NSG 209 Exam 4
A nurse is teaching a client who has HIV about the early manifestations of AIDS. Which of the following statements should the nurse include in the teaching? A. you can expect a persistent fever & swollen glands B. you can expect an elevated WBC count C. you can expect increased BP & edema D. you can expect weight gain
A
After talking with the parents of a child with Down syndrome, the nurse should help the parents establish which goal? A. encourage self-care skills in the child B. teach child something new each day C. encourage more lenient behavior limits for the child D. achieve age-appropriate social skills
A
A nurse is caring forma group of infants with CHDs. For which of the following defects should the nurse expect to observe cyanosis? A. transposition of the great vessels B. VSD C. coarctation of the aorta D. PDA
A
A nurse is developing a plan of care for a client who has GERD. The nurse should plan to monitor the client for which of the following complications? A. aspiration B. infection C. anemia D. weight loss
A
A nurse is providing teaching to the guardians of an infant who has FTT. Which of the following pieces of info should the nurse include in the teaching? A. add fortified rice cereal to infant's formula B. alternate feedings btw several family members C. offer infant juice between feedings D. provide feedings on demand rather than on a schedule
A
A nurse is recommending dietary mods for a client who has GERD. The nurse should suggest eliminating which of the following foods from the client's diet? A. oranges & tomatoes B. carrots & bananas C. potatoes & squash D. whole wheat & beans
A
An 18 month old infant has Pneumocystis carinii pneumonia. Results of ELISA testing indicate that she is HIV+. When planning care, the nurse should consider which of the following factors? A. the infant's mother is likely HIV+ B. the infant's ELISA test result is probably a false + C. ART medications are inappropriate for infants & children who have HIV D. HIV+ status is a contraindication for MMR immunizations
A
The nurse caring for a client dx with HIV is stuck with the stylet used to start an IV. Which intervention should the nurse implement first? A. flush the skin with water & try to get the area to bleed B. notify charge & complete an incident report C. report to employee health for prophylactic medication D. F/U with infection control to have lab work done
A
The nurse is admitting a client dx with protein-calorie malnutrition secondary to AIDS. Which intervention(s) should the nurse implement first? A. assess client's body weight & ask what they have been able to eat B. place in contact isolation & don mask & gown before entering the room C. check the HCP's orders & determine what labs will be done D. teach client about TPN & monitor the subclavian IV site
A
The nurse is caring for a 2 y/o boy with CP. The medical record indicates "hypertonicity & permanent contractures affecting both extremities on one side". Based on these findings, the nurse identifies this type of CP as: A. spastic B. athetoid or dyskinetic C. mixed D. ataxic
A
The nurse is describing HIV infection to a client dx with HIV. Which info regarding the virus is important to teach? A. HIV is a retrovirus, which means it never dies as long as it has a host to live in B. HIV can be eradicated from the host body with the correct medical regimen C. it is difficult for HIV to replicate in humans b/c it is a monkey virus D. HIV uses the client's own red blood cells to reproduce the virus in the body
A
The nurse is obtaining a health history from a client who has a sliding hiatal hernia associated with reflux. The nurse should ask the client about the prescence of which symptom? A. heartburn B. jaundice C. anorexia D. stomatitis
A
The nurse knows that PPIs: A. decrease acid production in stomach B. stop acid production in stomach C. should be taken PRN only D. are habit forming
A
The nurse knows which statement is true regarding ODD & Conduct disorder? A. a client dx with conduct disorder violates rules & often times end up in trouble with the law B. a client dx with ODD violates rules & often times ends up in trouble with the law C. both conduct disorder & ODD clients violate rules & often times end up in trouble with the law
A
The nurse on a medical floor is caring for clients dx with AIDS. Which client should be seen first? A. client with flushed, warm skin with tented turgor B. client reporting the staff ignores the call light C. client with VS: T 99.9, HR 101, RR 26, BP 110/68 D. client unable to provide a sputum specimen
A
The nurse would expect a client with a duodenal ulcer to have increased pain: A. 1.5-3 hrs after eating B. when laying supine C. when exercising D. 30-60 min after eating
A
Which clinical manifestation should the nurse expect to find in a client dx with ulcerative colitis? A. 20 bloody stools a day B. oral temp 102 F C. hard, rigid abdomen D. urinary stress incontinence
A
Which clinical manifestations would indicate GERD? A. pyrosis, water brash, eructation B. weight loss, dysarthria, diarrhea C. decreased abd fat, proteinuria, constipation D. mid epigastric pain, positive H. pylori test, melena
A
Which developmental milestone should the nurse be concerned about if a 10 month old cannot do it? A. crawl B. cruise C. walk D. have a pincer grasp
A
Which dietary measure would be useful in preventing esophageal reflux? A. eating small, frequent meals B. increasing fluid intake C. avoid air swallowing with meals D. adding a bedtime snack to the dietary plan
A
Which is a diagnostic criterion for the dx of ADHD? A. inattention B. recurrent & persistent thoughts C. physical aggression D. anxiety & panic attacks
A
Which physiological changes occur as a result of hypoxemia? A. polycythemia & clubbing B. anemia & barrel chest C. increased WBC & low platelets D. elevated ESR & peripheral edema
A
The nurse is caring for an adult client dx with GERD. Which condition is most common comorbid disease assoc with GERD? A. adult onset asthma B. pancreatitis C. peptic ulcer disease D. increased gastric emptying
A In adult onset asthma, a large number of cases are caused by GERD. Additionally, GERD can make existing asthma sx difficult to control. PUD are related to H. pylori bacterial infections & can lead to changes in the levels of gastric acid, but it is not related to reflux.
