EXAM 3: Practice Questions
While doing a health history, a client tells the nurse that her mother, her grandmother, and her sister died of breast cancer. The client asks what she can do to keep from getting cancer. What is the best response by the nurse? "With your family history, there is nothing you can do to prevent getting cancer, so be mindful of your family risk factors." "Cancer prevention and detection can be done with blood analysis for tumor markers to measure your risk level." "Cancer often skips a generation, so don't worry about it." "If you eat right, exercise, and get enough rest, you can always prevent breast cancer."
"Cancer prevention and detection can be done with blood analysis for tumor markers to measure your risk level." Specialized tests have been developed for tumor markers, specific proteins, antigens, hormones, genes, or enzymes that cancer cells release. The nurse cannot say that cancer can be avoided with healthy behaviors; this is inaccurate information. A family history is a reason for the client to be concerned. Cancer does not skip a generation; this response minimizes and negates the client's concern.
The nurse is caring for a child who has just been admitted to the pediatric unit with sickle cell crisis. He is complaining that his right arm and leg hurt. What is the priority nursing intervention? 1. administer pain medication every 3h IV until pain is controlled 2. perform passive range of motion of the arm and leg to maintain function 3. try acetaminophen for pain first, moving up to opioids only if needed 4. use narcotic analgesics and warm compresses as needed to control pain
1. administer pain medication every 3h IV until pain is controlled
A nurse is preparing a program for a parent group about various techniques that can beused to manage behavior. Which of the following would the nurse be least likely toinclude? A) Focus the child's attention on the negative behavior. B) Set limits with the child for responsible behavior. C) Ignore inappropriate behaviors. D) Provide positive feedback for self-control efforts.
A
The nurse is caring for 3-day-old girl with Down syndrome whose mother had no prenatal care. Which of the following will be the priority nursing diagnosis? A) Imbalanced nutrition, less than body requirements related to the effects of hypotonia B) Deficient knowledge related to the presence of a genetic disorder C) Delayed growth and development related to a cognitive impairment D) Impaired physical mobility related to poor muscle tone
A
The nurse is obtaining the health history for a 15-month-old boy from the parents. The child is not yet speaking. Which finding would be eliminated as a risk factor for a possible genetic disorder? A) The child is male and Caucasian. B) The grandmother and father have hearing impairments. C) The child was a breech delivery 3 weeks early. D) The mother was 37 when she became pregnant.
A
A woman who has sickle cell anemia asks the nurse if her infant will develop sickle cell disease. The nurse would base the answer on which information? A.Sickle cell anemia is recessively inherited. B.Sickle cell anemia has more than one polygenic inheritance pattern. C.Sickle cell anemia is dominantly inherited. D.Sickle cell anemia is not inherited; it occurs following a malaria infection.
A sickle cell anemia is a autosomal recessive disease, one gene from each parent; if one parent has disease but other doesn't - chances of inheritance are 0; if woman has disease but partner has TRAIT, there's a 50% chance; if both parents have disease - all children will have disease; depends on having disease, trait, and nothing
•A client is hospitalized with sickle cell anemia and the nurse is preparing a teaching plan to review with the client and the client's family. Which interventions should be included? (Select all that apply). A.Never exceed the recommended dosages of analgesics. B.Dress warmly in cold temperatures. C.While participating in physical exercise, wear constrictive clothing to support circulation. D.During a sickle cell crisis, fluids are to be restricted.
