Unit 2 ?s from Saunders
1. An infant of a birth parent infected with human immunodeficiency virus (HIV) is seen in the clinic each month and is being monitored for symptoms indicative of HIV infection. With knowledge of the most common opportunistic infection of children infected with HIV, the nurse assesses the infant for which sign? 1. Cough 2. Liver failure 3. Watery stool 4. Nuchal rigidity
1. Answer: 1 Rationale: Acquired immunodeficiency syndrome (AIDS) is a disorder caused by HIV and characterized by generalized dysfunction of the immune system. The most common opportunistic infection of children infected with HIV is Pneumocystis jiroveci pneumonia, which occurs most frequently between the ages of 3 and 6 months, when HIV status may be indeterminate. Cough is a common sign of this opportunistic infection. Cytomegalovirus infection is also characteristic of HIV infection; however, it is not the most common opportunistic infection. Liver failure is a common sign of this complication. Although gastrointestinal disturbances and neurological abnormalities may occur in a child with HIV infection, options 3 and 4 are not specific opportunistic infections noted in the HIV-infected child. Watery stool is noted with gastroenteritis, and nuchal rigidity is seen in meningitis.
1. The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care of the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response would the nurse make to the client? 1. "You will need to bottle-feed your newborn." 2. "You will need to feed your newborn by nasogastric tube feeding." 3. "You will be able to breast/chest-feed for 6 months and then will need to switch to bottle-feeding." 4. "You will be able to breast/chest-feed for 9 months and then will need to switch to bottle-feeding."
1. Answer: 1 Rationale: Perinatal transmission of HIV can occur during the antepartum period, during labor and birth, or in the postpartum period if the birthing parent is breast/chest-feeding. Clients who have HIV will most likely be advised not to breast/chest-feed; however, the PHCP's recommendations regarding breast/chest-feeding are always followed. There is no physiological reason why the newborn needs to be fed by nasogastric tube.
1. The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure (HF). The nurse would assess the infant for which early sign of HF? 1. Pallor 2. Cough 3. Tachycardia 4. Slow and shallow breathing
1. Answer: 3 Rationale: HF is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. The early signs of HF include tachycardia, tachypnea, profuse scalp sweating, fatigue and irritability, sudden weight gain, and respiratory distress. A cough may occur in HF as a result of mucosal swelling and irritation, but it is not an early sign. Pallor may be noted in an infant with HF, but it is not an early sign.
10. Which interventions would the nurse include when creating a care plan for a child with hepatitis? Select all that apply. 1.Providing a low-fat, well-balanced diet 2.Teaching the child effective handwashing techniques 3.Scheduling playtime in the playroom with other children 4.Notifying the primary health care provider (PHCP) if jaundice is present 5.Instructing the parents to avoid administering medications unless prescribed 6.Arranging for indefinite homeschooling because the child will not be able to return to school
10. Answer: 1, 2, 5 Rationale: Hepatitis is an acute or chronic inflammation of the liver that may be caused by a virus, a medication reaction, or another disease process. Because hepatitis can be viral, standard precautions need to be instituted in the hospital. The child would be discouraged from sharing toys, so playtime in the playroom with other children is not part of the plan of care. The child will be allowed to return to school 1 week after the onset of jaundice, so indefinite homeschooling would not need to be arranged. Jaundice is an expected finding with hepatitis and would not warrant notification of the PHCP. Provision of a low-fat, well-balanced diet is recommended. Parents are cautioned about administering any medication to the child, because normal doses of many medications may become dangerous, owing to the liver's inability to detoxify and excrete them. Handwashing is the most effective measure for control of hepatitis in any setting, and effective handwashing can prevent the immunocompromised child from contracting an opportunistic type of infection.
10. The clinic nurse is performing a psychosocial assessment of a client who is pregnant. Which assessment findings indicate to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)? Select all that apply. 1.The client has a history of intravenous drug use. 2.The client has a significant other who is heterosexual. 3.The client has a history of sexually transmitted infections. 4.The client has had one sexual partner for the past 10 years. 5.The client has a previous history of gestational diabetes mellitus.
10. Answer: 1, 3 Rationale: HIV is transmitted by intimate sexual contact and the exchange of body fluids, exposure to infected blood, and passage from an infected birthing parent to the fetus. Clients who fall into the high-risk category for HIV infection include individuals who have used intravenous drugs, individuals who experience persistent and recurrent sexually transmitted infections, and individuals who have a history of multiple sexual partners. Gestational diabetes mellitus does not predispose the client to HIV. A client with a heterosexual partner, particularly a client who has had only one sexual partner in 10 years, does not have a high risk for contracting HIV.
