Problem Nursing Q's

A nurse is teaching a client about Rho(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching? a.) I will receive this medication if my baby is Rh-negative b.) I will receive this medication when I am in labor c.) I will need a second dose of this medication when my baby is 6 weeks old d.) I will need this medication if I have an amniocentesis

Answer: d Rho(D) immune globulin is given following an amniocentesis because of the potential of fetal RBCs entering the maternal circulation.

A nurse is planning care for a client who has heart failure. Which of the following prescriptions should the nurse plan to administer to increase cardiac contractility? a.) Lovastatin b.) Furosemide c.) Nitroglycerine d.) Digoxin

Answer: d The client takes digoxin to increase cardiac contractility. The client takes lovastatin to reduce cholesterol levels. The client takes furosemide to reduce circulating blood volume. The client takes nitroglyceride to dilate the coronary arteries and lower blood pressure.

A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following manifestations of this disorder should the nurse include in the teaching? a.) Fear of abandonment b.) Motor and verbal tics c.) Hostile behavior d.) Language delay

Answer: D Children with autism had impaired language, behavioral, and social interaction development

A nurse palpates a primipara mother's fundus at the syphisis pubis. What is the gestational age of the child? When should the nurse palpate the fundus at the umbilicus? a.) 12 weeks then 20 weeks b) 16 weeks then 20 weeks c.) 14 weeks then 36 weeks d.) 20 weeks then 36 weeks

Answer: b

What is the biggest difference between a pacemaker and a defibrillator?

A pacemaker will discharge to maintain the programmed rate. A packemaker in asynchronous mode discharges at a continuous fixed rate. A defibrillator is used to treat tachydysrhythmias.

A nurse is reviewing the potential adverse effects of lithium with a client who began the medication 2 weeks ago. For which of the following should the nurse instruct the client to monitor and report to the provider? a.) Hearing loss b.) Dry persistnet cough c.) Bruising d.) Coarse hand tremors

Answer: D Signs of Lithium Toxicity include: Projectile vomiting Explosive Diarrhea and Tremors The therapeutic range is: 0.4 - 1.0

A nurse is performing discharge teaching for a client who has an above-the-knee amputation and a temporary prosthesis. Which of the following responses by the client indicates a need for further teaching? a.) I will make sure I have a soft mattress on my bed b.) I will wear my compression bandage as much as possible c.) I will try to keep my leg in extension d.) I will clean the prosthesis insert on a regular basis

Answer: a A firm mattress is important in preventing contractures.

A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnositc tests? a.) Biophysical profile b.) Amniocentesis c.) Cordocentesis d.) Kleihauer-Betke test

Answer: a A positive contraction stress test indicates that further evaluation of the fetus is necessary. A biophysical profile will provide further evaluation with real-time ultrasound.

A nurse is caring for a client in the PACU who has hypothermia. For which of the following complications should the nurse monitor? a.) Hypertension b.) Metabolic alkalosis c.) Cardiac tamponade d.) Flail chest

Answer: a Hypothermia can cause vasoconstriction leading to hypertension. Metabolic acidosis can result from hypothermia due to shivering. Flail chest and cardiac tamponade are not complications of hypothermia.

A nurse is caring for a client who was admitted following an overdose of amitriptyline. The nurse should monitor the client for which of the following adverse effects associated with this medication? a.) Loose stools b.) Urinary retention c.) Fever d.) Dyspnea

Answer: b amitriptyline is a Tricyclic Antidepressant (TCA) Side Effects of TCAs: SO WATS Sedation Orthstatic Hypotension Weight Gain Anticholinergic (Can't pee, can't see, can't spit, can't shit) Tachycardia Sexual Dysfunction

A nurse is caring for a client who has schizophrenia and is prescribed risperidone. Which of the following laboratory tests should the nurse monitor? a.) BUN b.) Hemoglobin c.) Platelet count d.) Blood glucose

Answer: D Risperidone can cause diabetes to develop. Antipsychotic side effects include: iSHADE Impotence Sedation / Seizures Hypotension Akathisia Dermatolgical SEs EPS (Acute dystonia, rigidity, tremor, tachycardia)

During a client's initial interview in a mental health inpatient setting, the nurse identifies that the client is maintaining eye contact and leaning forward. Which of the following assumptions should the nurse make based on the client's nonverbal behaviors? a.) The client is interested in what the nurse is saying b.) The client is attempting to manipulate the nurse c.) The client is physically attracted to the nurse d.) The client needs to feel accepted by the nurse

Answer: The client's posture and eye contact demonstrate that she is interested in the interview and what the nurse is saying.