A, B client should drink water,, avoid heat/cold extremes because they are triggers, cautious at high altitudes because of oxygen, any type of vasoconstriction can take you into a crisis and avoid self medicating or exceeding analgesic dosages
The nurse is assessing a newborn and suspects that the newborn was exposed to drugs in utero because the newborn is exhibiting signs of neonatal abstinence syndrome. Which of the following would the nurse expect to assess? (Select all that apply.) A) Tremors B) Diminished sucking C) Regurgitation D) Shrill, high-pitched cry E) Hypothermia F) Frequent sneezing
A, C, D, F Answer: A, C, D, F Rationale: Signs and symptoms of neonatal abstinence syndrome include tremors, frantic sucking, regurgitation or projectile vomiting, shrill high-pitched cry, fever, and frequent sneezing
a nurse is providing care for a client who has a sensory deficit, which of the following actions is the nurse's priority for the client - keep the environment free from clutter - offer opportunities for the client to exercise - prevent the client's social isolation - provide nutritional education
A: sensory deficit indicates risk for injury so priority is to maintain safety
A nurse is preparing a teaching session for a group of parents with children newly diagnosed with attention deficit/hyperactivity disorder (ADHD). When explaining this disorder to the parents, which of the following would the nurse include as being involved? Select all answers that apply. A) Impulsivity B) Inattention C) Distractibility D) Hyperactivity E) Defiance F) Anxiety
ABCD Defiance and Anxiety are comorbidities that MAY occur along w/ ADHD Impulsivity, Inattention, Distractibility, and Hyperactivity and increase Psychomotor activity are all behaviors involved with ADHD
What is true about the genetic transmission of sickle cell disease? a. Both parents must carry the sickle cell trait. b. Both parents must have sickle cell disease. c. One parent must have the sickle cell trait. d. Sickle cell disease has no known pattern of inheritance.
ANS: A Feedback: A In this scenario, there is a 50% risk of having a child with sickle cell disease.B The sickle cell trait, not the disease itself, must be present in the parents for the child to have the disease.C An autosomal recessive pattern of inheritance means that both parents must be carriers of the sickle cell trait.D Sickle cell disease is known to have an autosomal recessive pattern of inheritance.
A condition in which the normal adult hemoglobin is partly or completely replaced by abnormal hemoglobin is known as a. Aplastic anemia b. Sickle cell anemia c. Thalassemia major d. Iron-deficiency anemia
ANS: B Feedback: A Aplastic anemia is a lack of cellular elements being produced.B Sickle cell anemia is one of a group of diseases collectively called hemoglobinopathies, in which normal adult hemoglobin is replaced by an abnormal hemoglobin.C Hemophilia refers to a group of bleeding disorders in which there is deficiency of one of the factors necessary for coagulation.D Iron-deficiency anemia affects size and depth of color and does not involve an abnormal hemoglobin.
What are the nursing priorities for a child with sickle cell disease in vaso-occlusive crisis? a. Administration of antibiotics and nebulizer treatments b. Hydration and pain management c. Blood transfusions and an increased calorie diet d. School work and diversion
ANS: B FeedbackA Antibiotics may be given prophylactically. Oxygen therapy rather than nebulizer treatments is used to prevent further sickling.B Hydration and pain management decrease the cells' oxygen demands and prevent sickling.C Although blood transfusions and increased calories may be indicated, they are not primary considerations for vaso-occlusive crisis.D School work and diversion are not major considerations when the child is in a vaso-occlusive crisis
The nurse is caring for a child with aplastic anemia. What nursing diagnoses are appropriate? Select all that apply.' a. Acute Pain related to vaso-occlusion b. Risk for Infection related to inadequate secondary defenses or immunosuppression c. Ineffective Protection related to thrombocytopenia d. Ineffective Tissue Perfusion related to anemia e. Ineffective Protection related to abnormal clotting
ANS: B, C, D FeedbackCorrect These are appropriate nursing diagnosis for the nurse planning care for a child with aplastic anemia. Aplastic anemia is a condition in which the bone marrow ceases production of the cells it normally manufactures, resulting in pancytopenia. The child will have varying degrees of the disease depending on how low the values are for absolute neutrophil count(affecting the body's response to infection), platelet count (putting the child at risk for bleeding), and absolute reticulocyte count (causing the child to have anemia).Incorrect Acute pain related to vaso-occlusion is an appropriate nursing diagnosis for sickle cell anemia for the child in vaso-occlusive crisis, but it is not applicable to a child with aplastic anemia. Ineffective protection related to abnormal clotting is an appropriate diagnosis for von Willebrand disease.
