Final Exam

Which assessment findings should lead the nurse to suspect that a toddler is experiencing respiratory distress? Select all that apply. 1. Coughing 2. RR of 35 breaths/min 3. HR of 95 bpm 4. Restlessness 5. Malaise 6. Diaphoresis

1, 2, 4, 6. Coughing, especially at night and in the absence of an infection, is a common symptom of asthma. Early signs of respiratory distress include restlessness, tachypnea, tachycardia, and diaphoresis. Other signs also include HTN, nasal flaring, grunting, wheezing, and intercostal retractions. A HR of 95 bpm is normal for a toddler. Malaise typically does not indicate respiratory distress.

In additions to disturbances in cognition and orientation, individuals with AD may also show changes in which of the following? Select all that apply. 1. Personality 2. Vision 3. Speech 4. Hearing 5. Mobility

1, 3 &5 Personality, Speech, Mobility

A child has viral pharyngitis. The RN should advise the parents to do which of the following? select all that apply. 1. Use a cool mist vaporizer 2. offer a soft to liquid diet 3. Administer amoxicillin 4. administer acetaminophen 5. place the child on secretion precautions

1,2,4. Viral pharyngitis is treated with symptomatic, supportive therapy. Treatment includes use of cool mist vaporizer, feeding a soft or liquid diet, and administration of acetaminophen for comfort. Viral infections do not respond to abx administration. The child does not need to be on secretion precautions because viral pharyngitis is NOT contagious.

A teaching care plan to prevent the transmission of respiratory syncytial virus (RSV) should include which of the following? Select all that apply. 1. The virus can be spread by direct contact 2. The virus can be spread by indirect contact 3. Palivizumab is recommended to prevent RSV for all toddlers in day care. 4. The virus is typically contagious for 3 weeks 5. Older children seldom spread RSV 6. Frequent hand washing helps reduce the spread of RSV

1,2,6 RSV can be spread through direct contact such as kissing the face of an infected person, and it can be spread through indirect contact by touching surfaces covered with infected secretions. Hand washing is one of the best ways to reduce the risk of disease transmission. Palivizumab can prevent severe RSV infections but is only recommended for the most at risk infants and children. RSV typically contagious for 3-8 days. RSV frequently manifests in older children as cold-like sx. Infected school-age children frequently spread the virus to other family members.

The Earliest sign of neurological injuries is: 1. A change in the level of consciousness 2. Ipsilateral pupil changes

1. A change in the level of consciousness.

Which of the following outcome criteria would the RN develop for a child with CF who has ineffective airways clearance r/t increased pulmonary secretions and inability to expectorate? 1. RR and rhythm within expected range 2. absence of chills and fever 3. ability to engage in age-related activities 4. ability to tolerate usual diet without vomiting

1. After treatment, the client outcome would be that Respiratory status would be within normal limits, as evidenced by a RR and. rhythm within expected range. Absence of chills and fever, although r/t an underlying problem causing the respiratory problem (the infection), do not specifically r/t the respiratory problem of ineffective airway clearance.

Lesions or injuries affecting the parietal lobe can include: 1. Alterations in sensation and touch. 2. Alteration in vision 3. Alteration in coordination. 4. Alteration in judgement.

1. Alterations in sensation and touch

The daughter of a patient with Alzheimer's disease becomes frustrated when talking to her father. What should the nurse suggest to improve communication? 1. Answer his questions simply even if the question is asked repeatedly 2. Finish his sentences before he becomes agitated 3. Focus the conversations on future events 4. Play word games to stimulate his mind and slow progression of the disease

1. Answer his questions simply even if the question is asked repeatedly.

Which of the following, if described by the parents of a child with CF, indicates that the parents understand the underlying problem of the disease? 1. an abnormality in the body's mucus-secreting glands. 2. formation of fibrous cysts in various body organs. 3. failure of the pancreatic ducts to develop properly 4. reaction to the formation of antibodies against streptococcus.

1. CF is characterized by a dysfunction in the body's mucus-producing exocrine glands. The mucus secretions are thick and sticky rather than thin and slippery.