A nurse is caring for a client who has alcoholic cardiomyopathy. Which of the following laboratory values should the nurse expect? a.) Increased creatine phosphokinase (CPK) b.) Increased low-density lipoproteins (LDL) c.) Decreased fasting blood sugar (FBS) d.) Decreased aspartate aminotransferase (AST)

Answer: A An increase in CPK, a muscle enzyme released when muscle tissue is damaged, occurs with cardiomyopathy. The other choices don't have to do specifically with cardiomyopathy.

A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which of the following could interfere with the absorption of the medication? a.) Gingko biloba b.) Glucosamine c.) Calcium supplements d.) Vitamin C

Answer: C Calcium supplements interfere with the absorption of levothyroxine and they should no be taken together. The others don't interfere with the absorption of levothyroxine.

A nurse is teaching a school-age child who has a severe allergy to bee venom and his parents about epinephrine. Which of the following instructions should the nurse include in the teaching? a.) Use a second dose if the first dose of epinephrine does not completely reverse the symptoms b.) Store unused epinephrine syringes in the refrigerator c.) Shake the epinephrine syringe prior to use to dissolve the precipitate d.) Administer the medication subcutaneously in the back of the arm.

Answer: a If symptoms aren't completely resolved use another dose. The nurse should instruct the parent and child to store epinephrine in a dark area at room temperature. Refrigeration of an epinephrine syringe can result in failure of the injection mechanism to work. The nurse should inform that the formation of precipitate or a brown coloration to the solution is an indication that the medication should be replaced and not used. The medication should be administer intramuscularly into the anterolateral aspect of the middle thigh.

A nurse is planning care for a client who constantly threatens others on the unit. Although the client does not want to leave the unit, the nurse requires the provider to transfer the client to a unit that is equipped to manage violent behavior. Which of the following ethical principals should the nurse apply in this situation? a.) Nonmaleficence b.) Veracity c.) Justice d.) Autonomy

Answer: a It is the responsibility of the nurse to do no harm to clients. The nurse is applying the ethical principle to transfer this client to a unit better to manage his behavior and thereby prevent injury to others on the unit.

A nurse is teaching a client who has bipolar disorder and a prescription for lithium. Which of the following instructions should the nurse include in the teaching? a.) Take this medication with food b.) Reduce sodium intake to 1,000 mg each day c.) Limit fluid intake to 1,200 mL each day d.) Be aware that this medication can be addictive.

Answer: a Lithium can cause GI distress. Therefore you should take it with food. Lithium Toxicity can result from low sodium and water intake. Teach patients to maintain a normal level of both sodium and water. Lithium is not addictive.

A nurse working in an outpatient clinic is assessing a university student who says he feels restless and irritable before taking an exam. The nurse should assess the cinical findings as which of the following? a.) Mild anxiety b.) Moderate anxiety c.) Severe anxiety d.) Panic

Answer: a Mild anxiety includes: Heightened perceptual field, alert and can grasp what is going on, restlessness, irritability or impatience, foot or finger tapping The others choices have more critical signs and symptoms.

A nurse is obtaining a nursing history from a client who has suspected cholecystitis. Which of the following findings should the nurse expect? a.) Vague pain radiating to the right shoulder b.) Intense, piercing abdominal pain c.) Rigid, board-like abdomen d.) Flank pain extending to the perineum

Answer: a Pain that radiates to the right shoulder can indicate cholecystitis. Intense, piercing abdominal pain can indicate pancreatitis. A rigid, board-like abdomen can indicate peritonitis. Flank pain extending to the perineum can indicate urolithiasis.