What describes the pathologic changes of sickle cell anemia? a. Sickle-shaped cells carry excess oxygen. b. Sickle-shaped cells decrease blood viscosity. c. Increased red blood cell destruction occurs. d. Decreased red blood cell destruction occurs
ANS: C FeedbackA Sickled red cells have decreased oxygen-carrying capacity and transform into the sickle shape in conditions of low oxygen tension.B When the sickle cells change shape, they increase the viscosity in the area where they are involved in the microcirculation.C The clinical features of sickle cell anemia are primarily the result of increased red blood cell destruction and obstruction caused by the sickle-shaped red blood cells. D Increased red blood cell destruction occurs.
What should the discharge plan for a school-age child with sickle cell disease include? a. Restricting the child's participation in outside activities b. Administering aspirin for pain or fever c. Limiting the child's interaction with peers d. Administering penicillin daily as ordered
ANS: D FeedbackA Sickle cell disease does not prohibit the child from outdoor play. Active and passive exercises help promote circulation.B Aspirin use should be avoided. Acetaminophen or ibuprofen should be administered for fever or pain.C The child needs to interact with peers to meet his developmental needs.D Children with sickle cell disease are at a high risk for pneumococcal infections and should receive long-term penicillin therapy and preventive immunizations.
Which of the following is NOT part of the Modified Finnegan's Neonatal Abstinence Scoring System? a) Urine color b) Moro Reflex c) Respiratory Rate d) Sneezing
Answer: A Rationale: Although stools may be assessed and are a part of the Finnegan's Neonatal Abstinence Scoring System, urine color is not an area of scoring. Moro Reflexes, Respiratory Rate and sneezing are all scoring areas.
The nurse would take which action as part of nursing care of the infant experiencing neonatal abstinence syndrome? a) Place stuffed animals and mobiles in the crib to provide visual stimulation. b) Position the baby's crib in a quiet corner of the nursery. c) Avoid the use of pacifiers. d) Spend extra time holding and rocking the baby.
Answer: B Rationale: Neonatal abstinence syndrome, or drug withdrawal, causes hyperstimulation of the neonate's nervous system. Nursing interventions should focus on decreasing environmental and sensory stimulation during the withdrawal period. Pacifiers allow for nonnutritive sucking by the infant. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: Recall that neonatal abstinence syndrome is accompanied by hyperstimulation of the central nervous system. The correct answer would be the option that contains a strategy to reduce stimulation
Which of the following is NOT a sign or symptom of neonatal abstinence syndrome (NAS)? a. Excessive high-pitched cry b. Tremors c. Hypotonia d. Tremors e. Tachypnea
Answer: C Rationale: All of the options are possible common signs and symptoms of NAS except for hypotonia. Neonates presenting with NAS typically exhibit increased muscle tone.
Which of the following instructions would the nurse include in the teaching plan for a mother of a substance-exposed newborn? A) "Avoid using a pacifier because it can damage his teeth in the future." B) "Place your newborn on his side when you feed him." C) "Let your newborn sleep in his stomach for naps but not at night." D) "Wrap him snugly in a blanket and gently rock him if he's fussy."
Answer: D Rationale: The newborn should be positioned upright with the chin down to facilitate sucking and swallowing while feeding. All newborns should sleep on their backs at all times. A pacifier can be helpful in satisfying the newborn's need to nonnutritive sucking
Which medication would be included in the plan of care for a newborn with acute neonatal abstinence syndrome who is not responding to conservative nursing approaches? a) morphine sulfate b) diazepam c) naloxone d) fentanyl
Answer: a Rationale: Pharmacologic treatment is warranted for NAS if conservative measures are not adequate. It is recommended that for newborns with confirmed drug exposure drug therapy is indicated if the newborn has acute NAS. Common medications used in the management of newborn withdrawal include an opioid (morphine or methadone), and phenobarbital is the second drug if the opiate does not adequately control symptoms
A newborn is suspected of drug exposure. Which of the following is the most appropriate action by the nurse? a) collect a hair sample to be analyzed for drug exposure. b) regulate the infant's diet to meet changing phenylalanine needs. c) collect a urine or meconium specimen from infant for analysis. d) give oral calcium with feedings.
