus to movement and activity. A reactive test indicates that the fetus is healthy. No injections of any kind are used during a nonstress test; it involves only the use of a fetal monitor to record the fetal heart rate during periods of activity. The nonstress test will not influence the activity of the fetus because no exogenous stimulus is used. Early labor is unlikely because the nonstress test is noninvasive. Test-Taking Tip: Never leave a question unanswered. Even if answering is no more than an educated guess on your part, go ahead and mark an answer. You might be right, but if you leave it blank, you will certainly be wrong and lose precious points.

What is the average optimal blood pressure of an adolescent? 1 85/54 mm Hg 2 95/65 mm Hg 3 105/65 mm Hg 4 110/65 mm Hg

4 The optimal blood pressure of an adolescent is 110/65 mm Hg. The average optimal blood pressure in an infant is 85/54 mm Hg. The average optimal pressure in a toddler is 95/65 mm Hg. The average optimal blood pressure seen in children between the ages of 6 and 13 is 105/65 mm Hg.

Which theories are relevant only to development in adults? Select all that apply. One, some, or all responses may be correct. 1 Piaget's theory 2 Erikson's theory 3 Kohlberg's theory 4 Stage-Crisis theory 5 Life Span approach

4, 5

The nurse is performing an assessment of fine motor skills on an infant. Which actions would the nurse observe? Select all that apply. One, some, or all responses may be correct. 1 Crawling 2 Creeping 3 Sitting erect 4 Holding a rattle 5 Picking up objects 6 Holding a baby bottle

4,5,6

Which definition does the World Health Organization (WHO) use to define "health"? 1 A condition when people are free of disease 2 A condition of life rather than pathological state 3 An actualization of inherent and acquired human potential 4 A state of complete physical, mental, and social well-being

4. The WHO defines health as a "state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity." Pender, Murdaugh, and Parsons (2011) explains that all people free of disease are not healthy. Pender, Murdaugh, and Parsons (2011) suggest that for many people, health is a condition of life rather than pathological state. Life conditions such as environment, diet, or lifestyle choices can have positive or negative effects on health long before an illness is evident. Pender, Murdaugh, and Parsons (2011) define health as the actualization of inherent and acquired human potential through goal-directed behavior, competent self-care, and satisfying relationships with others.

What are the greatest risks for injury for an adolescent? Select all that apply. 1 Poisoning 2 Abduction 3 Home accidents 4 Substance abuse 5 Automobile accidents

45 Substance abuse and automobile accidents pose the greatest risks of injury among adolescents. Poisoning and child abduction are more common among toddlers and preschoolers. Home accidents are common among toddlers as well.

which behavior is seen in children at the undifferentiated stage of spiritual development, as propounded by Fowler? A) children have no concept of right or wrong to guide their behaviors B) children imitate the religious behaviors without comprehending any meaning C) children reason and question some of the established parental religious standards D) children have a reverence for religious matters and are able to articulate their faith.

Which gross motor skill is found in children between 2 to 4 months of age? 1 The child can creep on its hands and knees. 2 The child has predominant inborn reflexes. 3 The child can sit alone without any kind of support. 4 The child can bear weight on forearms when prone.

A child between 2 and 4 months of age is able to bear his or her weight on the forearms when in the prone position. A child between 8 and 10 months of age can creep on his or her hands and knees. A child between birth and 1 month has predominant inborn reflexes. A child between 6 and 8 months of age can sit alone without support.

Which cognitive developmental stage would the nurse expect for a 3-year-old child? 1 Intuitive 2 Abstract 3 Concrete 4 Preconceptual

According to Piaget, at approximately 2 years of age the toddler enters the preconceptual phase of cognitive thought, which lasts, at most, until about 4 years of age; the preconceptual phase is a subdivision of the preoperational stage, which lasts from 2 years to 7 years of age. Four-year-old children are in the stage of intuitive thought, which gives rise to imaginative play. Abstract thought is developed during the adolescent ages of 15 to 20 years. Concrete operational thought occurs in school-age children when they perform actions mentally rather than through behavior, as in the earlier years.

During a routine checkup a client reports concerns over weight gain despite trying juice cleanses and other trend diets. The nurse records the client's weight and BMI at a healthy range, but the client states, "I wish I were as thin as my co-workers." The client is at risk for what culturally-bound condition? Neurasthenia Anorexia nervosa Shenjing shuairuo Ataque de nervios

Anorexia nervosa Rationale Anorexia nervosa is a Western culture-bound eating disorder characterized by obsession with body image. A client who continues to follow weight loss diets despite being a healthy weight may be at risk for malnutrition. The client with neurasthenia may feel a lack of energy but not necessarily from following a strict diet to maintain body image. Shenjing shuairuo is a condition associated with Chinese culture that focuses on a weakness of nerves and is not associated with eating disorders or body image. Ataque de nervios is a Latino-Caribbean culture-bound syndrome and is not associated with body image.

The nurse is helping a client maintain and regain health, manage his or her disease and symptoms, and attain a maximal level of function and independence through the healing process. Which role is the nurse playing? 1 Manager 2 Advocate 3 Caregiver 4 Communicator

As a caregiver, the nurse helps clients maintain and regain health, manage diseases and symptoms, and attain a maximal level of function and independence through the healing process. As a manager, the nurse coordinates the activities of members of the nursing staff in delivering nursing care and has personnel, policy, and budgetary responsibility for a specific nursing unit or agency. As a client's advocate, the nurse protects the client's human and legal rights and provides assistance in asserting these rights if the need arises. As a communicator, the nurse learns about a client's strengths and weaknesses and his or her needs through effective communication.

which of these cultural groups adopts a combination of dietary, herbal and other naturalistic therapies to prevent and treat illness? A) east asian B) hispanic C) asian indian D) native american

Which intervention would the nurse do before formulating a teaching plan for a child who is to undergo ostomy surgery? 1 Assess the child's developmental level. 2 Determine the family's comprehension of the procedure. 3 Provide a list of available community resources to the family. 4 Collaborate with the school in ensuring the child's smooth return

Assess the child's developmental level Teaching methods in each age group vary with the child's cognitive ability; individual differences depend on a variety of factors, including both intelligence and emotional status. Also, the child's readiness to learn must be assessed before a teaching plan that will support success can be developed. Although determining the comprehension of the treatment by family members is important, it does not focus on the learning needs of the child, which is the priority. Providing a list of community resources will be important later, but not initially. Working with the school's staff will be important later, but not initially.

what concept of death should a nurse expect a 4 year old child to have? A) cessation of life B) reversible separation C) only affects old people D) force takes one way from family

A client with a seizure disorder is receiving phenytoin and phenobarbital. Which client statement indicates that the instructions regarding the medications are understood? A. I will not have any seizures on this medication B. These medicines must be continued to prevent falls and injury C. Stopping the medications can cause continuous seizures and I may die D. By staying on the medications I will prevent postseizure confusion

On the first evening after a lumbar laminectomy, a client states, "My feet are as numb as they were before the operation." Which response would the nurse make? A. Let me elevate your feet so the numbness will decrease more quickly B. That's important to know. I will contact your health care provider about the numbness C. Continue to let me know how you feel. It often takes time before that feeling subsides D. There is no cause for concern. The numbness will disappear when the anesthesia wears off

Status epilepticus develops in an adolescent with a seizure disorder who is taking antiseizure medication. Which reason would the nurse identify as the most common reason for this development? A. The provider failed to account for growth spurt B. The amount prescribed is insufficient to cover activities C. The prescribed antiseizure medication is not taken consistently D. The client is prescribed a medication that is ineffective in preventing seizures

Which ethnic group has a greater incidence of osteoporosis due to musculoskeletal differences? Irish Americans African Americans Chinese Americans Egyptian Americans

Chinese Americans Rationale Chinese Americans have an increased incidence of osteoporosis because they have shorter and smaller bones with lower bone density. Irish Americans have taller and broader bones than other Euro-Americans. African Americans have a decreased incidence of osteoporosis. Egyptian Americans are shorter in stature than Euro-Americans and African Americans.

A client who only speaks Spanish is being cared for at a hospital in which nursing personnel only speak English. What communication technique would be appropriate for the nurse to use when discussing healthcare decisions with the client? Contact an interpreter provided by the hospital. Contact the client's family member to translate for the client. Communicate with the client using Spanish phrases the nurse learned in a college course. Communicate with the client with the use of a hospital-approved Spanish dictionary.

Contact an interpreter provided by the hospital. Rationale Interpreters provided by the healthcare organization should be used to communicate with clients with limited English proficiency to ensure accuracy of communicated information. In hospital settings, it is not suitable for family members to translate healthcare information, but they can assist with ongoing interactions during the client's care. The other options do not ensure accurate interpretation of language.

A hospice nurse is caring for a dying client and the client's family members during the developing awareness stage of grief. What is the most important thing about the family that the nurse should assess before providing care? Cohesiveness Educational level Cultural background Socioeconomic status

Cultural background Rationale During the developing awareness stage of grief the degree of anguish experienced or expressed is influenced by the cultural background of the individual and family. Although cohesiveness does enter into the grief process, it is not as important in the developing awareness stage as cultural background is. Educational level has no relationship to the grieving process. Socioeconomic status is not a defining factor in how a family will respond to the loss of a loved one.

Which is the purpose of block and parish nursing? 1 To provide services to older clients 2 To promote health throughout a school curriculum 3 To provide nursing services with a focus on health promotion and education 4 To deliver primary care to a client population living in a community

In block and parish nursing, nurses living within a neighborhood provide services to older clients or those unable to leave their homes. Health promotion throughout a school curriculum is provided by school health. Nurse-managed clinics provide nursing services with a focus on health promotion and education, chronic disease assessment management, and support for self-care and caregivers. Community health centers are outpatient clinics that provide primary care to a client population living in a community.

After treatment for a bladder infection, a client asks whether there is anything she can do to prevent cystitis in the future. Which response would the nurse give? 1 "Avoid regular use of tampons." 2 "Decrease your intake of prune juice." 3 "Increase your daily fluid consumption." 4 "Cleanse the perineum from back to front."

Increasing fluid intake flushes the urinary tract of microorganisms. Use of tampons does not increase the risk of cystitis. Fluid consumption should be increased, not decreased. The preferred method of cleansing is from front to back (urethra to vagina); however, studies have shown that this method of cleansing is not a significant factor in the prevention of cystitis. Test-Taking Tip: Key words or phrases in the stem of the question such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. As in life, no real absolutes exist in nursing; however, every rule has its exceptions, so answer with care.

What should a nurse consider about the past experiences of clients who have immigrated to this country? It affects all of their inherited traits. There will be little impact on their lives today. It is important that their values be assessed first. How they will interact is permanently established.

It is important that their values be assessed first. Rationale Past experiences are important and must be recognized because they help set the individual's values throughout life. Past experiences will not affect inherited traits. Past experiences play an important role in an individual's life. Nothing establishes how an individual responds forever; new experiences continue to influence future responses.

A 26-year-old G1 P0 client at 29 weeks' gestation has gained 8 lb (3.6 kg) in 2 weeks; her blood pressure has increased from 128/74 Hg to 150/90 mm Hg; and she has developed 1+ proteinuria on urine dipstick. Which condition do these signs suggest? 1 Mild preeclampsia 2 Severe preeclampsia 3 Chronic hypertension 4 Gestational hypertension

Mild preeclampsia "Preeclampsia is hypertension that develops after 20 weeks' gestation in a previously normotensive woman. With mild preeclampsia the systolic blood pressure is below 160 mm Hg and diastolic BP is below 110 mm Hg. Proteinuria is present, but there is no evidence of organ dysfunction. Severe preeclampsia is a systolic blood pressure of greater than 160 mm Hg or diastolic blood pressure of at least 110 mm Hg and proteinuria of 5 g or more per 24-hour specimen. Chronic hypertension is hypertension that is present before the pregnancy or diagnosed before 20 weeks' gestation. Gestational hypertension is the onset of hypertension during pregnancy without other signs or symptoms of preeclampsia and without preexisting hypertension. Test-Taking Tip: Read carefully and answer the question asked; pay attention to specific details in the question."

The nurse is instructing a community group regarding risk factors for coronary artery disease. Which risk factor cannot be modified? a) Heredity b) Hypertension c) Cigarette smoking d) Diabetes mellitus

a) Heredity

A nurse is caring for an adult client who immigrated to this country 5 years ago. What does the nurse know about the past experiences of clients who have immigrated to this country? They affect their inherited traits. They have little effect on their lives today. They are important in assessment of their values. They establish personal interactions throughout life.

They are important in assessment of their values. Rationale Past experiences are important and must be recognized because they set the parameters for the individual's enduring values throughout life. Past experiences do not affect inherited traits. Past experiences play an important role in an individual's life. Nothing establishes how an individual responds over a lifetime; new experiences continue to influence future responses.

The nurse is asking a client with arthritis questions to collect information. Which questions asked by the nurse are closed-ended questions? Select all that apply. One, some, or all responses may be correct. a) "Are you having pain?" b) "Tell me how your pain has been." c) "Describe how your husband is helping you at home." d) "Do you think the medication is helping you get pain relief?" e) "Give me an example of a method that helps you get pain relief at home."

a) "Are you having pain?" d) "Do you think the medication is helping you get pain relief?"

