EAQ #2

In which settings would the nurse prepare to administer developmental assessment for pediatric clients? Select all that apply. A. Home B. School C. Hospital D. Daycare center E. Assisted living center

A, B, C, and D

Pulse oximetry is prescribed for an adolescent. Which would the nurse do to ensure accuracy for the pulse oximeter reading? A. Attach the probe to a finger or earlobe B. Wait 30 minutes before obtaining a reading C. Calibrate the oximeter at least every 8 hours D. Place the probe on the abdomen or upper leg

A. Attach the probe to a finger or earlobe Capillary beds are closest to the surface in a finger or earlobe; this proximity permits more accurate measurement of arterial oxygen saturation.

Which assessment finding would the nurse observe in a client with bipolar disorder, manic phase? A. Constant singing B. Ritualistic behavior C. Flat affect D. Apathetic demeanor

A. Constant singing Constant singing would be typical in a client with bipolar disorder, manic phase. Ritualistic behavior is indicative of obsessive-compulsive disorder. A flat affect and apathetic demeanor are more indicative of a schizophrenic or depressive disorder.

Which treatment would the nurse anticipate for an infant admitted with bronchiolitis caused by respiratory syncytial virus (RSV)? A. Humidified cool air and adequate hydration B. Postural drainage and oxygen by hood C. Bronchodilators and cough suppressants D. Corticosteroids and broad-spectrum antibiotics

A. Humidified cool air and adequate hydration Humidified cool air and hydration are essential to facilitating improvement in the child's physical status. Postural drainage is not effective w/ this disorder; oxygen is used only if the infant has sever dyspnea and hypoxia. Bronchodilators are not used, because the bronchial tree is not in spams; cough suppressants are ineffective. Corticosteroids are ineffective; antibiotics are also ineffective, because the causative agent is viral.

How many hours of sleep would the nurse recommend for the 11-year-old client? A. 8 B. 9 C. 11 D. 12

B. 9 A school-age client who is 11 years of age would require 9 hours of sleep each night. Ten hours of sleep is not recommended for the school-age client. A 5-year-old school-age client requires 11.5 hours of sleep per night; however, 11 and 12 hours of sleep is not recommended for an 11-year-old school-age client.

The spouse of a client with pulmonary tuberculosis (TB) received a tuberculin skin test. The nurse examined the skin test and identified an area of induration greater than 10 mm, Which response to this finding would the nurse implement? A. No further action is required at this time B. Additional tests are necessary to determine infection status C. Immediately repeat the skin test for confirmation D. Results are positive, indicating an active infection

B. Additional tests are necessary to determine infection status The test does not indicate whether TB is dormant or active. However, a client with an induration of 5 mm or grater is considered positive. If there is repeated close contact w/ a person dx w/ pulmonary TB or if the client has a disease causing decreased resistance, this requires further diagnostic study, such as chest c-rays and sputum culture. A newly infected client will receive preventative therapy w/ isoniazid (INH). Isoniazid will be continued for 6 months if chest x-rays are normal, or 12 months if chest x-rays are abnormal. Repeating the skin test is not necessary; the test is considered positive.

Which sexually transmitted infection (STI) is most commonly reported? A. Syphilis B. Chlamydia C. Gonorrhea D. Human immunodeficiency virus

B. Chlamydia

Which term describes the practice of placing clients with the same infection in a semi-private room? A. Isolating B. Cohorting C. Colonizing D. Cross-referencing

B. Cohorting Cohorting is the practice of grouping clients who are colonized or infected with the same pathogen. Isolating is limiting the exposure to individuals with an infection. Colonizing refers to the development of an infection in the body. Cross-referencing has nothing to do with an infectious process.

The nurse would identify which medication as the most common cause of extrapyramidal side effects (EPSs)? A. Clozapine B. Haloperidol C. Risperidone D. Aripiprazole

B. Haloperidol Haloperidol is a typical antipsychotic that commonly causes extrapyramidal side effects. Clozapine is an atypical antipsychotic that has low risk of causing extrapyramidal side effects. Risperidone and aripiprazole have a low risk of causing extrapyramidal side effects.

