Communication Custom Quiz (Applying)

A nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral side of a client's foot is stroked with an applicator stick during a neurologic examination. What should the nurse document in the client's medical record?

1. "Has intact plantar reflexes" 2. "Exhibits a positive Babinski sign" 3. "Demonstrates normal sensory function" 4. "Able to perform active range of motion" *2.* This is a positive Babinski sign; it is expected in infants but suggests upper motor neuron disease of the pyramidal tract in adults. The plantar reflex involves flexion of the toes and plantar flexion of the feet. "Demonstrates normal sensory function" is incorrect; positive Babinski is not an indication of normal sensation. "Able to perform active range of motion" is inaccurate; a Babinski is not caused by intentional movement. Active range of motion is a type of exercise, not reflex.

A toddler on the pediatric unit is required to have temporary dietary restrictions after colorectal surgery. What is the best way for the nurse to promote adherence to the restrictions?

1. By limiting restrictions to nonessential foods 2. By handling dietary changes in a matter-of-fact way 3. By having the dietitian explain the restrictions to the parents 4. By arranging to have an adult other than a parent stay at mealtime *2.* Toddlers are ritualistic and do not tolerate change well; any change in diet should be done matter of factly. Because of their characteristic struggle for autonomy, toddlers should not be forced to eat. Limited restrictions on nonessential foods are not always possible. Although the parents should consult with the dietitian, this will not affect the toddler's response to the dietary restrictions. The toddler is still dependent on the parents and therefore will respond better to them than to a stranger.

A nurse in the pediatric clinic is assessing an 11-month-old client who is sitting on the mother's lap crying and tugging at the right ear. What likely problem does this behavior indicate?

1. Child abuse 2. Otitis media 3. Hearing impairment 4. Upper respiratory infection *2* Young children who cannot verbalize the presence of pain use nonverbal behaviors to indicate discomfort; crying and tugging at a painful ear are typical behaviors of an infant with otitis media. There are no data to indicate child abuse. Tugging at the ear is not an indication that the child has a hearing problem. Tugging at the ear is specific to otitis media, not an upper respiratory infection.

A 15-year-old client tells a school nurse, "I have this awful pain during my periods—it never stops." What should the nurse encourage her to do?

1. Continue daily activities. 2. Have a gynecologic examination. 3. Eat a nutritious diet containing iron. 4. Practice relaxation of abdominal muscles. *2.* Persistent pain of any kind during menstruation (dysmenorrhea) usually indicates a problem, and the client should seek medical attention. Although diversion is a means of altering pain perception, the presence of pain requires investigation of possible causes. Although a nutritious diet is beneficial, iron does not prevent the pain of dysmenorrhea. Voluntary relaxation of the abdominal muscles does not result in cessation of dysmenorrhea.

The nurse plans to assess a postpartum client's uterine fundus. What should the nurse ask the client to do before this assessment?

1. Drink fluids 2. Empty her bladder 3. Perform the Valsalva maneuver 4. Assume the semi-Fowler position *2.* Having the client empty her bladder will help ensure accurate assessment of fundal height. A full bladder may promote a boggy uterus and may elevate the uterus upward and toward the client's right side. There is no need to drink fluids before this assessment; however, the client should drink at least 2 L of fluid a day during the postpartum period. The Valsalva maneuver has no effect on the assessment of fundal height. Assessing the fundus while the client is in the semi-Fowler position will result in an inaccurate assessment. The bed should be flat, and the client should assume the supine position.

During a critical incident stress debriefing (CISD) session conducted by the nurse for clients affected by a natural disaster, a client says, "The worst thing that happened on that day was that my child was severely injured and I was not in a position to help. I would like to forget that day as soon as possible. It was the most painful experience of my life." Which phase of CISD does this indicate?

1. Reentry phase 2. Thought phase 3. Reaction phase 4. Symptom phase *3.* In the reaction phase, CISD participants talk about the worst thing of the incident - what they would like to forget and what was most painful. In the reentry phase, participants review materials discussed, ask questions, and discuss how they would like to bring closure to the debriefing. In the thought phase, participants discuss their first thoughts of the incident. In the symptom phase, participants describe their physical, cognitive, emotional, or behavioral experiences that happened at the incidence scene.

