Nur 237 - test 1 (Q&A)
Aspirin has been ordered for the child with rheumatic fever (RF) in order to: 1. Keep the patent ductus arteriosus (PDA) open. 2. Reduce joint inflammation. 3. Decrease swelling of strawberry tongue. 4. Treat ventricular hypertrophy of endocarditis.
2. .Joint inflammation is experienced in RF; aspirin therapy helps with inflammation and pain.
The client diagnosed with septicemia has the following health-care provider orders. Which HCP order has the highest priority? 1. Provide clear liquid diet. 2. Initiate IV antibiotic therapy. 3. Obtain a STAT chest x-ray. 4. Perform hourly glucometer checks.
2. An IV antibiotic is the priority medication for the client with an infection, which is the definition of sepsis—a systemic bacterial infection of the blood. A new order for an IV antibiotic should be implemented within one (1) hour of receiving the order.
Which statement by the mother of a child with rheumatic fever (RF) shows she has an understanding of prevention for her other children? 1. "Whenever one of them gets a sore throat, I will give that child an antibiotic." 2. "There is no treatment. It must run its course." 3. "If their culture is positive for group A streptococcus, I will give them their antibiotic." 4. "If their culture is positive for staphylococcus A, I will give them their antibiotic."
1, 3. 1. Do not use an antibiotic if the disease is not bacterial in origin. Most sore throats are viral. 3. RF is caused by a streptococcus infection, not by staphylococcus.
A patient with SLE is admitted to the hospital for evaluation and management of acute joint inflammation. Which information obtained in the admission laboratory testing concerns you most? 1. The BUN level is elevated 2. The C-reactive protein level is increased 3. The antinuclear antibody test result is positive. 4. The lupus erythematosus cell preparation is positive.
1. A high number of patients with SLE develop nephropathy, so an increase in BUN level may indicate a need for a change in therapy or for further diagnostic testing such as a creatinine clearance test or renal biopsy.
The client has full-thickness burns to 65% of the body, including the chest area. After establishing a patent airway, which collaborative intervention is priority for the client? 1. Replace fluids and electrolytes. 2. Prevent contractures of extremities. 3. Monitor urine output hourly. 4. Prepare to assist with an escharotomy.
1. After airway, the most urgent need is preventing irreversible shock by replacing fluids and electrolytes
The intensive care unit (ICU) burn nurse is developing a nursing care plan for a client with severe full-thickness and deep partial-thickness burns over half the body. Which client problem has priority? 1. High risk for infection. 2. Ineffective coping. 3. Impaired physical mobility. 4. Knowledge deficit.
1. Although this is a potential problem, it is priority because the body's protective barrier, the skin, has been compromised and there is an impaired immune response
The nurse is caring for a 6-month-old infant diagnosed with meningitis. When the child is placed in the supine position and flexes his neck, the nurse notes he flexes his knees and hips. This is referred to as: 1. Brudzinski sign. 2. Cushing triad. 3. Kernig sign. 4. Nuchal rigidity.
1. Brudzinski sign occurs when the child responds to a flexed neck with an involuntary flexion of the hips and/or knees.
The nurse is caring for clients on a medical floor. Which client should be assessed first? 1. The client diagnosed with SLE who is complaining of chest pain. 2. The client diagnosed with MS who is complaining of pain at a "10." 3. The client diagnosed with myasthenia gravis who has dysphagia. 4. The client diagnosed with GB syndrome who can barely move his toes.
1. Chest pain should be considered a priority regardless of the admitting diagnosis. Clients diagnosed with SLE can develop cardiac complications.
The nurse received a male client from the post-anesthesia care unit. Which assessment data would warrant immediate intervention? 1. The client's vital signs are T 97 ̊F, P 108, R 24, and BP 80/40. 2. The client is sleepy but opens the eyes to his name. 3. The client is complaining of pain at a "5" on a 1-to-10 pain scale. 4. The client has 20 mL of urine in the urinary drainage bag.
1. These are symptoms of hypovolemic shock and require immediate intervention
The staff nurse answers the telephone on a medical unit and the caller tells the nurse that he has planted a bomb in the facility. Which actions should the nurse implement? Select all that apply. 1. Do not touch any suspicious object. 2. Call 911, the emergency response system. 3. Try to get the caller to provide additional information. 4. Immediately pull the red emergency wall lever. 5. Write down exactly what the caller says.
1, 3, and 5 are correct.
The client diagnosed with septicemia has the following health-care provider orders. Which HCP order has the highest priority? 1. Provide clear liquid diet. 2. Initiate IV antibiotic therapy. 3. Obtain a STAT chest x-ray. 4. Perform hourly glucometer checks.
2. An IV antibiotic is the priority medication for the client with an infection, which is the definition of sepsis—a systemic bacterial infection of the blood. A new order for an IV antibiotic should be implemented within one (1) hour of receiving the order
The client sustained a hot grease burn to the right hand and calls the emergency room for advice. Which information should the nurse provide to the client? 1. Apply an ice pack to the right hand. 2. Place the hand in cool water. 3. Be sure to rupture any blister formation. 4. Go immediately to the doctor's office.