Which measure would be most effective in helping the infant with a cleft lip & palate to retain oral feedings? A. burp infant at regular intervals B. feed infant small amounts at one time C. place end of the nipple far back of infant's tongue D. maintain infant in supine position when feeding
A an infant with cleft lip & palate typically swallows large amounts of air while being fed & therefore should be burped frequently
On the 2nd post-op day after repair of a cleft palate, what should the nurse use to feed a toddler? A. cup B. straw C. rubber-tipped syringe D. large-holed nipple
A at the age that this repair is done, children are typically able to drink from a cup-- use of a cup avoids having to place a utensil in the mouth, which would increase the potential for injury to the suture lines
Which oral med should the nurse question before administering to the client dx with PUD? A. celecoxib B. omeprazole C. metronidazole D. acetaminophen
A celecoxib is an NSAID- can cause irritation to the stomach & the use by a client dx with PUD should be questioned
A child born with Down syndrome should be evaluated for which assoc. cardiac manifestation? A. CHD B. systemic HTN C. hyperlipidemia D. cardiomyopathy
A health problems assoc. with Down syndrome include congenital heart defects (40-50% of cases)
The nurse is caring for client dx with rule out peptic ulcer disease. Which test confirms this diagnosis? A. EGD B. MRI C. occult blood test D. gastric acid stimulation test
A the EGD, or upper GI endoscopy, is an invasive dx test that visualizes the esophagus, stomach, & duodenum to diagnose an ulcer accurately & evaluate the effectiveness of the client's treatment
The parents of a child with CP are learning how to feed their child & avoid aspiration. The nurse would question which of the following when reviewing the teaching plan? A. place food on tip of the tongue B. place child in upright position during feedings C. feed child soft & blended foods D. feed child slowly
A the food should be placed far back in the mouth to avoid tongue thrust
The client is dx with Crohn's disease. Which statement by the client supports this diagnosis? A. my pain is on the right lower side of my abdomen B. I have bright red blood in my stool all the time C. I have episodes of diarrhea & constipation D. my abdomen is hard & rigid, and I have a fever
A the terminal ileum is the most common site for Crohn's which causes RLQ pain
When developing a teaching plan for the parents of a child diagnosed with tricuspid atresia, the nurse would integrate knowledge of what factor as the major mechanism involved? A. obstruction of blood flow to the lungs B. mixing of well-oxygenated & poorly oxygenated lungs C. increased pulmonary blood flow D. narrowing of the major vessel
A the tricuspid valve fails to develop, resulting in no opening to allow blood to flow from RA to RV and subsequently through the pulmonary artery into the lungs
For which of the following CHDs should the nurse expect to observe cyanosis? A. transposition of the great arteries B. ventricular septal defect C. coarctation of the aorta D. patent ductus arteriosus
A will see cyanosis b/c reversal of the aorta & PA allows venous blood to enter systemic circulation without O2
A nurse is planning care for a 10 month old infant who has suspected FTT. Which of the following interventions should the nurse include in the plan of care? SATA A. observe the parent's actions when feeding the child B. maintain a detailed record of food & fluid intake C. follow the child's cues to time food & fluids D. sit beside the child's high chair for feedings E. play music videos during scheduled meal times
A, B a child who has FTT may not offer feeding cues, caregivers should sit directly in front of child to promote eye contact, a quiet environment should be provided at meal times to avoid distractions
A client with peptic ulcer reports epigastric pain that frequently causes the client to wake up during the night. The nurse should instruct the client to do which activities? SATA A. obtain adequate rest to reduce stimulation B. eat small, frequent meals throughout the day C. take all meds on time as prescribed D. sit up for 1 hour when awakened at night E. stay away from crowded areas
A, B, C, D
A nurse in a provider's office is assessing a client who has GERD. The nurse should expect to report which of the following manifestations? SATA A. regurgitation B. nausea C. belching D. heartburn E. weight loss
A, B, C, D
Hypoxic spells in the infant with a CHD can cause which of the following? SATA A. polycythemia B. blood clots C. CVA D. developmental delays E. viral pericarditis F. brain damage G. alkalosis
A, B, C, D, F
A nurse's priority assessment for a client with IBD would be: SATA A. nutrition B. hydration C. oxygenation D. pain
A, B, D
The nurse instructs a client with GERD to avoid which foods? SATA A. diet soda B. tomato sauce C. milk D. curried rice
A, B, D
The nurse is developing a care management plan with a client who has been dx with GERD. What should the nurse instruct the client to do? SATA A. avoid diet high in fatty foods B. avoid beverages that contain caffeine C. eat 3 meals a day with the largest meal being at dinner in the evening D. avoid all alcoholic beverages E. lie down after consuming each meal for 30 min F. use OTC antisecretory agents rather than prescriptions
A, B, D
Which s/sx would lead the nurse to suspect a child has tetralogy of fallot? SATA A. murmur B. hx of squatting C. bounding pulses D. cyanosis E. faint pulse F. tachypnea
A, B, D, F
TOF involves which defects? SATA A. VSD B. right ventricular hypertrophy C. left ventricular hypertrophy D. PS (pulmonary stenosis) E. pulmonic atresia F. overriding aorta G. PDA
A, B, D, F RAPS!!!! right ventricular hypertrophy aorta displacement/overriding pulmonary stenosis septal defect (ventricles)
Which should be included in the plan of care for a 14 month old whose cleft palate was repaired 12 hours ago? SATA A. allow the infant to have familiar items of comfort, such as a favorite stuffed animal & sippy cup B. once liquids have been tolerated, encourage a bland diet such as soup, Jell-O, & saltine crackers C. admin pain medication on a regular schedule as opposed to an as-needed schedule D. use a Yankauer suction catheter in the infant's mouth to decrease the risk of aspiration of oral secretions E. when discharged, remove elbow restraints
A, C child should not be allowed to use anything that creates suction in the mouth such as pacifiers or straws-- sippy cups are acceptable. Pain meds should be admin regularly to avoid crying which places stress on the suture line. Yankauer should not be used b/c it creates suction that could irritate suture line. Child should be positioned to allow secretions to drain out the child's mouth.
Which of the following are appropriate medications for the acute tx of IBD? SATA A. prednisone B. cefdinir C. metronidazole D. amoxicillin E. polytrim
A, C corticosteroid (A) is used to induce a remission and antibiotics (C) are used to treat infections or complications in these clients
The theory of family dynamics has been implicated as contributing to the etiology of conduct disorders. Which of the following are factors related to this theory? SATA A. frequent shifting of parental figures B. birth temperament C. father absenteeism D. large family size E. fixation in the separation individuation phase of development
A, C, D
Which of the following stimulant medications are prescribed in tx of ADHD? SATA A. methylphenidate B. guanfacine C. lisdexamfetamine D. amphetamine/dextroamphetamine E. clonidine
A, C, D
Which would the nurse expect a child with spastic CP to demonstrate? SATA A. increased DTRs B. decreased muscle tone C. scoliosis D. contractures E. scissoring when walking F. good control of posture G. good fine motor skills
A, C, D, E children with spastic CP have increased muscle tone & have poor control of posture & poor fine motor skills
The nurse caring for a 2 y/o boy with CP. The medical record indicates "hypertonicity & permanent contractures affecting both extremities on one side". Based on these findings, the nurse identifies this type of CP as: A. ataxic B. spastic C. athetoid or dyskinetic D. mixed