10. The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions would the nurse include in the plan of care? Select all that apply. 1.Place the infant in a private room. 2.Ensure that the infant's head is in a flexed position. 3.Wear a mask, gown, and gloves when in contact with the infant. 4.Place the infant in a tent that delivers warm humidified air. 5.Position the infant on the side, with the head lower than the chest.
10. Answer: 1, 3, 6 Rationale: RSV is a highly communicable disorder and is transmitted via droplets or contact with respiratory secretions. The use of contact, droplet, and standard precautions during care (wearing gloves, mask, and a gown) reduces nosocomial transmission of RSV. In addition, it is important to ensure that nurses caring for a child with RSV do not care for other high-risk children to prevent the transmission of the infection. An infant with RSV needs to be placed in a private room. The infant would be positioned with the head and chest at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and decrease pressure on the diaphragm. Cool humidified oxygen is delivered to relieve dyspnea, hypoxemia, and insensible water loss from tachypnea.
10. Assessment findings of an infant admitted to the hospital reveal a machinery-like murmur on auscultation of the heart and signs of heart failure. The nurse reviews congenital cardiac anomalies and identifies the infant's condition as which disorder? Refer to figure (the circled area) to determine the condition.
10. Answer: 3 Rationale: A patent ductus arteriosus is failure of the fetal ductus arteriosus (artery connecting the aorta and the pulmonary artery) to close. A characteristic machinery-like murmur is present, and the infant may show signs of heart failure. Aortic stenosis is a narrowing or stricture of the aortic valve. Atrial septal defect is an abnormal opening between the atria. Ventricular septal defect is an abnormal opening between the right and left ventricles.
12. The nurse creates a plan of care for a birthing parent with human immunodeficiency virus (HIV) infection and the newborn. The nurse would include which intervention in the plan of care? 1. Monitoring the newborn's vital signs routinely 2. Maintaining standard precautions at all times while caring for the newborn 3. Initiating referral to evaluate for blindness, deafness, learning problems, or behavioral problems 4. Instructing the breast-feeding/chest-feeding parent regarding the treatment of the nipples with nystatin ointment
12. Answer: 2 Rationale: An infant born to a birthing parent infected with HIV must be cared for with strict attention to standard precautions. This prevents the transmission of HIV from the newborn, if infected, to others and prevents transmission of other infectious agents to the possibly immunocompromised newborn. Options 1 and 3 are not associated specifically with the care of a potentially HIV-infected newborn. Parents infected with HIV should not feed their newborn human milk.
13. The nurse is planning care for the newborn of a birthing parent with diabetes mellitus. What is the priority nursing consideration for this newborn? 1. Developmental delays because of excessive size 2. Maintaining safety because of low blood glucose levels 3. Choking because of impaired suck and swallow reflexes 4. Elevated body temperature because of excess fat and glycogen
13. Answer: 2 Rationale: The newborn of a diabetic birthing parent is at risk for hypoglycemia, so maintaining safety because of low blood glucose levels would be a priority. The newborn would also be at risk for hyperbilirubinemia, respiratory distress, hypocalcemia, and congenital anomalies. Developmental delays, choking, and an elevated body temperature are not expected problems.
13. The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs would the nurse anticipate? Select all that apply. 1.Bed rest as a necessary preventive measure may be prescribed. 2.Administration of subcutaneous heparin post-delivery as prescribed. 3.An overbed lift may be necessary if the client requires a cesarean section. 4.Less frequent cleansing of a cesarean incision, if present, may be prescribed. 5.Thromboembolism stockings or sequential compression devices may be prescribed.
13. Answer: 2, 3, 5 Rationale: The obese pregnant client is at risk for complications such as venous thromboembolism and increased need for cesarean section. Additionally, the obese client requires special considerations pertaining to nursing care. To prevent venous thromboembolism, particularly in the client who required cesarean section, frequent and early ambulation (not bed rest), prior to and after surgery, is recommended. Routine administration of prophylactic pharmacological venous thromboembolism medications such as heparin is also commonly prescribed. An overbed lift may be needed to transfer a client from an operating table to bed if cesarean section is necessary. Increased monitoring and cleansing of a cesarean incision, if present, is necessary due to the increased risk for infection secondary to increased abdominal fat. Thromboembolism stockings or sequential compression devices will likely be prescribed because of the client's increased risk of blood clots.