A nurse is providing teaching to a client who has just received a new hearing aid. Which of the following responses by the client indicates understanding? a.) I may have the most difficulty with background noises b.) I should use my hearing aid continuously to become used to it c.) Hearing with my hearing aid will be the same as my normal hearing was d.) I should adjust the volume to the highest setting that prevents feedback squeaking

Answer: a The amplification of background noise is often a challenging aspect of adjusting to a hearing aid. When adjusting to a new hearing aid, the client should begin by wearing it at home in intervals during a day, but not continuously to adjust to new sounds. Hearing aids amplify sounds but are not able to enhance the sound discrimination characteristic of normal, unassisted hearing. A hearing aid should be adjusted to the lowest volume that allows the client to hear.

A client who has a history of anxiety disorder reports numbness and tingling in the fingertips and has a pulse rate of 140/min and respirations of 42/min. Which of the following is the nurse's priority intervention? a.) Apply a nonrebreather mask without oxygen b.) Provide guided imagery c.) Administer antianxiety agent d.) Obtain an arterial blood gas speciment

Answer: a The greatest risk to the client is hypocapnia and subsequent development of respiratory alkalosis; therefore, the priority intervention is to assist the client to retain more carbon dioxide, minimizing the potential for development of respiratory alkalosis by using a nonrebreather mask. Guided imagery and an antianxety agent may decrease anxiety but it is not the priority intervention. The client's ABGs can provide useful data, but this is not the nurse's priority intervention.

A nurse is assessing an infant who has a ventricular septal defect. Which of the following findings should the nurse expect? a.) Loud, harsh murmur b.) Dysrhythmias c.) Weak femoral pulses d.) High blood pressure

Answer: a The nurse should hear a loud, harsh murmur with a ventricular septal defect due to the left-to-right shunting of blood, which contributes to hypertrophy of the infant's heart muscle. Weak femoral pulses and elevated blood pressure are manifestations of coarctation of the aorta.

A nurse is providing discharge teaching to a client who is postpartum and was taking insulin for gestational diabetes mellitus. Which of the following instructions should the nurse include in the teaching? a.) You should get a 2-hour oral glucose tolerance test in 6 to 12 weeks b.) You should avoid using low-dose oral contraceptives for birth control c.) You will need to monitor your blood glucose levels daily at home for 2 to 3 weeks d.) You will need to take a lower dose of insulin than you took during your pregnancy

Answer: a The nurse should instruct the client to get a 2-hr oral glucose tolerance test 6 to 12 weeks postpartum and every 3 years to screen for type II diabetes mellitus. The nurse should instruct the client that blood glucose levels return to the expected reference range after childbirth. Therefore the client does not need to monitor her blood glucose levels at home or continue to take insulin.

A nurse is caring for a client who has a Stage III pressure ulcer. Which of the following should the nurse use when changing the client's dressing? a.) Hydrocolloid dressing b.) Nonadherent guaze dressing c.) Adhesive transparent film d.) Wet-to-damp dressing

Answer: a The nurse should use a hydrocolloid dressing to keep the wound bed moist. The nurse should use a nonadherent gauze dressing for a wound that has little to no drainage. The nurse should use adhesive transparent film over intact skin. The nurse should use a wet-to-damp dressing for mechanical debridement.

A nurse is assisting a provider with a cholinesterase inhibitor test for a client who was previously diagnosed with myasthenia gravis. After admission of the cholinesterase inhibitor, the client demonstrates increased muscle weakness and twitching. The nurse concludes that the client is exhibiting which of the following conditions? a.) Cholinergic crisis b.) Myasthenic crisis c.) Thyrotoxicosis d.) Thymoma

Answer: a In a cholinergic crisis, the client exhibits increased muscle weakness and twitching after administration of the cholinesterase inhibitor. Muscle weakness should improve after administration of the cholinesterase inhibitor if the client was having myasthenic crisis.

A newly delivered infanthas a pink trunk and blue hands and feet, pulse rate of 60 and does not respond to your attempts to stimulate her. She also appears to be limp and taking slow, gasping breaths. What is her APGAR score? a.) 3 b.) 1 c.) 2 d.) 5

Answer: a (3)

A nurse is caring for a pre-school age child who is dying. Which of the following findings is an age-appropriate reaction to death by the child (Select all that apply) a.) The child views death as similar to sleep b.) The child is interested in what happens to his body after death c.) The child recognizes that death is permanent d.) The child believes his thoughts can cause death e.) The child thinks death is a punishment

Answer: a,d, and e Pre-school age children due all of these following. Pre-school age children view death as reversible School-age children are more interested in post-death services and what happens to the body after death due to an improved ability to comprehend what is happening.