Which statement by the nurse reflects understanding of therapeutic communication with a client experiencing domestic violence? Select all that apply. One, some, or all responses may be correct a) "Tell me about your struggles." b) "Everything is going to be okay." c) "Get out of the house right away." d) "You'll feel better after you leave." e) "Why do you stay when he hits you?" f) "Why did you return to him after the abuse?"

a) "Tell me about your struggles."

What does the presence of ketones in the urine of a client with renal dysfunction indicate? 1 Cystitis 2 Heart failure 3 Urinary calculi 4 Anorexia nervosa

Which drug prescribed to a client with a urinary tract infection (UTI) turns urine reddish-orange in color? 1 Amoxicillin 2 Ciprofloxacin 3 Nitrofurantoin 4 Phenazopyridine

A client is diagnosed as having invasive cancer of the bladder, and brachytherapy is scheduled. What should the nurse expect the client to demonstrate that indicates success of this therapy? 1 Decrease in urine output 2 Increase in pulse strength 3 Shrinkage of the tumor on scanning 4 Increase in the quantity of white blood cells (WBCs)

A client is admitted to the hospital with a diagnosis of acute Guillain-Barré syndrome. Which assessment is priority? 1 Urinary output 2 Sensation to touch 3 Neurologic status 4 Respiratory exchange

Which visual system assessment technique provides a magnified view of the retina and optic nerve head? 1 Keratometry 2 Ophthalmoscopy 3 Visual acuity testing 4 Confrontation visual filed test

An 80-year-old client is admitted to the hospital with severe dehydration. The client's daughter asks the nurse how her mother could have become dehydrated. Which response by the nurse is correct? 1 "The body's fluid needs decrease with age because of tissue changes." 2 "Access to fluid may be insufficient to meet the daily needs of the older adult." 3 "Memory declines with age, and the older adult may forget to ingest adequate amounts of fluid." 4 "The thirst reflex diminishes with age, and the recognition of the need for fluid is decreased."

"The thirst reflex diminishes with age, and the recognition of the need for fluid is decreased." For reasons that are still unclear, the thirst reflex diminishes with age, and this may lead to a concomitant decline in fluid intake. There are no data to support the statement "The body's fluid needs decrease with age because of tissue changes." The statement "Access to fluid may be insufficient to meet the daily needs of the older adult" is not true for an alert person who is able to perform the activities of daily living. Research does not support progressive memory loss in normal aging as a contributor to decreased fluid intake. STUDY TIP: Begin studying by setting goals. Make sure they are realistic. A goal of scoring 100% on all exams is not realistic, but scoring an 85% may be a better goal.

A client reports intolerance to music played at sound levels that do not bother other people. On assessing, the nurse observes impaired hearing in one ear. What could be the possible condition of the client? 1 Vertigo 2 Tinnitus 3 Hyperopia 4 Hyperacusis

A client is being initiated on bisphosphonates. Which advice will the nurse provide? 1. "Take it on an empty stomach." 2. "This medication should be taken at night before bed." 3. "These medications should be taken with food or milk." 4. "Lie down for a bit after taking the medication."

1. "Take it on an empty stomach." Bisphosphonates should be taken on an empty stomach in the morning because food and some minerals reduce absorption. The client should remain upright for 30 minutes after taking the medication.

a resident in a nursing home recently immigrated to the US from italy. how does the nurse plan to provide emotional support? A) by offering choices consistent with the client's heritage B) by assisting the client in adjusting to american culture C) by ensuring that the client understands american beliefs D) by correcting the client's misconceptions about appropriate health practices

the nurse is caring for an asian client who had a laparoscopic cholecystectomy six hours ago. when asked whether there is pain, the client smiles and says, no. what should the nurse do? A) monitor for nonverbal cues of pain B) check the pressure dressing for bledding C) assist the client to ambulate around his room D) irrigate the client's nasogastric tube with sterile water

A daughter of a Chinese-speaking client approaches a nurse and asks multiple questions while maintaining direct eye contact. What culturally related concept does the daughter's behavior reflect? Prejudice Stereotyping Assimilation Ethnocentrism

Assimilation Rationale Assimilation involves incorporating the behaviors of a dominant culture. Maintaining eye contact is characteristic of the American or Canadian culture and not of Asian cultures. Prejudice is a negative belief about another person or group and does not characterize this behavior. Stereotyping is the perception that all members of a group are alike. Ethnocentrism is the perception that one's beliefs are better than those of others.

The nurse is assessing a Latino-Caribbean client who was brought to the hospital by family members. The family reports the client started crying, shouting, trembling, had uncontrolled jerking of the extremities, and then fell into a trance-like state. What condition does the nurse suspect? Bulimia nervosa Anorexia nervosa Shenjing shuairuo Ataque de nervios

Ataque de nervios Rationale Ataque de nervios is a Latino-Caribbean culture-bound syndrome that usually happens in response to specific stressors. This culture-bound syndrome is characterized by crying, uncontrollable spasms, trembling, shouting, dissociation, and trance-like states. Bulimia nervosa and anorexia nervosa are culture-bound syndromes in the form of eating disorders, but they are not characterized by crying, spasms, and shouting. Shenjing shuairuo is not associated with the Latino-Caribbean culture; instead, it is associated with Chinese culture.

a multigravida of asian descent weighs 104 lb, having gained 14 pounds during pregnancy. on her second postpartum day, the client's temperature is 99.2 degrees. she has had poor dietary intake since admission. What should the nurse? A) ask the nursing supervisor to discuss this with the healthcare provider B) encourage the family to bring in special foods preferred by their culture C) order a high-protein milkshake as a between-meal snack to stimulate her appetite D) explain to the family that the dietitian plans nutritious meals that the client should eat

how should nurses provide effective nursing care to clients from different cultural backgrounds? A) by advising clients that some cultural practices may be harmful to health B) by providing care that fits the client's cultural beleifs C) by strictly adhering to organization policies regarding nursing care D) by ignoring the cultural aspect and focusing on the medical aspect of care

obesity in children is an ever-worsening problem. what concept should a nurse consider when caring for school-aged children who are obese? A) enjoyment of specific foods is inherited B) these are familial influences on childhood eating habits C) childhood obesity is usually not a predictor of adult obesity D) children with obese parents are destined to become obese themselves

A back brace is prescribed for a client who had a laminectomy. What should the nurse include in the client's teaching plan? A. Use the brace when the back feels tired. B. Apply the brace before getting out of bed. C. Put the brace on while in the sitting position. D. Wear the brace when performing twisting exercises.

A client is admitted to the emergency department after experiencing a seizure. Which action would the nurse take first? A. Ask the emergency provider for a prophylactic anticonvulsant B. Obtain a history of seizure type and incidence C. Ask the client to remove any dentures and eyeglasses D. Observe the client for increased restlessness and agitation

A client presents with cutaneous lesions with swelling of the face, eyelids, and lips from dilation and engorgement of the capillaries. The nurse does not observe welts or vesicles. Which hypersensitivity condition does the nurse suspect the client is experiencing? A. Urticarial dermatitis B. Angioedema C. Atopic dermatitis D. Systemic Lupus Erythematosus (SLE)

The nurse is obtaining a health history from a client with HIV with a low viral load who has been asymptomatic for years. Which statement by the client indicates the need for additional teaching? A. I inform all my partners of my HIV positive status B. I should not skip any doses of antiretroviral medication C. I occasionally have oral sex without the use of protection D. I have never shared or reused any of my diabetic supplies

Which assessments are the most significant for a client who is believed myasthenia gravis? A. Capacity to smile and close eyelids B. Ability to chew and speak words distinctly C. Effectiveness of respiratory exchange and ability to swallow D. Degree of anxiety and concern about the suspected diagnosis

Which complication would the nurse assess in both clients who have Parkinson disease and clients who have myasthenia gravis? A. Cogwheel gait B. Impaired cognition C. Difficulty swallowing D. Nonintention tremors

Which information would the nurse consider when planning care for a group of clients with myasthenia gravis, Guillain-Barré, and ALS? A. Progressive deterioration until death B. Deficiencies of essential neurotransmitters C. Increased risk for respiratory complications D. Involuntary twitching of small muscle groups

Which is the priority assessment for the client who has Guillain-Barré syndrome with rapidly ascending paralysis? A. Monitoring urine output B. Assessing nutritional status C. Monitoring respiratory status D. Assessing communication needs

Which statement by a client who has myasthenia gravis indicates understanding for managing self care? A. Plan my activities for later in the day B. Eat meals in semirecumbent position C. Avoid people with respiratory infections D. Take muscle relaxants when under stress

A client is scheduled to have a Tensilon test. Which response to the test would confirm the diagnosis of myasthenia gravis? A. Brief exaggeration of symptoms B. Prolonged symptomatic improvement C. Rapid but brief symptomatic improvement D. Symptomatic improvement of only the ptosis

C. Tensilon is like a treatment? a quick one

Which clinical manifestations are consistent with Sjögren syndrome? Select all that apply A. Iritis B. Scleritis C. Xerostomia D. Baker's cyst E. Keratoconjunctivitis sicca

C., E. Xerostomia is dry mouth Keratoconjunctivitis sicca is dry eyes

Which identified clinical manifestation is a sign of allergic rhinitis? A. Presence of a high grade fever B. Reduced breathing through the mouth C. Presence of pinkish nasal discharge D. Reduced transillumination on the skin over the sinuses

D. because of inflammation and stuffiness

According to current studies, what percentage of adolescents has used alcohol by the end of high school? Record your answer using a whole number. _____%

Current statistics show that by the end of their high school years, 85% of adolescents have used alcohol.

which internal variable influences health beliefs and practices? A) family practices B) cultural background C) socioeconomic factors D) intellectual background

Which is a primary focus of teaching for a pregnant adolescent at her first prenatal clinic visit? 1 Instructing her about the care of an infant 2 Informing her of the benefits of breast-feeding 3 Advising her to watch for danger signs of preeclampsia 4 Encouraging her to continue regularly scheduled prenatal care

It is not uncommon for adolescents to avoid prenatal care; many do not recognize the deleterious effect that lack of prenatal care can have on them and their infants. Instruction in the care of an infant can be done in the later part of pregnancy and reinforced during the postpartum period. Informing the client of the benefits of breast-feeding should come later in pregnancy but not before the client's feelings about breast-feeding have been ascertained. Advising the client to watch for danger signs of preeclampsia is necessary, but it is not the priority intervention at this time.

Which information would the nurse include in the discharge teaching of a postpartum client? Correct1 The prenatal Kegel tightening exercises should be continued. 2 A bowel movement may not occur for up to a week after the birth. 3 The episiotomy sutures will be removed at the first postpartum visit. 4 A postpartum checkup should be scheduled as soon as menses returns.

Kegel exercises may be resumed immediately and should be done for the rest of the client's life because they help strengthen muscles needed for urinary continence and may enhance sexual intercourse. Episiotomy sutures do not have to be removed. Bowel movements should spontaneously return in 2 to 3 days after the client gives birth; a delay of bowel movements promotes constipation, perineal discomfort, and trauma. The usual postpartum examination is 6 weeks after birth; the menses may return earlier or later than this and should not be a factor when the client is scheduling a postpartum examination. Test-Taking Tip: Pace yourself when taking practice quizzes. Because most nursing exams have specified time limits, you should pace yourself during the practice testing period accordingly. It is helpful to estimate the time that can be spent on each item and still complete the examination in the allotted time. You can obtain this figure by dividing the testing time by the number of items on the test. For example, a 1-hour (60-minute) testing period with 50 items averages 1.2 minutes per question. The NCLEX exam is not a timed test. Both the number of questions and the time to complete the test vary according to each candidate's performance. However, if the test-taker uses the maximum of 5 hours to answer the maximum of 265 questions, each question equals 1.3 minutes.

A client who has a hemoglobin of 6 gm/dL (60 mmol/L) is refusing blood because of religious reasons. What is the most appropriate action by the nurse? Call the chaplain to convince the client to receive the blood transfusion. Discuss the case with coworkers. Notify the primary healthcare provider of the client's refusal of blood products. Explain to the client that they will die without the blood transfusion.

Notify the primary healthcare provider of the client's refusal of blood products. Rationale The nurse serves as an advocate for the client to uphold their wishes. Synthetic blood products are available but must be prescribed by the primary healthcare provider. Therefore the primary healthcare provider needs to be notified of the client's refusal for blood so alternatives can be considered. The chaplain's role is to offer support, not to convince the client to go against beliefs. It is a Health Insurance Portability and Accountability Act (HIPAA) (Canada: Personal Health Information Protection Act [PHIPA]) violation to discuss the case with coworkers unless they are involved in the care of the client. The nurse should not use threats or fear to coerce the client.

A nurse understands that when a client is a member of a different ethnic community it is important to do what? Ensure that the nurse's biases are understood by the family. Make plans to counteract the client's misconceptions about therapies. Offer a therapeutic regimen compatible with the lifestyle of the family. Recognize that the client's responses will be similar to other clients' responses.

Offer a therapeutic regimen compatible with the lifestyle of the family. Rationale The client cannot be expected to accept or even respond to a plan that is incompatible with the family's lifestyle. The family should not have to adjust to the nurse's biases; the nurse must self-identify biases and ensure that they do not interfere with nursing care. There is no evidence that misconceptions will occur. All individuals respond differently to situations.