2. A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted on assessment? Select all that apply. 1. Proteinuria of 3+ 2. Respirations of 10 breaths per minute 3. Presence of deep tendon reflexes 4. Urine output of 20 mL in an hour 5. Serum magnesium level of 4 mEq/L (2 mmol/L)
2. Answer: 2, 4 Rationale: Magnesium toxicity can occur from magnesium sulfate therapy. Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression, loss of deep tendon reflexes, and a sudden decline in fetal heart rate and client's heart rate and blood pressure. Respiratory rate below 12 breaths per minute is a sign of toxicity. Urine output needs to be at least 25 to 30 mL per hour. Proteinuria of 3+ is an expected finding in a client with preeclampsia. Presence of deep tendon reflexes is a normal and expected finding. Therapeutic serum levels of magnesium are 4 to 7.5 mEq/L (2 to 3.75 mmol/L).
2. An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse would place the infant in which best position at this time? 1. Prone position 2. On the stomach 3. Left lateral position 4. Right lateral position
2. Answer: 3 Rationale: A cleft lip is a congenital anomaly that occurs as a result of failure of soft tissue or bony structure to fuse during embryonic development. After cleft lip repair, the nurse avoids positioning an infant on the side of the repair or in the prone position, because these positions can cause rubbing of the surgical site on the mattress. The nurse positions the infant on the side opposite the repair or on the back upright and positions the infant to prevent airway obstruction by secretions, blood, or the tongue. From the options provided, placing the infant on the left side immediately after surgery is best to prevent the risk of aspiration if the infant vomits.
2. The nurse provides home care instructions to the parent of a child with acquired immunodeficiency syndrome (AIDS). Which statement by the parent indicates the need for further teaching? 1. "I will wash my hands frequently." 2. "I will keep my child's immunizations up to date." 3. "I will avoid direct unprotected contact with my child's body fluids." 4. "I can send my child to day care with a fever as long as it is a low-grade fever."
2. Answer: 4 Rationale: AIDS is a disorder caused by human immunodeficiency virus (HIV) and characterized by generalized dysfunction of the immune system. A child with AIDS who is sick or has a fever needs to be kept home and not brought to a day care center. Options 1, 2, and 3 are correct statements and would be actions a caregiver needs to take when the child has AIDS.
2. The home care nurse visits a pregnant client who has a diagnosis of preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the primary health care provider (PHCP)? 1. Urinary output has increased. 2. Dependent edema has resolved. 3. Blood pressure reading is at the prenatal baseline. 4. The client complains of a headache and blurred vision.
2. Answer: 4 Rationale: If the client complains of a headache and blurred vision, the PHCP needs to be notified because these are signs of worsening preeclampsia. Options 1, 2, and 3 are normal findings.
3. The clinic nurse is instructing the parent of a child with human immunodeficiency virus (HIV) infection regarding immunizations. The nurse would provide which instruction to the parent? 1. The hepatitis B vaccine will not be given to the child. 2. The inactivated influenza vaccine will be given yearly. 3. The varicella vaccine will be given before 6 months of age. 4. A Western blot test needs to be performed and the results evaluated before immunizations.
3. Answer: 2 Rationale: Immunizations against common childhood illnesses are recommended for all children exposed to or infected with HIV. The inactivated influenza vaccine that is given intramuscularly will be administered (influenza vaccine would be given yearly). The hepatitis B vaccine is administered according to the recommended immunization schedule. Varicella-zoster virus vaccine would not be given, because it is a live virus vaccine; varicella-zoster immunoglobulin may be prescribed after exposure to chicken pox. Option 4 is unnecessary and inaccurate.
3. A pediatric client with ventricular septal defect repair is placed on a maintenance dosage of digoxin. The dosage is 8 mcg/kg/day, and the client's weight is 7.2 kg. The pediatrician prescribes the digoxin to be given twice daily. The nurse prepares how many mcg of digoxin to administer to the child at each dose? 1. 12.6 mcg 2. 21.4 mcg 3. 28.8 mcg 4. 32.2 mcg
3. Answer: 3 Rationale: Calculate the daily dosage by weight first: The pediatrician prescribes digoxin twice daily; 2 doses in 24 hours will be administered:
3. The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching? 1. "I need to stay on the diabetic diet." 2. "I need to perform glucose monitoring at home." 3. "I need to avoid exercise because of the negative effects on insulin production." 4. "I need to be aware of any infections and report signs of infection immediately to my obstetrician."
3. Answer: 3 Rationale: Exercise is safe for a client with gestational diabetes mellitus and is helpful in lowering the blood glucose level. Dietary modifications are the mainstay of treatment, and the client is placed on a standard diabetic diet. Many clients are taught to perform blood glucose monitoring. If the client is not performing the blood glucose monitoring at home, it is performed at the clinic or obstetrician's office. Signs of infection need to be reported to the obstetrician.