A child with CF is receiving gentamicin. Which of the following nursing actions is most important? 1. Monitoring I&Os 2. Obtaining daily weights 3. Monitoring patient for indications of constipation 4. obtaining stool samples for hem occult testing.

1. Monitoring intake and output is the most important RN anion when administering an amino glycoside, such as gentamicin, because a decrease in output is an early sign of renal damage. Daily weight monitoring is not indicated when the client is receiving an amino glycoside. Constipation and bleeding are not adverse effects of aminoglycosides.

Which of the following factors is NOT associated with increased incidence of NCD due to AD? 1. Multiple small strokes 2. Family hx of AD 3. Head trauma 4. Advanced Age

1. Multiple small strokes

A school age child with CF asks the RN what sports she can become involved in as she becomes older. Which of the following activities would be appropriate for the RN to suggest? 1. swimming 2. track 3. Baseball 4. Javeling throwing

1. Swimming would be the most appropriate suggestion because it coordinates breathing and movement of all muscle groups and can be done on an individual basis or as a team sport. Because track events, baseball and javelin throwing usually are performed outdoors, the child would be breathing in large amounts of dust and dirt, which would be irritating to her mucous membranes and pulmonary system.

A battered woman presents to the ED with multiple cuts. Her right eye is swollen shut. She says her husband did this to her. The priority intervention is: 1. Tending to the immediate care of her wounds. 2. providing her with information about a safe place to stay. 3. Administering the PRN tranquilizer ordered by MD. 4. Explaining how she may go about bringing charges against her husband.

1. Tending to the immediate care of her wounds.

When interviewing the parents of an injured child, which sign is an objective indicator that child abuse may be a problem? 1. The injury isn't consistent with the child's history or age. 2. The parents offer consistent explanations for the injury 3. The family is poor and the mother and father are not married 4. The parents are argumentative and demanding.

1. The injury isn't consistent with the child's history or age.

When developing a teaching plan for the mother of an asthmatic child concerning measures to reduce allergic triggers, which of the following suggestions should the RN include? 1. Keep the humidity in the home between 50-60% 2. Have the child sleep in the bottom bunk bed 3. Use a scented room deodorizer to keep the room fresh 4. Vacuum the carpet one or twice a week.

1. To help reduce allergic triggers in the home, the RN should recommend that the humidity level be kept between 50-60%. Doing so keeps the air moist and comfortable for breathing. When air is dry, the risk for respiratory infections increases.

The father of a 16 month old child calls the clinic because the child has a low-grade fever, cold sx, and a hoarse cough. Which of the following should the RN suggest that the father do? 1. Offer extra fluids frequently 2. Bring the child to the clinic immediately 3. count the Childs RR 4. Use a hot air vaporizer

1. the toddler is exhibiting cold sx. A hoarse cough may be part of the upper respiratory tract infection. The best suggestion is to have the father offer the child additional fluids at frequent intervals to help keep secretions loose and membranes moist. There is no evidence presented to suggest that the child needs to be brought to the clinic immediately. A hot air vaporizer is NOT recommended. However, a cool mist vaporizer would cause vasoconstriction of the respiratory passages, making it easier for the child to breathe and loosening secretions.

There is a very narrow margin between the therapeutic and toxic levels of lithium carbonate. Sx of toxicity are most likely to appear if the serum levels exceed which of the following levels? 1. 0.15 mEq/L 2. 1.5 mEq/L 3. 15.0 mEq/L 4. 150 mEq/L

2 1.5 mEq/L

Mrs. G, who has NCD due to AD, says to the RN, "I have a date tonight. I always have a date on Christmas." Which of the following is the most appropriate response? 1. "Don't be silly. It's not Christmas, Mrs.G" 2. "Today is Tuesday, October 21, Mrs.G, We will have supper soon, and then your daughter will come to visit." 3."Who is your date with, Mrs. G?" 4. "I think you need some medication, Mrs.G, I'll bring it to you now."

2. "Today is Tuesday, October 21, Mrs. G, We will have supper soon, and then your daughter will come to visit."

The RN would be most concerned if the ICP readings measured which of the following for a sustained period of time? 1. 3 mmHg 2. 22 mmHg

2. 22mmHg Readings above 15 are life threatening.

