Final Review @ Jean Erney

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The nurse is caring for a patient with a bleeding disorder. Which manifestation might first alert the nurse to the possibility of disseminated intravascular coagulation? a. Petechiae b. Absence of pulses in extremities c. Weakness or paralysis on one side d. Increasing blood pressure and pulse

While collecting data, the nurse suspects that a patient is experiencing renal calculi. What did the nurse assess to come to this conclusion? (Select all that apply.) a. Nausea b. Flank pain c. Fever and chills d. Costovertebral tenderness e. Pain radiating to the genitalia

a, b, d, e

What is the first sign of hypovolemic shock from postpartum hemorrhage? a. Cold, clammy skin b. Tachycardia c. Hypotension d. Decreased urinary output

The nurse is reinforcing teaching provided to a patient about risk factors for the development of bladder cancer. What risk factor should the patient state that indicates understanding of this teaching? a. Smoking b. Hyperlipidemia c. Diet high in calcium d. Recurrent UTIs

Which assessment would the nurse report to the physician immediately? a. 2-month-old with a urine output of 150 mL in 24 hours b. 3-year-old with a urine output of 650 mL in 24 hours c. 8-year-old with a urine output of over 1000 mL in 24 hours d. 14-year-old with a urine output of 800 mL in 24 hourse

Which is the most appropriate intervention for a 3-month-old infant who has gastroesophageal reflux? a. Position the infant in the crib on his or her abdomen, with the head elevated. b. Administer medication as ordered to stimulate the pyloric sphincter. c. Give thin rice cereal with formula before feeding solid foods. d. Place the infant in an infant seat after feedings.

Which nursing diagnosis would be a priority when preparing a plan of care for a child in a leg cast? a. Risk for altered peripheral tissue perfusion b. Risk for altered urine elimination c. Knowledge deficit d. Risk for infection

What factor(s) may trigger abuse in a parent? (Select all that apply.) a. Being abused as a child b. High self-esteem c. Substance abuse d. Overwhelming responsibility e. Knowledge deficit relative to child care

a, c, d, e

A child is brought to the emergency department with severe frostbite. Which body parts should be warmed first? a. Hands and arms b. Feet and legs c. Fingers and toes d. Head and torso

A child is brought to the pediatric clinic because he has been vomiting for the past 2 days. What acid-base imbalance would the nurse expect to occur from this persistent vomiting? a. Hyperkalemia b. Hypernatremia c. Acidosis d. Alkalosis

The nurse is discharging a patient with endometriosis from an office visit. The patient says her medication helps but does not relieve all her discomfort. What other measures acan the nurse recommend? a. "Check with the health food store. There are several herbal remedies that can be very effective." b. "Try using the relaxation exercises you learned in your childbirth classes. A warm compress to your abdomen might also help." c. "You can double up on your pain medication on occasion, but you shouldn't do it on a regular basis." d. "If the medications aren't effective, then it is time to talk to the physician about a hysterectomy."

b. Relaxation exercises and warm compresses can help relax the patient and reduce the perception of pain, when used with medication

1. Which male reproductive duct carries sperm into the abdominal cavity? a. Urethra b. Epididymis c. Ductus deferens d. Ejaculatory duct

c. Ductus deferens

Retinopathy of Prematurity

condition in which there is separation and fibrosis of retina, which can lead to blindness

treatment for RDS

corticosteroids 1-2 days before delivery; in preterm, surfactant can be administered via ET tube at birth or when symptoms occur

The nurse determines that a patients urine output is normal. How many mL of urine did the patient void within the last 24 hours? a. 150 to 400 mL b. 250 to 500 mL c. 750 to 1000 mL d. 1000 to 2000 mL

The nurse encourages adequate intake of folic acid for women of childbearing age before and during pregnancy. What is folic acid thought to decrease the incidence of in fetal development? a. Structural heart defects b. Craniofacial deformities c. Limb deformities d. Neural tube defects

The nurse explains that the birth weight of monozygotic twins is frequently below average. What is the most likely cause? a. Inadequate space in the uterus b. Inadequate blood supply c. Inadequate maternal health d. Inadequate placental nutrition

The nurse explains that the softening of the cervix and vagina is a probable sign of pregnancy. What is the appropriate term for this sign? a. Chadwicks b. Hegars c. McDonalds d. Goodells