3. The nurse reviews the record of a newborn infant and notes that a diagnosis of esophageal atresia with tracheoesophageal fistula is suspected. The nurse expects to note which most likely sign of this condition documented in the record? 1. Incessant crying 2. Coughing at nighttime 3. Choking with feedings 4. Severe projectile vomiting
3. Answer: 3 Rationale: In esophageal atresia and tracheoesophageal fistula, the esophagus terminates before it reaches the stomach, ending in a blind pouch, and a fistula is present that forms an unnatural connection with the trachea. Any child who exhibits the "3 Cs"—coughing and choking with feedings and unexplained cyanosis— would be suspected to have tracheoesophageal fistula. Options 1, 2, and 4 are not specifically associated with tracheoesophageal fistula.
4. A client in preterm labor (31 weeks) who is dilated to 4 cm has been started on magnesium sulfate, and contractions have stopped. If the client's labor can be inhibited for the next 48 hours, the nurse anticipates a prescription for which medication? 1. Nalbuphine 2. Betamethasone 3. Rho(D) immune globulin 4. Dinoprostone vaginal insert
4. Answer: 2 Rationale: Betamethasone, a glucocorticoid, is given to increase the production of surfactant to stimulate fetal lung maturation. It is administered to clients in preterm labor at 28 to 32 weeks of gestation if the labor can be inhibited for 48 hours. Nalbuphine is an opioid analgesic. Rho(D) immune globulin is given to Rh-negative clients to prevent sensitization. Dinoprostone vaginal insert is a prostaglandin given to ripen and soften the cervix and to stimulate uterine contractions.
4. The school nurse has provided an instructional session about impetigo to parents of the children attending the school. Which statement, if made by a parent, indicates a need for further instruction? 1. "It is extremely contagious." 2. "It is most common in humid weather." 3. "Lesions most often are located on the arms and chest." 4. "It might show up in an area of broken skin, such as an insect bite."
4. Answer: 3 Rationale: Impetigo is a contagious bacterial infection of the skin caused by group A streptococcus (GAS; Streptococcus pyogenes) and Staphylococcus aureus. Impetigo is most common during hot, humid summer months. Impetigo may begin in an area of broken skin, such as an insect bite or atopic dermatitis. Impetigo is extremely contagious. Lesions usually are located around the mouth and nose but may be present on the hands and extremities.
4. The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin. Which statement made by the parent indicates the need for further instruction? 1. "I will not mix the medication with food." 2. "If more than one dose is missed, I will call the pediatrician." 3. "I will take my child's pulse before administering the medication." 4. "If my child vomits after medication administration, I will repeat the dose."
4. Answer: 4 Rationale: Digoxin is a cardiac glycoside. The parents need to be instructed that if the child vomits after digoxin is administered, they are not to repeat the dose. Options 1, 2, and 3 are accurate instructions regarding the administration of this medication. In addition, the parents need to be instructed that if a dose is missed and the missed dose is not identified until 4 hours later, the dose would not be administered.
4. A pediatrician prescribes laboratory studies for the infant of a birthing parent positive for human immunodeficiency virus (HIV). The nurse anticipates that which laboratory study will be prescribed for the infant? 1. Chest x-ray 2. Western blot 3. CD4+ cell count 4. p24 antigen assay
4. Answer: 4 Rationale: Infants born to HIV-infected mothers need to be screened for the HIV antigen. The detection of HIV in infants is confirmed by a p24 antigen assay, virus culture of HIV, or polymerase chain reaction. A Western blot test confirms the presence of HIV antibodies. The CD4+ cell count indicates how well the immune system is working. A chest x-ray evaluates the presence of other manifestations of HIV infection, such as pneumonia.
4. The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis? 1. Enlargement of the breasts 2. Complaints of feeling hot when the room is cool 3. Periods of fetal movement followed by quiet periods 4. Evidence of bleeding, such as in the gums, petechiae, and purpura
4. Answer: 4 Rationale: Severe preeclampsia can trigger disseminated intravascular coagulation (DIC) because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and needs to be reported to the primary health care provider if noted on assessment. Options 1, 2, and 3 are normal occurrences in the last trimester of pregnancy.
5. The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse would use which most appropriate method to assess the urine output? 1. Weighing the diapers 2. Inserting a urinary catheter 3. Comparing intake with output 4. Measuring the amount of water added to formula
5. Answer: 1 Rationale: Heart failure is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. The most appropriate method for assessing urine output in an infant receiving diuretic therapy is to weigh the diapers. Comparing intake with output would not provide an accurate measure of urine output. Measuring the amount of water added to formula is unrelated to the amount of output. Although urinary catheter drainage is most accurate in determining output, it is not the most appropriate method in an infant and places the infant at risk for infection.