The RN would expect to find which of the following in a child diagnosed with COA? 1. Squatting posture 2. Absent or diminished femoral pulses 3. severe cyanosis at birth 4. cyanotic "tet" spells

2. Absent or diminished femoral pulses. Classic characteristic of COA

The RN interviewing a patient on the psychiatric unit. The patient tilts his head to the side, stops talking and listens intensely. The most appropriate nursing intervention for this symptom is to: 1. Ask the patient to describe the physical symptom. 2. Ask the patient to describe wheat they are hearing 3. Administer a dose of benztropine (Cogentin). 4. Call the MD for additional orders

2. Ask the patient to describe what they are hearing.

The RN recognizes which of the following as a sign of digoxin toxicity in a toddler diagnosed with CHF? 1. Headache 2. Bradycardia 3. Last BM 4 days ago 4. Respiratory Stridor

2. Bradycardia. Extreme bradycardia is a cardinal sign of dig toxicity.

The patient has been diagnosed with paranoid schizophrenia and has been socially isolated and hearing voices tell him to kill his parents. The initial nursing implementation is: 1. Give him an injection of Chlorpromazine (Thorazine) 2. Ensure a safe environment for him and others 3. Place him in restraints 4. Order the patient a nutritious diet

2. Ensure a safe environment for him and others.

Mrs. G has been diagnosed with NCD due to AD. The primary nursing interventions in working with Mrs. G is which of the following? 1. Ensuring that she receives food she likes to prevent hunter 2. Ensuring that the environment is safe to prevent injury 3. Ensuring that she meets the other patients to prevent social isolation 4. Ensuring that she takes care of her own ADLs to prevent dependence.

2. Ensuring that the environment is safe to prevent injury

At a follow up appointment after being hospitalized, an adolescent with a hx of CF describes his stools to the RN. Which of the following descriptions should the RN interpret as indicative of continued problems with malabsorption? 1. Soft with little odor 2. Large and foul-smelling 3. loose with bits of food 4. hard with streaks of blood

2. In children with CF, poor digestion and absorption of foods, especially fats, results in frequent bowel movements that are bulky, large and foul-smelling. The stools also contain abnormally large quantities of fat, which is called steatorrhea. An adolescent experiencing good control of the disease would describe soft stools with little odor. Stool described as loose with bits of food indicates diarrhea. Stool described as hard with streaks of bleed may indicate constipation.

When developing the plan of care for a child with CF who is scheduled to receive postural drainage, the RN should anticipate performing postural drainage at which of the following times? 1. After meals 2. Before meals 3. After rest periods 4. Before inhalation treatments

2. Postural drainage, which aids in mobilizing the thick, tenacious secretions commonly associated with CF, is usually performed before meals to avoid the possibility of vomiting or regurgitating food.

Which of the following conditions is primarily responsible for the hyper cyanotic episodes of Tetralogy of Fallot? 1. Ventricular septal defect 2. Pulmonic Valve Stenosis 3. Overriding Aorta 4. Right Ventricular Hypertrophy

2. Pulmonic Valve Stenosis.

A 12 year old with asthma wants to exercise. Which of the following activities should the nurse suggest to improve breathing? 1. Soccer 2. Swimming 3. Track 4. Gymnastics.

2. Swimming is appropriate for this child because it requires controlled breathing, assists in maintaining cardiac health, enhances skeletal muscle strength, and promotes ventilation and perfusion. Stop and start activities such as soccer, track and gymnastics, commonly trigger sx in asthmatic clients.

A 21 month old child admitted with the dx of croup now has a respiratory rate of 48 breaths/min, a HR of 120 bpm, and a temp of 100.8 rectally. The RN is having difficulty calming the child. Which of the following should the RN do next? 1. administer acetaminophen 2. Notify the HCP immediately 3. Allow the toddler to continue to cry 4. offer clear fluids every few minutes

2. The RN may be having difficulty calming the child because the child is experiencing increasing respiratory distress. The normal RR for a 21 month old is 25-30 breaths/min. The child's RR is 48 breaths/min. Therefore the primary care provider needs to be notified immediately. Typically, acetaminophen is not given to a child unless the temperature is 101 or higher. Letter the toddler cry is inappropriate with group because crying increases respiratory distress. Offering fluid every few minutes to a toddler experiencing increasing respiratory distress would do little, if anything, to calm the child. Also, the child would have difficulty coordinating breathing and swallowing, possible increasing the risk of aspiration.