2. Cool water gives immediate and striking relief from pain and limits local tissue edema and damage.
The nurse writes the nursing diagnosis "impaired skin integrity related to open burn wounds." Which intervention would be appropriate for this nursing diagnosis? 1. Provide analgesia before pain becomes severe. 2. Clean the client's wounds, body, and hair daily. 3. Screen visitors for respiratory infections. 4. Encourage visitors to bring plants and flowers.
2. Daily cleaning reduces bacterial colonization.
The client comes into the emergency room in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet are edematous. Which depth of burn should the nurse document? 1. Superficial partial thickness. 2. Deep partial thickness. 3. Full thickness. 4. First degree.
2. Deep partial-thickness burns are scalds and flash burns that injure the epidermis, upper dermis, and portions of the deeper dermis. This causes pain, blistered and mottled red skin, and edema
The parent of a child with hemophilia is asking the nurse what caused the hemophilia. Which is the nurse's best response? 1. It is an X-linked dominant disorder. 2. It is an X-linked recessive disorder. 3. It is an autosomal dominant disorder. 4. It is an autosomal recessive disorder.
2. Hemophilia is transmitted as an X-linked recessive disorder. About 60% of children have a family history of hemophilia. The usual transmission is by a female with the trait and an unaffected male.
Which order would the nurse question for a child just admitted with the diagnosis of bacterial meningitis? 1. Maintain isolation precautions until 24 hours after receiving intravenous antibiotics. 2. Intravenous fluids at 1 ½ times regular maintenance. 3. Neurological checks every hour. 4. Administer acetaminophen for temperatures higher than 38°C (100.4°F).
2. Intravenous fluids at 1 ½ times regular maintenance could cause fluid overload and lead to increased ICP.
The 26-year-old female client is complaining of a low-grade fever, arthralgias, fatigue, and a facial rash. Which laboratory tests should the nurse expect the HCP to order if SLE is suspected? 1. Complete metabolic panel and liver function tests. 2. Complete blood count and antinuclear antibody tests. 3. Cholesterol and lipid profile tests. 4. Blood urea nitrogen and glomerular filtration tests.
2. No single laboratory test diagnoses SLE, but the client usually presents with moderate to severe anemia, thrombocytopenia, leukopenia, and a positive antinuclear antibody
Which clinical assessment of a neonate with bacterial meningitis would warrant immediate intervention? 1. Irritability. 2. Rectal temperature of 100.6°F (38.1°C). 3. Quieter than usual. 4. Respiratory rate of 24 breaths per minute.
4. A normal neonate's respiratory rate is 30 to 60 breaths per minute. Neonates' respiratory systems are immature, and the rate may initially double in response to illness. If no immediate interventions are begun when there is respiratory distress, a neonate's respiratory rate will slow down, develop worsening respiratory distress, and, eventually, respiratory arrest. Neonates with slower or faster respiratory rates are true emergency cases; they require identification of the cause of distress.
The nurse is caring for a client diagnosed with septic shock who has hypotension, decreased urine output, and cool, pale skin. Which phase of septic shock is the client experiencing? 1. The hypodynamic phase. 2. The compensatory phase. 3. The hyperdynamic phase. 4. The progressive phase
1 The hypodynamic phase is the last and irreversible phase of septic shock, characterized by low cardiac output with vasoconstriction. It reflects the body's effort to compensate for hypovolemia caused by the loss of intravascular volume through the capillaries.
Which of the following activities should a nurse suggest for a client diagnosed with hemophilia? Select all that apply. 1. Swimming. 2. Golf. 3. Hiking. 4. Fishing. 5. Soccer.
1, 2, 3, 4. 1. Children with hemophilia should be encouraged to take part in noncontact activities that allow for social, psychological, and physical growth, such as swimming. 2. Children with hemophilia should be encouraged to take part in noncontact activities that allow for social, psychological, and physical growth, such as golf. 3. Children with hemophilia should be encouraged to take part in noncontact activities that allow for social, psychological, and physical growth, such as hiking. 4. Children with hemophilia should be encouraged to take part in noncontact activities that allow for social, psychological, and physical growth, such as fishing.
A child with hemophilia A fell and injured a knee while playing outside. The knee is swollen and painful. Which of the following measures should be taken to stop the bleeding? Select all that apply. 1. The extremity should be immobilized. 2. The extremity should be elevated. 3. Warm moist compresses should be applied to decrease pain. 4. Passive range-of-motion exercises should be administered to the extremity. 5. Factor VIII should be administered.
1, 2, 5. 1. Measures are needed to induce vasoconstriction and stop the bleeding, including immobilization of the extremity. 2. Measures are needed to induce vasoconstriction and stop the bleeding. Treatment should include elevating the extremity. 5. Hemophilia A is a deficiency in factor VIII, which causes delay in clotting when there is a bleed.