5. The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings would alert the nurse to the possibility of this syndrome? Select all that apply. 1. Cyanosis 2. Tachypnea 3. Hypotension 4. Retractions 5. Audible grunts 6. Presence of a barrel chest
5. Answer: 1, 2, 4, 5 Rationale: A newborn infant with respiratory distress syndrome may present with clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts. Hypotension and a barrel chest are not clinical manifestations associated with respiratory distress syndrome.
5. A birthing parent with human immunodeficiency virus (HIV) infection brings a 10-month-old infant to the clinic for a routine checkup. The pediatrician has documented that the infant is asymptomatic for HIV infection. After the checkup the parent tells the nurse about being so pleased that the infant will not get HIV infection. The nurse would make which most appropriate response to the parent? 1. "I am so pleased also that everything has turned out fine." 2. "Because symptoms have not developed, it is unlikely that your infant will develop HIV infection." 3. "Everything looks great, but be sure to return with your infant next month for the scheduled visit." 4. "Most children infected with HIV develop symptoms within the first 9 months of life, and some become symptomatic sometime before they are 3 years old."
5. Answer: 4 Rationale: Acquired immunodeficiency syndrome (AIDS) is caused by HIV infection and characterized by generalized dysfunction of the immune system. Most children infected with HIV develop symptoms within the first 9 months of life. The remaining infected children become symptomatic sometime before age 3 years. With their immature immune systems, children have a much shorter incubation period than adults. Options 1, 2, and 3 are incorrect. Additionally, these options offer false reassurance.
6. The home care nurse is monitoring a pregnant client who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which sign of preeclampsia? 1. Hypertension 2. Low-grade fever 3. Generalized edema 4. Increased pulse rate
6. Answer: 1 Rationale: A sign of preeclampsia is persistent hypertension. A low-grade fever or increased pulse rate is not associated with preeclampsia. Generalized edema may occur but is not a specific sign of preeclampsia because it can occur in many conditions.
6. The nurse is preparing to administer exogenous surfactant to a premature infant who has respiratory distress syndrome. The nurse prepares to administer the medication by which route? 1. Intradermal 2. Intratracheal 3. Subcutaneous 4. Intramuscular
6. Answer: 2 Rationale: Respiratory distress syndrome is a serious lung disorder caused by immaturity and the inability to produce surfactant, resulting in hypoxia and acidosis. It is common in premature infants and may be due to lung immaturity as a result of surfactant deficiency. The mainstay of treatment is the administration of exogenous surfactant, which is administered by the intratracheal route. Options 1, 3, and 4 are not routes of administration for this medication.
6. The clinic nurse reviews the record of a child just seen by the pediatrician and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder? 1. Pallor 2. Hyperactivity 3. Activity intolerance 4. Gastrointestinal disturbances
6. Answer: 3 Rationale: Aortic stenosis is a narrowing or stricture of the aortic valve, causing resistance to blood flow in the left ventricle, decreased cardiac output, left ventricular hypertrophy, and pulmonary vascular congestion. A child with aortic stenosis shows signs of activity intolerance, chest pain, and dizziness when standing for long periods. Pallor may be noted, but it is not specific to this type of disorder alone. Options 2 and 4 are not related to this disorder.
6. The nurse is caring for a newborn with a suspected diagnosis of imperforate anus. The nurse monitors the infant, knowing that which is a clinical manifestation associated with this disorder? 1. Bile-stained fecal emesis 2. The passage of currant jelly-like stools 3. Failure to pass meconium stool in the first 24 hours after birth 4. Sausage-shaped mass palpated in the upper right abdominal quadrant
6. Answer: 3 Rationale: Imperforate anus is the incomplete development or absence of the anus in its normal position in the perineum. During the newborn assessment, this defect would be identified easily on sight. However, a rectal thermometer or tube may be necessary to determine patency if meconium is not passed in the first 24 hours after birth. Other assessment findings include absence or stenosis of the anal rectal canal, presence of an anal membrane, and an external fistula to the perineum. Options 1, 2, and 4 are findings noted in intussusception.
6. A 6-year-old child with human immunodeficiency virus (HIV) infection has been admitted to the hospital for pain management. The child asks the nurse if the pain will ever go away. The nurse would make which best response to the child? 1. "The pain will go away if you lie still and let the medicine work." 2. "Try not to think about it. The more you think it hurts, the more it will hurt." 3. "I know it must hurt, but if you tell me when it does, I will try to make it hurt a little less." 4. "Every time it hurts, press on the call button and I will give you something to make the pain go all away."
6. Answer: 3 Rationale: The multiple complications associated with HIV are accompanied by a high level of pain. Aggressive pain management is essential for the child to have an acceptable quality of life. The nurse must acknowledge the child's pain and let the child know that everything will be done to decrease the pain. Telling the child that movement or lack thereof would eliminate the pain is inaccurate. Allowing children to think that they can control pain simply by thinking or not thinking about it oversimplifies the pain cycle associated with HIV. Giving false hope by telling the child that the pain will be taken "all away" is neither truthful nor realistic.