When developing a recreational therapy plan of care for a 3yo hospitalized with pneumonia and CF, which of the following toys would be appropriate? 1. 100-piece jigsaw puzzle 2. child's favorite doll 3. Fuzzy stuffed animal 4. Scissors, paper and paste

2. The child's favorite doll would be a good choice of toys. The doll provides support and is familiar to the child. A 100 piece jigsaw puzzle is too complicated for an ill 3 year old child. In view of the child's lung pathology, a fuzzy stuffed animal would not be advised because of its potential as a reservoir for dust and bacteria, possibly predisposing the child to additional respiratory problems.

A 10 year old child who is 5'4" tall with a hx of asthma uses an inhaled bronchodilator only when needed. He takes no other medications routinely. His best peak expiratory flow rate is 270 L/Min. This child's current peak flow reading is 180 L/Min. The RN interprets this reading as indicating which of the following? 1. The Childs asthma is under good control, so the routine treatment plan should continue. 2. The child needs to use his short-acting inhaled beta2-agonist med 3. This is a medical emergency requiring a trip to the emergency department for treatment. 4. The child needs to use his inhaled cromolyn sodium (Intal).

2. The peak flow of 180 l/min is in the yellow zone, or 50-80% of the child's personal best. This means that the Childs asthma is not well controlled, thereby necessitating the use of short-acting beta2-agonist med to relieve the bronchospasm.

What is the reason that does of bupropion should be administered at least 4-6 hours apart and never doubled when a dose is missed? 1. To prevent orthostatic hypotension 2. To prevent seizures 3. To prevent hypertensive crisis 4. To prevent extrapyramidal symptoms

2. To prevent seizures

A 9-month-old child with CF does not like taking pancreatic enzyme supplement with meals and snacks. The mother does not like to force the child to take the supplement. The most important reason for the child to take the pancreatic enzyme supplement with meals and snacks is: 1. the child will become dehydrated if the supplement is not taken with meals and snacks 2. The child needs these pancreatic enzymes to help the digestive system absorb fats, carbohydrates, and proteins 3. The child needs the pancreatic enzymes to aid in liquefying mucus to keep the lungs clear. 4. The child will experience severe diarrhea if the supplement is not taken as prescribed.

2. the child must take the pancreatic enzyme supplement with meals and snacks to help absorb nutrients so he can grow and develop normally. In CF, the normally liquid mucus is tenacious and blocks three digestive enzymes from entering the duodenum and digesting essential nutritions.

An example of a treatable (reversible) form of NCD is one that is caused by which of the following? Select all that apply. 1. Multiple sclerosis 2. Multiple small brain infarcts 3. Electrolyte imbalances 4. HIV disease 5. Folate deficiency

3 & 5 Electrolyte imbalances & Folate Deficiency

The night RN finds a patient, a client with AD, wandering the hallway at 4am. And trying to open the door to the side yard. Which statement by the RN probably reflects the most accurate assessment of this situation? 1. "That door leads out to the patio. It's nighttime. You don't want to go outside now." 2. "You look confused, what is bothering you?" 3. "That is the patio door. Are you looking for the bathroom?" 4" Are you lonely? Perhaps you'd like to go back to your room and talk for a while?"

3. "That is the patio door. Are you looking for the bathroom?"

While the RN is working in a homeless shelter, assessment of a 6 month old infant reveals a RR of 53 breaths/min, retractions, and wheezing. The mother states that her infant was doing fine until yesterday. Which of the following actions would be most appropriate? 1. Administer a nebulizer treatment 2. Send the patient for a chest radiograph 3. Refer the infant to the ED 4. Provide teaching about cold care to the mother

3. Based on assessment findings of increased RR, retractions and wheezing, this infants needs further evaluation, which could be obtained in the ED. W/o definitive dx, administering a nebulizer treatment would be outside the nurse's scope of practice unless there was a prescription for such a treatment. Sending infant for radiography may not be in RN scope of practice. The infant is exhibiting sx of respiratory distress and is too ill to send out with just instructions on cold care for the mother.