Answer: c Rationale: When drug exposure is suspected, a urine specimen or meconium sample is collected from the infant for analysis. Drugs or their metabolites are present in the newborn's urine and meconium for various lengths of time after the mother has used them. Regulating a diet to meet changing phenylalanine needs is necessary in infants diagnosis with PKU. Oral calcium is given with feedings in cases of hypocalcemia to prevent gastric irritation
A nurse is doing a pre-natal assessment on a patient who has a hx of heroin abuse, and is currently on methadone to treat the addiction. She asks the nurse if her baby will act any differently than her babies born before she took any drugs. The nurse lists which symptoms of withdrawal as ones the baby may display a. somnalance b. High pitched crying c. poor feeding d. constipation e. tremors f. excessive hair growth
Answers: a, b, c, e Rationale: Constipation and excessive hair growth are not symptoms, diarrhea or watery stools are.Source: Modified Finnegan Neonatal Abstinence Score Sheet
A client is readmitted with an exacerbation of celiac disease 2 weeks after discharge. Which statement by the client indicates the need for a dietary consult? A) "I don't understand this; I took the medication the doctor ordered and followed the diet." B) "I didn't eat anything I shouldn't have; I just ate roast beef on rye bread." C) "I don't like oatmeal, so it doesn't matter that I can't have it." D) "I don't understand why this happened again; I didn't travel out of the country."
B
A nurse is conducting a screening program for autism in infants and children. Which ofthe following would the nurse identify as a warning sign? A) Lack of babbling by 6 months B) Inability to say a single word by 16 months C) Lack of gestures by 8 months D) Inability to use two words by 18 months
B
The nurse is teaching a couple about X-linked disorders. They are concerned that they might pass on hemophilia to their children. Which of the following responses indicates the need for further teaching? A) "The father can't be a carrier if he doesn't have hemophilia." B) "If the father doesn't have it, then his kids won't either." C) "If the mother is a carrier, her daughter could be one too." D) "If the mother is a carrier, her sons may have hemophilia."
B
The nurse is teaching the mother of a 12-year-old boy about the risk factors associatedwith drug and alcohol abuse. Which response by the mother indicates a need for further teaching? A) "A family history of alcoholism is a risk factor for substance abuse." B) "Just because his friends are experimenting does not mean that he will." C) "If my husband or I have a substance abuse problem it could increase his risk." D) "Negative life events are a potential risk factor."
B
The nurse is teaching the parents of a 1-month-old girl with Down syndrome how to maintain good health for the child. Which instruction would the nurse be least likely to include? A) Getting cervical radiographs between 3 and 5 years of age B) Adhering to the special dietary needs of the child C) Getting an echocardiogram before 3 months of age D) Monitoring for symptoms of respiratory infection
B
When planning the care of a newborn addicted to cocaine who is experiencing withdrawal, which of the following would be least appropriate to include? A) Wrapping the newborn snugly in a blanket B) Waking the newborn every hour C) Checking the newborn's fontanels D) Offering a pacifier
B Rationale: Stimuli need to be decreased. Waking the newborn every hour would most likely be too stimulating. Measures such as swaddling the newborn tightly and offering a pacifier help to decrease irritable behaviors. A pacifier also helps to satisfy the newborn's need for nonnutritive sucking. Checking the fontanels provides evidence of hydration.
A client is found to have a low hemoglobin and hematocrit when laboratory work was performed. What does the nurse understand the anemia may have resulted from? Select all that apply. A.Infection B.Blood loss C.Abnormal erythrocyte production D.Destruction of normally formed red blood cells E.Inadequate formed white blood cells
B, C, D most of anemia results from these 3; most common are hypovolemic, iron deficiency, pernicious, folic acid deficiency, SCA, hemolytic; each form has unique manifestations but have common core symptoms; anemia does not form from infection or inadequate formed WBC
A nurse is caring for a client who is scheduled for an otoacoustic emissions (OAE) test. The client asks what to expect during the test. Which of the following responses should the nurse make? - you will have small electrodes placed on your scalp during the test - you will have a small probe places in your ear canal during the test - you will have dye injected through an IV during the test
B: during OAE, a small probe is placed in the auditory canal; a series of sounds are played through the probe which measures the returned echo electrodes are during an ABR test; dye is injected during a fluorescein angiography test
A woman who has a history of cocaine abuse gives birth to a newborn. Which of the following would the nurse expect to assess in the newborn? (Select all that apply) A) Prolonged periods of sleep B) Poor sucking C) Inconsolable crying D) Piercing cry E) Flaccid positioning
BCD Rationale: A newborn going through withdrawal will have a poor sucking reflex, inconsolable crying and a high pitched, piercing cry. The Finnegan NAS score sheet will commonly be used with these neonates.