An adolescent visits the allergy clinic for testing. Which laboratory finding indicates that an allergic response is in progress? A. Decreased platelet count B. Increased eosinophil level C. Increased lymphocyte count D. Decreased immunoglobulin level

B. Increased eosinophil level Eosinophils increase to inhibit the inflammatory response to histamine, which is released in allergic reactions. Platelets and lymphocytes are unrelated to allergic reactions. Immunoglobulins increase, not decrease, in response to an allergic reaction.

A 2-year-old toddler has hearing loss caused by recurrent otitis media. Which treatment would the nurse anticipate that the practitioner will recommend? A. Eardrops B. Myringotomy C. Mastoidectomy D. Steroid therapy

B. Myringotomy Myringotomy is a surgical opening into the eardrum to permit drainage of accumulated fluid associated with otitis media. Ear drops are not used because they will obscure the view of the tympanic membrane. Removal of the mastoid will not relieve pressure within inflamed ears. Antibiotics, not steroids, are used for an infectious process.

Which type of delusion would the nurse chart about a client who says, I've figured out how foreign agents have infiltrated the news media. Now they want to shut me up? A. Nihilistic B. Persecution C. Control D. Grandeur

B. Persecution The nurse would chart about delusions of persecution. Thoughts of being pursued by powerful agents because of one's special attributes or powers are fixed false beliefs and are referred to as delusions of persecution. There is no evidence to indicate that there are nihilistic delusions of total or partial nonexistence. There is also no evidence to support that external forces are controlling the client (delusions of control) or that the client has false beliefs of being a famous figure (delusions of grandeur).

When obtaining a health history from a client recently diagnosed w/ type 1 diabetes, the nurse expects the client to report which clinical information? A. Nervousness B. Polyuria C. Nocturia D. Diaphoresis

B. Polyuria Excessive thirst (polydipsia), excessive hunger (polyphagia), and frequent urination (polyuria) are caused by the body's inability to metabolize glucose adequately. Lethargy, not nervousness, occurs because of a lack of metabolized glucose for energy. Frequent urination occurs throughout a 24-hour period because glucose in the urine pulls fluid with it. Diaphoresis occurs w/ severe hypoglycemia (low blood sugar), not hyperglycemia (high blood sugar).

Which stage of the human immunodeficiency virus (HIV) would a client with a CD4+ T cell count of 325 cells/mm3 be classified? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

B. Stage 2 Stage 2 describes a client with a CD4+ T-cell count between 200 and 499 cells/mm3. Stage 1 describes a client with a CD4+ T-cell count of greater than 500 cells/mm3. Stage 3 describes a client with a CD4+ T-cell count of less than 200 cells/mm3. Stage 4 describes a client with a confirmed HIV infection but no information regarding CD4+ T-cell counts is available.

To which client would the nurse provide education regarding the pubertal growth spurt? A. An 8-year-old school age male client B. A 16-year-old adolescent male client C. A 12-year-old school-age female client D. An 18-year-old adolescent female client

C. A 12-year-old school-age female client The pubertal growth spurt reaches a peak for female clients at 12 years of age; therefore, the nurse should provide education to this client regarding expected growth during this time period. The 8-year-old male client would not be expected to experience the pubertal growth spurt until the age of 14 years. The 16-year-old and the 18-year-old adolescent clients would have already experienced the pubertal growth spurt.

Which joint helps in the gliding movement of the wrist? A. Pivot joint B. Hinge joint C. Biaxial joint D. Balla nd socket joint

C. Biaxial joint The biaxial joint helps in the gliding movement of the joint. Pivot joints permit rotation in the radioulnar area. Hinge joints allow for flexion and extension. Ball and socket joints permit movement in the shoulders and hips.

A child becomes cyanotic during a generalized tonic-clonic seizure. Which is the most appropriate action by the nurse? A. Inserting an oral airway B. Administering oxygen (O2) by mask C. Continuing to observe the seizure D. Notifying the practitioner immediately

C. Continuing to observe the seizure Continuing to observe the seizure. The child's status and progression of seizure should be monitored; child will not breathe until seizure is over and cyanosis should then subside at that time. Attempting to open a clenched haw may result in injury to the child. O2 is useless until the child breathed when the seizure is over. The practitioner may be notified later; provisions for the child's safety and observation are the priorities.