A nurse is providing teaching to a client who is discharged from an inpatient detoxification program and plans to attend Alcoholics Anonymous. Which of the following statements by the client indicates an understanding of the teaching? a.) I will learn ways to decrease my alcohol use b.) I will use peer support to maintain my abstinence c.) I will learn to take responsibility for my addiction d.) I will use a health care professional as my sponser

Answer: b Alcoholics anonymous encourages recovery through peer support. AA promotes abstinence rather than decreasing alcohol use. It also allows AA members to take responsibility for their recovery rather than their addiction. It is also better to choose a sponsor who has recovered from substance abuse

A nurse is planning teaching for a client who has acute kidney failure. Which of the following over-the-counter medications should the nurse recommend as safe for this client? a.) Naproxen b.) Calcium carbonate c.) Magnesium hydroxide d.) Gentamicin

Answer: b Calcium carbonate is safe for clients who have acute kidney failure. Naproxen and Gentamicin can cause nephrotoxicity. Magnesium hydroxide is contraindicated for clients with acute kidney failure.

A nurse is providing care to a client in the PACU immediately following a coronary artery bypass graft (CABG). Which of the following interventions should the nurse implement during the immediate postoperative period? a.) Monitor for an elevated magnesium level b.) Assess for a decrease in the client's temperature c.) Offer oral pain medication d.) Initiate a 24-hr urine collection

Answer: b During a CABG procedure, the client is cooled to decrease metabolic needs. Even thought the client is warmed prior to leaving the surgical suite,body temperature can fall again; therefore, the nurse should assess the client's temperature to determine the need for rewarming procedures. Mag levels are frequently reduced following a CABG due to hemodilution. The client receiving care in the PACU will be intubated and receiving sedatives and unable to take oral pain medication. It is not necessary to initiate a 24-hr urine collection for a client following a CABG.

A nurse is caring for a client who is 1 day postoperative following a thoracotomy. Which of the following findings indicates a tension pneumothorax? a.) Bibasilar rales b.) Chest asymmetry c.) Paradoxic chest movement d.) Hemoptysis

Answer: b The air that is forced into the chest cavity causes the affected lung to collapse, and the air enters the pleural space during inspiration does not exit during expiration. This causes chest asymmetry. A client who has a tension pneumothorax will have no breath sounds on the affected side. Pardoxic chest movement is the movement of the thorax outward on expiration and inward on inspiration. This is seen with flail chest. Hemoptysis or bloody sputum occurs with pulmonary infections or pulmonary embolism.

A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new prescription for metformin once daily. Which of the following statements by the client indicates an understanding of the teaching? a.) I will monitor my blood glucose carefully because the medication increases the secretion of insulin b.) I should take this medication with a meal c.) I can expect to gain weight while taking this medication d.) While taking this medication, I may experience flushing of my skin

Answer: b The client should take metformin with or right after meals. Metformin decreases the amount of glucose produced in the liver and tissue sensitivity to insulin. Typically, clients lose weight when they first start taking this medication due to nausea and vomiting. Flushing of the skin is not an adverse effect of metformin.

A nurse is caring for a client who is in an abusive relationship and is assisting in the development of a safety plan. Which of the following actions is the first component of a safety plan? a.) Develop a code word that means "time to go" b.) Identify signs of escalation of violence c.) Have a predetermined place to go in the event of violence d.) Keep a hidden packed bag of necessities

Answer: b The first component of the safety plan is to increase awareness of when danger is imminent and time to leave.