B
The nurse expects that the end result for a client with UC may be: A. colostomy B. ileostomy C. urostomy D. fundoscopy
B
A child's medical record contains the diagnosis FTT. What does this suggest? SATA A. could be related to poverty B. cause may be organic or inorganic C. may have developmental delay as contributing factor D. growth chart shows an extended period of poor weight gain E. special needs children often carry this diagnosis
All :)
The nurse assesses a child after heart surgery to correct tetralogy of Fallot. Which finding would the nurse report to the HCP as an indication that the client has low cardiac output? A. bounding pulses & mottled skin B. altered LOC & thready pulse C. cap refill 2 sec & BP 96/67 D. extremities warm to touch & pale skin
B
The male client tells the nurse he has been experiencing heartburn at night that awakens him. Which assessment question should the nurse ask? A. how much weight have you gained recently B. what have you done to alleviate the heartburn C. do you consume many milk & dairy products D. have you been around anyone with the stomach virus
B
The mother of an infant with a cleft lip asks when the repair will be scheduled. What is the nurse's best response? A. at birth B. during first 6 months of life C. after 6 months of age D. at 1 year of age
B
A 3 month old child was dx with failure to thrive. What action will be most helpful in assisting the nurse to determine if there is an inorganic cause? A. observing child's interest in & ability to feed B. observing parent-child interaction during feeding & hygiene activities C. assessing for adequate calorie intake through recording oz of formula consumed D. reviewing medical records for a hx of prematurity or congenital anomaly
B
A child dx with autism withdraws into self and when spoken to makes inappropriate nonverbal expressions. The nursing dx of impaired verbal communication is documented. Which intervention would address this problem? A. assist the child is recognizing separateness during self-care activities B. use a face to face and eye to eye approach when communicating C. provide the child with a familiar toy or blanket to increase feelings of security D. offer self to the child during times of increasing anxiety
B
A child with Down syndrome is having a well child visit. What is the best way for the nurse to assess this child's developmental milestones? A. plot milestones on a growth chart B. assess the sequence of the milestones C. assess the age at which each milestone occured D. have the child demonstrate psychomotor skills
B
A client newly dx with UC who has been placed on steroids asks the nurse why steroids are prescribed. What should the nurse tell the client? A. UC can be cured by the use of steroids B. steroids are used in severe flare-ups b/c they can decrease the incidence of bleeding C. long-term use of steroids will prolong periods of remission D. the side effects of steroids outweigh their benefits to clients with UC
B
A client with Crohn's has concentrated urine, decreased urinary output, dry skin with decreased turgor, hypotension, & weak, thready pulses. What should the nurse do first? A. encourage client to drink at least 1000 mL/day B. provide parenteral rehydration therapy as prescribed C. turn & reposition every 2 hours D. monitor vital signs every shift
B
A nurse in a provider's office is assessing a client who has GERD. When documenting the client's history, the nurse should expect the client to report that symptoms worsen with which of the following actions? A. stair climbing B. bending over C. sitting D. walking
B
A nurse is providing teaching about antiretroviral medication therapy o a client who has a new dx of AIDS. Which of the following statements should the nurse include in the teaching? A. your provider will prescribe a single ART med at a time B. you should take ART meds on a routine schedule C. you should increase your intake of raw fruits & veggies while taking these meds D. your provider will prescribed ART to kill the HIV
B
Parents of a 2 y/o with Down syndrome are told the child should be screening for atlantoaxial instability. The nurse tells the parents that which of the following are symptoms of this instability? A. intellectual disability B. neck pain & torticollis C. vision & hearing loss D. early onset of puberty
B
The client with an exacerbation of UC is to be on bed rest with bathroom privileges. What will indicate to the nurse that being on bed rest has had the desired outcome? The client has: A. not fallen B. slowed intestinal peristalsis C. slept through the night D. minimized stress
B
The nurse is caring for a 10 y/o child recently dx with ADHD. The nurse would expect to provide teaching regarding which med? A. buspirone B. methylphenidate C. fluoxetine D. trazodone
B
The nurse is caring for a NB with a cleft lip & palate. The mother states, "I will not be able to breastfeed my baby". Which is the nurse's best response? A. it sounds like you are feeling discouraged, would you like to talk about it? B. sometimes breastfeeding is still an option for babies with a cleft lip & palate; would you like more information? C. although breastfeeding is not an option, you can pump your milk & then feed it to your baby with a special nipple D. we usually discourage breastfeeding babies with cleft lip & palate as it puts then at an increased risk for aspiration
B
The nurse is reviewing the medical record of a child with a cleft lip & palate. When reviewing the child's history, what would the nurse identify as a risk factor for this condition? A. history of hypoxia at birth B. mother age 42 with pregnancy C. preterm birth D. maternal use of acetaminophen in 3rd trimester
B
The parents of a 3 month old ask why their baby will not have an operation to correct a VSD. The nurse's best response is: A. it is always helpful to get a 2nd opinion about any serious condition like this B. your baby's defect is small & will likely close on its own by 1 year of age C. it is common for HCPs to wait until an infant develops respiratory distress before they do the surgery D. with a small defect like this, they wait until the child is 10 y/o to do the surgery
B
What should the nurse assess before admin digoxin? A. sclera B. apical pulse C. cough D. LFT
B
Which assessment made by the client indicates to the nurse the client may be experiencing GERD? A. my chest hurts when I walk up the stairs in my home B. I take antacids tablets with me wherever I go C. my spouse tells me I snore very loudly at night D. I drink 6-7 soft drinks every day
B
Which diet would be most appropriate for the client with UC? A. high calorie, low protein B. high protein, low residue C. low fat, high fiber D. low sodium, high carb
B
Which goal for the client's care should take priority during the first days of hospitalization for an exacerbation of UC? A. promoting self-care & independence B. managing diarrhea C. maintaining adequate nutrition D. promoting rest & comfort
B
Which instruction should the nurse include in the teaching plan for a client who is experiencing GERD? A. limit caffeine intake to 2 cups of coffee a day B. do not lie down for 2 hrs after eating C. follow a low protein diet D. take meds with milk to decrease irritation
B
Which is a priority focus of care for a client experiencing an exacerbation of Crohn's disease? A. encouraging regular ambulation B. promoting bowel rest C. maintaining current weight D. decreasing episodes of rectal bleeding
B
Which lifestyle mod should the nurse encourage the client with a hiatal hernia to include in ADLs? A. engaging in daily aerobic exercise B. eliminating smoking & alcohol use C. balancing activity & rest D. avoiding high-stress situations
B
Which of the following activities would be most appropriate for the child with ADHD? A. monopoly B. volleyball C. pool D. checkers
B
Which of the following drug classes is most commonly used for management of ADHD? A. CNS depressants B. CNS stimulants C. Anticonvulsants D. antipsychotics
B
A 10 y/o has undergone a cardiac catheterization. At the end of the procedure, the nurse should first assess: A. pain B. pulses C. H&H D. catheterization report
B ABCs!!!!!