The nurse explains to a patient in preterm labor that what may be ordered by the physician to accelerate fetal lung maturity? a. Prostaglandins b. Oxytocin c. Magnesium sulfate d. Corticosteroids

The nurse is participating in the planning of care for a patient who has HIV. Which therapeutic action should the nurse recognize as the treatment goal for HIV? a. Stimulating the immune system b. Treating opportunistic infections c. Killing the virus with medication d. Keeping the virus from replicating

The nurse is performing a neurological assessment on a 10-month-old infant using a modified Glasgow Coma Scale. What score will the nurse give if the child is babbling? a. 1 b. 2 c. 3 d. 4

The nurse is providing information to parents of a child born with bilateral cryptorchidism. What information is accurate to include? a. This is the most common form. b. Fertility will be unaffected. c. Surgical intervention is not recommended. d. An inguinal hernia may be present.

What will the nurse expect when assessing the anterior fontanelle of a healthy, full-term newborn? a. Depressed and sunken b. Triangular shaped c. Smaller than the posterior fontanelle d. Open and diamond shaped

What will the nurse include when teaching about general skin care measures that could help prevent acne? a. Eliminating chocolate, peanuts, and cola from the diet b. Washing the face with a cleansing product frequently c. Planning indoor activities to avoid sun exposure d. Eating a balanced diet and getting sufficient rest

24. Which of the following should the nurse anticipate teaching about when caring for a man with infertility? a. Penile implants b. Prostatectomy c. TURP d. Decrease in nicotine and alcohol use

d. Nicotine and alcohol use can interfere with male fertility

Nursing Care of Infant With NEC

observe vitals, measure abdomen, listen for bowel sounds, carefully resume oral fluids as ordered, maintain infection control techniques; surgical removal of necrosed bowel may be indicated

Nursing Care Related to Nutrition

observe/record bowel sounds and passage of meconium; for gavage feedings, aspiration before feeding is important, if no residual it is safe to start feeding, if higher than ordered limit, hold feeding and notify physician

early hypocalcemia

occurs when parathyroid fails to respond to preterm's low calcium levels

A nursing student correctly identifies that a person's outward appearance or expression of genes is referred to as which of the following? a) allele b) genome c) phenotype d) genotype

phenotype Correct Explanation: Alleles are two like genes. Phenotype refers to a person's outward appearance or the expression of genes. Genotype refers to his or her actual gene composition. Genome is the complete set of genes present in a person.

A female patient reports her menstrual cycle consistently occurs every 32 days. What day of her cycle can the woman anticipate ovulation? a. 14 b. 16 c. 18 d. 20

A full-term newborn weighs 3600 grams at birth. What would the nurse expect the newborn to weigh in grams 3 days later? a. 2900 b. 3100 c. 3300 d. 3800

Upper portion of the uterus bends forward

ANTEFLEXION

Noncancerous overgrowth of prostate tissue

BENIGN PROSTATIC HYPERTROPHY

19. With both hands

BIMANUAL

The nurse is caring for a patient with a clotting disorder. Which blood product should the nurse anticipate being prescribed? a. Albumin b. Normal saline c. Cryoprecipitates d. Packed WBCs

Consisting of fibrocysts, which are fibrous tumors that have undergone cystic degeneration or accumulated fluid

FIBROCYSTIC

15. Number of pregnancies

GRAVIDA

23. Damage of the sacral spinal nerves

SACRAL RADICULOPATHY

Which restraint is most appropriate for the insertion of an intravenous line in a scalp vein of an infant? a. Mummy b. Clove hitch c. Jacket d. Elbow

What noninvasive forms of pain relief might a nurse implement with a newborn? (Select all that apply.) a. Swaddling b. Rocking c. Offering a pacifier d. Distraction e. Cuddling

a, b, c, e

preventing preterm from bleeding

bed should be in slight Fowler's, avoid unnecessary stimulation that can cause increased intracerebral pressure

After birth, the nurse quickly dries and wraps the newborn in a blanket. How does this action prevent heat loss? a. Conduction b. Radiation c. Evaporation d. Convection

The embryo is termed a fetus at which stage of prenatal development? a. 2 weeks b. 4 weeks c. 9 weeks d. 16 weeks