The nurse understands which vaccine may cause intussusception in children? 1 Rotavirus 2 Hepatitis 3 Measles, mumps, and rubella 4 Diphtheria, tetanus, and pertussis

Rotavirus vaccines very rarely cause intussusception, a form of bowel obstruction in which the bowel telescopes in on itself. Hepatitis vaccines can cause anaphylactic reactions. The measles, mumps, and rubella vaccine may cause thrombocytopenia. The diphtheria, tetanus, and pertussis vaccine carries a small risk of causing acute encephalopathy, convulsions, and a shock-like state.

Which question will the nurse ask to assess a client's potential exposure to inhaled environmental irritants or toxic gases? a) "Do you garden?" b) "Are there ashtrays in your home?" c) "How much water or fluids do you drink daily?" d) "What type of work have you done in the past?"

d) "What type of work have you done in the past?"

After a prolonged period in a regional hospital far from home to which the parents were unable to travel, an 18-month-old toddler becomes depressed, withdrawn, and apathetic. Eventually the toddler begins playing with toys and relating to others, even strangers. When the parents visit, the child ignores them. The parents tell the nurse that their child has forgotten them. How would the nurse explain the child's behavior? 1 The nurse suggests that they may be right and that their child will have to get to know them again. 2 This indicates approval of the staff and the child's understanding that they will not inflict bodily harm. 3 It reflects acceptance of the hospitalization and the experience will enhance their child's maturation. Correct4 This is typical behavior in toddlers who are separated from their parents for prolonged periods, and indicates that their child will need special attention from them.

The child has progressed to the third phase of separation anxiety, detachment or denial, in which there is a resignation to the loss of the parents and a superficial appearance of adjustment to the environment. Eighteen-month-old children do not forget their parents. The child's behavior indicates resignation, not acceptance or understanding of the situation. Toddlers who have parental support usually view staff members as unfamiliar, frightening, and often threatening. Acceptance of the hospitalization is often the mistaken interpretation of such behavior.

During the assessment of a client in labor, the cervix is determined to be dilated 4 cm. Which stage of labor would the nurse record? 1 First 2 Second 3 Prodromal 4 Transitional

The first stage of labor is from zero cervical dilation to full cervical dilation (10 cm). The second stage is from full cervical dilation to delivery. The prodromal stage is before cervical dilation begins. The transitional phase is the first stage of labor, from 8 cm of dilation to 10 cm of dilation.The first stage of labor is from zero cervical dilation to full cervical dilation (10 cm). The second stage is from full cervical dilation to delivery. The prodromal stage is before cervical dilation begins. The transitional phase is the first stage of labor, from 8 cm of dilation to 10 cm of dilation.

What is the maximum heart rate of a 16 year old? Record your answer using a whole number. ____________________ beats per minute

The maximum heart rate of a 16 year old is 90 beats per minute.

Arrange the stages of the menstrual cycle in sequential order. 1. Ovulation 2. Follicular phase 3. Feedback mechanism 4. Follicular involution

The menstrual cycle begins with the follicular phase. During this phase, one ovarian follicle becomes dominant and produces a large amount of estrogen. After this phase is ovulation; this occurs when the dominant follicle releases an ovum around day 14 of the cycle. After the ovum is released, the follicle involutes with the decreased production of estrogen and thus progesterone in blood. As a feedback response to this decrease, the pituitary gland increases the production of follicle stimulating hormone, which initiates a new menstrual cycle.

What is the minimum respiratory rate in a normal adolescent? Record your answer using a whole number. _____________________ breaths/minute

The minimum respiratory rate in a normal adolescent is 16 breaths/minute.

What is the average systolic blood pressure in a 13-year-old adolescent? Record your answer using a whole number. _____ mm Hg

The normal systolic blood pressure in a 13-year-old adolescent is 110 mm Hg.

Which is the recommended protein intake for preschoolers? 1 1 g/day 2 13 g/day 3 300 mg/day 4 700 mg/day

The recommended protein intake for preschoolers is 13 to 19 g/day. The recommended protein intake for preschoolers is not 1 g/day. The recommended cholesterol consumption for children over the age of 2 years should be less than 300 mg/day, whereas the recommended daily allowance for calcium for children 1 to 3 years old is 700 mg.

Obesity in children is an ever-worsening problem. What concept should a nurse consider when caring for school-aged children who are obese? Enjoyment of specific foods is inherited. There are familial influences on childhood eating habits. Childhood obesity is usually not a predictor of adult obesity. Children with obese parents are destined to become obese themselves.

There are familial influences on childhood eating habits. Rationale Studies have demonstrated that culture and family eating habits have an impact on a child's eating habits. Inheritance is not known to influence eating habits, although it is believed that other hereditary factors are associated with obesity. Childhood obesity is a known predictor of adult obesity. Children with obese parents are not necessarily destined to become obese themselves.

The nurse is preparing to teach a community health program for senior citizens. Which physical findings would the nurse include that are typical in older adults? 1 Increased skin elasticity and an increase in testosterone production 2 Impaired fat digestion and an increase in pepsin production 3 Increased blood pressure and decreased cardiac output 4 An increase in body warmth and some swallowing difficulties

With aging, narrowing of the arteries causes some increase in the systolic and diastolic blood pressures. Decreases occur in diastolic pressure, diastolic filling, and beta-adrenergic stimulation; increases occur in arterial pressure, systolic pressure, wave velocity, and left ventricular end diastolic pressure. Decreased cardiac output and cardiac reserve decrease the older adult's response to stress. Changes in libido may occur. Testosterone appears to influence the frequency of nocturnal erections; however, low testosterone levels do not affect erections produced by erotic stimuli. There is a loss of skin elasticity. By the age of 60, gastric secretions decrease 70% to 80% of those of the average adult. A decrease in pepsin may hinder protein digestion. There may be a decrease in subcutaneous fat and decreasing body warmth. Some swallowing difficulties occur because older people are susceptible to fluid loss and electrolyte imbalance. This results from decreased thirst sensation, difficulty swallowing, chronic disease, reduced kidney function, diminished cognition, or adverse medication reactions.

Which nurse statement reflects positive cultural sensitivity to help reduce potential health disparities? a) "Which type of food do you usually eat at home?" b) "You need to ask your family to bring food of your choice." c) "The hospital staff will not be able cook food with your requirements." d) "You need to eat the food that the hospital provides."

a) "Which type of food do you usually eat at home?"

Which factor that influences the spread of sexually transmitted infections (STIs) would the nurse include in a teaching session? Select all that apply. One, some, or all responses may be correct. a) Age b) Drug abuse c) Lack of education d) Multiple sex partners e) Absent or subtle symptoms f) Limited access to health care

a) Age b) Drug abuse c) Lack of education d) Multiple sex partners e) Absent or subtle symptoms f) Limited access to health care

Which risk factor increases a client's risk for infection in the community? Select all that apply. One, some, or all responses may be correct. a) Lifestyle b) Occupation c) Chronic diseases d) Frequent traveling e) Diagnostic procedures

a) Lifestyle b) Occupation d) Frequent traveling

Which risk of adolescent pregnancy would the community nurse teach? a) Risk for premature birth b) Risk for having a large baby c) Risk for chromosomal defects d) Risk for increased weight gain

a) Risk for premature birth

Which scenario would contribute to health disparities? a) An English-speaking critical care nurse assesses a Hispanic client in a coma. b) An English-speaking nurse plans the nursing procedures for a black Latino client. c) An English-speaking nurse provides discharge instructions to an English-speaking client who is hard of hearing. d) An English-speaking nurse conducts the admission interview of a Puerto Rican immigrant with limited knowledge of English.

d) An English-speaking nurse conducts the admission interview of a Puerto Rican immigrant with limited knowledge of English.

A client with a history of chemical exposure and environmental toxins is diagnosed with mycosis fungoides (MF), which led to the development of Sézary syndrome. The primary health care provider advised extracorporeal photopheresis. Which would the nurse expect as the diagnosis of the client? a) Actinic keratosis b) Basal cell carcinoma c) Malignant melanoma d) Cutaneous T-cell lymphoma

d) Cutaneous T-cell lymphoma

Which factor increases an adolescent's risk for injury in the community? a) Employment b) Eating disorders c) Sleep deprivation d) Distracted driving

d) Distracted driving

The registered nurse (RN) is organizing a community health care program for administering tetanus vaccinations. Which member of the health care team is most suitable for being delegated the task of administering vaccinations? a) Nursing aide b) Certified technician c) Patient care associate (PCA) d) Licensed practical nurse (LPN)

d) Licensed practical nurse (LPN)

While organizing a community health care program for polio vaccinations, the registered nurse (RN) delegates the task of administering vaccines to members of the health care team. Which health care team member is most suitable to carry out the task? a) Technician b) Patient care associate (PCA) c) Certified nursing aide d) Licensed practical nurse (LPN)

d) Licensed practical nurse (LPN)

The nurse in the health clinic is counseling a college student who recently was diagnosed with asthma. Which aspect of counseling would the nurse focus on? o Teaching how to make a room allergy-free o Referring to a support group for individuals with asthma o Arranging with the college to ensure a speedy return to classes o Evaluating whether the necessary lifestyle changes are understood

o Evaluating whether the necessary lifestyle changes are understood · Understanding the disorder and the details of care are essential for the client to be self-sufficient. Although teaching is important, a perceived understanding of the need for specific interventions must be expressed before there is a readiness for learning. Referring to a support group is premature; this may be done eventually. Although ensuring a speedy return to classes is important, involving the college should be the client's decision.

Which type of acid-base imbalance would the nurse expect in a child admitted with a severe asthma exacerbation? o Metabolic alkalosis caused by excessive production of acid metabolites o Respiratory alkalosis caused by accelerated respirations and loss of carbon dioxide o Respiratory acidosis caused by impaired respirations and increased formation of carbonic acid o Metabolic acidosis caused by the kidneys' inability to compensate for increased carbonic acid formation

o Respiratory acidosis caused by impaired respirations and increased formation of carbonic acid · The restricted ventilation accompanying an asthma attack limits the body's ability to blow off carbon dioxide. As carbon dioxide accumulates in the body fluids, it reacts with water to produce carbonic acid; the result is respiratory acidosis. The problem basic to asthma is respiratory, not metabolic. Respiratory alkalosis is caused by the exhalation of large amounts of carbon dioxide; asthma attacks cause carbon dioxide retention. Asthma is a respiratory problem, not a metabolic one; metabolic acidosis can result from an increase of nonvolatile acids or from a loss of base bicarbonate.

An infant with cardiopulmonary disease displays signs and symptoms of bronchiolitis and pneumonia. Which condition would the nurse anticipate when planning care? o Poliomyelitis o Pneumococcal infection o Meningococcal infection o Respiratory syncytial virus infection

o Respiratory syncytial virus infection · Respiratory syncytial virus infections are the most common cause for hospitalization of infants younger than 1 year of age; this disease especially affects premature infants and infants with cardiopulmonary disease. Poliomyelitis is caused by the poliovirus. Streptococcus pneumonia infections cause meningitis, sepsis, pneumonia, and otitis media. Neisseria meningitidis causes meningitis.

The nurse administers albuterol to a child with asthma. Which common side effect would the nurse monitor for in the child? o Flushing o Dyspnea o Tachycardia o Hypotension

o Tachycardia · Albuterol produces sympathetic nervous system side effects such as tachycardia and hypertension. Pallor, not flushing, is a common side effect. Dyspnea is not a common side effect; this medication is given to decrease respiratory difficulty. Hypertension, not hypotension, is a common side effect.

a client has just been admitted to the psychiatric unit on the involuntary admission status. during the admission assessment the client tells the nurse, I am the second son of God and need to stay a prayer. what is the best response by the nurse? A) interrupting the client and continuing the assessment B) joining the client in prayer and then focusing on the assessment C) quietly leaving the client and coming back later to complete the assessment D) waiting until the client finishes the prayer and then completing the assessment

A woman who has just delivered an infant asks to take the placenta home with her upon discharge. What is the most appropriate response by the nurse? "I'll wrap that right up for you." "I'm sorry, but you can't do that." "I'll give it to you for your husband to take home now." "I need to check the hospital protocol for our policy on that practice."

"I need to check the hospital protocol for our policy on that practice." Rationale The placenta is a part of the body and therefore contains body fluids. It must first be assessed by the healthcare provider to be sure that it is not infected and to be sure that all parts of the placenta have been accounted for. The nurse must follow hospital policy regarding the release of the placenta to the family. All necessary documentation must be signed and the policies must be followed before the release of the placenta to the family.

During discharge teaching, a client with an ileal conduit asks how frequently the urine pouch should be emptied. Which reply by the nurse is best? 1 "To prevent leakage and pulling of the pouch from the skin, it should be emptied every few hours." 2 "To prevent skin irritation, it should be emptied every hour if any urine has collected in the bag." 3 "To reduce the risk of infection, the system should be opened as little as possible; two times a day is adequate." 4 "To reduce the cost of drainage pouches, it should be emptied once the system is switched to a bedside collection bag."

Pulse oximetry is prescribed for an adolescent. What should the nurse do to ensure accuracy of the pulse oximeter reading? 1 Attach the probe to a finger or earlobe. 2 Wait 30 minutes before obtaining a reading. 3 Calibrate the oximeter at least every 8 hours. 4 Place the probe on the abdomen or upper leg.