A nurse is observing hospitalized toddlers in the playroom. What does the nurse identify as their most important need?

1. Stimulating play 2. Therapeutic play 3. Contact with their parents 4. Gentle discipline from the nurse *3* Separation anxiety becomes an issue at this age; toddlers need contact with parents, who provide a sense of security. Stimulating play may offer a distraction, but the greater need is for parental contact. Toddlers are too young for therapeutic play, which is more successful with preschoolers and young school-age children. Gentle discipline from the nurse may be necessary at times, but the greatest need of hospitalized toddlers is to have parental contact.

After prostate surgery a client's indwelling catheter and continuous bladder irrigation (CBI) are to be removed. The nurse discusses with the client the procedure and what to expect after the removal. Which statement by the client indicates teaching by the nurse is understood?

1. "I probably will have dilute urine." 2. "I probably will be unable to urinate." 3. "I probably will produce dark red urine." 4. "I probably will experience some burning on urination." *4.* Because of the trauma to the mucous membranes of the urinary tract, burning on urination is an expected response that should subside gradually. The urine should no longer be dilute after the continuous bladder irrigation is discontinued and removed. However, the urine may have a slight pink tinge because of the trauma from the surgery and the presence of the catheter. An inability to urinate should not occur unless the indwelling catheter is removed too soon and there is still edema of the urethra. Production of dark red urine is a sign of hemorrhage, which should not occur.

A client is being discharged after a first-trimester aspiration abortion. Which statement indicates to the nurse that the client has understood the instructions?

1. "I'll be able to have sex in 4 or 5 days." 2. "I can switch from sanitary pads to tampons after 24 hours." 3. "I can expect my menstrual period to start again in 2 to 3 weeks." 4. "I need to call you if I have to change my pad more than once in 4 hours." *4.* Having to change a pad more than once in 4 hours indicates that the bleeding is excessive, and the primary healthcare provider should be notified. Although instructions vary among primary healthcare providers, sexual intercourse usually may be resumed in 1 to 3 weeks and tampons are contraindicated for 3 days to 3 weeks. The menstrual period usually resumes in 4 to 6 weeks.

The spouse of a client with an intracranial hemorrhage asks the nurse, "Why aren't they administering an anticoagulant?" How will the nurse respond?

1. "It is not advisable because bleeding will increase." 2. "If necessary it will be started to enhance circulation." Incorrect 3. "If necessary it will be started to prevent pulmonary thrombosis." 4. "It is inadvisable because it masks the effects of the hemorrhage." *1.* An anticoagulant should not be administered to a client who is bleeding because it will interfere with clotting and will increase hemorrhage. Anticoagulants are unsafe and will not be used to enhance the circulation or prevent pulmonary thrombosis. The response "It is inadvisable because it masks the effects of the hemorrhage" is not the reason why it is contraindicated; if given, it will increase, not mask, the effects of the hemorrhage.

In the well-child clinic a nurse teaches a group of parents about guidelines that may prevent Reye syndrome in their preschool-aged children. What should the nurse tell the parents?

1. "Use a medication other than aspirin when your child has a fever." 2. "Restrict your child's carbohydrate intake when there are signs of a cold." 3. "Begin sponge bathing with cold water if your child experiences a high fever." 4. "You may want to have your child immunized with a recently developed vaccine." *1* Reye syndrome is associated with viral infections, such as influenza or varicella, and commonly follows the ingestion of aspirin during the prodromal stage of these diseases. The child's metabolism is increased during illness; the child should have a high caloric intake. Cold-water sponge baths should not be used; the temperature may decrease too quickly and be too shocking for the child. There is no vaccine to prevent Reye syndrome.

A client who menstruates regularly every 30 days asks a nurse on what day she is most likely to ovulate. Because the client's last menses started on January 1, the nurse should tell her that ovulation should occur on which day in January?