A child with CP has been fitted for braces & is beginning PT to assist with ambulation. The parents ask why he needs braces when he was crawling w/o any assistive devices. Select the nurse's best response: A. the CP has progressed & he now needs more assistance to ambulate B. as your child grows, different muscle groups may need more assistance C. most children with CP need braces to help with ambulation D. we have found that when children with CP wear braces, they are less likely to fall
B CP can manifest in different ways as the child grows. It does not progress, but its clinical manifestations may change
The client dx with AIDS is reporting a sore mouth & tongue. When the nurse assesses the buccal mucosa, the nurse notes white, patchy lesions covering the hard & soft palates & the right inner cheek. Which interventions should the nurse implement? A. teach client to brush the teeth & patchy area with soft-bristle toothbrush B. notify the HCP for an order of antifungal swish & swallow medication C. have the client gargle w/ an antiseptic based mouthwash several times a day D. determine what types of food the client has been eating for the last 24 hrs
B Most likely oral candidiasis, a fungal infection. Antifungal medication is needed to treat this condition
Which specific data should the nurse obtain from the client suspected of having peptic ulcer disease? A. Hx of side effects experienced from all meds B. use of NSAIDs C. any known allergies to drugs & environmental factors D. medical histories of at least 3 generations
B NSAID use places client at risk for PUD & hemorrhage. NSAIDs suppress the production of prostaglandin in the stomach, which is a protective mechanism to prevent damage from hydrochloric acid
Which expected outcome should the nurse include for a client dx with PUD? A. client's pain is controlled with use of NSAIDs B. client maintains lifestyle mods C. client has no clinical manifestations of hemoptysis D. client takes antacids with each meal
B NSAIDs increases & causes problems assoc. with PUD. Maintaining lifestyle changes such as following an appropriate diet & reducing stress indicates the client is complying with the medical regimen. Hemoptysis is not a clinical manifestation of PUD. Antacids should be taken 1-3 hrs after meals, not with each meal
A child has been seen by the school nurse for dizziness since the start of school. It happens when standing in line for recess & homeroom. The child now reports that she would rather sit and watch her friends play b/c she cannot count out loud & jump at the same time. When the nurse asks if her chest ever hurts, she says yes. Based on this hx, the nurse suspects she has: A. VSD B. aortic stenosis C. mitral valve prolapse D. tricuspid atresia
B VSD is often found in infancy with a murmur & CHF. Aortic stenosis can progress, and the child can develop exercise intolerance that can better when resting. Mitral valve prolapse usually manifests in adulthood. Tricuspid atresia causes hypoxemia in infancy (cannot live w/o surgery)
The nurse is doing a F/U assessment of a 9 month old. The infant rolls both ways, sits with some support, pushes food out of the mouth, & pushes away when held. The parent asks about the infant's development. The nurse responds by saying which of the following? A. your child is developing normally B. your child needs to see a PCP C. you need to help your child learn to sit unassisted D. push the food back when your child pushes food out
B a 9 month old should be able to sit alone, crawl, pull up, not push food out of the mouth (tongue thrust) & push away when being held when wanting to get down. The developmental screening the child received should be followed by a complete hx, physical exam, and more specific developmental testing
The client has been taking magnesium hydroxide (milk of magnesia) to control hiatal hernia symptoms. The nurse should assess the client for which condition most commonly associated with the ongoing use of magnesium-based antacids? A. anorexia B. weight gain C. diarrhea D. constipation
C
Which assessment data indicate to the nurse the client's gastric ulcer has perforated? A. reports of sudden, sharp pain in back B. rigid, board-like abdomen with rebound tenderness C. frequent clay-colored liquid stool D. reports of vague abdominal pain in the RUQ
B a rigid, boardline abdomen with rebound tenderness is the classic clinical manifestation of peritonitis, which is a complication of a perforated gastric ulcer
Which child is at increased risk for CP? A. infant born at 34 weeks with Apgar of 6 at 5 min B. 17 day old infant with GBS meningitis C. 24 month old child who has experienced a febrile seizure D. 5 y/o with a closed head injury after falling off a bike
B any infection of the CNS increases infant's risk of CP
Which is a predisposing factor in the dx of autistic spectrum disorder? A. having a sibling dx with intellectual developmental disorder B. congenital rubella C. dysfunctional family systems D. inadequate ego development
B children dx with congenital rubella, postnatal neurological infections, phenylketonuria, or fragile X syndrome are predisposed to being dx with autism
The school nurse has been following a child who comes to the office frequently for vague complaints of dizziness & HA. Today, she is brought in after fainting in the cafeteria following a nosebleed. Her BP is 122/85 & her radial pulses are bounding. The nurse suspects she has: A. transposition of great vessels B. coarctation of the aorta C. aortic stenosis D. pulmonary stenosis
B in the older child, COA causes dizziness, HA, fainting, elevated BP & bounding radial pulses. Transposition of great vessels, AS, and PS do not cause these symptoms
The nurse knows that Nissen fundoplication involves which of the following? A. fundus of the stomach is wrapped around the inferior stomach, mimicking a lower esophageal sphincter B. fundus of the stomach is wrapped around the inferior esophagus, mimicking a cardiac sphincter C. fundus of the stomach is wrapped around the middle portion of the stomach, decreasing the capacity of the stomach D. fundus of the stomach is dilated, decreasing the likelihood of reflux
B involves wrapping the fundus of the stomach around the inferior esophagus, creating a lower esophageal, or cardiac, sphincter
The parent of a toddler newly dx with CP asks the nurse what caused it. The nurse should answer with which of the following? A. most cases are caused by unknown prenatal factors B. it is commonly caused by perinatal factors C. exact cause is unknown D. the exact cause is known in every instance
B it is generally thought that the majority of infants with CP had insult in utero. Some of the causes of perinatal insult include hypoxia, trauma, infection, or genetic abnormalities
A nurse is administering a client's 1st dose of sucralfate. Which of the following explanations should the nurse provide about the action of this medication? A. decreases gastric acid secretions B. forms a gel-like substance that protects ulcers C. inactivates H. pylori D. inhibits production of gastric acid
B sucralfate is a GI protectant
A 3 y/o child with CP is admitted for dehydration following an episode of diarrhea. The nurse's assessment follows: awake, pale, thin child laying in bed; multiple contractures, drooling, coughing spells noted when parent feeds. T 97.8, HR 75, RR 25, weight 7.2 kg, no diarrheal stools for 48 hours. Which nursing dx is most important? A. potential for skin breakdown: lying in one position B. alteration in nutrition: less than body requirements C. potential for impaired social support: parent sole caretaker D. alteration in elimination: diarrhea
B the child is severely malnourished & underweight for a 3 y/o. The coughing episodes while feeding put the child at risk for aspiration & pneumonia
Which child requires continued F/U because of behaviors suspicious of CP? A. a 1 month old who demonstrates the startle reflex when a loud noise is heard B. a 6 month old who always reaches for toys with right hand C. a 14 month old who has not yet begun to walk D. a 2 y/o who has not yet achieved bladder control during waking hours
B the clinical characteristic of hemiplegia can be manifested by the early preference of one hand-- this may be an early sign of CP. The startle reflex is expected in 1 month old. Not walking at 14 months is not considered a motor delay. Many 2 y/o have not achieved bladder control
While assessing a NB with resp. distress, the nurse ausculates a machine-like heart murmur. Other findings are a wide pulse pressure, periods of apnea, increased PaCO2, & decreased O2. The nurse suspects that the NB has: A. pulmonary HTN B. PDA C. VSD D. bronchopulmonary dysplasia