1 Capillary beds are closest to the surface in a finger or earlobe; this proximity permits more accurate measurement of arterial oxygen saturation. An almost instantaneous, accurate readout may be obtained with the use of a pulse oximeter. The pulse oximeter does not require routine calibration. Placing the probe on the abdomen or upper leg is contraindicated because the capillary beds are not close to the surface on the abdomen or upper thigh.

Which phrase would the nurse use to document a fetal heart rate (FHR) increase of 15 beats over the baseline rate of 135 beats per minute that lasts 15 seconds? 1. An acceleration 2. An early increase 3. A sonographic motion 4. A tachycardic heart rate

1. An acceleration An acceleration is an abrupt increase in FHR above the baseline of 15 beats/min for 15 seconds; if the acceleration persists for more than 10 minutes, it is considered a change in baseline rate. Early decelerations, not increases, occur. An early deceleration starts before the peak of the uterine contraction and returns to baseline when the uterine contraction ends. A sonographic motion is not a term used in fetal monitoring. A tachycardic FHR is one faster than 160 beats per minute.

What is female athlete triad? 1 Amenorrhea in athlete females 2 Hypogonadotropic amenorrhea 3 Amenorrhea, an eating disorder, and osteoporosis 4 Amenorrhea and osteoporosis

3 Athletes with amenorrhea, irregular eating habits and reduced nutritional intake, and osteoporosis are said to have female athlete triad. Simple amenorrhea is not considered female athlete triad. Hypogonadotropic amenorrhea results from a problem in the central hypothalamic-pituitary axis, where there is a hypothalamic suppression resulting in amenorrhea.

Which is the subset of clinical health care informatics? 1 Clinical informatics 2 Nursing informatics (NI) 3 Public health informatics 4 Clinical research informatics

2. Nursing informatics (NI) NI is the subset of clinical health care informatics. This is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice. Clinical health care informatics is a subdomain of clinical informatics. Public health informatics is one of the major domains of informatics that uses computer science and technology to improve public health. Clinical research informatics is a subdomain of clinical informatics.

The nurse is discussing the neurological reflexes seen in an infant with the parents. Which reflex would the nurse state as being present indefinitely? 1 Landau 2 Parachute 3 Body righting 4 Neck righting

2. Parachute The parachute reflex appears at 7 to 9 months and persists indefinitely. The Landau reflex appears at 6 to 8 months and lasts until 12 to 24 months. Body righting appears at 6 months and lasts until 24 to 36 months. Neck righting appears at 3 months and lasts until 24 to 36 months.

During which week of pregnancy does placental development occur? 1 First 2 Third 3 Fifth 4 Seventh

2. Placental development begins during the third week of pregnancy. The other answer options, first, fifth, and seventh, are not when placental development occurs.

Which statement is true regarding the importance of play for children? 1 Pretend play hampers the cognitive development of children. 2 Playing is important because it helps children to release frustration. 3 Children should be introduced to reality if they have imaginary playmates. 4 Children should completely avoid television, electronic games, and computer programs.

2. Playing serves as a medium for children to release frustration. Pretend play allows children to learn to understand others' points of view, develop skills in solving social problems, and become more creative. Some children have imaginary playmates. Imaginary playmates are a sign of health and help children distinguish between reality and fantasy. Television, videos, electronic games, and computer programs support development and the learning of basic skills. There should be limited use of these for preschoolers, but these need not be completely avoided. On the other hand, television, electronic games, and computer programs have lasting negative effects on a toddler's language development, reading skills, and short-term memory.

Which stages are a part of conventional reasoning, according to the Kohlberg's theory of moral development? Select all that apply. 1 Social contract orientation 2 Good boy-nice girl orientation 3 Society-maintaining orientation 4 Instrument relativist orientation 5 Universal ethical principle orientation

23 According to Kohlberg's theory, good boy-nice girl orientation and society-maintaining orientation are parts of conventional reasoning. Social contract orientation is stage 5 under postconventional reasoning. Instrument relativist orientation is stage 2 of preconventional reasoning. Universal ethical principle orientation is stage 6 under postconventional reasoning of Kohlberg's theory.

A client with a diagnosis of polyarteritis nodosa asks the nurse for information about this disorder. What information should the nurse include in the response? 1 Clients with this disease have an excellent prognosis. 2 The disorder affects males and females in equal numbers. 3 The disorder is considered one of hypersensitivity, and the exact cause is unknown. 4 Clients with this disease have problems with only the kidneys and the retina of the eyes.

The nurse working in a cardiac center is preparing to enter client data using health information technology. The nurse needs to refer to these data during subsequent follow-up client visits. Which type of record would the nurse use to enter the client's data? 1 Personal health record (PHR) 2 Electronic health record (EHR) 3 Electronic medical record (EMR) 4 Regional Health Information Organization (RHIO) health record

3. EMR The EMR is a client's health record within a health care provider's facility. These records are not intended to be shared between multiple facilities and agencies. The PHR is self-recorded and maintained by the client. An EHR is an individual's official, digital health record; it is shared among multiple facilities and agencies. RHIO health records are client records that can be exchanged among providers and across geographic areas.

While inspecting the external eye structure of a client, the nurse finds bulging of the eyes. Which condition would be suspected in the client? 1. Eye tumors 2. Hypothyroidism 3. Hyperthyroidism 4. Neuromuscular injury

3. Hyperthyroidism Bulging eyes may indicate hyperthyroidism. Tumors are characterized by abnormal eye protrusions. Hypothyroidism can be revealed by the coarseness of the hair of the eyebrows and the failure of the eyebrows to extend beyond the temporal canthus. Crossed eyes or strabismus may result from neuromuscular injury or inherited abnormalities.

The nurse is teaching crutch-walking to an adolescent. Which action indicates the need for more teaching? 1. Takes short steps of equal length 2. Looks forward to maintain balance 3. Looks down when placing the crutches 4. Assumes an erect posture when walking

3. Looks down when placing the crutches The child should maintain an erect walking posture, without looking down, to ensure equilibrium and prevent loss of balance. Taking short steps is the correct technique for safe ambulation while crutch-walking. Looking forward is the correct technique for safe ambulation while crutch-walking; it keeps the body's center of gravity over the hips. Maintaining an erect posture is the correct technique for safe ambulation during crutch-walking; it keeps the body's center of gravity over the hips.

Which would the nurse teach the parents of a child who is being discharged from the hospital after a diagnosis of acute spasmodic laryngitis to help prevent another croup episode? 1. Perform postural drainage. 2. Discourage before-bedtime snacks. 3. Use a cool mist vaporizer in the child's room. 4. Demonstrate to the child how to expel air after inspiration.

3. Use a cool mist vaporizer in the child's room. Cool mist provides humidification. Postural drainage would likely increase the child's anxiety. There is no relationship between eating and the onset of spasmodic croup. It is useless to give instruction while the child is fighting to breathe.

Which information is correct about the cognitive changes of a teenager? 1 A teenager deals with actual problems. 2 A teenager thinks in terms of the present. 3 A teenager cannot consider the possibilities of a situation occurring. 4 A teenager considers an infinite variety of causes and solutions.

4 A teenager considers an infinite variety of causes and solutions when encountered with a problem. A teenager is able to deal with hypothetical problems and takes the future into consideration. A teenager is able to imagine multiple outcomes of a situation.

Which statement is true for collaborative problems in a client? 1 They are the identification of a disease condition. 2 They include problems treated primarily by nurses. 3 They are identified by the primary health care provider. 4 They are identified by the nurse during the nursing diagnosis stage.

4 They are identified by the nurse during the nursing diagnosis stage. The nurse assesses the client to gather information for reaching diagnostic conclusions. Collaborative problems are identified by the nurse during this process. If the client's health problem requires treatment by other disciplines, such as medical or physical therapy, the client has a collaborative problem. A medical diagnosis is the identification of a disease condition. Problems that require treatment by the nurse are referred to as nursing diagnoses. A medical diagnosis is identified by the primary health care provider based on the results of diagnostic tests.

Which conditions pose the greatest risk for injury for an adolescent? Select all that apply. One, some, or all responses may be correct. 1 Poisoning 2 Abduction 3 Home accidents 4 Substance abuse 5 Motor vehicle accidents

4, 5 Substance abuse and motor vehicle accidents pose the greatest risks of injury among adolescents. Poisoning and child abduction are more common among toddlers and preschoolers. Home accidents are common among toddlers as well.

4,5,6 Holding a rattle, picking up objects, and holding a baby bottle are demonstrations of fine motor skills. Gross motor skills include crawling, creeping, and sitting erect.

An increase in which factor causes urinary frequency in the first trimester of pregnancy? Incorrect1 Estrogen level 2 Extracellular fluid volume 3 Kidney glomerular filtration 4 Bladder pressure from the enlarged uterus

The nurse is instructing a group of clients in the community about food preparation. Which statement indicates that a client is at an increased risk for contracting botulism? 1 "I do not usually brush my teeth after I finish eating a meal." 2 "Sometimes I eat grapes before I have a chance to wash them." 3 "Utensils that I use to cut up chicken are put into the dishwasher." 4 "I save money when I buy the slightly damaged cans of vegetables."

Which of these characteristics are found in an adolescent according to Erikson's theory of psychosocial development? Select all that apply.1 The adolescent concentrates on work and play. 2 The adolescent develops autonomy by making choices. 3 The adolescent develops a conscience. 4 The adolescent is concerned about his or her appearance and body image. 5 The adolescent acquires a sense of identity by participating in decision-making.

4.5. According to Erikson's theory, an adolescent has a marked preoccupation with his or her appearance and body image. Also during this stage, the adolescents develop a sense of identity by participating in decision-making. A toddler develops his or her autonomy by making choices. A child between three and six years old develops a superego or conscience. According to Erikson's theory of psychosocial development, ages 3-5 years old concentrates on work and play, not adolescents.

According to current statistics, what percent of adolescents try marijuana by the end of high school? Record your answer using a whole number. ________

a 5 year old child who is newly arrived from latin america attends a nursery school where everyone speaks english. the child's mother tells the nurse that her child is no longer outgoing and has become very passive in the classroom. what is the probable reason for the children's behavior? A) culture shock B) social immaturity C) experience of discrimination D) lack of interest in school activites

a client who only speaks spanish is being cared for at a hospital in which nursing personnel only speaks english. what communication technique would be appropriate for the nurse to use when discussing healthcare decisions with the client? A) contact an interpreter provided by the hospital B) contact the client's family member to translate for the client C) communicate with the client using spanish phrases the nurse learned in a college course D) communicate with the client with the use of a hospital approved spanish dictionary

a mother brings her 9 month old infant to the clinic. the nurse is familiar with the mother's culture and knows that belly binding to prevent extrusion of the umbilicus is a common practice. the nurse accepts the mother's cultural beliefs and is concerned for the infant's safety. what variation of belly binding does the nurse discourage? A) coin the umbilicus B) tight diaper over the umbilicus C) binder that encircles the umbilicus adhesive tape across the umbilicus

a nurse understands that value clarification is a technique useful in therapeutic communication because initially it helps clients do what? A) become aware of their personal values B) gain information related to their needs C) make correct decisions related to their health D) alter their value systems to make them more socially acceptable

a public health nurse is working with a family with three school-aged children as the unit of service. what should the nurse consider when caring for this family? A) certain members of the family may be capable of giving more support than the nurse B) assessing each family member is not necessary to plan care for the family as a whole C) family values are not as important as other factors regarding how assistance is perceived D) helping the family requires separating health problems from other aspects of the family's life

the preschool age client is learning sociocultural mores. what should this imply to the nurse regarding this client? A) the child is developing a conscience B) the child is learning about gender roles C) the child is developing a sense of security D) the child is learning about the political process

an asian client arrives at the mental health clinic with symptoms of anxiety and panic. while speaking with the client, the nurse notes that the client makes very little eye contact. what does this assessment data suggest? A) shyness B) cultural variation C) symptoms of depression D) shame regarding treatment

Which clinical finding would the nurse expect to find with a new diagnosis of myasthenia gravis? A. Tearing B. Diplopia C. Nystagmus D. Exophthalmos

B. Diplopia - double vision Nystagmus - MS Exophthalmos - hyperthyroidism

Which information would the nurse include in the teaching plan for a client diagnosed with epilepsy? A. The client will take anticonvulsant medications for life B. Individuals taking phenytoin must floss their teeth regularly C. A diagnosis of epilepsy prevents individuals from ever obtaining a driver's license D. Loss of consciousness during a seizure requires emergency evaluation

B. Gingival hyperplasia is a common side effect of phenytoin

Which condition presents with elevated IgE levels, positive allergic skin test reactivity, and widespread skin vesicles A. Allergic rhinitis B. Atopic dermatitis C. Contact dermatitis D. Goodpasture syndrome

B. Allergic rhinitis is seasonal allergies Goodpasture involves the lungs and kidneys Contact dermatitis is delayed reaction

A pregnant immigrant notices cultural differences in the way that pregnant women are cared for where she now lives. Which component of cultural competence is being demonstrated when the nurse motivates the immigrant to accept these differences? Cultural desire Cultural awareness Cultural knowledge Cultural encounters

Cultural desire Rationale The nurse is using cultural desire as a part of cultural competence. This component is related to motivation and commitment towards the care of an individual. Through this, an immigrant may become open to cultural differences and accept them. Cultural awareness is an in-depth self-examination of backgrounds and recognizing biases and prejudices. Cultural knowledge is a comparative study about the beliefs and care practices of other cultures. Cultural encounter is about transcultural interactions for effective communication and development.

a nurse is with the parents of a 3 year old child who has just died. what is the most therapeutic question for the nurse to ask the parents? A) do you feel ready to consent to an autopsy? B) have you made a decision about organ donation C) would you like to talk about how you'll tell your other children D) can i be of any help with traditional practices that are important to you?