When administering RBCs to a client, which of the following actions should the nurse take? a.) Prime the administration set with lactated Ringer's solution b.) Stay with the client during the first 30 minutes of the infusion c.) Wait until the RBC's warm to room temperature before infusing d.) Start a 22-gauge peripheral intravenous line

Answer: b The nurse should stay with the client for at least 30 minutes, as most transfusion reactions manifest during the infusion of the first 50-100mL of blood product. The nurse should administer blood with 0.9% sodium chloride solution and never with lactated Ringer's solution or with a solution that contains dextrose. The nurse should administer the blood asap to decrease the risk of bacterial growth. Blood components are too viscous to infuse properly through a needle with a lumen any narrower than 20 gauge. The nurse should use an 18 or 19 gauge needle.

A nurse is teaching a client who has a depressive disorder about fluoxetine. Which of the following information should the nurse include in the teaching? a.) You may notice an increase in saliva while taking this medication b.) You may experience difficulties with sexual functioning while taking this medication c.) You should expect an improvement in symptoms of depression in 3 - 4 days d.) You should experience weight gain while taking this medication

Answer: b fluoxetine is a Selective Serotonin Reuptake Inhibitor (SSRI) Side Effects of SSRIs: BAD SSRI ↑ Body Weight Anxiety Dizziness Serotonin Syndrome Stimulated CNS Reproductive / Sexual Dysfuction Insomnia

A nurse is admitting an infant who has intussusception. Which of the following findings should the nurse expect? (Select all that apply) a.) Steatorrhea b.) Vomiting c.) Lethargy d.) Constipation e.) Weight gain

Answer: b & c With intussusception the nurse should expect bloody stools that are currant jelly-like in appearance. The nurse should also monitor for weight loss due to anorexia and episodes of vomiting and diarrhea.

A nurse is caring for a client who has COPD and the is receiving nebulizer treatments of acetylcysteine. Which of the following client statements indicates the medication is effective? a.) I can breath more deeply now b.) I don't have to cough as much as I did before the treatment c.) I can cough up my secretions more easily now d.) I don't have as much pain when I breath now

Answer: c Acetylcysteine thins pulmonary secretions, which increases the client's ability to cough up secretions

A nurse is communicating with a client in an inpatient mental health facility. Which of the following actions by the nurse demonstrates the use of active listening? a.) Offering self b.) Use of silence c.) Attention to body language d.) Reflection of feelings

Answer: c Active listening includes: Observing the client's nonverbal behaviors and understanding & reflecting on the client's verbal message.

A nurse is caring for an older adult client who is experiencing delirium. Which of the following interventions should the nurse include in the client's plan of care? a.) Offer the client various choices for meal selection b.) Assigns different nursing personnel for each shift c.) Permit the client to perform daily rituals to decrease anxiety d.) Maintain an environment that has low lighting

Answer: c Allowing clients who have delirium to practice daily rituals will decrease anxiety and confusion. Client with delirium should have well-lit environment with a low stimulating environment (No noise such as radios, TV, etc...) Caregivers should be consistent Client's with delirium may become frustrated easily when presented with multiple choices.

A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching? a.) I will get injections of the medication once daily until my labor stops b.) My blood sugar may be low while i'm on this medication c.) I will have blood tests because my potassium might decrease d.) My blood pressure may increase while i'm on this medication

Answer: c An adverse effect of terbutaline is hypokalemia. Others include: hypotension, and hyperglycemia. Terbutaline is administered Subcut q.4.h. for no longer than 24 hours.

Clozapine an antipsychotic is known to cause which deadly symptoms? a.) Respiratory depression b.) Cardiac tamponade c.) Agranulocytosis d.) Disseminated intravascular coagulation (DIC)

Answer: c Clozapine / Clozaril causes agranulocytosis. Signs include: Sore throat Malaise Fever ↓ WBC

A nurse is assessing a client who has hypokalemia. Which of the following clinical manifestations should the nurse expect? a.) Facial twitching b.) Bounding peripheral pulses c.) Decreased peristalsis d.) Hyperreflexia

Answer: c Facial twitching and hyperreflexia is a manifestation of hyperkalemima. Bounding peripheral pulses are clinical manifestations of hypernatremia.

A nurse on a pediatric unit is reviewing the health record of a client who is demonstrating increasing levels of stress after admission. The nurse should identify which of the following findings as a risk factor for a stress-related reaction to hospitalization? a.) Age 10 b.) First hospitalization c.) Male gender d.) Calm, quiet demeanor

Answer: c Male clients are at increased risk for hospitalization-related stress compared to female clients. Children ages 6 months - 5 years, multiple hospitalizations, and children who demonstrate irritable and difficult temperaments are more vulnerable to stress related reactions.