6. A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The parent becomes concerned because the child is frightened, consistently crying, and trying to climb out of the tent. Which is the most appropriate nursing action? 1. Tell the parent that the child must stay in the tent. 2. Place a toy in the tent to make the child feel more comfortable. 3. Call the pediatrician and obtain a prescription for a mild sedative. 4. Let the parent hold the child and direct the cool mist over the child's face.
6. Answer: Rationale: Laryngotracheobronchitis (croup) is the inflammation of the larynx, trachea, and bronchi and is the most common type of croup. Cool mist therapy may be prescribed to liquefy secretions and to assist in breathing. If the use of a tent or hood is causing distress, treatment may be more effective if the child is held by the parent and a cool mist is directed toward the child's face (blow-by). A mild sedative would not be administered to the child. Crying would increase hypoxia and aggravate laryngospasm, which may cause airway obstruction. Options 1 and 2 would not alleviate the child's fear.
7. The home care nurse provides instructions regarding basic infection control to the parent of an infant with human immunodeficiency virus (HIV) infection. Which statement, if made by the parent, indicates the need for further instruction? 1. "I will clean up any spills from the diaper with diluted alcohol." 2. "I will wash baby bottles, nipples, and pacifiers in the dishwasher." 3. "I will be sure to prepare foods that are high in calories and high in protein." 4. "I will be sure to wash my hands carefully before and after caring for my infant."
7. Answer: 1 Rationale: HIV is transmitted through blood, semen, vaginal secretions, and human milk. The birthing parent of an infant with HIV would be instructed to use a bleach solution for disinfecting contaminated objects or cleaning up spills from the child's diaper. Alcohol would not be effective in destroying the virus. Options 2, 3, and 4 are accurate instructions related to basic infection control.
7. The clinic nurse reads the results of a tuberculin skin test (TST) on a 3-year-old child. The results indicate an area of induration measuring 10 mm. The nurse would interpret these results as which finding? 1. Positive 2. Negative 3. Inconclusive 4. Definitive and requiring a repeat test
7. Answer: 1 Rationale: Induration measuring 10 mm or more is considered to be a positive result in children younger than 4 years of age and in children with chronic illness or at high risk for exposure to tuberculosis. A reaction of 5 mm or more is considered to be a positive result for the highest risk groups, such as a child with an immunosuppressive condition or a child with human immunodeficiency virus (HIV) infection. A reaction of 15 mm or more is positive in children 4 years or older without any risk factors.
7. The nurse is assessing a pregnant client with type 1 diabetes mellitus about an understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement? 1. "I will need to increase my insulin dosage during the first 3 months of pregnancy." 2. "My insulin dose will probably need to be increased during the second and third trimesters." 3. "Episodes of hypoglycemia are more likely to occur during the first 3 months of pregnancy." 4. "My insulin needs will return to prepregnant levels within 7 to 10 days after birth if I am bottle-feeding."
7. Answer: 1 Rationale: Insulin needs decrease in the first trimester of pregnancy because of increased insulin production by the pancreas and increased peripheral sensitivity to insulin. The statements in options 2, 3, and 4 are accurate and signify that the client understands control of the diabetes during pregnancy.
7. An opioid analgesic is administered to a client in labor. The nurse assigned to care for the client ensures that which medication is readily accessible in the event that respiratory depression occurs? 1. Naloxone 2. Morphine sulfate 3. Betamethasone 4. Hydromorphone hydrochloride
7. Answer: 1 Rationale: Opioid analgesics may be prescribed to relieve moderate to severe pain associated with labor. Opioid toxicity can occur and cause respiratory depression. Naloxone is an opioid antagonist, which reverses the effects of opioids and is given for respiratory depression. Morphine sulfate and hydromorphone hydrochloride are opioid analgesics. Betamethasone is a corticosteroid administered to enhance fetal lung maturity.
7. The nurse has provided home care instructions to the parents of a child who is being discharged after cardiac surgery. Which statement made by the parents indicates a need for further instruction? 1. "A balance of rest and activity is important." 2. "We can apply lotion or powder to the incision if it is itchy." 3. "Activities in which our child could fall need to be avoided for 2 to 4 weeks." 4. "Large crowds of people need to be avoided for at least 2 weeks after surgery."
7. Answer: 2 Rationale: The parents need to be instructed that lotions and powders would not be applied to the incision site after cardiac surgery. Lotions and powders can irritate the surrounding skin, which could lead to skin breakdown and subsequent infection of the incision site. Options 1, 3, and 4 are accurate instructions regarding home care after cardiac surgery.