A group of students are reviewing information about the effects of substances on the newborn. The students demonstrate understanding of the information when they identify which drug as not being associated with teratogenic effects on the fetus? A) Alcohol B) Nicotine C) Marijuana D) Cocaine
C
A newborn is suspected of having fetal alcohol syndrome. Which of the following would the nurse expect to assess? A) Bradypnea B) Hydrocephaly C) Flattened maxilla D) Hypoactivity
C
The nurse is assessing a 4-year-old boy whose mother was 40 years old when he was born. Which of the following findings suggests this child has a genetic disorder? A) Inquiry determines the child had feeding problems. B) Observation shows nasal congestion and excess mucus. C) Inspection reveals low-set ears with lobe creases. D) Auscultation reveals the presence of wheezing.
C
The nurse is caring for a 1-month-old girl with low-set ears and severe hypotonia who was diagnosed with trisomy 18. Which nursing diagnosis would the nurse identify as most likely? A) Interrupted family process related to the child's diagnosis B) Deficient knowledge deficit related to the genetic disorder C) Grieving related to the child's poor prognosis D) Ineffective coping related to stress of providing care
C
The nurse is caring for a 3-year-old boy. The parents are concerned that he is exhibitingsigns of cognitive delays. Which statement by the parents would lead the nurse tosuspect autism spectrum disorder rather than possible learning disability? A) "He is not speaking in complete sentences." B) "We can understand a lot of what he says, but no one else can." C) "He seems to be speaking words less and less frequently." D) "He is unable to sit still for a short story."
C
A 3-year-old child is hospitalized with a diagnosis of sickle cell anemia and is experiencing a pain crisis. Using the FACES scale, the nurse assesses the child's pain to be a 10 on a scale of 1 to 10. The child is receiving intravenous fluids and oxygen at 2 L/min via nasal cannula. The parent is at the bedside holding the child's hand and has a concerned look. What is the nurse's priority in caring for the child? A.Ask the parent if he or she has questions about the plan of care. B.Provide diversional activities for the child. C.Implement strategies to address the child's pain. D.Contact the health care provider to meet with the parent.
C nurse priority is to address pain; child already receiving IV fluids and oxygen (a combo of this with analgesic will help stabilize crisis) During a pain crisis; the oxygen and fluids allows to break down and thin out blood and the pain management helps to avoid further sickling
After teaching the parents of a child with attention deficit/hyperactivity disorder aboutways to control the child's behavior, the nurse determines a need for additional teachingwhen the parents state which of the following? A) "If he starts to act out, we'll have him do a time-out to help him refocus." B) "We can use a reward system when he behaves appropriately." C) "If he misbehaves, we need to punish him instead of reward him." D) "We need to help him set realistic goals that he can achieve."
C) "If he misbehaves, we need to punish him instead of reward him."
A child with attention deficit/hyperactivity disorder is prescribed long-actingmethylphenidate. Which of the following would the nurse include when teaching thechild and his parents about this drug? A) "Give the drug three times a day: morning, midday, and after school." B) "This drug may cause drowsiness, so be careful when doing things." C) "Some increase in appetite may occur, so watch how much you eat." D) "Take this drug every day in the morning when you wake up."
D
The nurse is counseling a couple who suspect that they could bear a child with a genetic abnormality. Which of the following would be most important for the nurse to incorporate into the plan of care when working with this family? A) Gathering information from at least three generations B) Informing the family of the need for a wide range of information C) Maintaining the confidentiality of the information D) Presenting the information in a nondirective manner
D
The nurse is teaching a couple about the pros and cons of genetic testing. Which of the following statements best describes the capabilities of genetic testing? A) "Various genetic tests help the physician choose appropriate treatments." B) "Genetic testing helps couples avoid having children with fatal diseases." C) "Genetic tests identify people at high risk for preventable conditions." D) "Some genetic tests can give a probability for developing a disorder."