Why is it important for a nurse in the prenatal clinic to provide nutritional counseling to all newly pregnant women? Most weight gain is caused by fluid retention. Different cultural groups favor different essential nutrients. Dietary allowances should not increase throughout pregnancy. Pregnant women must adhere to a specific pregnancy dietary regimen.

Different cultural groups favor different essential nutrients. Rationale The nurse should become informed regarding the cultural eating patterns of clients so that foods containing the essential nutrients that are part of these dietary patterns may be included in the diet. Fluid retention is only one component of weight gain; growth of the fetus, placenta, breasts, and uterus also contributes to weight gain. The need for calories and nutrients increases during pregnancy. Pregnancy diets are not specific; they are composed of the essential nutrients.

Which age would the nurse teach the parents of a school-age client to expect mandibular second molars to erupt? 1 7 to 8 years 2 9 to 10 years 3 10 to 12 years 4 11 to 13 years

Mandibular second molars often erupt between 11 and 13 years of age. The maxillary central incisor is expected to erupt between 7 and 8 years of age. The mandibular cuspids are expected to erupt between 9 and 10 years of age. The mandibular second bicuspids are expected to erupt between 11 to 12 years of age.

The nurse is educating parents about the changes to expect when their child enters toddlerhood. Which information would the nurse include? 1 The toddler's body appears slender. 2 The toddler has a protruded abdomen. 3 The toddler's feet are severely everted. 4 The toddler has inconspicuous cervical curves.

The nurse explains to the parents that at the start of toddlerhood, the abdomen of the child will be protruded. The bodies of toddlers start appearing slender by the age of 3 years, not in the beginning of toddlerhood. As the child walks, the legs and feet are usually far apart, and the feet are slightly everted, not severely everted. Toward the end of toddlerhood, curves in the cervical and lumbar vertebrae are accentuated. STUDY TIP: Remember that intelligence plays a vital role in your ability to learn. However, being smart involves more than just intelligence. Being practical and applying common sense are also part of the learning experience.

Which instruction would the nurse provide to a group of parents with small children to promote safety and prevent injury? Select all that apply. One, some, or all responses may be correct. a) Turn pot handles away from edges. b) Install smoke detectors in the house. c) Lock medication away in a safe place. d) Place child safety latches on cabinets. e) Verify water temperature before baths.

a) Turn pot handles away from edges. b) Install smoke detectors in the house. c) Lock medication away in a safe place. d) Place child safety latches on cabinets. e) Verify water temperature before baths.

Which information would the nurse obtain in a health history for a sexually active 16-year-old to determine the client's risk for sexually transmitted infections (STIs)? Select all that apply. One, some, or all responses may be correct. a) Sexual practices b) Barrier protection use c) Gender of sexual partners d) Number of sexual partners e) Use of illicit drugs before sex

a) Sexual practices b) Barrier protection use c) Gender of sexual partners d) Number of sexual partners e) Use of illicit drugs before sex

The nurse is teaching first aid to a group of community members. A participant asks which first aid should be administered, after calling 911, to a person who suffers extensive burns. Which response by the nurse is appropriate? a) "Apply ice to burned areas because this decreases pain." b) "Cover the burned areas with a bed sheet because this provides protection." c) "Do nothing because attempting to treat the burned areas may cause further damage." d) "Use first aid cream to burned areas because this prevents infection and decreases pain."

b) "Cover the burned areas with a bed sheet because this provides protection."

Which activity by the community nurse is an illness prevention strategy? a) Encouraging the client to exercise daily b) Arranging an immunization program for chicken pox c) Teaching the community about stress management d) Teaching the client about maintaining a nutritious diet

b) Arranging an immunization program for chicken pox

Which environmental emergency requires the nurse to administer priority emergency abdominal and chest thrusts to clear a client's airway obstruction? a) Frostbite b) Drowning c) Hypothermia d) Lightening injury

b) Drowning

The nurse is instructing a group of clients in the community about food preparation. Which statement indicates that a client is at an increased risk for contracting botulism? a) "I do not usually brush my teeth after I finish eating a meal." b) "Sometimes I eat grapes before I have a chance to wash them." c) "Utensils that I use to cut up chicken are put into the dishwasher." d) "I save money when I buy the slightly damaged cans of vegetables."

d) "I save money when I buy the slightly damaged cans of vegetables."

Which education would the nurse provide the parents of preschool-aged children regarding injury prevention? a) "Preschool-aged children are more prone to falls than are toddlers." b) "Preschool-aged children are at risk for injury because of their poor gross motor skills." c) "Preschool-aged children are less likely to follow rules, which increases the risk for injury." e) "Preschool-aged children are at risk for head injuries from riding a tricycle or balance bike."

e) "Preschool-aged children are at risk for head injuries from riding a tricycle or balance bike."

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with acute pneumonia. The client is in moderate respiratory distress. The nurse would place the client in which position to enhance comfort? o Side-lying with head elevated 45 degrees o Sims with head elevated 90 degrees o Semi-Fowler with legs elevated o High Fowler using the bedside table to rest the arms

o High Fowler using the bedside table to rest the arms · The high-Fowler position elevates the clavicles and helps the lungs expand, thus easing respirations. The side-lying, Sims, and semi-Fowler positions do not promote more comfortable breathing.

A registered nurse (RN) is performing a physical examination of a client with chronic obstructive pulmonary disease. Which abnormal nail bed patterns would be expected in this client? o Spoon-shaped nails o Transverse depressions in nails o Softening of nail beds and flat nails o Red or brown linear streaks in nail bed

o Softening of nail beds and flat nails · Softening of the nail bed and enlarged finger tips with flattened nails are signs of clubbing of the nails. Clubbing results in a change of the angle between the nail and nail base and is seen in conditions of oxygen deficiency, such as in heart or pulmonary diseases. Conditions such as iron-deficiency anemia and syphilis cause curvature of nails, which is called koilonychia. Transverse depressions in nails indicate a temporary disturbance of nail growth called Beau lines. Red or brown linear streaks in the nail bed are caused by minor trauma to nails, subacute endocarditis, and trichinosis. They are called splinter hemorrhages.

Which blood gas result should the nurse expect an adolescent with diabetic ketoacidosis to exhibit? 1 pH 7.30, CO2 40 mm Hg, HCO3- 20 mEq/L (20 mmol/L) 2 pH 7.35, CO2 47 mm Hg, HCO3- 24 mEq/L (24 mmol/L) 3 pH 7.46, CO2 30 mm Hg, HCO3- 24 mEq/L (24 mmol/L) 4 pH 7.50, CO2 50 mm Hg, HCO3- 22 mEq/L (22 mmol/L)

1 A client in diabetic ketoacidosis will have blood gas readings that indicate metabolic acidosis. The pH will be acidic (7.30), and the HCO3- will be low (20 mEq/L [20 mmol/L]). The normal pH is 7.35 to 7.45; CO2 ranges from 35 to 45 mm Hg, and HCO3- ranges from 22 to 26 (22 to 26 mmol/L). A pH of 7.35 and a CO2 of 47 mm Hg indicate respiratory acidosis. pH values of 7.46 and 7.50 represent alkalosis, not acidosis.

After a teaching session a nurse determines that an adolescent with newly diagnosed type 1 diabetes has sufficient knowledge of the disorder. What is the next nursing action? 1 Setting goals with the client 2 Developing a rapport with the client 3 Teaching the client how to give insulin injections 4 Instructing the client how to monitor blood glucose

1 A negotiation of goals is essential to successful learning; mutual goal-setting provides a focus for learning. A rapport should have developed before teaching of the adolescent about diabetes was started. Teaching the client how to give injections or monitor the blood glucose level is premature. If the client does not identify a specific need or set a goal, motivation may be minimal.

Which is the preferred drug of choice for the treatment of syphilis in a pregnant adolescent? 1 Penicillin G 2 Doxycycline 3 Tetracycline 4 Erythromycin

1 According to the Center for Disease Control and Prevention, penicillin G is the preferred drug of choice for any stage of syphilis in pregnant women. Both doxycycline and tetracycline are contraindicated during pregnancy. Erythromycin may not be able to cure a fetal infection.

A nurse is teaching a high school student about scoliosis treatment options. On what should the nurse focus? 1 Effect on body image 2 Least invasive treatment 3 Continuation with schooling 4 Maintenance of contact with peers

1 Establishing an identity, the major developmental task of the adolescent, is related to the affirmation of self-image. To achieve this task there is a need to conform to group norms, one of which is appearance. The type of treatment is not an issue. Although it is important to continue schooling and to maintain contact with peers, the effect on body image is more important.

A female adolescent reports excessive hair growth in the pubic region and under the arms. What may be responsible for these changes? 1 High levels of estrogen 2 Low levels of progesterone 3 High levels of testosterone 4 Low levels of follicle stimulating hormone

1 High estrogen levels in the later stages of puberty generally promote the growth of pubic and axillary hair. Progesterone is generally involved in the implantation of the fertilized egg in the uterus and the maintenance of pregnancy. High testosterone levels increase pubic and axillary hair in males. Low follicle stimulating hormone levels reduce estrogen levels.

A nurse is teaching a 15-year-old adolescent with newly diagnosed type 1 diabetes about self-care. What is the primary long-term goal this nurse and client should agree on? 1 Maintaining normoglycemia 2 Complying with the diabetic diet 3 Adhering to an exercise program 4 Developing a nonstressful lifestyle

1 Maintaining normoglycemia is a realistic goal because it decreases the risk of complications such as neuropathy, retinopathy, and atherosclerosis. A regimen of insulin, exercise, and diet will help the adolescent achieve this goal. Compliance with a diabetic diet is an objective because it will help the adolescent achieve the long-term goal; diet alone is insufficient to achieve normoglycemia. Adherence to an exercise program is an objective because it will help the adolescent achieve the long-term goal; exercise alone is insufficient to achieve normoglycemia. Development of a nonstressful lifestyle is a worthwhile goal, but it is not realistic.

Which test is used to diagnose trichomoniasis? 1 Whiff test 2 Saline wet smear test 3 Normal saline smear test 4 Potassium hydroxide test

2 A saline wet smear test is used to diagnose trichomoniasis. A whiff test is used to diagnose bacterial vaginosis. A normal saline smear test is also used to diagnose bacterial vaginosis. A potassium hydroxide test is used to diagnose candidiasis.

How does group identity aid psychosocial development in adolescents? Select all that apply. 1 It helps them evaluate their own health. 2 It helps them feel a sense of admiration and approval. 3 It helps them develop decision-making and budgeting skills. 4 It provides them the opportunity to learn acceptable behavior. 5 It helps them lessen the feeling that they are different from their peers.

14 Group identity helps the adolescent feel a sense of admiration and approval. Peer groups provide the adolescent with a sense of belonging, approval, and the opportunity to learn acceptable behavior. Health identity helps the adolescent evaluate his or her own health. Family identity helps adolescents develop decision-making and budgeting skills. Sexual identity helps adolescents assuage the fear that they are different from peers.

What are the manifestations of hypoestrogenism? Select all that apply. 1 Hot flashes 2 Amenorrhea 3 Gynecomastia 4 Hypermenorrhea 5 Reduced bone density

125 Low levels of estrogen may cause hot flashes, amenorrhea, and reduced bone density. Gynecomastia and hypermenorrhea are manifestations of excess estrogen production.

What sexually transmitted diseases are caused by bacteria? Select all that apply. 1 Syphilis 2 Hepatitis 3 Gonorrhea 4 Herpes simplex 5 Trichomoniasis

13 Syphilis is caused by Treponema pallidum, a motile spirochete bacterium. Gonorrhea is caused by a bacteria called Neisseria gonorrhoeae. Hepatitis A and herpes simplex are caused by viruses. Trichomoniasis is caused by a protozoan.

What factors may cause an adolescent to develop a smoking addiction? Select all that apply. 1 Peer pressure 2 Academic success 3 Involvement in sports 4 Imitating adult behavior of smoking 5 Imitating lifestyles portrayed in movies and advertisements

145 Factors that influence an adolescent to smoke include peer pressure and imitating adult behavior of smoking and lifestyles portrayed in movies. Succeeding in academics and being involved in sports are not factors that cause an adolescent to begin smoking.

A teenager is being discharged with a cast. What should the nurse recommend if the client experiences pruritus around the cast edges? 1 "Scratch the itchy area gently." 2 "Put an ice pack on the affected area." 3 "Sprinkle a layer of powder around the itchy spots." 4 "Ask your doctor for a prescription for an antihistamine."

2 An ice pack numbs the area and may temporarily diminish the discomfort. Scratching stimulates the release of histamine, which worsens the pruritus; also, scratching may break the skin and open an avenue for infection. Powder may become caked and slip under the cast, causing additional discomfort. Also, powder should be avoided because it is toxic if inhaled. Antihistamines are not prescribed unless all other measures have failed.