7. The nurse is assessing a newborn who was born to a birthing parent who is addicted to drugs. Which findings would the nurse expect to note during the assessment of this newborn? Select all that apply. 1. Lethargy 2. Sleepiness 3. Irritability 4. Constant crying 5. Difficult to comfort 6. Cuddles when being held
7. Answer: 3, 4, 5 Rationale: A newborn of a birthing parent who uses drugs is irritable. The infant is overloaded easily by sensory stimulation. The infant may cry incessantly and be difficult to console. The infant would hyperextend and posture rather than cuddle when being held. This infant is not lethargic or sleepy.
8. Which home care instructions would the nurse provide to the parent of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply. 1.Monitor the child's weight. 2.Frequent handwashing is important. 3.The child needs to avoid exposure to other illnesses. 4.The child's immunization schedule will need revision. 5.Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach). 6.Fever, malaise, fatigue, weight loss, vomiting, and diarrhea are expected to occur and do not require special intervention.
8. Answer: 1, 2, 3, 5 Rationale: AIDS is a disorder caused by human immunodeficiency virus (HIV) infection and is characterized by a generalized dysfunction of the immune system. Home care instructions include the following: frequent handwashing; monitoring for fever, malaise, fatigue, weight loss, vomiting, and diarrhea and notifying the pediatrician if these occur; monitoring for signs and symptoms of opportunistic infections; administering antiretroviral medications and other medications as prescribed; avoiding exposure to other illnesses; keeping immunizations up to date; monitoring weight and providing a high-calorie, high-protein diet; washing eating utensils in the dishwasher; and avoiding the sharing of eating utensils. Gloves are worn for care, especially when in contact with body fluids and changing diapers; diapers are changed frequently and away from food areas, and soiled disposable diapers are folded inward, closed with the tabs, and disposed of in a tightly covered plastic-lined container. Any body fluid spills are cleaned with a bleach solution (10:1 ratio of water to bleach).
8. The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome? 1. Length of 19 inches 2. Abnormal palmar creases 3. Birth weight of 6 lb, 14 oz (3120 g) 4. Head circumference appropriate for gestational age
8. Answer: 2 Rationale: Fetal alcohol syndrome, a diagnostic category of fetal alcohol spectrum disorders (FASDs), is caused by birthing parent alcohol use during pregnancy. Features of newborns diagnosed with fetal alcohol syndrome include craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases, and respiratory distress. Options 1, 3, and 4 are normal assessment findings in the full-term newborn infant.
8. A pregnant client reports to a health care clinic, complaining of loss of appetite, cough, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction would the nurse include in the client's teaching plan? 1. Therapeutic abortion is required. 2. Isoniazid plus rifampin will be required for 9 months. 3. The client will have to stay at home until treatment is completed. 4. Medication will not be started until after delivery of the fetus.
8. Answer: 2 Rationale: More than one medication may be used to prevent the growth of resistant organisms in a pregnant client with tuberculosis. Treatment must continue for a prolonged period. The preferred treatment for the pregnant client is isoniazid plus rifampin daily for 9 months. Ethambutol is added initially if medication resistance is suspected. Pyridoxine (vitamin B6) often is administered with isoniazid to prevent fetal neurotoxicity. The client does not need to stay at home during treatment, and therapeutic abortion is not required.
8. The parent of a hospitalized 2-year-old child with viral laryngotracheobronchitis (croup) asks the nurse why the pediatrician did not prescribe antibiotics. Which response would the nurse make? 1. "The child may be allergic to antibiotics." 2. "The child is too young to receive antibiotics." 3. "Antibiotics are not indicated unless a bacterial infection is present." 4. "The child still has the maternal antibodies from birth and does not need antibiotics."
8. Answer: 3 Rationale: Laryngotracheobronchitis (croup) is the inflammation of the larynx, trachea, and bronchi and is the most common type of croup. It can be viral or bacterial. Antibiotics are not indicated in the treatment of croup unless a bacterial infection is present. Options 1, 2, and 4 are incorrect. In addition, no supporting data in the question indicate that the child may be allergic to antibiotics.
9. The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action? 1. Initiate strict enteric precautions. 2. Move the infant to a private room. 3. Leave the infant in the present room, because RSV is not contagious. 4. Inform the staff that using standard precautions is all that is necessary when caring for the child.
9. Answer: 2 Rationale: RSV is a highly communicable disorder and is transmitted via droplets and direct contact with respiratory secretions. The use of contact, droplet, and standard precautions during care is necessary. Good handwashing technique and protection with gloves, gown, and a mask are needed to prevent transmission. An infant with RSV would be placed in a private room to prevent transmission. Enteric precautions are unnecessary.