B the main identifier in the stem is the machine-like murmur, which is the hallmark of a PDA
The nurse is assessing the mouth & oral cavity of a client with HIV. Opportunistic infections in clients with HIV include which of the following? A. herpes simplex virus lesions on lips B. oral candidiasis C. cytomegalovirus infection D. aphthae on the gingiva
B the most common OI in HIV/AIDS clients is oral candidiasis
The client is dx with an acute exacerbation of ulcerative colitis. Which intervention should the nurse implement? A. provide a low-residue diet B. rest the client's bowel C. assess vital signs daily D. admin antiacids orally
B the first intervention is to place the bowel on rest-- the client should be NPO with IV fluids to prevent dehydration
The nurse teaches a client newly dx with GERD to do which of the following? SATA A. wear tight belts B. avoid eating 2 hrs before bed C. sleep with a wedge pillow D. eat large meals & avoid snacks
B, C
A client with PUD reports being nauseated most of the day & now feeling lightheaded & dizzy. Based upon these findings, which nursing actions would be most appropriate for the nurse to take? SATA A. admin an antacid hourly until nausea subsides B. monitor vitals C. notify HCP of client's sx D. initiating O2 therapy E. reassessing client in an hour
B, C these s/sx may indicate hemorrhage
The child with ADHD has a nursing dx of impaired social interaction. Which of the following nursing interventions are appropriate for this child? SATA A. socially isolate child when interactions with others are inappropriate B. set limits with consequences on inappropriate behaviors C. provide rewards for appropriate behaviors D. provide group situations for the child
B, C, D
The nurse is assessing a child with spastic CP. What findings would the nurse expect to assess? SATA A. dysarthria B. poor control of balance C. hemiplegia D. exaggerated deep tendon relfexes E. drooling F. hypertonicity
B, C, D, F
The nurse is caring for a child who has been experiencing hypercyanotic episodes. Which treatments will be effective in managing them? SATA A. admin Demerol as prescribed B. provide supplemental O2 C. reduce IV fluids D. assist child to a knee-chest position E. apply a cool cloth to child's forehead
B, D
A nurse is teaching the guardians of an infant who has mild GERD. Which of the following instructions about feeding therapies should the nurse recommend? A. apply the infant's diaper snugly prior to feedings B. admin NG feedings C. thicken feedings with rice cereal D. place infant in a lateral position for 1 hr after feedings
C
A child with spastic CP had an intrathecal dose of baclofen in the early afternoon. What is the expected result 3.5 hrs post-dose that suggests the child would benefit from a baclofen pump? A. ability to self-feed B. ability to walk with little assistance C. decreased spasticity D. increased spasticity
C
A client has had an exacerbation of UC with cramping & diarrhea persisting longer than 1 week. The nurse should assess the client for which complication? A. heart failure B. DVT C. hypokalemia D. hypocalcemia
C
A client who has UC has persistent diarrhea and has lost 12 lbs since the exacerbation of the disease. Which approach will be most effective in helping the client meet nutritional needs? A. continuous enteral feedings B. following a high cal, high protein diet C. TPN D. eating 6 small meals a day
C
A client who has a hx of Crohn's is admitted with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should review the client's labs to determine which potential complication of the client's symptoms? A. hyperalbuminemia B. thrombocytopenia C. hypokalemia D. hypercalcemia
C
A client who has been dx with GERD has heartburn. To decrease the heartburn, the nurse should instruct the client to eliminate which item from the diet? A. lean beef B. air-popped popcorn C. hot chocolate D. raw veggies
C
A nurse is teaching a client who has AIDS about the transmission of Pneumocystis jiroveci pneumonia (PCP). Which of the following pieces of info should the nurse include in the teaching? A. PCP is sexually transmitted from person to person B. you were most likely exposed to a contaminated surface such as a drinking glass C. PCP results from an impaired immune system D. you might have contracted PCP from a family pet
C
H. pylori is often found in clients suffering from: A. GERD B. IBD C. PUD D. constipation
C
The nurse is caring for a client from Southeast Asia who has HIV/AIDS. The client does not speak or comprehend the English language. What should the nurse do? A. contact the hospital chaplain B. do an internet search for the Joint United Nations Program on HIV/AIDS C. utilize language-appropriate interpreters D. ask a family member to obtain informed consent
C
The nurse is developing a plan of care for a child recently dx with CP. Which should be the nurse's priority goal? A. ensure ingestion of sufficient calories for growth B. decrease ICP C. teach appropriate parenting strategies for a child with special needs D. ensure child reaches full potential
C
The nurse is teaching a client with PUD about the diet that should be followed after discharge. What types of foods should the nurse suggest the client include in the diet? A. bland foods B. high protein foods C. any foods that are tolerated D. glass of milk with each meal
C
The nurse knows that UC: A. can impact the whole GI tract B. can impact all layers of the bowel C. affects colon & rectum D. results in fistulas
C
The nurse prepares baclofen for a child with CP who just had her hamstrings surgically released. The child's parents ask what the med is for. Select the nurse's best response: A. will help decrease the pain from surgery B. will prevent her from having seizures C. will help control her spasms D. will help with bladder control
C
The nursing history & assessment of an adolescent with a conduct disorder might reveal all of the following behaviors except: A. manipulation of others for fulfillment of own desires B. chronic violation of rules C. feelings of guilt associated with the exploitation of others D. inability to form close peer relationships
C
The nursing instructor is preparing to teach nursing students about ODD. Which fact should be included in the lesson plan? A. prevalence is higher in girls than boys B. dx of ODD occurs before age 3 C. dx of ODD occurs no later than early adolescence D. dx of ODD is not a developmental antecedent to conduct disorder
C
The parent of an infant with CP asks the nurse if the infant will be mentally retarded. Which is the nurse's best response? A. children with CP have some amount of mental retardation B. approx. 20% of children with CP have normal intelligence C. many children with CP have normal intelligence D. mental retardation is expected if motor & sensory deficits are severe
C
The parents of a child with meningitis & multiple seizures ask if the child will likely develop CP. Select the nurse's best response: A. when your child is stable she'll undergo CT & MRI-- the physicians will be able to let you know if she has CP B. most children do not develop CP at this late age C. your child will be closely monitored after discharge & a developmental specialist will be able to make the dx D. most children who have had complications following meningitis develop some amount of CP
C
When admitting a child dx with conduct disorder, which sx would the nurse expect to assess? A. excessive distress about separation from home & family B. repeated complaints of physical sx such as HA and stomachaches C. hx of cruelty toward people & animals D. confabulation when confronted with wrongdoing
C
When the nurse is developing the plan of care for an infant with a cleft lip before corrective surgery is performed, what should be priority? A. maintaining skin integrity in the oral cavity B. using techniques to minimize crying C. altering the usual method of feeding D. preventing infant from putting fingers in mouth
C
Which disease is the client dx with GERD at greater risk for developing? A. hiatal hernia B. gastroenteritis C. esophageal cancer D. gastric cancer
C Barrett's esophagus
Which med should the nurse give to an infant dx with transposition of the great vessels? A. ibuprofen B. betamethasone C. prostaglandin D. indomethacin
C Prostaglandin will inhibit the closing of the PDA, which connects the aorta and PA
A child dx with ASD makes no eye contact, is unresponsive to staff members, and continuously twists, spins, & head bangs. Which nursing dx would take priority? A. personal identity disorder R/T poor ego differentiation B. impaired verbal communication R/T withdrawal into self C. risk for injury R/T head banging D. impaired social interaction R/T delay in accomplishing developmental skills
C SAFETY!!!!!