A nurse is assessing a 30 month old toddler during a well-child visit. Which of the following findings requires further assessment by the nurse? a.) Primary dentition is complete b.) Unable to hop on one foot c.) Birth weight is tripled d.) Able to state first and last name

Answer: c The birth weight should triple by 12 months of age. By 30 months of age, the birth weight should be quadrupled.

A nurse is caring for a school-age child who has acute rheumatic fever. Which of the following actions should the nurse take? a.) Limit the child's sodium intake b.) Place a "no visitors" sign on the child's door c.) Maintain the child on bed rest d.) Avoid administering salicylates to the child

Answer: c The nurse should maintain the child on bed rest as well as limit the child's activity during the acute phase of rheumatic fever to assist with the prevention of cardiac damage. Rheumatic fever is an inflammatory disease resulting from an immune response that involves the heart, joints, skin, and central nervous system. There is no indication to limit the sodium intake. Rheumatic fever is not contagious to others. The nurse should administer salicylates to the child who has acute rheumatic fever to decrease fever and discomfort and help to control the inflammatory process.

A nurse is reviewing the lumbar puncture results of a school-age child suspected of having bacterial meningitis. Which of the following results should the nurse identify as a finding associated with bacterial meningitis? a.) Decreased cerebrospinal fluid pressure b.) Decreased WBC coung c.) Increased protein concentration d.) Increased glucose level

Answer: c The nurse should recognize that an increased protein concentration in the spinal fluid is a finding associated with bacterial meningitis. An increased WBC count and cerebrospinal fluid pressure are also findings of bacterial meningitis. A decrease in glucose level in the spinal fluid is a finding associated with bacterial meningitis.

A nurse is planning to irrigate and dress a clean, granulating wound of a client who has a pressure ulcer. Which of the following actions should the nurse take? a.) Apply a wet-to-dry gauze dressing b.) Irrigate with hydrogen peroxide solution c.) Use a 30mL syringe d.) Attach a 25-gauge angiocatheter to the syringe

Answer: c The nurse should use a 30 mL to 60 mL syringe with a 19-gauge catheter to deliver the ideal pressure when irrigating a wound. The nurse should not apply wet-to-dry dressings to clean, granulating wounds as they interrupt viable, healing tissues when they are removed.

A nurse is caring for a client who is 2 hours postoperative following a traditional open approach cholecystectomy. Which of the following indicates the need for further nursing assessment? a.) The T-tube has 500 mL of greenish-brown drainage b.) The dressing has a 3 cm diameter area of sanguineous drainage c.) The client has unilateral swelling of a lower extremity d.) The client reports having a sore throat

Answer: c Unilateral swelling of a lower extremity might indicate the development of a DVT, which will require further assessment. Greenish-brown drainage is an expected finding. Sanguineous drainage 2 hours postoperatively is an expected finding for the client. A report of a sore throat following endotracheal intubation is an expected finding for the client.

It has been 5 minutes since your patient delivered her baby. The infant is crying weakly and is curling his arms and legs. He is pink all over with a pulse of 90 and weak respirations. What is his APGAR score? a.) 3 b.) 5 c.) 6 d.) 9

Answer: c (6)

A nurse is teaching the parent of an infant about home safety. Which of the following information should the nurse include? (Select all that apply) a.) Use a wheeled infant walker b.) Place soft pillows around the edge of the infant's crib c.) Position the car seat so it is rear-facing d.) Secure the safety gate at the top and bottom of the stairs e.) Maintain the water heater temperature at 49 degrees celcius (120 degrees fahrenheit)

Answer: c,d, and e Infants and children should remain in the rear-facing position when in a car seat until the age of 2 years or until they reach the recommended height and weight per the manufacturer's guidelines. As the infant begins to crawl and becomes more mobile, the risk of falls increases. To prevent a burn injury, the temperature of the water heater should not exceed 120 degrees fahrenheit