The following are examples of acquired heart disease. Select all that apply. 1. Infective endocarditis. 2. Hypoplastic left heart syndrome. 3. Rheumatic fever (RF). 4. Cardiomyopathy. 5. Kawasaki disease (KD). 6. Transposition of the great vessels.
1, 3, 4, 5. 1. Infective endocarditis is an example of an acquired heart problem. 3. RF is an acquired heart problem. 4. Cardiomyopathy is an acquired heart problem. 5.KD is an acquired heart problem.
Iggie: Which vital sign change in a client with hypovolemic shock indicates to the nurse that the therapy is effective? 1. Urine output increase from 5 mL/hr to 25 mL/hr 2. Pulse pressure decrease from 35 mmHg to 28 mmHg 3. Respiratory rate increase from 22 breaths/min to 26 breaths/min 4. Core body temperature increase from 98.2 F (38C) to 98.8 F (37.1 C)
1. During shock, the kidneys and baroreceptors sense an ongoing decrease in MAP and trigger the release of renin, antidiuretic hormone (ADH), aldosterone, epinephrine, and norepinephrine to start kidney compensation, which is very sensitive to changes in fluid volume. Renin, secreted by the kidney, causes decreased urine output. ADH increases water reabsorption in the kidney, further reducing urine output. These actions compensate for shock by attempting to prevent further fluid loss. This response is so sensitive that urine output is a very good indicator of fluid resuscitation adequacy. If the therapy is not effective, urine output does not increase.
Which nursing interventions should be included for the client who has full-thickness and deep partial-thickness burns to 50% of the body? Select all that apply. 1. Perform meticulous hand hygiene. 2. Use sterile gloves for wound care. 3. Wear gown and mask during procedures. 4. Change invasive lines once a week. 5. Administer antibiotics as prescribed
1. Hand washing is the number-one intervention used to prevent infection, which is priority for the client with a burn. 2. Aseptic techniques minimize risk of cross-contamination and spread of bacteria. 3. Aseptic techniques minimize risk of cross-contamination and spread of bacteria. 5. Antibiotics reduce bacteria
Which is/are the most common, nonlethal complication(s) occurring from meningitis? 1. Cranial nerve deficits. 2. Epilepsy. 3. Bleeding intracranially. 4. Cerebral palsy.
1. If infection extends into the area of the cranial nerves, increased pressure may cause sensory deficits.
Which signs and symptoms would the nurse expect to assess in a child with rheumatic fever? 1. Ankle and knee joint pain. 2. Negative group A beta streptococcal culture. 3. Large red "bulls eye"-appearing rash. 4. Stiff neck with photophobia.
1. Joint pain or arthritis is the most common symptom of acute rheumatic fever (60% to 80% of first attacks). The joint pain usually occurs in two or more large joints (ankle, knee, wrist, or elbow).
The nurse is admitting a client diagnosed with R/O SLE. Which assessment data observed by the nurse support the diagnosis of SLE? 1. Pericardial friction rub and crackles in the lungs. 2. Muscle spasticity and bradykinesia. 3. Hirsutism and clubbing of the fingers. 4. Somnolence and weight gain.
1. SLE can affect any organ. It can cause pericarditis and myocardial ischemia as well as pneumonia or pleural effusions
The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients on a medical floor. Which action by the UAP warrants intervention by the nurse? 1. The UAP places a urine specimen in a biohazard bag in the hallway. 2. The UAP uses the alcohol foam hand cleanser after removing gloves. 3. The UAP puts soiled linen in a plastic bag in the client's room. 4. The UAP obtains a disposable stethoscope for a client in an isolation room.
1. Specimens should be put into biohazard bags prior to leaving the client's room
The client diagnosed with SLE is being discharged from the medical unit. Which discharge instructions are most important for the nurse to include? Select all that apply. 1. Use a sunscreen of SPF 30 or greater when in the sunlight. 2. Notify the HCP immediately when developing a low-grade fever. 3. Some dyspnea is expected and does not need immediate attention. 4. The hands and feet may change color if exposed to cold or heat. 5. Explain the client can be cured with continued therapy.
1. Sunlight or UV light exposure has been shown to initiate an exacerbation of SLE, so the client should be taught to protect the skin when in the sun 2. A fever may be the first indication of an exacerbation of SLE. 4. Raynaud's phenomenon is a condition in which the digits of the hands and feet turn red, blue, or white in response to heat or cold and stress. It occurs with some immune inflammatory processes.
The client is admitted with full-thickness and partial-thickness burns to more than 30% of the body. The nurse is concerned with the client's nutritional status. Which intervention should the nurse implement? 1. Encourage the client's family to bring favorite foods. 2. Provide a low-fat, low-cholesterol diet for the client. 3. Monitor the client's weight weekly in the same clothes. 4. Make a referral to the hospital social worker.