A foster child dx with ODD is spiteful, vindictive, & argumentative and has a hx of aggression toward others. Which nursing diagnosis would take priority? A. impaired social interaction R/T refusal to adhere to conventional social behavior B. defensive coping R/T unsatisfactory child-parent relationship C. risk for violence: directed at others R/T poor impulse control D. nonadherence R/T a negativistic attitude
C SAFETY!!!!!
The nurse has been assigned to care for a client dx with PUD. Which assessment data require further intervention? A. bowel sounds auscultated 15x in 1 min B. belching after eating a heavy & fatty meal late at night C. a decrease in systolic BP of 20 mmHg from lying to sitting D. a decreased frequency of distress located in the epigastric region
C a decrease in BP after changing position indicates orthostatic hypotension- this could indicate the client is bleeding
The client dx with ulcerative colitis is prescribed a low-residue diet during exacerbations. Which meal selection indicates the client understands the diet teaching? A. grilled hamburger on wheat bun & fried potatoes B. chicken salad sandwich & lettuce & tomato salad C. roast pork, white rice, plain custard D. fried fish, whole grain pasta, fruit salad
C a low-residue diet is a low-fiber diet. Products made of refined flour or finely milled grains, along with roasted, baked, or broiled meats are recommended
A heart transplant may be indicated for a child with severe heart failure and: A. PDA B. VSD C. hypoplastic left heart syndrome D. pulmonary stenosis
C hypoplastic left heart syndrome is treated by the Norwood procedure or heart transplant. PDAs & VSDs can close on their own or be surgically closed. Pulmonary stenosis can range from very constrictive to only slightly stenotic.
The nurse formulates a plan of care to address negative feeding patterns for a 5 month old infant dx with FTT. To meet short-term outcomes of the infant's plan of care, the nurse should expect to implement which intervention? A. instruct parents in proper feeding techniques B. give infant high calorie formula C. provide consistent staff to care for infant D. allow infant to sit in highchair during feedings
C in the short-term care of this infant, it is important that the same person feed the infant at each meal & that this person be able to assess for negative feeding patterns & replace them with positive patterns
The nurse is caring for a 2 month old infant who is at risk for CP due to extreme low birth weight & prematurity. His parents ask why a speech therapist is involved in his care. Select the nurse's best response: A. your baby is likely to have speech problems b/c of his early birth; involving the speech therapist now will ensure vocalization at a developmentally appropriate age B. the speech therapist will help with tongue & jaw movements to assist with babbling C. the speech therapist will help with tongue & jaw movements to assist with feeding D. many members of the health care team are involved in your child's care so that we will know if there are any unmet needs
C it is important to involve speech therapy to strengthen tongue & jaw movements to assist with feeding. The infant who is at risk for CP may have weakened & uncoordinated tongue & jaw movements
A client dx with ADHD & juvenile diabetes is prescribed methylphenidate. Which nursing intervention related to both dx takes priority? A. teach client & family that methylphenidate should be taken in morning b/c it can effect sleep B. teach client & family to report restlessness, insomnia, dry mouth C. teach client & family to monitor fasting blood sugar levels at various times during treatment D. teach client & family that methylphenidate should be taken exactly as prescribed
C methylphenidate lowers the client's activity level, which decreases the use of glucose & increases glucose levels-- b/c of this it is important to monitor fasting levels regularly
The nurse is caring for a 4 month old with GERD. The infant is due to receive omeprazole (Prilosec). Based on the medication's mechanism of action, when should this med be administered? A. immediately before a feeding B. 30 min after feeding C. 60 min before feeding D. at bedtime
C omeprazole decreases gastric acid secretion & should be admin at least 60 min before a feeding
The client engaging in needle-sharing activity has developed a flu-like infection. An HIV antibody test is negative. Which statement best describes the scientific rationale for this finding? A. client is fortunate enough to not have contracted HIV from infected needle B. the client must be repeatedly exposed to HIV before becoming infected C. client may be in the primary infection phase of HIV infection D. antibody test is negative b/c the client has a different flu virus
C the primary phase of infection ranges from being asymptomatic to severe flu-like sx, but during this time the test may be negative although the indiv. is infected with HIV
The client is dx with an acute exacerbation of IBD. Which priority intervention should the nurse implement? A. weight client daily & document in chart B. teach coping strategies such as dietary modifications C. record the frequency, amount, color of stools D. monitor client's oral fluid intake every shift
C the severity of diarrhea helps determine the need for fluid replacement
The nurse is caring for a 4 month old who has just had an isolated cleft lip repaired. Select the best position for the child in the immediate post-op period: A. right side lying B. left side lying C. supine D. prone
C the supine position is preferred b/c there is decreased risk of the infant rubbing the suture line. The infant may rub the face on the bedding if positioned on the side or on the stomach
During play, a toddler with a hx of TOF may assume which position? A. sitting B. supine C. squatting D. standing
C the toddler will naturally assume this position to decrease preload by occluding venous flow from the lower extremities & increasing afterload. Increasing SVR in this position increases pulmonary blood flow
In which CHD would the nurse need to take upper & lower BPs? A. transposition of the great vessels B. aortic stenosis C. coarctation of the aorta D. tetralogy of Fallot
C with COA there is narrowing of the aorta, which increases pressure proximal to the defect (upper extremities) & decreases pressure distal to the defect (lower extremities). There will be high BP & strong pulses in the upper extremities & the opposite in the lower
A child dx with autism has a nursing dx of impaired social interaction R/T withdrawal into self. Which of the following nursing interventions would be the most appropriate to address this problem? SATA A. prevent physical aggression by recognizing signs of agitation B. allow the client to behave spontaneously & shelter the client from peers C. remain with the client during initial interaction with others on the unit D. establish a procedure for behavior modification with rewards to the client for appropriate behaviors E. explain to other clients the meaning behind some of the client's non-verbal gestures & signals
C, D, E
When obtaining a nursing history from a client with a suspected gastric ulcer, which signs & symptoms should the nurse assess? SATA A. epigastric pain at night B. relief of epigastric pain after eating C. vomiting D. weight loss E. melena
C, D, E vomiting & weight loss are common w/ gastric ulcers. The client may also have blood in the stools (melena) from gastric bleeding. Clients w/ gastric ulcer are more likely to have a burning epigastric pain that occurs about 1 hr after eating. Eating frequently aggravates the pain. Clients with duodenal ulcers are more likely to have pain that occurs during the night & is relieved by eating
A 10 y/o client prescribed dextroamphetamine has a nursing dx of imbalanced nutrition: less than body requirements R/T a side effect of anorexia. Which of the following nursing interventions addresses this client's problem? SATA A. monitor output & sleep patterns daily B. admin meds with food to prevent nausea C. schedule medication admin after meals D. increase fiber & fluid intake to prevent contipation E. encourage frequent high cal snacks
C, E