A nurse is planning for a preschooler who has cystic fibrosis. Which of the following interventions should the nurse include in the plan? a.) Administer pancreatic enzymes 2 hrs after meals b.) Decrease pancreatic enzymes if steatorrhea develops c.) Limit fluid intake to 750mL per day d.) Increase fat content in the child's diet to 40% of total calories

Answer: d A child who has cystic fibrosis is unable to properly digest fats due to fibrosis of the pancreas and limited secretion of pancreatic enzymes. The nurse should increase the child's fat intake to equal 40% of total caloric intake. The nurse should plan to administer pancreatic enzymes within 30 minutes of meals and snacks. A child who develops steatorrhea needs to increase the intake of pancreatic enzymes. The nurse should encourage fluid intake.

A nurse is caring for a client who has pancreatitis. The nurse should expect which of the following laboratory findings to be below the expected reference range? a.) Serum amylase b.) Alkaline phosphatase c.) Serum bilirubin d.) Serum calcium

Answer: d A client who has pancreatitis will have decreased serum calcium due to fat necrosis. A client with pancreatitis will have elevated serum amylase, alkaline phosphatase, and serum bilirubin.

A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? a.) I should increase my protein to 60 grams each day b.) I should drink 2 liters of water each day c.) I should increase my overall daily caloric intake by 310 calories d.) I should take 600 micrograms of folic acid each day.

Answer: d A client who is pregnant should increase her folic acid intake to 600 mcg daily. Folic acid assists with preventing neural tube birth defects. Protein should be 71g / day Water should be 3L / day Overall calories should be 340 calories in the second trimester and 452 during the third trimester. 330 extra calories for a lactating mother.

A nurse is teaching the parent of a 12 month old infant about nutrition. Which of the following statements by the parent indicates a need for further teaching? a.) I can give my baby 4 oz of juice to drink each day b.) I will offer my baby dry cereal and chilled banana slices as snacks c.) I am introducing my baby to the same foods the family eats d.) My infant drinks at least 2 quarts of skim milk each day

Answer: d As the infant transitions into toddlerhood, whole milk intake should average 24-30 oz per day. Too much milk can affect intake of solid foods and result in iron deficiency anemia. Skim milk is not recommended until after age 2 since it lacks essential fatty acids which are needed for growth and development.

A nurse is caring for a 2 year old child who has cystic fibrosis. The nurse is planning to take the child to the playroom. Which of the following activities would be appropriate for the child? a.) Cutting figures with colored paper b.) Drawing stick figures using crayons c.) Riding a tricycle d.) Building towers of blocks

Answer: d Building towers of blocks is an appropriate activity for a 2 year old child. It promotes fine-motor development, and knocking blocks down provides a means of dealing with the stress of hospitalization.

A school nurse is assessing a school-age child who experienced the traumatic loss of a parent 8 months ago. Which of the following findings should the nurse identify as an indication that the child is experiencing PTSD? a.) Clinging behaviors directed toward a teacher b.) Increased time spent sleeping c.) Intense focus on school work d.) Lack of interest in an upcoming holiday.

Answer: d Individuals with PTSD re-experience a highly traumatic event through dreams, flashbacks, thoughts, and images. They often have negative moods and difficulty remembering aspects of the traumatic event. They often have trouble sleeping, concentrating, and detachment or estrangement from others. Lack of interest or participation is common.

A nurse is admitting a female client who has anorexia nervosa. Which of the following manifestations should the nurse expect during the admission assessment? a.) Diarrhea b.) Heavy menstrual bleeding c.) Tachycardia d.) Orthostatic hypotension

Answer: d Presenting s/s include: Bradycardia & hypotension Electrolyte imbalances Erosion of teeth Esophageal tears from vomiting Normal to slightly low body weight Muscle weakening Calluses/scars on hand from self-induced vomiting.

A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect? a.) Deep tendon reflexes 4+ b.) Fundal height 14cm c.) Urine protein 2+ d.) FHR 152/min

Answer: d The expected range for the FHR is 110-160 beats per minute. The FHR is higher earlier in gestation with an average of approximately 160bpm at 20 weeks. From gestational weeks 18-32 the height of the fundus is approximately equal to the number of weeks of gestation plus or minus 2 cm. Therefore the nurse should expect the fundal height to be 16-20cm.