1. The client needs sufficient nutrients for wound healing and increased metabolic requirements, and homemade nutritious foods are usually better than hospital food. This also allows the family to feel part of the client's recovery.
The nurse is caring for a client diagnosed with septic shock who has hypotension, decreased urine output, and cool, pale skin. Which phase of septic shock is the client experiencing? 1. The hypodynamic phase. 2. The compensatory phase. 3. The hyperdynamic phase. 4. The progressive phase.
1. The hypodynamic phase is the last and irreversible phase of septic shock, characterized by low cardiac output with vasoconstriction. It reflects the body's effort to compensate for hypovolemia caused by the loss of intravascular volume through the capillaries. In the compensatory phase of shock, the heart rate, blood pressure, and respiratory rate are within normal limits, but the skin may be cold and clammy and urinary output may be decreased. However, this is the first phase of all types of shock and is not specific to septic shock. The hyperdynamic phase, the first phase of septic shock, is characterized by a high cardiac output with systemic vasodilation. The BP may remain within normal limits, but the heart rate increases to tachycardia and the client becomes febrile. The progressive phase is the second phase of all shocks. It occurs when the systolic BP decreases to less than 80 to 90 mm Hg, the heart rate increases to greater than 150 beats per minutes, and the skin becomes mottled.
The client is admitted into the emergency department with diaphoresis, pale clammy skin, and BP of 90/70. Which intervention should the nurse implement first? 1. Start an IV with an 18-gauge catheter. 2. Administer dopamine intravenous infusion. 3. Obtain arterial blood gases (ABGs). 4. Insert an indwelling urinary catheter.
1. There are many types of shock, but the one common intervention which should be done first in all types of shock is to establish an intravenous line with a large-bore catheter. The low blood pressure and cold, clammy skin indicate shock
The client diagnosed with hypovolemic shock has a BP of 100/60. Fifteen minutes later the BP is 88/64. How much narrowing of the client's pulse pressure has occurred between the two readings?
16 mm Hg pulse pressure. The pulse pressure is the systolic BP minus the diastolic BP. 100 - 60 = 40 mm Hg pulse pressure in first BP reading 88 - 64 =24 mm Hg pulse pressure in second reading 40 - 24 =16 mm Hg pulse pressure narrowing. A narrowing or decreased pulse pressure is an earlier indicator of shock than a decrease in systolic blood pressure.
Iggie: Which newly admitted client does the nurse consider to be at highest risk for development of sepsis? 1. 75-year old man with hypertension and early Alzheimer's disease 2. 68-year old woman 2 days postoperative from bowel surgery 3. 80-year old community dwelling man with no other health problems undergoing cataract surgery 4. 54-year old woman with moderate asthma and severe degenerative joint disease of the right knee
2. The 68-year-old woman has several risk factors. First she is an older adult, and immune function decreases with age. The greatest risk factor is that she has just had bowel surgery. Not only does major surgery further reduce the immune response, the bowel cannot be "sterilized" for surgery. Therefore the usual bacteria of the bowel have the chance to escape the site and enter the bloodstream when the bowel is disrupted.
The nurse and a female unlicensed assistive personnel (UAP) are caring for a group of clients on a medical floor. Which action by the UAP warrants immediate intervention by the nurse? 1. The UAP washes her hands before and after performing vital signs on a client. 2. The UAP dons sterile gloves prior to removing an indwelling catheter from a client. 3. The UAP raises the head of the bed to a high Fowler's position for a client about to eat. 4. The UAP uses a fresh plastic bag to get ice for a client's water pitcher.
2. The UAP can remove an indwelling catheter with nonsterile gloves. This is a waste of expensive equipment. The nurse is responsible for teaching UAPs appropriate use of equipment and supplies and cost containment
An 18 year old college student with an exacerbation of SLE has been receiving prednisone (Deltasone) 20 mg daily for 4 days. Which of these medical orders should you question? 1. Discontinue prednisone after today's dose 2. Give a "catch -up" dose of varicella vaccine 3. Check the patient's C-reactive protein level 4. Administer ibuprofen (Advil) 800 mg PO
2. The chickenpox vaccine is a live virus vaccine and should not be administered to patients who are receiving immunosuppressive medications such as prednisone.
The client is diagnosed with neurogenic shock. Which signs/symptoms should the nurse assess in this client? 1. Cool moist skin. 2. Bradycardia. 3. Wheezing. 4. Decreased bowel sounds.
2. The client will have bradycardia instead of tachycardia, which is seen in other forms of shock.
The client is diagnosed with neurogenic shock. Which signs/symptoms should the nurse assess in this client? 1. Cool moist skin. 2. Bradycardia. 3. Wheezing. 4. Decreased bowel sounds.
2. The client will have bradycardia instead of tachycardia, which is seen in other forms of shock. The client diagnosed with neurogenic shock will have dry, warm skin, rather than cool, moist skin as seen in hypovolemic shock.