The nurse is planning the care of a client dx with lower esophageal sphincter dysfunction. Which dietary modifications should be included in the plan of care? SATA A. allow any of the client's favorite foods as long as the amount is limited B. have the client perform eructation exercises several times a day C. eat 4-6 small meals a day & limit fluids during mealtimes D. encourage the client to consume a glass of red wine with one meal a day E. maintain an ideal body weight with a healthy diet & exercise
C, E
A child dx with tetralogy of fallot becomes upset, cries, & thrashes around when a blood specimen is obtained. The child becomes cyanotic & RR increases to 44. Which action should the nurse do first? A. obtain a script for sedation for the child B. assess for an irregular HR & rhythm C. explain to the child it will only hurt for a short time D. place child in knee-to-chest position
D
A child is scheduled for a urea breath test. The nurse understands that this test is being performed for which reason? A. evaluate gastric pH B. confirm pancreatitis C. determine esophageal contractility D. detect H. pylori
D
A child with CP is referred for PT. When describing the rationale for this therapy, the nurse would emphasize what as the primary goal? A. development of fine motor skills B. enhance feeding capabilities C. promote optimal self-care ability D. development of gross motor movement
D
A client dx with PUD has an H.pylori infection. The client is following a 2 week drug regimen that includes clarithromycin along with omeprazole & amoxicillin. How should the nurse instruct the client to take these meds? A. alternate use of the drugs B. take drug at different times during the day C. discontinue all drugs is nausea occurs D. take the drugs for the entire 2 week period
D
A client is admitted to the hospital after vomiting bright red blood and is dx with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric region along with a rigid, board-like abdomen. After obtaining vitals, what should should the nurse do next? A. admin pain meds as prescribed B. raise HOB C. prepare to insert NG tube D. notify HCP
D
A client is taking an antacid for tx of a peptic ulcer. Which statement best indicates that the client understands how to correctly take the antacid? A. I should take my antacids before I take my other meds B. I need to decrease my intake of fluids so that I do not dilute the effects of my antacid C. My antacid will be most effective if I take it whenever I experience stomach pains D. It is best for me to take my antacid 1-3 hours after meals
D
A client who has UC says to the nurse, "I can't take this anymore; I'm constantly in pain & I can't leave my room b/c I need to stay by the toilet. I don't know how to deal with this". Based on these comments, what judgment should the nurse make about what the client is experiencing? A. extreme fatigue B. disturbed thought C. a sense of isolation D. difficulty coping
D
A group of nursing students are reviewing meds used to treat ADHD. The group demonstrates understanding of the info when they identify what as a nonstimulant norepinephrine reuptake inhibitor? A. lisdexamfetamine B. methylphenidate C. pemoline D. atomoxetine
D
A nurse is assessing a client who is experiencing perforation of a peptic ulcer. Which of the following manifestations should the nurse expect? A. increased BP B. decreased HR C. yellowing of skin D. boardlike abdomen
D
A nurse is assessing a toddler who has AIDS. Which of the following findings is an indication of an opportunistic infection? A. Koplik spots B. peripheral neuropathy C. chancre D. candidiasis
D
A nurse is caring for a client who is taking budesonide to treat Crohn's. Which of the following findings should indicate to the nurse that the treatment is effective? A. decreased blood glucose B. increased potassium C. increased prostaglandin synthesis D. decreased inflammation
D
A nurse is teaching a client who at 12 wks gestation & has HIV. Which of the following statements should the nurse include in the teaching? A. breastfeed your newborn to provide passive immunity B. abstain from sexual intercourse throughout the pregnancy C. you will be in isolation after delivery D. you should continue to take zidovudine throughout the pregnancy
D
After assessing a child, the nurse suspects coarctation of the aorta based on a finding of: A. bounding pulse B. narrow pulse C. hepatomegaly D. femoral pulse weaker than brachial pulse
D
Certain family dynamics often predispose adolescents to the development of conduct disorder. Which of the following patterns is thought to be a contributing factor? A. parents who are overprotective B. parents who have high expectations of their child C. parents who consistently set limits on their child's behavior D. parents who are alcohol dependent
D
In the NB nursery, the nurse assesses a NB and sees the ears are low-set. What action will the nurse take first? A. report finding to the HCP B. check family hx for genetic conditions C. document the findings D. assess for additional anomalies
D
The client with GERD has a chronic cough. The nurse should further assess the client for which other possible problem? A. development of laryngeal cancer B. irritation of esophagus C. esophageal scar tissue formation D. aspiration of gastric contents
D
The health care team determines that the family of an infant with failure to thrive who is to be discharged will need f/u care. Which approach would be the most effective method of f/u? A. daily phone calls from hospital nurse B. enrollment in community parenting classes C. 2x weekly clinic appts D. weekly visits by community health nurse
D
The nurse caring for a hospitalized child with failure to thrive will focus first on: A. determining the quality of the parent-child relationship B. providing appropriate developmental stimulation C. forming a positive relationship with the child D. assisting the child to attain adequate nutrition to demonstrate weight gain
D
The nurse discusses with the parents how best to raise the IQ of their child with Down syndrome. Which intervention would be most appropriate? A. serve hearty, nutritious meals B. give vasodilator meds as prescribed C. let the child play with more able children D. provide stimulating, nonthreatening life experiences
D
The nurse is caring for a 2 day old neonate in the post-anesthesia care unit 30 min after surgical corrected for the cardiac defect, transposition of the great vessels. Which finding would alert the nurse to notify the HCP? A. O2 90% B. pale pink extremities C. warm, dry skin D. femoral pulse of 90 bpm
D
The nurse is caring for a client dx with GERD. Which nursing interventions should be implemented? A. place client prone in bed & admin nonsteroidal anti-inflammatory meds B. have client remain upright at all times & walk for 30 min 3x/week C. instruct the client to maintain a supine position & take antacids before meals D. elevate the HOB 30 degrees & discuss lifestyle mods with the client
D
The nurse is taking a health history of a toddler with a suspected CHD. Which response by the parent could indicate the child is experiencing hypercyanotic spells? A. my child takes 1 nap a day & is fairly active B. my child walks very quickly & never stops moving C. my child does not seem to have difficulty breathing D. my child likes to stop & squat whenever they walk
D
The parents of a NB dx with cleft lip & palate ask the nurse when their child's lip & palate will most likely be repaired. Which is the nurse's best response? A. the palate & lip are usually repaired in the 1st few weeks of life so that the baby can grow & gain weight B. the palate & lip are usually not repaired until the baby is approx. 6 months old so that the mouth has enough time to grow C. the lip is repaired in the first few months of life, but the palate is not usually repaired until the child is 3 y/o D. the lip is repaired in the first few weeks of life, but the palate is not usually repaired until child about 18 months
D
Which type of isolation technique is designed to decrease the risk of transmission of recognized & unrecognized sources of infection? A. contact B. airborne C. droplet D. standard
D
The nurse is preparing a client dx with GERD for discharge following an EGD. Which statement indicates the client understands the discharge instructions? A. I should not eat for at least 1 day following this procedure B. I can lie down whenever I want after a meal, it won't make a difference C. the stomach contents won't bother my esophagus but will make me nauseous D. I should avoid orange juice & eating tomatoes after this procedure