A nurse is planning care for a school-age child who has a tunneling central venous access device. Which of the following interventions should the nurse include in the plan? a.) Use sterile scissors to remove the dressing from the site b.) Irrigate each lumen weekly with 10mL of 0.9% sodium chloride solution when not in use c.) Access the site using a noncoring angled needle d.) Use a semipermeable transparent dressing to cover the site

Answer: d The nurse should cover the site with a semipermeable transparent dressing to reduce the risk of infection The nurse should avoid using scissors to prevent accidentally cutting the catheter. The nurse should flush each lumen of the catheter with a heparin solution daily when not in use. The nurse should use a non-coring angled or straight needle when accessing an implanted port.

A nurse is assessing a preschooler who has cystic fibrosis and has been receiving oxygen therapy for the past 36 hours. Which of the following findings should the nurse identify is an indication that the client has developed oxygen toxicity? a.) Wheezes b.) Tachycardia c.) Restlessness d.) Bradycardia

Answer: d The nurse should recognize bradypnea, and crackles, as a manifestation of oxygen toxicity due to the depression of the respiratory drive in a client who has chronic hypoxia, such as a preschooler who has cystic fibrosis. Tachycardia and restlessness indicate hypoxemia, and requires oxygen therapy. Clients

A nurse is administering meperidine IM in the right deltoid of a client. The nurse aspirates and pulls back blood in the syringe. Which of the following actions should the nurse take? a.) Obtain a new needle and continue administering the medication as prescribed b.) Withdraw the syringe and reinsert it in a different location c.) Continue with the injection after pulling back on the needle slightly d.) Dispose of the medication

Answer: d The presence of blood indicates improper placement of the needle, and the solution and needle are now contaminated. The nurse should dispose of the medication according to facility protocol, and obtain a new dose of medication, syringe, and needle.

A school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the nurse expect? a.) Increase in anterior convexity of the lumbar spine b.) Increased curvature of the thoracic spine c.) Lateral flexion of the neck d.) A unilateral rib hump

Answer: d When assessing an adolescent for scoliosis, the school nurse should expect to see a unilateral rib hump with hip flexion. An increased curvature of the thoracic spine is a manifestation of kyphosis. An increased anterior convexity of the lumbar spine is a manifestation of lordosis.

A client who is at 34 weeks of gestation asks the nurse how she will know when she is in labor and should go to the hospital. Which of the following responses should the nurse make? a.) You will feel the contractions primarily in your upper abdomen b.) You will feel extremely fatigued when your labor starts c.) Your breasts will begin to excrete colostrum d.) You will notice blood-tinged discharge from your vagina.

Answer: d The nurse should inform the client that a sign of true labor is the bloody show, which is a blood-tinged discharge from the vagina the occurs when the cervix begins to efface and dilate. This is an indication that the client should go to the hospital. With true labor you feel contractions in the lower abdomen, and have a burst of energy. The body starts producing colostrum around 16 weeks of gestation therefore it doesn't indicate labor.

You are assessing the one minute APGAR score for a newborn. She is pink all over and has a pulse of 130. As you dry her off she begins to cry vigorously and kick her legs. Her APGAR score is________. a.) 6 b.) 8 c.) 10 d.) 9

Answer: d (10)

A nurse who is working on a mental health unit should recognize that which of the following are indications for the use of electroconvulsive therapy (ECT)? (Select all that apply) a.) A client who is suicidal and in need of rapid treatment b.) A client who has recently been diagnosed with severe depression c.) A client who has bipolar disorder with rapid cycling d.) A client who has mania and has not responded to medication therapy e.) A client whose depression is secondary to situational difficulties

Answers: a, c, and d ECT is never a first line treatment for any psychiatric disorder. It is used when medication therapy does not work or when the disorder is severe.

A 38-year-old woman quits her high-paying marketing job to focus on her children and become a school counselor. What stage would Erikson consider this to be?

Generativity vs. Stagnation

The Erikson's stage in which a child needs to learn important academic skills and compare favorably with peers in school to achieve competence is the ____________________v.______________________ stage.

Industry vs. Inferiority