A 7 year old child with a hx of asthma controlled w/o medications is referred to the school RN by the teacher because of persistent coughing. Which of the following should the RN do first? 1. Obtain the child's heart rate 2. Give the child a nebulizer treatment 3. Call a parent to obtain more information 4. Have a parent come and pick up the child

3. Because persistent coughing may indicate an asthma attack and a 7 yo child would be able to provide only minimal hx information, it would be important to obtain information from the parent. Although determining the Childs HR is an important part of the assessment, it would be done after the history is obtained.

a father brings his 3 month old infant to the clinic, reporting that the infant has a cold, is having trouble breathing, and "just doesn't seem to be acting right". Which of the following actions should the RN do first? 1. Check the infants HR 2. Weight the infant 3. Assess the infants oxygen saturation 4. Obtain more information from the father.

3. In an infant with these sx, the first action by the RN would be to obtain an O2 sat reading to determine how well the infant is oxygenating, which is valuable information for an infant having trouble breathing. Because the father probably can provide no other information, checking the HR would be the second action done by the RN. Then obtain infants weight.

An 11 year old is admitted for treatment of an asthma attack. Which of the following indicates immediate interventions is needed? 1. Thin, copious mucous secretions 2. Productive cough 3. Intercostal retractions 4. Respiratory rate of 20 breaths per minute

3. Intercostal retractions indicate an increase in respiratory effort, which is a sign of respiratory distress. During an asthma attack, secretions are thick, the cough is tight, and Respirations are difficult.

Which of the following RN interventions would reduce the cardiac workload in an infant with a congenital heart disorder? 1. Provide long periods of time for feedings 2. allow the infant to have "his/her" way to avoid crying 3. Schedule uninterrupted rest periods 4. Weight the infant daily and record strict intake and output

3. Schedule uninterrupted rest periods Organized nursing care to provide for uninterrupted periods of sleep.

When preparing the teaching plan for the mother of a child with asthma, which of the following should the RN include as signs to alert the mother that her child is having an asthma attack? 1. Secretion of thin, copious mucus 2. Tight, productive cough 3. Wheezing on expiration 4. Temperature of 99.4

3. The child who is experiencing an asthma attack typically demonstrates wheezing on expiration initially. This results from air moving through narrowed airways secondary to bronchoconstriciton. The child's expiratory phase is normally longer than the inspiratory phase.

The desired outcome of working with an individual who has witnessed a traumatic event and is now experiencing panic anxiety is: 1. The individual will experience no anxiety 2. The individual will demonstrate hope for the future. 3. The individual will maintain anxiety at a manageable level 4. The individual will verbalize acceptance of self as worthy.

3. The individual will maintain anxiety at a manageable level.

Initial symptoms of lithium toxicity include which of the following? 1. Constipation, dry mouth 2. Dizziness, thirst 3. Vomiting, Diarrhea 4. Anuria, arrhythmias

3. Vomiting, Diarrhea

A patients dx of CF was made 13 years ago, and he has since been hospitalized several times. On the latest admission, the client has labored respirations, fatigue, malnutrition, and failure to thrive. Which nursing actions are most important initially? 1. Placing the client on bed rest and prescribing a blood gas analysis 2. Prescribing a high-calorie, high-protein, low-fat, vitamin enriched diet and pancreatic granules 3. Applying an oximeter and initiating respiratory therapy 4. Inserting an IV line and initiating abx therapy

3. patients with CF commonly die from respiratory problems. The mucus in the lungs in tenacious and difficult to expel, leading to lung infections and interference with O2 and carbon dioxide change.

After discussing asthma as a chronic condition, which of the following statements by the father of a child with asthma best reflects the family's positive adjustment to this aspect of the child's disease? a) "We try to keep him happy at all costs; otherwise, he has an asthma attack." b) "We keep our child away from other children to help cut down on infections." c) "Although our child's disease is serious, we try not to let it be the focus of our family." d) "I'm afraid that when my child gets older, he won't be able to care for himself like I do."

3. positive adjustment to a chronic condition requires placing the child's illness in its proper perspective. Children with asthma need to be treated as normally as possible within the scope of the limitations imposed by the illness.