An adolescent reports scrotal pain, redness, dysuria, and fever. Which condition does this adolescent have? 1 Varicocele 2 Epididymitis 3 Testicular torsion 4 Testicular cancer

2 Epididymitis is a condition associated with scrotal pain, dysuria, redness, and fever. Varicocele can be palpated as a worm-like mass situated above the testicles. Manifestations of testicular torsion include nausea, vomiting, and abdominal pain. The presence of a heavy, hard mass that is palpable accompanied by back pain and shortness of breath is associated with testicular cancer.

At what age, the pubertal growth spurt reaches its peak in males? 1 12 years 2 14 years 3 16 years 4 18 years

2 Pubertal growth spurt reaches peak during 14 years in males marked by general increase in the growth of skeleton, muscles, and internal organs. The pubertal growth spurt reaches peak during 12 years in females. The middle adolescent period occurs at 15 to 17 years shows a slowdown in growth. Physical maturity is attained in late adolescent stage around 18 to 20 years.

The mother of an adolescent asks the nurse, "What's the best way to remove a tick from the skin?" What is the best response by the nurse? 1 "Touch the tick with a lit cigarette." 2 "Remove the tick carefully with tweezers." 3 "Pour ammonia over the tick, and it will shrivel up." 4 "Spray the tick with insect repellent, and it will fall off."

2 The tick must be carefully removed with tweezers or forceps so the body and head are both removed; this technique prevents further inoculation of the individual. Using a lit cigarette, ammonia, or insect repellent is unsafe; the tick may further inoculate the child, and the method may hurt the child.

Which of these statements are true about an adolescent according to Lawrence Kohlberg's theory of moral development? Select all that apply. 1 "An individual recognizes that there is more than one correct view." 2 "An individual's thoughts are influenced by moral decisions and behaviors." 3 "An individual expands his or her focus from a relationship with others to societal concerns." 4 "An individual wants to win the approval of and maintain the expectations of one's immediate group." 5 "An individual's response to a moral dilemma is in terms of absolute obedience to authority and rules."

23 During the conventional reasoning level, an adolescent's thought is influenced by moral decisions and right behaviors. Also, adolescents expand their focus from a relationship with others to societal concerns. During the postconventional reasoning level, an individual follows societal laws but recognize the possibility of changing the law to improve society. During the preconventional reasoning stage, a child's response to a moral dilemma is in terms of absolute obedience to authority and rules. During the preconventional reasoning stage, an individual recognizes that there is more than one correct view, and wants to win the approval of and maintain the expectations of one's immediate group.

Which of these statements about pregnancy in the adolescent population are true? Select all that apply. 1 Infants of teen mothers are at risk of delivering babies late. 2 Pregnant adolescents often seek out less prenatal care. 3 Adolescent mothers need competent day care for their infants. 4 Infants of adolescent mothers are at increased risk for prematurity. 5 Fetuses of adolescent mothers are at higher risk for chromosomal defects.

234 Pregnant adolescents are less likely to seek out prenatal care. Adolescent mothers need competent day care for their infants. Infants born to adolescent mothers are more likely to be premature than are infants born to adult mothers. Infants born to teen mothers are at risk of being born prematurely. Pregnancies in older mothers are at greater risk for chromosomal defects.

An adolescent wants to have bariatric surgery. What are the criteria for this surgery? Select all that apply. 1 Regular exercise 2 Adherence to nutritional guidelines after surgery 3 BMI of at least 40 with severe obesity 4 Avoidance of pregnancy for 3 months after surgery 5 Ability to give informed consent to surgery

235 Bariatric surgery is performed on clients with morbid obesity. Adolescent after surgery should strictly adhere to the nutritional guidelines. A body mass index of at least 40 with severe obesity and other health problems is a criterion to have bariatric surgery. The adolescent should agree to avoid pregnancy for 1 year postoperatively. The adolescent should give informed consent to the surgery. Regular exercise is needed to stay healthy but is not a criteria.

"But you don't understand" is a common statement associated with adolescents. What is the nurse's best response when hearing this? 1 "I don't understand what you mean." 2 "I do understand; I was a teenager once too." 3 "It would be helpful to understand; let's talk." 4 "It's you who should try to understand others."

3 "It would be helpful to understand; let's talk" attempts to open the communication process. Reflecting the words, not the feelings, serves to entrench the communicant's position and does little to open the flow of communication. Saying "I was a teenager once too" shifts the focus away from the client. Telling the client to try to understand others is authoritative and closes the flow of communication.

At which stage does an adolescent develop abstract thinking? 1 Genital stage 2 Conventional reasoning 3 Formal operations period 4 Identity vs. role confusion

3 According to Piaget's moral development theory depicts, an adolescent develops abstract thinking during the formal operations period. According to Freud's genital stage, sexual urges reawaken and are directed to an individual outside the family circle. During the conventional reasoning stage, a person establishes his or her morals based on his or her own personal internalization of societal expectations. According to the identity versus role confusion stage, there is a marked preoccupation with appearance and body image.

What would be the drug of choice for a client who is diagnosed with chlamydia? 1 Imiquimod 2 Ceftriaxone 3 Azithromycin 4 Benzathine penicillin

3 Azithromycin is recommended for clients with chlamydia infections. Imiquimod is beneficial for treating genital warts in clients with human papillomavirus infections. Ceftriaxone is the drug of choice for treating gonorrhea. Benzathine penicillin is recommended for treating syphilis.

An adolescent who has just been found to have type 1 diabetes asks a nurse about exercise. What is the best response by the nurse? 1 "Exercise should be restricted." 2 "Exercise will increase blood glucose." 3 "Extra snacks are needed before exercise." 4 "Extra insulin is required during exercise."

3 Exercise lowers the blood glucose level; an extra snack can prevent hypoglycemia. Exercise is encouraged, not restricted. Exercise lowers, not increases, blood glucose. Extra insulin is contraindicated because exercise decreases the blood glucose level; extra insulin may precipitate hypoglycemia.

A professor asks a student nurse to explain the stage when an adolescent has prevalence of egocentric thought. Which period of the Piaget's theory will the nurse explain? 1 Sensorimotor 2 Preoperational 3 Formal operations 4 Concrete operations

3 Piaget's theory divides child development into four periods. During the period of formal operations, there is a prevalence of egocentric thought in adolescents. During the sensorimotor period, infants develop a schema or action pattern for dealing with the environment. During the preoperational period, a toddler has egocentric thoughts. During the concrete operations period, the child thinks about an action before it was performed physically.

3 Pin sites provide a direct avenue for organisms into the bone. Pin care will not ease pain. Some scarring will occur at the pin insertion site regardless of pin site care. Skin has a tendency to grow around the pin, rather than break down, as long as infection is prevented.

An obese adolescent who has short stature and is hyperphagic is diagnosed with hypogonadism. Which congenital disorder may be present in this adolescent? 1 Alström syndrome 2 Laurence-Moon-Biedl syndrome 3 Prader-Willi syndrome 4 Pseudohypoparathyroidism

3 Prader-Willi syndrome is a congenital disorder characterized by hypogonadism. The client may have short stature and be hyperphagic. Alström syndrome, Laurence-Moon-Biedl syndrome, and pseudohypoparathyroidism are congenital disorders characterized by obesity but not hypogonadism.

What are the physiologic changes noticed in an adolescent during puberty? Select all that apply. 1 Increase in the respiratory rate 2 Increase in the number of neurons 3 Increase in number of neural connections 4 Decrease in the basal body temperature gradually 5 Increase in serum iron, hemoglobin, and hematocrit

345 During puberty, as a part of normal physiologic growth, there is proliferation of support cells that nourish the neurons along with increase in number of neural connections in the brain. The basal body temperature decreases gradually and reaches adult value by 12 years of age. The size and strength of heart, blood volume, systolic blood pressure, serum iron levels, hemoglobin, and hematocrit values increase whereas heart rate decreases and reaches adult value. The diameter and length of the lungs increase, but respiratory rate decreases gradually to reach the adult value by adolescence. The growth of neurons does not increase but slows to a more gradual rate by adolescence.

What drugs are used to induce abortion in an adolescent? Select all that apply. 1 Leuprolide 2 Zidovudine 3 Misoprostol 4 Mifepristone 5 Methotrexate

345 Misoprostol is a prostaglandin analog that acts directly on the cervix, stimulating contractions. Mifepristone acts by binding to progesterone receptors and blocking the action of progesterone, which is necessary for maintaining a pregnancy. Methotrexate is a cytotoxic drug that can cause early abortion by blocking folic acid in fetal cells. Leuprolide is a gonadotropin-releasing hormone (GnRH) agonist used to treat endometriosis. Zidovudine is an antiviral drug used in a pregnant woman in the prenatal and the perinatal periods to prevent the transmission of human immunodeficiency virus to the fetus.

A young pregnant adolescent is diagnosed as having bacterial vaginosis. What further complications related to bacterial vaginosis may occur during pregnancy? Select all that apply. 1 Neonatal sepsis 2 Cervical dysplasia 3 Preterm labor and birth 4 Intraamniotic infection 5 Postpartum endometritis

345 Preterm birth and labor may occur because bacteria that enters the cervix irritates the uterus, which cause contractions. Bacterial vaginosis is associated with high risk of intraamniotic infection and postpartum endometritis. Neonatal sepsis occurs because of gonococcal infections. Cervical dysplasia occurs in clients with human immunodeficiency virus infections.

An adolescent tries dangerous stunts on a bike without fearing that this activity could result in life-threatening injury. Which characteristic does this signify? 1 Animism 2 Personal fable 3 Imaginary audience 4 Sense of invulnerability

4 Adolescents have the belief that they are invulnerable. Feelings of invulnerability often lead to risk-taking behaviors, especially in early adolescence. A toddler experiences animism, in which he or she personifies objects and believes that they have feelings. The personal fable is seen in adolescents; the adolescent thinks of him- or herself as the center of attention and believes that he or she is unique. Adolescents also feel that they have an imaginary audience, enthusiastically listening to or watching him or her.

An adolescent girl with a seizure disorder refuses to wear a medical alert bracelet. What should the nurse tell the girl that may help her wear the bracelet consistently? 1 Hide the bracelet under long-sleeved clothes. 2 Wear the bracelet when engaging in contact sports. 3 Ask her friends to wear bracelets that look like hers. 4 Select a bracelet similar to bracelets worn by her peers.

4 Because adolescents have a developmental need to conform to their peers, the teenager should be able to select a bracelet of a design similar to that of those worn by her peers. Hiding the bracelet under long-sleeved clothes might be acceptable in cool weather, but not when it is warm and friends are wearing T-shirts. The bracelet should be worn at all times when the girl is not with responsible family members. Asking friends to wear a similar bracelet may be difficult, especially if the girl does not wish to tell her friends why she needs the bracelet.

Which herbal medication would the nurse suggest to a client to reduce premenstrual discomfort? 1 Fennel 2 Bugleweed 3 Chamomile 4 Black cohosh root

4 Black cohosh root is used to reduce premenstrual discomfort and tension associated with menstrual disorders. Fennel is an uterotonic agent that is used to reduce menstrual cramping and dysmenorrhea. Bugleweed is an antigonadotropic agent that decreases prolactin levels and reduces breast pain. Chamomile is an antispasmodic agent that helps to reduce breast pain.

The nurse receives an order to prepare a solution for administering a cleansing enema for a 15-year-old client. What is the volume of solution that the nurse should prepare? 1 150 to 250 mL 2 250 to 350 mL 3 300 to 500 mL 4 500 to 750 mL

4 In adolescents, the volume of solution required is 500 to 750 mL. The nurse should prepare 150 to 250 mL of warmed solution for infants. The nurse should prepare 250 to 350 mL of warmed solution for administering a cleansing enema in a toddler. In school-age children, the volume of warmed solution is 300 to 500 mL.

According to the Erikson's theory, which stage describes the will of an adolescent to achieve a goal? 1 Initiative versus guilt 2 Integrity versus despair 3 Intimacy versus isolation 4 Identity versus role confusion

4 The stage of identity versus role confusion is the fifth stage of development as per Erikson's theory. During this stage, identity development begins with the goal of achieving some perspective or direction. The initiative versus guilt stage is the third stage of Erikson's theory. During this stage, children like to pretend and try out new roles. The integrity versus despair stage is the eighth stage of Erikson's theory. At this stage, many older adults view their lives with a sense of satisfaction. The development of sense of care in a young adult occurs at the stage of intimacy versus isolation. This is the sixth stage of development according to Erikson's theory.

Arrange the events of an examination of a rape victim for a sexually transmitted infection in correct order. 1. Repetition of serologic tests for syphilis and HIV infection. 2. Serum sample for HIV infection, hepatitis B, and syphilis. 3. Nucleic acid amplified testing for chlamydia and gonorrhea. 4. Wet mount and culture or point-of-care testing of a vaginal swab specimen for trichomoniasis.

First, the sexual assault nurse should conduct nucleic acid amplified testing for chlamydia and gonorrhea. Next, the nurse should check for trichomoniasis via a wet mount and culture or point-of-care testing of a vaginal swab specimen. After this, a serum sample for HIV infection, hepatitis B, and syphilis should be conducts. Finally, serologic tests for syphilis and HIV infection are repeated every 3 to 6 months after the assault.