D
When providing guidance to the parents of a child with Down syndrome, which of the following would be most appropriate? A) Encourage the parents to home-school the child. B) Advise the parents that the child will need monthly thyroid testing. C) Instruct them on the need for yearly dental visits. D) Teach the parents about the need for a high-fiber diet.
D
When reviewing the medical record of a child, which of the following would the nurseinterpret as the most sensitive indicator of intellectual disability? A) History of seizures B) Preterm birth C) Vision deficit D) Language delay
D
A client is scheduled for a nerve-sparing prostatectomy. The emotional spouse confides in the nurse that the client will not talk about the cancer and/or upcoming surgery. Which nursing diagnosis will the nurse choose as primary diagnosis for this client? Sexual Dysfunction Knowledge Deficit Fear Grieving
Fear Fear of the unknown is probably the major concern for this client. This includes fear of the diagnosis of cancer, fear of the effects of the surgery, and fear of loss of control and functioning. Sexual Dysfunction may be one of the fears but not primary at this stage. Knowledge Deficit is unclear at this time. Grieving would not be a likely response at this time.
The nurse is caring for a client undergoing an incisional biopsy. Which statement does the nurse understand to be true about an incisional biopsy? It treats cancer with lymph node involvement. It removes a wedge of tissue for diagnosis. It is used to remove cancerous cells using a needle. It removes an entire lesion and the surrounding tissue.
It removes a wedge of tissue for diagnosis. Explanation: The three most common biopsy methods are excisional, incisional, and needle. In an incisional biopsy, a wedge of tissue is removed from the tumor and analyzed. In an excisional biopsy, the surgeon removes the tumor and the surrounding marginal tissues. Needle aspiration biopsy involves aspirating tissue fragments through a needle guided into the cancer cells.
Which type of surgery is used in an attempt to relieve complications of cancer? Prophylactic Salvage Palliative Reconstructive
Palliative Palliative surgery is performed to relieve complications of cancer. Prophylactic surgery involves removing nonvital tissues or organs that are likely to develop cancer. Reconstructive surgery may follow curative or radical surgery and is carried out in an attempt to improve function or to obtain a more desirable cosmetic effect. Salvage surgery is an additional treatment option that uses an extensive surgical approach to treat the local recurrence of a cancer after the use of a less extensive primary approach.
The nurse at the clinic explains to the patient that the surgeon will be removing a mole on the patient's back that has the potential to develop into cancer. The nurse informs the patient that this is what type of procedure? Diagnostic Palliative Prophylactic Reconstructive
Prophylactic surgery involves removing nonvital tissues or organs that are at increased risk of developing cancer. When surgical cure is not possible, the goals of surgical interventions are to relieve symptoms, make the patient as comfortable as possible, and promote quality of life as defined by the patient and family. Palliative surgery and other interventions are performed in an attempt to relieve complications of cancer, such as ulceration, obstruction, hemorrhage, pain, and malignant effusions (Table 15-6). Reconstructive surgery may follow curative or radical surgery in an attempt to improve function or obtain a more desirable cosmetic effect. Diagnostic surgery, or biopsy, is performed to obtain a tissue sample for histologic analysis of cells suspected to be malignant.