The new graduate working on a medical unit night shift is concerned that the charge nurse is drinking alcohol on duty. On more than one occasion, the new graduate has smelled alcohol when the charge nurse returns from a break. Which action should the new graduate nurse implement first? 1. Confront the charge nurse with the suspicions. 2. Talk with the night supervisor about the concerns. 3. Ignore the situation unless the nurse cannot do her job. 4. Ask to speak to the nurse educator about the problem.
2. The night supervisor or the unit man- ager has the authority to require the charge nurse to submit to drug screening. In this case, the supervisor on duty should handle the situation.
The male visitor on a medical unit is shouting and making threats about harming the staff because of perceived poor care his loved one has received. Which statement is the nurse's best initial response? 1. "If you don't stop shouting, I will have to call security." 2. "I hear that you are frustrated. Can we discuss the issues calmly?" 3. "Sir, you are disrupting the unit. Calm down or leave the hospital." 4. "This type of behavior is uncalled for and will not resolve anything."
2. The nurse should remain calm and try to allow the client to vent his frustrations in a more acceptable manner. The nurse should repeat calmly in a low voice any instructions given to the client.
The elderly female client with vertebral fractures who has been self-medicating with ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), presents to the ED complaining of abdominal pain, is pale and clammy, and has a P of 110 and a BP of 92/60. Which type of shock should the nurse suspect? 1. Cardiogenic shock. 2. Hypovolemic shock. 3. Neurogenic shock. 4. Septic shock.
2. These client's signs/symptoms make the nurse suspect the client is losing blood, which leads to hypovolemic shock, which is the most common type of shock and is characterized by decreased intravascular volume. The client's taking of NSAID medications puts her at risk for hemorrhage because NSAIDs inhibit prostaglandin production in the stomach, which increases the risk of developing ulcers, which can erode the stomach lining and lead to hemorrhaging
The elderly female client with vertebral fractures who has been self-medicating with ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), presents to the ED complaining of abdominal pain, is pale and clammy, and has a P of 110 and a BP of 92/60. Which type of shock should the nurse suspect? 1. Cardiogenic shock. 2. Hypovolemic shock. 3. Neurogenic shock. 4. Septic shock.
2. These client's signs/symptoms make the nurse suspect the client is losing blood, which leads to hypovolemic shock, which is the most common type of shock and is characterized by decreased intravascular volume. The client's taking of NSAID medications puts her at risk for hemorrhage because NSAIDs inhibit prostaglandin production in the stomach, which increases the risk of developing ulcers, which can erode the stomach lining and lead to hemorrhaging.
The medical unit is governed by a system of shared governance. Which statement best describes an advantage of this system? 1. It guarantees that unions will not be able to come into the hospital. 2. It makes the manager responsible for sharing information with the staff. 3. It involves staff nurses in the decision-making process of the unit. 4. It is a system used to represent the nurses in labor disputes.
3. Shared governance is an organizational framework in which the nurse has autonomy over his or her own prac- tice. The nurse is given direct input into the working of the unit.
Select the best room assignment for a newly admitted child with bacterial meningitis. 1. Semiprivate room with a roommate who also has bacterial meningitis. 2. Semiprivate room with a roommate who has bacterial meningitis but has received intravenous antibiotics for more than 24 hours. 3. Private room that is dark and quiet with minimal stimulation. 4. Private room that is bright and colorful and has developmentally appropriate activities available.
3. A quiet private room with minimal stimulation is ideal as the child with meningitis should be in a quiet environment to avoid cerebral irritation
The client is scheduled to have a xenograft to a left lower-leg burn. The client asks the nurse, "What is a xenograft?" Which statement by the nurse would be the best response? 1. "The doctor will graft skin from your back to your leg." 2. "The skin from a donor will be used to cover your burn." 3. "The graft will come from an animal, probably a pig." 4. "I think you should ask your doctor about the graft."
3. A xenograft or heterograft consists of skin taken from animals, usually porcine
The nurse in the emergency department administered an intramuscular antibiotic in the left gluteal muscle to the client with pneumonia who is being discharged home. Which intervention should the nurse implement? 1. Ask the client about drug allergies. 2. Obtain a sterile sputum specimen. 3. Have the client wait for 30 minutes. 4. Place a warm washcloth on the client's left hip.
3. Anytime a nurse administers a medication for the first time, the client should be observed for a possible anaphylactic reaction, especially with antibiotics.
Which statement by the mother of a child with rheumatic fever (RF) shows she has good understanding of the care of her child? 1. "I will apply heat to his swollen joints to promote circulation." 2. "I will have him do gentle stretching exercises to prevent contractures." 3. "I will give him the aspirin that is ordered for pain and inflammation." 4. "I will apply cold packs to his swollen joints to reduce pain."