The nurse understands which condition as being contraindicated for St. John's wort herbal therapy? A. Anxiety B. Seizures C. Dementia D. Cardiac disease

C. Dementia Dementia is contraindicated for St. John's wort herbal therapy; this herbal therapy is used to treat anxiety. Bupropion therapy is contraindicated for seizures. Valerian (Valeriana Officinalis) is contraindicated for cardiac disease.

Which manifestation indicates tertiary syphilis? A. Chancre B. Alopecia C. Gummas D. Condylomata lata

C. Gummas Gummas are chronic, destructive lesions affecting the skin, bone, liver, and mucous membranes occur during tertiary syphilis. A chancre appears during primary syphilis. Alopecia and condylomata lata occur during secondary syphilis.

Which stage of development classifies boys and girls as differing very little in terms of size? A. Toddler B. Preschool C. School-age D. Adolescence

C. School-age During the school-age stage development, boys and girls differ very little in terms of size. During the toddler, preschool, and adolescence stages of development, boys are often larger than girls.

The nurse receives an order to prepare a solution for administering a cleansing enema for an adolescent client. Which is the volume of solution that would be prepared? A. 150 to 250 mL B. 250 to 350 mL C. 300 to 500 mL D. 500 to 750 mL

D. 500 to 750 mL In adolescents, the volume of solution required is 500 to 750 mL. The nurse would prepare 150 to 250 mL of warmed solution for infants. The nurse would prepare 250 to 350 mL of warmed solution for administering a cleansing enema in a toddler. In school-age children, the volume of warmed solution is 300 to 500 mL.

A client reports left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding? A. Dull sound on percussion B. Vocal fremitus on palpation C. Rales w/ rhonchi on auscultation D. Absence of breath sounds on auscultation

D. Absence of breath sounds on auscultation The left lung is collapsed; therefore, there are no breath sounds. A tympanic, not a dull, sound will be heard with a pneumothorax. There is no vocal fremitus because there is no airflow into the left lung as a result of the pneumothorax. Rales with rhonchi will not be heard because there is no airflow into the left lung as a result of the pneumothorax.

Which antibody forms first, after exposure to an antigen? A. Immunoglobulin A (IgA) B. Immunoglobulin E (IgE) C. Immunoglobulin G (IgG) D. Immunoglobulin M (IgM)

D. Immunoglobulin M (IgM) IgM is the first antibody formed by a newly sensitized B-lymphocyte plasma cell. IgA has very low circulating levels and is responsible for preventing infection in the upper and lower respiratory tracts, and the gastrointestinal and genitourinary tracts. IgE has variable concentrations in the blood and is associated with antibody-mediated hypersensitivity reactions. IgG is heavily expresses on second and subsequent exposures to antigens to provide sustained, long-term immunity against invading microorganisms.

The weight of a 3-month-old infant w/ tetralogy of Fallot has declined from the 25th percentile to the 5th. Which mechanism would the nurse suspect is the reason for this inadequate gain? A. Cyanosis resulting in cerebral changes B. Decreased arterial oxygen level resulting in polycythemia C. Pulmonary hypertension resulting in recurrent respiratory infections D. Inadequate oxygen perfusion leading to activity intolerance, resulting in diminished energy to nurse

D. Inadequate oxygen perfusion leading to activity intolerance, resulting in diminished energy to nurse Because of quick fatigue, it is difficult for the infant to consume sufficient calories for adequate weight gain. Increased caloric intake is needed to meet the infant's nutritional needs. Although cyanosis is present, it may not lead to cerebral changes. Cyanosis is not directly related to inadequate weight gain. Although decreased Po2 does lead to polycythemia, it does not affect the infant's ability to gain adequate weight. Although there is pulmonary hypertension, it is not directly related to inadequate weight gain or respiratory infections

Which criteria would the nurse consider when determining if an infection is a health care associated infection?

Occurred in conjunction with the treatment for an illness.