The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). Which laboratory test would the nurse monitor for hypoxia? o Red blood cell count o Sputum culture o Arterial blood gas o Total hemoglobin

o Arterial blood gas · Red blood cell count, sputum culture, and total hemoglobin tests assist in the evaluation of a client with respiratory difficulties; however, arterial blood gas analysis is the only test that evaluates gas exchange in the lungs. This provides accurate information about the client's oxygenation status.

Some events trigger the production of gonadotropin-releasing hormone (GnRH) by the hypothalamus. GnRH travels through a network of capillaries to the anterior pituitary gland and stimulates the production and secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). When the levels of these hormones increase, they in turn stimulate the gonadal response.

What is the average normal diastolic pressure in a 13 year old? Record your answer using a whole number. _______ mm Hg

The average normal diastolic pressure in in a 13 year old is 65 mm Hg.

Which recommendation from the school nurse to the parent of an older child reflects the safest plan for managing the child's asthma in the school setting? o "Your child's inhaler will be kept locked in the health center." o "I will provide all supervision when your child uses the inhaler." o "Your child's teacher will supervise your child's use of the inhaler." o "I need your permission for your child to carry the inhaler at all times."

o "I need your permission for your child to carry the inhaler at all times." · With parental permission, older children with asthma can carry their inhalers with them at all times in case of an emergency. Locking the inhaler in the health center or telling a parent that a nurse or teacher will always be available to supervise the child may not be realistic, because they may not be immediately present if the child requires the inhaler, which would delay treatment and risk an asthma exacerbation.

After the home health nurse has taught a client with asthma how to use a peak flow meter, which statement by the client needs correction? o "I will record the highest reading of 3." o "I will use the peak flow meter while standing." o "I will take a deep breath before blowing into the peak flow meter." o "I will repeat the test in 15 minutes if the reading is in the red zone."

o "I will take a deep breath before blowing into the peak flow meter." · A red zone reading is a serious situation; the client should be instructed to use airway reliever medications and seek immediate medical care. Clients need to conduct a peak flow test 3 times and record the highest reading. Clients should use the peak flow meter while standing independently without leaning. Correct use of the peak flow meter begins with the client taking a deep breath before blowing into the meter.

A 6-year-old child with asthma is prescribed an inhaled corticosteroid. The nurse would conclude the mother understands teaching about the medication side effects when the mother makes which statement? o "I'll watch for frequent urination." o "I'll check for white patches in the mouth." o "I'll be alert for short episodes of not breathing." o "I'll monitor for an increased blood glucose level."

o "I'll check for white patches in the mouth." · Oral candidiasis is a potential side effect of inhaled steroids because of steroids' anti-inflammatory effect; the child should be taught to rinse the mouth after each inhalation. Frequent urination is not a side effect of steroid therapy. Apneic episodes are not a side effect of steroid therapy. Hyperglycemia is not a side effect of inhaled steroid therapy; it may occur when steroids are administered for a systemic effect.

The school nurse recommends suitable physical activity for a child with exercise-induced asthma. Which statement by a parent indicates the need for additional teaching? o "I'll sign him up for swimming lessons." o "She'd really enjoy being on a bowling team." o "I'll encourage him to join a youth running club." o "I know she'd enjoy going to the gym and lifting weights."

o "I'll encourage him to join a youth running club." · Exercise-induced asthma is triggered by rapid mouth breathing of large volumes of dry, cool air, so running increases the risk for an attack. Recommended exercises for people with asthma include swimming, weight lifting, and similar activities that do not necessitate rapid breathing through the mouth.

After the nurse has taught a client with asthma about use of a peak flow meter, which client statements indicate that the teaching has been effective? Select all that apply. o "Readings in the green zone mean that my asthma is under control." o "If I get a reading in the yellow zone, I need to stop what I'm doing and rest for a while." o "If I get a reading in the red zone, then I need to use the quick relief inhaler and have my family take me to the hospital." o "I should check the peak flow readings at least twice a day until my baseline is established." o "I don't need to check my peak flow readings if I use the quick relief medication."

o "Readings in the green zone mean that my asthma is under control." o "If I get a reading in the red zone, then I need to use the quick relief inhaler and have my family take me to the hospital." o "I should check the peak flow readings at least twice a day until my baseline is established." · Peak flow meters are used to measure how well the client's asthma is controlled. Readings in the green zone mean the asthma is under control. Peak flows in the red zone indicate serious airflow problems; the client should use the quick relief inhaler and plan to see the health care provider or go the emergency department. Peak flow readings should be done 2 to 4 times a day for the first few weeks to establish a baseline. With yellow zone peak flow readings, the client should use the quick relief inhaler and then recheck peak flows in an hour. Clients who need the quick relief medication should continue to check peak flows to assure that peak flows improve.

Which rationale would the nurse use when teaching a client with chronic obstructive pulmonary disease (COPD) to use pursed-lip breathing? o Decrease air trapping o Prevent bronchial dilation o Strengthen intercostal muscles o Reduce diaphragmatic excursion

o Decrease air trapping · Pursed-lip breathing prolongs the expiratory phase and increases airway positive pressure, leading to more complete expiration and reduced air trapping. Bronchi and bronchioles stay open longer and are expanded during pursed-lip breathing. Pursed-lip breathing does not strengthen the intercostal muscles or reduce diaphragmatic excursion.

A client has chronic obstructive pulmonary disease (COPD). To decrease the risk of CO2 intoxication (CO2 narcosis), which would the nurse do? o Initiate pulmonary hygiene to clear air passages of trapped mucus. o Instruct to deep-breathe slowly with inhalation longer than exhalation. o Encourage continuous rapid panting to promote respiratory exchange. o Administer oxygen at a low concentration to maintain respiratory drive.

o Administer oxygen at a low concentration to maintain respiratory drive. · With chronically high levels of carbon dioxide, it is believed that decreased oxygen levels become the stimulus to breathe; high oxygen administration negates this mechanism. Initiating pulmonary hygiene to clear air passages of trapped mucus is an appropriate intervention but is not directly related to CO2 intoxication (CO2 narcosis). Encouraging continuous rapid panting to promote respiratory exchange will not bring oxygen into the alveoli for exchange, nor will it adequately remove carbon dioxide because it will increase bronchiolar obstruction. Inhalation should be of regular depth, and expiration should be prolonged to prevent carbon dioxide trapping (air trapping).

When a client is newly diagnosed with chronic obstructive pulmonary disease (COPD), which action by the nurse has the highest priority? o Teach the client how to use the prescribed inhalers. o Discuss the normal progression of the disease process. o Ask whether the client is interested in quitting smoking. o Explain the purpose of a pulmonary rehabilitation program.

o Ask whether the client is interested in quitting smoking. · Smoking cessation slows the progression of COPD and is the most important action that the client can take to help maintain lung function. Although many clients may not be ready to stop smoking, the nurse will assess the client's interest in smoking cessation at every encounter. Teaching correct inhaler use is important, but inhaled medications only treat the symptoms of COPD and do not slow disease progression. The client will be educated on the progression of COPD, but education alone does not change the progression of the disease. Pulmonary rehabilitation programs are helpful in improving ability to do activities of daily living and also will assist the client with tobacco cessation, but assessment of readiness to quit smoking is done before developing a plan to quit.

The nurse is preparing to discharge a client who presented to the emergency room for an acute asthma attack. The nurse notes that upon discharge the health care provider has prescribed theophylline 300 mg orally to be taken daily at 9:00 AM. The nurse will teach the client to take the medication on which schedule? o One hour before or 2 hours after eating o At bedtime o At the specific time prescribed o Daily until symptoms are gone

o At the specific time prescribed · For theophylline to be effective, therapeutic serum levels must be maintained by taking the medication at the prescribed time. If the medication is not taken at the prescribed time, the level may drop below the therapeutic range. The medication will not be effective if it drops below the therapeutic range. Theophylline should be given after a meal and with a full glass of water to decrease gastric irritability. Giving it 2 hours after a meal (on an empty stomach) can result in gastric discomfort. It should not be taken at night, because it can cause central nervous system stimulation resulting in insomnia, restlessness, irritability, etc. Theophylline is used for long-term medication therapy.

Which clinical finding of an 8-year-old child with a history of asthma requires immediate intervention? o Barrel chest o Audible wheezing o Heart rate of 105 beats per minute o Respiratory rate of 30 breaths per minute

o Audible wheezing · Audible wheezing that is heard without a stethoscope is an indication that the airways are significantly compromised, and this requires immediate medical intervention. Barrel chest is a sign of chronic asthma. Repeated attacks result in a fixed hyperaerated thoracic cavity; this clinical finding does not require intervention. A heart rate of 105 beats per minute is expected in an 8-year-old child, as is a respiratory rate of 30 breaths per minute.

When a client with chronic obstructive pulmonary disease (COPD) reports a 5-lb (2.3-kg) weight gain in 1 week, the nurse will assess for other signs and symptoms of which complication? o Polycythemia o Cor pulmonale o Compensated acidosis o Left ventricular failure

o Cor pulmonale · Fluid retention and weight gain caused by right ventricular failure is a clinical manifestation of cor pulmonale, or right ventricular failure caused by pulmonary hypertension associated with COPD. Polycythemia may be caused by COPD, but it does not cause weight gain. Compensated respiratory acidosis is caused by COPD, but it would not lead to weight gain. Left ventricular failure may lead to weight gain, but it is not a complication of COPD.

In which position would the nurse place an 8-year-old child with asthma who is short of breath? o Supine o Left lateral o High-Fowler o Trendelenburg

o High-Fowler · Clients find it easier to breathe while sitting up than lying down. Helping them get into a comfortable sitting position is crucial. The high-Fowler position gives the lungs more room to expand, thereby promoting respiration and affording more comfort. The supine, left lateral, and Trendelenburg positions will all increase dyspnea; they do not permit chest expansion.

Which goal is the priority for a client with asthma who has a prescription for an inhaled bronchodilator? o Is able to obtain pulse oximeter readings o Demonstrates use of a metered-dose inhaler o Knows the health care provider's office hours o Can identify triggers that may cause wheezing

o Demonstrates use of a metered-dose inhaler · Clients with asthma use metered-dose inhalers to administer medications prophylactically or during times of an asthma attack; this is an important skill to have. Home management typically includes self-monitoring of the peak expiratory flow rate rather than pulse oximetry. Although knowing the health care provider's office hours is important, it is not the priority; during a persistent asthma attack that does not respond to planned interventions, the client should go to the emergency department of the local hospital or call 911 for assistance. Although it is important to be able to identify triggers that may cause wheezing, knowing these cannot prevent all wheezing; therefore, being able to abort wheezing with a bronchodilator is the greater priority.

The nurse teaches a client with chronic obstructive pulmonary disease (COPD) and cor pulmonale about nutrition. Which instruction would the nurse include? o Eat small meals six times a day to limit oxygen needs. o Drink large amounts of fluid to help liquefy secretions. o Lie down after eating to conserve energy needed for digestion. o Increase the intake of protein to decrease intravascular hydrostatic pressure.

o Eat small meals six times a day to limit oxygen needs. · Eating small meals will decrease the amount of oxygen necessary for ingestion and digestion at any one time; a small volume of food in the stomach will not impede the downward movement of the diaphragm during inhalation. Although fluids can help liquefy secretions, they should not be encouraged for a client with heart failure. Lying down increases intra-abdominal pressure, pushing a full stomach against the diaphragm and limiting respiratory excursion. Protein maintains or increases hydrostatic pressure; it does not decrease it.

A child admitted to the hospital with a diagnosis of status asthmaticus appears to be improving. Which is the most objective way for the nurse to evaluate the child's response to therapy? o Auscultating breath sounds o Monitoring the respiratory pattern o Assessing the lips for decreased cyanosis o Evaluating the child's peak expiratory flow rate

o Evaluating the child's peak expiratory flow rate · A peak expiratory flow meter (PEFM) is used to obtain the peak expiratory flow rate (PEFR). The PEFM provides an objective measure of the maximal flow of air that can be forcefully exhaled in 1 second. The PEFM individualizes data for the child because after a personal best value is established, this baseline can be compared with current values to determine progress or lack of progress regarding the child's respiratory status. Although breath sounds may be auscultated, the child's respiratory pattern may be monitored, and the color of the lips may be assessed, none is as objective a measure as a PEFR result.

Which intervention would the nurse implement for a client admitted for an exacerbation of asthma? o Determine the client's emotional state. o Give prescribed medications to promote bronchiolar dilation. o Provide education about the effect of a family history. o Encourage the client to use an incentive spirometer routinely.

o Give prescribed medications to promote bronchiolar dilation. · Asthma involves spasms of the bronchi and bronchioles as well as increased production of mucus; this decreases the size of the lumina, interfering with inhalation and exhalation. Bronchiolar dilation will reduce airway resistance and improve the client's breathing. Although identifying and addressing a client's emotional state is important, maintaining airway and breathing are the priority. In addition, emotional stress is only one of many precipitating factors, such as allergens, temperature changes, odors, and chemicals. Although recent studies indicate a genetic correlation along with other factors that may predispose a person to the development of asthma, exploring this issue is not the priority. The use of an incentive spirometer is not helpful because of mucosal edema, bronchoconstriction, and secretions, all of which cause airway obstruction.