3. Aspirin is the drug of choice for treatment of RF.
Which should the nurse teach the parent of a child with suspected meningitis? 1. Antibiotics are not initiated until the cerebrospinal fluid cultures are definitive for specificity to prevent resistance. 2. Antibiotics are useless against viral infections, so they are not used for meningitis. 3. Antibiotics should be started before the cerebrospinal fluid cultures are definitive; culture results may take up to 3 days. 4. Antibiotic initiation is based on the age, signs, and symptoms of the child, not on the causative agent.
3. Immediate antibiotic therapy is necessary to prevent death and avoid disabilities.
The nurse is discussing autoimmune diseases with a class of nursing students. Which signs and symptoms are shared by rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE)? 1. Nodules in the subcutaneous layer and bone deformity. 2. Renal involvement and pleural effusions. 3. Joint stiffness and pain. 4. Raynaud's phenomenon and skin rash.
3. Joint stiffness and pain are symptoms occurring in both diseases.
Which assessment of an 18-month-old with burns on his feet would cause suspicion of child abuse? 1. Splash marks on his right lower leg. 2. Burns noted on right arm. 3. Symmetrical burns on both feet. 4. Burns mainly noted on right foot.
3. Physical abuse has certain characteristics. Symmetrical burns on both feet indicate abuse.
The client has recently experienced a myocardial infarction. Which action by the nurse helps prevent cardiogenic shock? 1. Monitor the client's telemetry. 2. Turn the client every two (2) hours. 3. Administer oxygen via nasal cannula. 4. Place the client in the Trendelenburg position.
3. Promoting adequate oxygenation of the heart muscle and decreasing the cardiac workload can prevent cardiogenic shock
The nurse is developing a care plan for a client diagnosed with SLE. Which goal is priority for this client? 1. The client will maintain reproductive ability. 2. The client will verbalize feelings of body-image changes. 3. The client will have no deterioration of organ function. 4. The client's skin will remain intact and have no irritation.
3. SLE can invade and destroy any body system or organ. Maintaining organ function is the primary goal of SLE treatment.
The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a client's lower extremity burn. Which assessment data would require immediate attention by the nurse? 1. The client complains of pain when the medication is administered. 2. The client's potassium level is 3.9 mEq/L and sodium level is 137 mEq/L. 3. The client's ABGs are pH 7.34, PaO2 98, Pa CO2 38, and HCO3 20. 4. The client is able to perform active range-of-motion exercises.
3. Sulfamylon is a strong carbonic anhydrase inhibitor that may reduce renal buffering and can cause metabolic acidosis. These ABGs indicate metabolic acidosis and therefore require immediate intervention.
The client diagnosed with an acute exacerbation of SLE is being discharged with a prescription for an oral steroid which will be discontinued gradually. Which statement is the scientific rationale for this type of medication dosing? 1. Tapering the medication prevents the client from having withdrawal symptoms. 2. So thyroid gland starts working, because this medication stops it from working. 3. Tapering the dose allows the adrenal glands to begin to produce cortisol again. 4. This is the health-care provider's personal choice in prescribing the medication.
3. Tapering steroids is important because the adrenal gland stops producing cortisol, a glucocorticosteroid, when the exogenous administration of steroids exceeds what normally is produced. The functions of cortisol in the body are to regulate glucose metabolism and maintain blood pressure.
The parents of a child with meningitis and multiple seizures ask if the child will likely develop cerebral palsy (CP). Select the nurse's best response. 1. "When your child is stable, she'll undergo computed tomography (CT) and magnetic resolution imaging (MRI). The physicians will be able to let you know if she has CP." 2. "Most children do not develop CP at this late age." 3. "Your child will be closely monitored after discharge, and a developmental specialist will be able to make the diagnosis." 4. "Most children who have had complications following meningitis develop some amount of CP."
3. The child will be given a chance to recover and will be monitored closely before a diagnosis is made.
A child with hemophilia fell while riding his bicycle. He was wearing a helmet and did not lose consciousness. He has a mild abrasion on his knee that is not oozing. He is complaining of abdominal pain. What is the priority nursing assessment? 1. Perform neurologic checks. 2. Assess ability to void frequently. 3. Carefully assess his abdomen. 4. Examine his knee frequently.
3. The child's complaint of abdominal pain indicates that undetected bleeding may be present in the abdomen. Determining whether internal bleeding is present would take priority over the knee abrasion, which has nearly stopped bleeding.
The nurse is caring for a client diagnosed with septic shock. Which assessment data warrant immediate intervention by the nurse? 1. Vital signs T 100.4 ̊F, P 104, R 26, and BP 102/60. 2. A white blood cell count of 18,000/mm3. 3. A urinary output of 90 mL in the last four (4) hours. 4. The client complains of being thirsty.
3. The client must have a urinary output of at least 30 mL/hr, so 90 mL in the last four (4) hours indicates impaired renal perfusion, which is a sign of worsening shock and warrants immediate intervention.