Illicit substance use (illegal drug use) by a pregnant woman may expose the fetus to the following possibilities: (select all that apply) a. Fetal growth restriction b. Birth defects c. Infection d. Foster care placement
a, b, c Substance use during pregnancy exposes the fetus to the possibility of fetal growth restriction, prematurity, neurobehavioral and neurophysiologic dysfunction, birth defects, infections, and long-term developmental sequelae (Ricci, page 924)
When the nurse is assessing a 2-day-old newborn and suspects Down syndrome, what factors would lead to this assessment? Select all that apply. a) Epicanthal folds b) Rigid joints c) Flat facial profile d) Large tongue compared to mouth e) Downward slant to the eyes f) Simian crease
a, c, d, f A flattened face, especially the bridge of the nose. Almond-shaped eyes that slant up. A short neck. Small ears. A tongue that tends to stick out of the mouth. Tiny white spots on the iris (colored part) of the eye. Small hands and feet. A single line across the palm of the hand (palmar crease)
a nurse is preparing to administer medications to a client; which of the following classifications of medications should the nurse identify as being ototoxic; select all that apply - loop diuretics - benzodiazepines - NSAIDS - antihistamines - aminoglycoside antibiotics
a, c, e
a nurse is caring for a client who has hearing loss; which of the following actions should the nurse use to enhance communication with the client. Select All that Apply - provide client w large print materials - ensure client wears their hearing aids - use sign language interpreter - communicate using paper and pen - face the client when speaking
b, c, d, e encourage them to wear hearing aids and assist with cleaning; a sign language interpreter can be used in hospital or provider's office, nurse can provide pre printed info for the client or write information down; the nurse should face the client
The nurse is talking with a group of clients who are older than age 50 years about the recognition of colon cancer to access early intervention. What should the nurse inform the clients to report immediately to their primary care provider? Change in bowel habits Excess gas Daily bowel movements Abdominal cramping when having a bowel movement
change in bowel habits The chief characteristic of cancer of the colon is a change in bowel habits, such as alternating constipation and diarrhea. Excess gas, daily bowel movements, and abdominal cramping when having a bowel movement are not indicators of colon cancer.
A nurse notes a score of 18 on the Finnegans NAS chart for an infant. While he is in the room giving the appropriate methadone dose, the baby's mother asks if the baby will be able to go home with her tomorrow. What is the nurses appropriate response? a. It will depend on the baby's score tomorrow b. No, the baby will not be allowed to return home with you, social services will be taking the baby. c. No, the baby must score less than 8 without medication for at least 24 hours before we can discharge the baby. d. No, the baby must score less than 8 without medication for at least 3 days before the doctor can consider discharging the baby.
d is the correct answer. After 3 days of scores under 8 without pharmaceuticals the monitoring may cease. This does not mean the baby will automatically be discharged.Source: Modified Finnegan Neonatal Abstinence Score Sheet
Which characteristic is a risk factor for colorectal cancer? Age younger than 40 years Low-fat, low-protein, high-fiber diet History of skin cancer Familial polyposis
familiar polyposis Family history of colon cancer or familial polyposis is a risk factor for colorectal cancer. Age older than 40 years and a high-fat, high-protein, low-fiber diet are risk factors for colorectal cancer. A history of skin cancer is not a recognized risk factor for colorectal cancer.
The nurse is caring for a newborn of a substance abusing mother who is withdrawing from alcohol. Which of the following would the nurse likely see in this newborn? hyperactivity hypothermia effective sucking irritability lack of cry
hyperactivity, irritability
A home health nurse is visiting a client who lives in an older home and is concerned about their child's exposure to lead paint in the house. The nurse should identify that which of the following is a potential health risk from exposure to lead paint? strabismus dental caries accelerated growth learning disabilities
learning disabilities - as well as lowered IQ, difficulty with speech, muscle coordination issues. Lead is found in old paint, water, some pottery, dust, pipes, cosmetics, even gasoline.
Which facial change is characteristic in a neonate with fetal alcohol syndrome (FAS)? microcephaly hydrocephaly
microcephaly
Celiac disease (celiac sprue) is an example of which category of malabsorption? Infectious diseases Mucosal disorders causing generalized malabsorption Luminal problems causing malabsorption Postoperative malabsorption
mucosal disorders causing generalized malabsorption Celiac disease (celiac sprue, gluten-sensitive enteropathy) results from a toxic response to the gliadin component of gluten by the surface epithelium of the intestine; eventually, the mucosal villi of the small intestine become denuded and cannot function. Crohn's disease (regional enteritis) and radiation enteritis are other examples of mucosal disorders.
The nurse is caring for a baby born to a mother with a history of alcohol abuse. For what characteristics should the nurse observe to determine if the newborn has fetal alcohol syndrome? (Select all that apply.) reduced ocular growth short palpebral fissures high nasal bridge flattened nasal bridge normal hearing
• Reduced ocular growth• Short palpebral fissures• Flattened nasal bridge