1. 7 2. 16 3. 24 4. 29 *2.* Ovulation should occur on January 16. The time between ovulation and the next menstruation is relatively constant. In a 30-day cycle the first 15 days are preovulatory, ovulation occurs on day 16, and the next 14 days are postovulatory. January 7, January 24, and January 29 all reflect inaccurate calculation of the date of ovulation.

Which safeguards should the school nurse teach parents to assess for prior to allowing school-age clients to participate in athletic programs? Select all that apply.

1. A life-long enjoyment of fitness 2. The use of appropriate equipment 3. The development of basic motor skills 4. A physical examination every two years 5. Participation in warm-up exercises prior to physical activity *2, 4, 5* Safeguards prior to participation in athletic programs include a physical examination every two years, the use of appropriate equipment, and participating in warm-up exercise prior to physical activity. A life-long enjoyment of fitness and the development of basic motor skills are goals related to the participation in athletic programs, not safeguards.

The nurse is planning to use a newborn's foot to obtain blood for the required newborn metabolic testing. Which part of the foot is the best site to use for the puncture?

1. Big toe 2. Foot pad Incorrect 3. Inner sole 4. Outer heel *4* The outer heel is well perfused and heals quickly. The big toe, foot pad, and inner sole are all inappropriate sites from which to obtain a blood specimen from a newborn.

What are the qualities of an effective leader? Select all that apply.

1. Born with the right stuff 2. Elicit a vision from people 3. Bring out the best in people 4. Engender discipline and obedience 5. Inspire people to bring the vision into reality *2, 3, 5* Leadership is the ability to elicit a vision from people and to inspire and empower those people to do what it takes to bring the vision into reality. A leadership quality is to bring out the best in people. Leaders are not born with the right stuff; rather they develop these qualities gradually over time when they perform with the right kind of attitude and determination. Leaders must possess the ability to inspire the commitment of followers and allow them to achieve goals autonomously rather than simply engendering discipline and obedience.

A psychologist has been a client on a mental health unit for 3 days. The client has questioned the authority of the treatment team, advised other clients that their treatment plans are wrong, and been disruptive in group therapy. What is the most appropriate nursing intervention?

1. Telling the other clients to disregard what the client is saying 2. Ignoring the client's disruptive behavior and waiting for it to subside 3. Restricting the client's contact with other clients until the disruptive behavior ceases 4. Accepting that the client is unable to control this behavior and setting appropriate limits *4* Clients who are out of control need to have limits set for them. The staff must understand that the client is not deliberately trying to disrupt the unit. Telling the other clients to disregard what the client is saying is demeaning the client in the eyes of the other clients and does not address the problem directly. Ignoring the client will not stop the disruptive behavior; also, the nurse has a responsibility to the other clients. Restricting the client's contact with other clients until the disruptive behavior ceases may be done as a last resort, but this approach should not be used until other alternatives have been explored.

The nurse is assessing an 8-month-old child's gross motor development. Which action by the child indicates late development?

1. The child is unable to stand by holding onto furniture. 2. The child cannot change from a prone to a sitting position. 3. The child cannot sit down from a standing position without help. 4. The child cannot sit steadily on the floor for a prolonged period of time. *1.* At 8 months of age the child should be able to stand by holding onto furniture, because the child readily bears weight on the legs when supported. When a child is 10 months old, the child can change from a prone to a sitting position. When a child is 12 months old, the child is able to sit down from a standing position without any help. When a child is at least 9 months old, the child can sit steadily on the floor for a prolonged period of time.

The day after surgery a client is encouraged to ambulate. The client angrily asks the nurse, "Why am I being made to walk so soon after surgery?" How should the nurse explain the primary purpose of early ambulation?

1. To promote healing of the incision 2. To decrease the incidence of urinary tract infections 3. To use energy to help the client sleep better at night 4. To keep blood from pooling in the legs to prevent clots *4.* The muscular action during ambulation facilitates the return of venous blood to the heart; this reduces venous stasis and minimizes the risk of postoperative thrombophlebitis. Protein and vitamin C promote wound healing. Walking is not related to the prevention of urinary tract infections. Although activity during the day may promote sleeping at night, it is not the reason for ambulating after surgery.