The client is being discharged after being in the burn unit for six (6) weeks. Which strategies should the nurse identify to promote the client's mental health? 1. Encourage the client to stay at home as much as possible. 2. Discuss the importance of not relying on the family for needs. 3. Tell the client to remember that changes in lifestyle take time. 4. Instruct the client to discuss feelings only with the therapist.
3. The client needs to know that it will take time to adjust to life after burns and that returning to work, family role, sexual intimacy, and body image will take time.
The client diagnosed with an acute exacerbation of SLE is prescribed high-dose steroids. Which statement best explains the scientific rationale for using high-dose steroids in treating SLE? 1. The steroids will increase the body's ability to fight the infection. 2. The steroids will decrease the chance of the SLE spreading to other organs. 3. The steroids will suppress tissue inflammation, which reduces damage to organs. 4. The steroids will prevent scarring of skin tissues associated with SLE.
3. The main function of steroid medications is to suppress the inflammatory response of the body
The nurse is assessing a client with cutaneous lupus erythematosus. Which intervention should be implemented? 1. Use astringent lotion on the face and skin. 2. Inspect the skin weekly for open areas or rashes. 3. Dry the skin thoroughly by patting. 4. Apply anti-itch medication between the toes.
3. The skin should be washed with mild soap, rinsed, and patted dry. Rubbing can cause abrasions and skin breakdown
The client diagnosed with septicemia is receiving a broad-spectrum antibiotic. Which laboratory data require the nurse to notify the health-care provider? 1. The client's potassium level is 3.8 mEq/L. 2. The urine culture indicates high sensitivity to the antibiotic. 3. The client's pulse oximeter reading is 94%. 4. The culture and sensitivity is resistant to the client's antibiotic.
4. A sensitivity report indicating a resistance to the antibiotic being administered indicates the medication the client is receiving is not appropriate for the treatment of the infectious organism, and the HCP needs to be notified so the antibiotic can be changed
The client diagnosed with septicemia is receiving a broad-spectrum antibiotic. Which laboratory data require the nurse to notify the health-care provider? 1. The client's potassium level is 3.8 mEq/L. 2. The urine culture indicates high sensitivity to the antibiotic. 3. The client's pulse oximeter reading is 94%. 4. The culture and sensitivity is resistant to the client's antibiotic.
4. A sensitivity report indicating a resistance to the antibiotic being administered indicates the medication the client is receiving is not appropriate for the treatment of the infectious organism, and the HCP needs to be notified so the antibiotic can be changed.
Which of the following measures should the nurse teach the parent of a child with hemophilia to do first if the child sustains an injury to a joint causing bleeding? 1. Give the child a dose of Tylenol. 2. Immobilize the joint, and elevate the extremity. 3. Apply heat to the area. 4. Administer factor per the home-care protocol.
4. Administration of factor should be the first intervention if home-care transfusions have been initiated.
The nurse caring for a client with sepsis writes the client diagnosis of "alteration in comfort R/T chills and fever." Which intervention should be included in the plan of care? 1. Ambulate the client in the hallway every shift. 2. Monitor urinalysis, creatinine level, and BUN level. 3. Apply sequential compression devices to the lower extremities. 4. Administer an antipyretic medication every four (4) hours PRN.
4. Antipyretic medication will help decrease the client's fever, which directly addresses the etiology of the client's nursing diagnosis
The nurse caring for a client with sepsis writes the client diagnosis of "alteration in comfort R/T chills and fever." Which intervention should be included in the plan of care? 1. Ambulate the client in the hallway every shift. 2. Monitor urinalysis, creatinine level, and BUN level. 3. Apply sequential compression devices to the lower extremities. 4. Administer an antipyretic medication every four (4) hours PRN.
4. Antipyretic medication will help decrease the client's fever, which directly addresses the etiology of the client's nursing diagnosis.
Which statement most accurately describes child abuse? 1. Intentional physical abuse and neglect. 2. Intentional and unintentional physical and emotional abuse and neglect. 3. Sexual abuse of children, usually by an adult. 4. Intentional physical, emotional, and sexual abuse and neglect.
4. Child abuse is intentional physical, emotional, and/or sexual abuse and/or neglect.
A child is being admitted with the diagnosis of meningitis. Select the procedure the nurse should do first: 1. Administration of intravenous antibiotics. 2. Administration of maintenance intravenous fluids. 3. Placement of a Foley catheter. 4. Send the spinal fluid and blood samples to the laboratory for cultures.
4. Cultures of spinal fluid and blood should be obtained, followed by administration of intravenous antibiotics.
The nurse is caring for a client with deep partial-thickness and full-thickness burns to the chest area. Which assessment data would warrant notifying the health-care provider? 1. The client is complaining of severe pain. 2. The client's pulse oximeter reading is 95%. 3. The client has T 100.4 ̊F, P 100, R 24, and BP 102/60. 4. The client's urinary output is 50 mL in two (2) hours.