9. The nurse is providing instructions to a pregnant client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse? 1. "I need to increase my sodium intake during pregnancy." 2. "I need to lower my blood volume by limiting my fluids." 3. "I need to maintain a low-calorie diet to prevent any weight gain." 4. "I need to drink adequate fluids and increase my intake of high-fiber foods."
9. Answer: 4 Rationale: Constipation can cause the client to use the Valsalva maneuver. The Valsalva maneuver needs to be avoided in clients with cardiac disease because it can cause blood to rush to the heart and overload the cardiac system. Constipation can be prevented by the addition of fluids and a high-fiber diet. A low-calorie diet is not recommended during pregnancy and could be harmful to the fetus. Sodium needs to be restricted as prescribed by the primary health care provider, because excess sodium would cause an overload to the circulating blood volume and contribute to cardiac complications. Diets low in fluid can cause a decrease in blood volume, which could deprive the fetus of nutrients.
9. The nurse is creating a plan of care for a newborn diagnosed with fetal alcohol syndrome. The nurse would include which priority intervention in the plan of care? 1. Allow the newborn to establish own sleep-rest pattern. 2. Maintain the newborn in a brightly lighted area of the nursery. 3. Encourage frequent handling of the newborn by staff and parents. 4. Monitor the newborn's response to feedings and weight gain pattern.
9. Answer: 4 Rationale: Fetal alcohol syndrome, a diagnostic category delineated under fetal alcohol spectrum disorders (FASDs), is caused by birthing parent alcohol use during pregnancy. A primary nursing goal for the newborn diagnosed with fetal alcohol syndrome is to establish nutritional balance after birth. These newborns may exhibit hyperirritability, vomiting, diarrhea, or an uncoordinated sucking and swallowing ability. A quiet environment with minimal stimuli and handling would help establish appropriate sleep-rest cycles in the newborn as well. Options 1, 2, and 3 are inappropriate interventions.
9. A pediatrician has prescribed oxygen as needed for an infant with heart failure. Which situation would likely increase the oxygen demand, requiring the nurse to administer oxygen to the infant? 1. During sleep 2. When changing the infant's diapers 3. When a parent is holding the infant 4. When drawing blood for electrolyte level testing
9. Answer: 4 Rationale: Heart failure (HF) is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. Crying exhausts the limited energy supply, increases the workload of the heart, and increases the oxygen demands. Oxygen administration may be prescribed for stressful periods, especially during bouts of crying or invasive procedures. Options 1, 2, and 3 are unlikely to produce crying in the infant.
9. The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented? 1. Watery diarrhea 2. Ribbon-like stools 3. Profuse projectile vomiting 4. Bright red blood and mucus in the stools
9. Answer: 4 Rationale: Intussusception is a telescoping of one portion of the bowel into another. The condition results in an obstruction to the passage of intestinal contents. A child with intussusception typically has severe abdominal pain that is crampy and intermittent, causing the child to draw in the knees to the chest. Vomiting may be present, but is not projectile. Bright red blood and mucus are passed through the rectum and commonly are described as currant jelly-like stools. Watery diarrhea and ribbon-like stools are not manifestations of this disorder.
9. The nurse provides home care instructions to the parents of a child hospitalized with pertussis who is in the convalescent stage and is being prepared for discharge. Which statement by a parent indicates a need for further instruction? 1. "We need to encourage our child to drink fluids." 2. "Coughing spells may be triggered by dust or smoke." 3. "Vomiting may occur when our child has coughing episodes."
9. Answer: 4 Rationale: Pertussis is transmitted by direct contact or respiratory droplets from coughing. The communicable period occurs primarily during the catarrhal stage. Respiratory precautions are not required during the convalescent phase. Options 1, 2, and 3 are accurate components of home care instructions.
4. The nurse provides feeding instructions to the parent of an infant diagnosed with gastroesophageal reflux disease. Which instruction would the nurse give to the parent to assist in reducing the episodes of emesis? 1. Provide less frequent, larger feedings. 2. Burp the infant less frequently during feedings. 3. Thin the feedings by adding water to the formula. 4. Thicken the feedings by adding rice cereal to the formula.
Answer: 4 Rationale: Gastroesophageal reflux is backflow of gastric contents into the esophagus as a result of relaxation or incompetence of the lower esophageal or cardiac sphincter. Small, more frequent feedings with frequent burping often are prescribed in the treatment of gastroesophageal reflux. Feedings thickened with rice cereal may reduce episodes of emesis. If thickened formula is used, cross-cutting of the nipple may be required.