Which treatment would the nurse anticipate for an infant admitted with bronchiolitis caused by respiratory syncytial virus (RSV)? o Humidified cool air and adequate hydration o Postural drainage and oxygen by hood o Bronchodilators and cough suppressants o Corticosteroids and broad-spectrum antibiotics

o Humidified cool air and adequate hydration · Humidified cool air and hydration are essential to facilitating improvement in the child's physical status. Postural drainage is not effective with this disorder; oxygen is used only if the infant has severe dyspnea and hypoxia. Bronchodilators are not used, because the bronchial tree is not in spasm; cough suppressants are ineffective. Corticosteroids are ineffective; antibiotics are also ineffective, because the causative agent is viral.

A client is receiving dexamethasone to treat acute exacerbation of asthma. For which side effect would the nurse monitor the client? o Hyperkalemia o Liver dysfunction o Orthostatic hypotension o Increased blood glucose

o Increased blood glucose · Dexamethasone increases gluconeogenesis, which may cause hyperglycemia. Hypokalemia, not hyperkalemia, is a side effect. Liver dysfunction is not a side effect. Hypertension, not hypotension, is a side effect.

The nurse provides instructions about how to use a metered-dose inhaler (MDI) to a client with chronic obstructive pulmonary disease. The nurse concludes that additional teaching is needed when the client demonstrates which technique? o Places the tip of the inhaler just past the lips o Holds the inspired breath for at least 3 seconds o Activates the inhaler during inspiration o Inhales rapidly with the lips sealed around the nebulizer opening

o Inhales rapidly with the lips sealed around the nebulizer opening · The client should inhale slowly rather than rapidly when using a metered-dose inhaler (MDI) to optimize delivery of the nebulized medication into the lungs. If the client has a dry powder inhaler (DPI), then rapid inhaling would be an important action because the powder is not nebulized. The MDI should be gently held in the mouth just past the lips to deliver the medication into the airway. Holding the inspired breath for at least 3 seconds promotes contact of the medication with the bronchial mucosa. The inhaler should be activated during inspiration.

An infant is admitted to the pediatric unit with bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions would the nurse provide for the infant? Select all that apply. o Limiting fluid intake o Instilling saline nose drops o Maintaining droplet precautions o Nasal suctioning to remove mucus o Administering inhaled bronchodilators

o Instilling saline nose drops o Maintaining droplet precautions o Nasal suctioning to remove mucus · Saline nose drops help clear the nasal passage, which improves breathing and aids the intake of fluids. RSV is contagious; infants with RSV should be isolated from other children, and the number of people visiting or caring for the infant should be limited. Infants with RSV produce copious amounts of mucus, which hinders breathing and feeding; suctioning before meals and at naptime and bedtime provides relief. Fluid intake should be increased; adequate hydration is essential to counter fluid loss. These infants have difficulty nursing and often vomit their feedings. If measures such as suctioning before feeding and instilling saline nose drops are ineffective, intravenous fluid replacement is instituted. Research has shown that bronchodilators are not effective in the treatment of bronchiolitis.

When the nurse is evaluating a client with an acute asthma attack who has just received a nebulized bronchodilator treatment, which finding requires the most rapid action? o Labored breathing and absent breath sounds o Continued high-pitched expiratory wheezes o Use of pursed-lip breathing during expiration o Hyperresonance to percussion of posterior chest

o Labored breathing and absent breath sounds · Absent breath sounds and labored appearing respirations indicate that the client has extremely limited airflow and is at risk for respiratory arrest. The nurse would notify the health care provider immediately and anticipate interventions such as intubation, systemic bronchodilators, and mechanical ventilation. Continued high-pitched respiratory wheezes indicate that further treatment is needed, but the client would not be at risk for respiratory arrest. Pursed-lip breathing is frequently used by clients with obstructive airway disease to help improve expiratory effort. Hyperresonance to percussion indicates air trapping in the lungs, but is not an uncommon finding in clients with asthma.

A child with status asthmaticus is admitted to the pediatric intensive care unit. Which would the nurse include in the plan of care as the child starts to recover from the episode? o Maintain the high-Fowler position. o Restrict fluids to two thirds of the usual intake. o Keep droplet precautions in place for 24 hours. o Administer the prescribed prophylactic antibiotic.

o Maintain the high-Fowler position. · The high-Fowler position decreases pressure on the diaphragm and promotes lung expansion. Fluids should not be restricted. Adequate fluid intake should be maintained to promote hydration. Droplet precautions are not required. Asthma is not an infectious disease, and there are no data to indicate an accompanying infection. If the practitioner prescribes an antibiotic, it is to treat a concurrent infection; prophylactic antibiotic therapy is not required for children with status asthmaticus.

Which trigger would the nurse instruct a client to avoid to decrease the incidence of asthma attacks? Select all that apply. o Mold o Cold air o Pet dander o Air pollution o Cigarette smoke

o Mold o Cold air o Pet dander o Air pollution o Cigarette smoke · Clients with asthma should be instructed to avoid asthma attack triggers such as mold, cold air, pet dander, air pollution, and cigarette smoke.

Which finding in a client with asthma exacerbation requires the most rapid action by the nurse? o Report of chest tightness o Heart rate of 112 beats per minute o Expiratory wheezes in both lungs o Markedly decreased breath sounds

o Markedly decreased breath sounds · Markedly decreased breath sounds may indicate very limited airflow and life-threatening asthma exacerbation. The nurse would immediately check oxygen saturation and anticipate possible need for mechanical ventilation. Clients with asthma exacerbation frequently report chest tightness, but this finding does not indicate possible impending respiratory arrest. Tachycardia is common with asthma exacerbation because of stress and increased work of breathing, but a heart rate of 110 beats per minute is not life-threatening. Expiratory wheezes are heard early in asthma exacerbation; inspiratory wheezes are a more ominous finding and indicate further progression of airway obstruction.

Which statement must the nurse emphasize to the family when preparing a school-aged child with persistent asthma for discharge? o A cold, dry environment is desirable. o Limits should not be placed on the child's behavior. o The health problem is gone when symptoms subside. o Medications must be continued even when the child is asymptomatic.

o Medications must be continued even when the child is asymptomatic. · Children with persistent asthma must continue taking medications to keep them asymptomatic. Inhaled corticosteroids, long-acting β2-agonists, and leukotriene modifiers are used as controller medications. Some environmental moisture is necessary for these children. Consistent limits should be placed on any child's behavior, regardless of the disease; a chronic illness does not remove the need for setting limits. The child's symptoms are being controlled by medications that are necessary to keep the child asymptomatic.

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The client's arterial blood gases deteriorate, and respiratory failure is impending. Which clinical indicator is consistent with the client's condition? o Cyanosis o Bradycardia o Mental confusion o Distended neck veins

o Mental confusion · Decreased oxygen to the vital centers in the brain results in restlessness and confusion. Cyanosis is a late sign of respiratory failure. Tachycardia, not bradycardia, will occur as a compensatory mechanism to help increase oxygen to body cells. Distended neck veins occur with fluid volume excess (e.g., pulmonary edema).

A client with chronic obstructive pulmonary disease (COPD) is breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. Which action would the nurse take? o Encourage the client to take slow, deep breaths and administer 5 L/min oxygen per nasal cannula. o Place the client in a side-lying position and perform chest physiotherapy using clapping and vibration. o Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula. o Assist the client in assuming a position of comfort and perform postural drainage.

o Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula. · Sitting facilitates breathing by increasing lung expansion; 2 L of oxygen promotes respirations while preventing carbon dioxide narcosis. However, the results of one recent study of clients with stable COPD indicate that the hypercarbic drive is preserved with oxygen higher than 2 L. More research is needed before this theory is applied clinically. Five liters of oxygen may cause respiratory depression and carbon dioxide narcosis in a client with COPD. Chest physiotherapy (postural drainage) may be done later after the client's condition improves. Delaying intervention is likely to worsen the respiratory distress.

A client is admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). Which action would the nurse take to prevent client fatigue? o Provide small, frequent meals. o Encourage pursed-lip breathing. o Schedule nursing activities to allow for rest. o Encourage bed rest until energy level improves.

o Schedule nursing activities to allow for rest. · Rest limits muscle contractions, which diminishes oxygen needs and decreases fatigue. Although small, frequent meals may decrease pressure on the diaphragm and facilitate breathing, this precaution does not address the client's fatigue. Although pursed-lip breathing facilitates gas exchange, it does not reduce the metabolic demand for oxygen. Bed rest promotes pooling of pulmonary secretions, which may aggravate the client's respiratory status.

A 4-month-old infant with severe tachypnea, flaring of the nares, wheezing, and irritability is admitted to the pediatric unit with bronchiolitis. Which clinical finding is associated with possible respiratory failure? o Expiratory wheezing o Intercostal retractions o Fine crackles on deep inspiration o Sudden absence of breath sounds

o Sudden absence of breath sounds · A sudden absence of breath sounds occurs when bronchioles become obstructed and respiratory failure is imminent. Expiratory wheezing is a common manifestation of bronchiolitis and is caused by the passage of air through the airways narrowed by inflammation and mucus; it does not herald respiratory failure. Intercostal retractions occur with mild and moderate respiratory distress in infants. Fine crackles are a routine occurrence with bronchiolitis, not a sign of respiratory failure.

Which instruction would the nurse include when teaching a client with asthma how to use a peak flow meter? o Sit up straight in a firm chair. o Check peak flow early in the morning. o Take the deepest breath you can, then blow out hard and fast. o Calculate the average of 3 readings to obtain your peak flow.

o Take the deepest breath you can, then blow out hard and fast. · A peak flow meter measures the peak expiratory flow rate and is used by taking the deepest breath possible, then forcefully exhaling as quickly as possible. The client is taught to stand when measuring peak flows to assure accurate readings. Peak flow measurements should be done between noon and 2:00 PM when peak flows are highest. The peak flow reading is done 3 times, and the highest reading is recorded as the peak flow.

A client is prescribed albuterol to relieve severe asthma. Which adverse effects will the nurse instruct the client to anticipate? Select all that apply. o Tremors o Lethargy o Palpitations o Bronchoconstriction o Decreased pulse rate

o Tremors o Palpitations · Albuterol's sympathomimetic effect causes central nervous system (CNS) stimulation, precipitating tremors, tachycardia, and palpitations. Lethargy is an adverse effect of medications that cause CNS depression, not CNS stimulation. Albuterol causes bronchodilation, not bronchoconstriction. Albuterol will cause tachycardia, not bradycardia.

Which type of hypersensitivity may have occurred in the client with elevated histamine and prostaglandin levels, allergic rhinitis, and asthma? o Type I o Type II o Type III o Type IV

o Type I · Type I hypersensitivity reactions (immediate hypersensitivity reactions) involve the immunoglobulin E (IgE)-mediated release of histamines and other mediators from mast cells and basophils. Allergic rhinitis and asthma may occur when mediators such as histamine and prostaglandins are involved as mediators of injury. Type II hypersensitivity reaction is cytotoxic mediated; it occurs in transfusion reactions. Type III reactions are immune complex-mediated hypersensitivity reactions such as rheumatoid arthritis. Type IV hypersensitivity reactions are delayed hypersensitivity reactions; an example is contact dermatitis.

A client with chronic obstructive pulmonary disease (COPD) reports chest congestion, especially upon awakening in the morning. To address the concern, the nurse would make which suggestion? o Use a humidifier in the bedroom. o Sleep with two or more pillows. o Cough regularly even if the cough does not produce sputum. o Cough and deep-breathe each night before going to sleep.

o Use a humidifier in the bedroom. · A humidifier will help liquefy secretions and promote their expectoration. Sleeping on pillows facilitates breathing; it does not relieve chest congestion. Nonproductive coughing should be avoided because it is irritating and exhausting. Deep breathing and coughing at night will not help relieve early-morning congestion.

Which topic would the nurse plan to include in teaching a client with a new diagnosis of asthma? o Home oxygen therapy o Antibiotic treatment o Incentive spirometer use o Use of peak flow meter

o Use of peak flow meter · Daily peak flow monitoring is recommended for clients with asthma because changes in peak flow frequently occur before the client notices any respiratory distress. Because asthma is an intermittent airway problem, home oxygen therapy is not needed. Asthma is not an infectious process and antibiotics are not prescribed. Incentive spirometers are prescribed to encourage clients to take deep breaths and prevent atelectasis, which is not a concern with asthma.

Which physiologic responses to bronchiolitis would the nurse expect to observe in the pediatric intensive care unit? Select all that apply. o Wheezing o Bradycardia o Sternal retractions o Nasal flaring o Prolonged expiratory phase

o Wheezing o Sternal retractions o Nasal flaring o Prolonged expiratory phase · Bronchiolitis in most infants is caused by respiratory syncytial virus. Wheezing occurs as the air passages narrow, resulting in the typical whistling sound. As breathing becomes more difficult, the infant must expend more energy and use accessory muscles of respiration to breathe. Nasal flaring is a predominant characteristic of bronchiolitis. The infectious and inflammatory changes narrow the bronchial passage, making it difficult for air to leave the lungs. As a result of increased respiratory effort and decreased oxygen exchange, tachycardia, not bradycardia, develops. Breath sounds are diminished because of edema of the bronchiolar mucosa and filling of the lumina with mucus and exudate.

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