4. Fluid and electrolyte balance is the priority for a client with a severe burn. Fluid resuscitation must be maintained to keep a urine output of 30 mL/hr. Therefore, a 25-mL/hr output would warrant immediate intervention
Which approach should the nurse use to gather information from a child brought to the ED for suspected child abuse? 1. Promise the child that her parents will not know what she tells the nurse. 2. Promise the child that she will not have to see the suspected abuser again. 3. Use correct anatomical terms to discuss body parts. 4. Tell the child that the abuse is not her fault and that she is a good person.
4. Many young children believe abuse or illness is their fault, and they should be reminded they are not to blame. Many children this age believe they have acquired a disease or have been abused because they are bad people.
Iggie: Why are the manifestations of most types of shock the same regardless of what specific events or condition caused the shock to occur? 1. The blood, blood vessels, and heart are directly connected to each other so that when one is affected, all three are affected. 2. Because blood loss occurs with all types of shock, the most common first manifestation is hypotension. 3. Every type of shock interferes with oxygenation and metabolism of all cells in the same sequence. 4. The sympathetic nervous system is triggered by any type of shock and initiates the stress response
4. Most manifestations of shock are similar regardless of what starts the process or which tissues are affected first. These common manifestations result from physiologic adjustments (compensatory mechanisms) in an attempt to ensure continued oxygenation of vital organs. These adjustment actions are performed by the sympathetic nervous system triggering the stress response and activating the endocrine and cardiovascular systems. 25.
Which applies to encephalitis? Select all that apply. 1. Usually caused by a bacterial infection. 2. A chronic disease. 3. Most commonly seen after a varicella infection in the newborn population. 4. Newborns diagnosed with encephalitis often have extensive neurological problems. 5. Can be seen with meningitis.
4. Newborns diagnosed with encephalitis often have extensive neurological problems. 5. Encephalitis can be seen with meningitis.
Which of the following will be abnormal in a child with the diagnosis of hemophilia? 1. Platelet count. 2. Hemoglobin level. 3. White blood cell count. 4. Partial thromboplastin time
4. The abnormal laboratory results in hemophilia are related to decreased clotting function. Partial thromboplastin time is prolonged.
The client with full-thickness burns to 40% of the body, including both legs, is being transferred from a community hospital to a burn center. Which measure should be instituted before the transfer? 1. A 22-gauge intravenous line with normal saline infusing. 2. Wounds covered with moist sterile dressings. 3. No intravenous pain medication. 4. Adequate peripheral circulation to both feet ensured.
4. The client's legs should have pedal pulses and be warm to the touch, and the client must be able to move the toes.
The nurse enters the room of a female client diagnosed with SLE and finds the client crying. Which statement is the most therapeutic response? 1. "I know you are upset, but stress makes the SLE worse." 2. "Please explain to me why you are crying." 3. "I recommend going to an SLE support group." 4. "I see you are crying. We can talk if you would like."
4. The nurse stated a fact, "You are crying," and then offered self by saying "Would you like to talk?" This addresses the nonverbal cue, crying, and is a therapeutic response.
The client recently diagnosed with SLE asks the nurse, "What is SLE and how did I get it?" Which statement best explains the scientific rationale for the nurse's response? 1. SLE occurs because the kidneys do not filter antibodies from the blood. 2. SLE occurs after a viral illness as a result of damage to the endocrine system. 3. There is no known identifiable reason for a client to develop SLE. 4. This is an autoimmune disease that may have a genetic or hormonal component.
4. There is evidence for familial and hormonal components to the development SLE. SLE is an autoimmune disease process in which there is an exaggerated production of autoantibodies.
A child has been diagnosed with valvular disease following rheumatic fever (RF). During patient teaching, the nurse discusses the child's long-term prophylactic therapy with antibiotics for dental procedures, surgery, and childbirth. The parents indicate they understand when they say: 1. "She will need to take the antibiotics until she is 18 years old." 2. "She will need to take the antibiotics for 5 years after the last attack." 3. "She will need to take the antibiotics for 10 years after the last attack." 4. "She will need to take the antibiotics for the rest of her life."
4. Valvular involvement indicates significant damage, so antibiotics would be taken for the rest of her life.
The ED nurse is caring for a client admitted with extensive, deep partial-thickness and full-thickness burns. Which interventions should the nurse implement? List in order of priority. 1. Estimate the amount of burned area using the rule of nines. 2. Insert two (2) 18-gauge catheters and begin fluid replacement. 3. Apply sterile saline dressings to the burned areas. 4. Determine the client's airway status. 5. Administer morphine sulfate, a narcotic analgesic, IV.
In order of priority: 4, 2, 3, 1, 5. 4. Airway is always the first priority for any process in which the airway might be compromised. 2. The nurse should start fluid resuscitation as soon as possible before then client's blood pressure makes it more difficult to establish an IV route. 3. Covering the open burns will prevent further intrusion of bacteria. 1. Estimating the extent of the burned area should be done but does not have priority over airway, fluid replacement, and the prevention of infection. 5. Pain is priority but not over determining airway and fluid status and prevention of infection.