D Acidic foods are prone to trigger acid reflux
The nurse has admin an antibiotic, a PPI, & bismuth subsalicylate for PUD secondary to H. pylori. Which data would indicate to the nurse the meds are effective? A. a decrease in alcohol intake B. maintaining a bland diet C. return to previous activities D. decrease in gastric distress
D Antibiotics, PPIs, and bismuth subsalicylate (Pepto-Bismol) are admin to decrease the irritation of the ulcerative area & cure the ulcer. A decrease in gastric distress indicates the med is effective
A nurse is teaching a client about controlling the spread of HIV. What strategy is the most effective way to control the spread of HIV infection? A. premarital serologic screening B. prophylactic treatment of exposed people C. lab screening of pregnant women D. ongoing sex education about preventative behaviors
D Education to prevent behaviors that cause HIV transmission is the primary method of controlling HIV infection
When developing a teaching plan for the parents of a child with Down syndrome, the nurse focuses on activities to increase which factor for the parents? A. affection for their child B. responsibility for their child's welfare C. understanding of their child's disability D. confidence in their ability to care for their child
D Parents must continue to work daily with their child, as the parent's confidence in their caring abilities increases, their understanding of the disability also increases on all levels
The client on a medical floor is dx with HIV encephalopathy. Which client problem is the priority? A. altered nutrition, less than body requirements B. anticipatory grieving C. knowledge deficit D. risk for injury
D Safety is always the priority with diminished mental capacity
A nurse is caring for a client who has PUD and reports a HA. Which of the following meds should the nurse plan to admin? A. ibuprofen B. naproxen C. aspirin D. acetaminophen
D all others are NSAIDs
The parent of an infant asks the nurse what to watch for to determine whether the infant has CP. Which is the nurse's best response? A. whether the infant cannot sit up w/o support before 8 months B. whether the infant demonstrates tongue thrust before 4 months C. whether the infant has poor head control after 2 months D. whether the infant has clenched fists after 3 months
D clenched fists after 3 months of age may be a sign of upper motor injury & CP
Which intervention is the highest priority for the therapeutic management of a child with CHF caused by pulmonary stenosis? A. educating the family about s/sx of infection B. admin enoxaparin to improve left ventricular contractility C. assessing HR & BP every 2 hrs D. admin furosemide to decrease systemic venous congestion
D diuretics help to thin blood
A client with peptic ulcer disease is taking ranitidine. What is the expected outcome of this drug? A. heal the ulcer B. protect the ulcer surface from acids C. reduce acid concentration D. limit gastric acid secretion
D histamine 2 receptor antagonists reduce gastric acid secretion
The nurse on an inpatient pediatric psych unit is admitting a client dx with autism spectrum disorder. Which would the nurse expect to assess? A. a strong connection with siblings B. an active imagination C. abnormalities in physical appearance D. absence of language
D one of the 1st characteristics a nurse would note is client's abnormal language patterning or total absence of language. Children dx with ASD display an uneven development of intellectual skills. Impairments are noted in verbal & non-verbal communication. These children cannot use or understand abstract language, and they may make unintelligible sounds or say the same word repeatedly
Which assessment data support the client's dx of gastric ulcer to the nurse? A. presence of blood in the client's stool for past month B. reports of burning sensation moving like a wave C. sharp pain in the upper abdomen after eating a heavy meal D. reports of epigastric pain shortly after ingesting food
D pain usually occurs shortly after eating a meal. In contrast, a client dx with a duodenal ulcer has pain beginning 2-3 hrs after meals that is often relieved by eating
Which problems should the nurse include in the plan of care for the client dx with peptic ulcer disease to observe for physiological complications? A. alteration in bowel elimination patterns B. knowledge deficit in the causes of ulcers C. inability to cope with changing family roles D. potential for alteration in gastric emptying
D potential for alteration in gastric emptying is caused by edema or scarring assoc. w/ an ulcer, which may cause a feeling of "fullness", vomiting of undigested food, or abdominal distention
The client dx with IBD is prescribed sulfasalazine. Which statement best describes the rationale for administering this medication? A. it's admin rectally to help decrease colon inflammation B. slows GI motility & reduces diarrhea C. kills bacteria causing the exacerbation D. acts topically on the colon mucosa to decrease inflammation
D sulfasalazine is a DMARD
During a well-child checkup for an infant with TOF, the child develops severe resp. distress & becomes cyanotic. The nurse's first action should be to: A. lay child flat to promote hemostasis B. lay child flat with legs elevated to increase blood flow to heart C. sit child on parent's lap, with legs dangling, to promote venous pooling D. hold child in knee-chest position to decrease venous blood return
D the increase in the SVR would increase afterload & increase blood return to the pulmonary artery
The nurse evaluates teaching of parents of a child newly dx with CP as successful when the parents state that CP is which of the following? A. inability to speak & uncontrolled drooling B. involuntary movements of lower extremities only C. involuntary movements of upper extremities only D. an increase in muscle tone & DTRs
D the primary disorder is of muscle tone, but there may be other neurological disorders, such as seizures, visual disturbances, & impaired intelligence. Spastic CP is most common type & is characterized by generalized increase in muscle tone, increased DTRs, & rigidity of the limbs on both flexion & extension.
The nurse is administering morning meds at 0730. Which med should have priority? A. Proton pump inhibitor B. nonnarcotic analgesic C. histamine receptor antagonist D. mucosal barrier agent
D to coat the stomach before eating
A patient with HIV who has been started on antiretroviral therapy is seen in the clinic for F/U. Which test will be best to monitor when determining the response to therapy? A. CD4 level B. CBC C. total lymphocyte percent D. viral load
D viral load testing measures the amount of HIV genetic material in the blood, so a decrease in viral load indicates that the therapy is effective
Which should the nurse include in the plan of care to decrease symptoms of GERD in a 2 month old? SATA A. place infant in an infant seat immediately after feedings B. place infant in prone position immediately after feedings to decrease risk of aspiration C. encourage the parents not to worry b/c most infants outgrow GERD within the 1st year of life D. encourage the parents to hold the infant upright for 30 min following a feeding E. suggest that the parents burp the infant after every 1-2 oz consumed
D, E
The ________________ serves as the septal opening between the atria of the fetal heart
Foramen ovale
A 3 month old has been diagnosed with a VSD. The flow of blood through the heart is: (looking for direction)
Left to Right
PDA causes what type of shunt?
Left to right
The flow of blood through the heart with an ASD is:
Left to right
A NB is dx with a CHD. The test results reveal that the lumen of the duct between the aorta & pulmonary artery remains open. This defect is known as:
Patent ductus arteriosus (PDA)
For a child with hypoplastic left heart syndrome, which drug may be given to allow the PDA to remain open until surgery?
Prostaglandin!!!!!
A 6 month old who has episodes of cyanosis after crying could have the CHD of decreased pulmonary blood flow called:
Tetralogy of Fallot (TOF)