An adolescent with chest pain goes to the school RN. The RN determines that the teenager has a hx of asthma but has had no problems for years. Which of the following should the RN do next? 1. Call the adolescent's parent 2. Have the adolescent lie down for 30 minutes 3. Obtain a peak flow reading 4. Give two puffs of a short-acting bronchodilator

3. problems of chest pain in children and adolescents are rarely cardiac. With a hx of asthma, the most likely cause of chest pain is r/t asthma. Therefore, the RN should check the adolescent's peak flow reading to evaluate the status of the air flow. Calling the adolescent's parent would be appropriate, but this would be done after the RN obtains the peak flow reading and additional assessment data.

When teaching the parents of an older infant with CF about the type of diet the child should consume, which of the following would be appropriate? 1. Low protein diet 2. high fat diet 3 low carb diet 4. high calorie diet

4. CF affects the exocrine glands. Mucus is thick and tenacious, sticking to the walls of the pancreatic and bile ducts and eventually causing obstruction. Because of the difficulty with digestion and absorption, a high-calorie, high-protein, high-carbohydrate, moderate fat diet is indicated.

During bedside report, the RN learns that the cardiac circulation of an infant is shunting from Right to Left. The RN recognizes that the infant may have impaired gas exchange related to: 1. Decreased pulmonary vascular pressure 2. Dilated pulmonary capillaries 3. Decreased ventilation in relation to perfusion 4. Decreased pulmonary blood flow

4. Decreased pulmonary blood flow If there is a shunt from R to L. There is less blood flow due to blood going to left side of heart instead of up pulmonary artery.

You're patient on the floor who has been diagnosed with NCD due to AD, has trouble sleeping and wanders around at night. Which of the following nursing actions would be best to promote sleep? 1. Ask the doctor to prescribe flurazepam (Dalmane) 2. Ensure that they get an afternoon nap so they will not be overtired at bedtime. 3. Make them a cup of tea with honey before bedtime 4. Ensure they get regular physical exercise during the day.

4. Ensure they get regular physical exercise during the day.

Which of the following demonstrates strict adherence to the medical regimen in an 8 year old boy with a dx of CHF? 1. Daily use of abs 2. pulse rate less than 50 bpm 3. Elevation in RBC 4. Normal weight for age

4. Normal weight for age.

An 8-year-old child with asthma states, "I want to play some sports like my friends. What can I do?" The RN responds to the child based on the understanding of which of the following? 1. physical activities are inappropriate for children with asthma. 2. Children with asthma must be excluded from team sports 3. Vigorous physical exercise frequently precipitates an asthmatic episode. 4. Most children with asthma can participate in sports if the asthma is controlled.

4. Physical activities are beneficial to asthmatic children, physically and psychologically. Most children with asthma can engage in school and sports activities that are geared to the child's condition and within the limits imposed by the disease. Those children who have exercise-induced asthma usually use a short-acting bronchodilator before exercising.

A 3 yo is brought into the ED in her mother's arms. The child's mouth is open and she is drooling and lethargic. Her mother states that she became ill suddenly within the past 2 hours. What should the RN do first? 1. draw blood cultures for CBC 2. start an IV Line 3. inspect the child's throat with a tongue blade 4. Maintain the child in an undisturbed, upright position

4. This child is in severe respiratory distress with the potential for complete airway obstruction. The RN should refrain from disturbing the child at this time to avoid irritating the epiglottis and causing it to completely obstruct the child's airway.

Mrs. G has been diagnosed with NCD due to AD. The cause of this disorder is which of the following? 1. Multiple small brain infarcts 2. chronic alcohol abuse 3. Cerebral abscess 4. Unknown

4. Unknown

During an examination of an infant with a PDA, the HCP should expect to observe: Select all that apply 1. Profound cyanosis 2. Widening pulse pressure 3. Systolic murmur 4. Bounding peripheral pulses 5. Clubbing of fingers and toes

B,C,D Widening pulse pressure, systolic murmur, bounding peripheral pulses. Blood shunted from aorta to pulmonary artery and to left side of heart increases circulatory volume. Results in bounding pulses.