A patient has a glomerular filtration rate of 20 mL/min. For which stage of renal failure should the nurse plan care for this patient? a. Mild b. Slight c. Severe d. Moderate

How long does sperm remain viable in the female reproductive tract? a. 12 hours b. 1 day c. 2 days d. 4 days

The nurse is caring for a 3-year-old with severe burns. What is the nurse aware is the minimum adequate hourly urine output? a. 5 mL/hr b. 10 mL/hr c. 15 mL/hr d. 20 mL/hr

A nurse is teaching an adolescent with type 1 diabetes about the disease. Which instruction by the nurse about how to prevent hypoglycemia would be most appropriate for the adolescent? a) "Increase the insulin dosage before planned or unplanned strenuous exercise." b) "Limit participation in planned exercise activities that involve competition." c) "Carry crackers or fruit to eat before or during periods of increased activity." d) "Check your blood glucose level before exercising, and eat a protein snack if the level is elevated."

"Carry crackers or fruit to eat before or during periods of increased activity." Correct Explanation: Hypoglycemia can usually be prevented if an adolescent with diabetes eats more food before or during exercise. Because exercise with adolescents isn't commonly planned, carrying additional carbohydrate foods is a good preventive measure.

Which statement by the parent of a 12-month-old child diagnosed with Down syndrome shows the need for further education? a) "Thyroid testing is needed every year." b) "I will need to delay any further immunizations." c) "In a couple of years, my child will need an x-ray of the neck." d) "I will watch closely for development of respiratory infection."

"I will need to delay any further immunizations." Correct Explanation: Down syndrome children are at higher risk for infection because of a lowered immune system. Delaying immunizations may expose the child to illnesses that could have been prevented. Down syndrome children are at greater risk for developing thyroid disorders, 1st and 2nd vertebrae disorders, and respiratory infections.

Parents tell the nurse who is admitting their infant for a well-child exam that they recently saw a "white glow" in their child's left pupil. What is the nurse's best response? a) "Has your baby been rubbing either eye?" b) "Most parents mention a red color." c) "I will report this to the pediatrician." d) "A plugged tear duct would not be unusual."

"I will report this to the pediatrician." Correct Explanation: The "white glow" may indicate retinoblastoma; immediate investigation is needed. The red reflex is indicative of eye health. Eye rubbing and a plugged tear duct are unrelated to the symptom described.

After explaining the causes of hypothyroidism to the parents of a newly diagnosed infant, the nurse should recognize that further education is needed when the parents ask which question? a) "So, hypothyroidism can be treated by exposing our baby to a special light, right?" b) "Are you saying that hypothyroidism is caused by a problem in the way the thyroid gland develops?" c) "So, hypothyroidism can be only temporary, right?" d) "Do you mean that hypothyroidism may be caused by a problem in the way the body makes thyroxine?"

"So, hypothyroidism can be treated by exposing our baby to a special light, right?" Explanation: Congenital hypothyroidism can be permanent or transient and may result from a defective thyroid gland or an enzymatic defect in thyroxine synthesis. Only the last question, which refers to phototherapy for physiologic jaundice, indicates that the parents need more information.

Which statement by the nurse accurately describes the term phenotype? a) "The genetic makeup of an individual" b) "The somatic cells of an individual" c) "The individual's outward appearance" d) "Only the homozygous genes outwardly expressed"

"The individual's outward appearance" Correct Explanation: Phenotype is the outward characteristic of an individual. The genetic makeup of an individual is a genotype. A somatic cell is an individual cell that combines with others to form an organism. Phenotype can be determined by both homozygous genes and heterozygous genes.

The young child has been diagnosed with a secondary growth hormone deficiency. The child weighs 58 pounds. The physician orders the child to receive 0.2 mg of growth hormone for each kilogram of body weight per week, divided into daily doses. How many milligrams of growth hormone would the child receive with each dose? Round to the thousandths place.

0.075 Explanation: The child weighs 58 pounds and 2.2 pounds = 1 kg. 58 pounds x 1 kg/2.2 pounds = 26.3636 kg of body weight. 26.3636 x 0.2 mg/1 kg = 0.5273 mg of growth hormone per week. 0.5273 mg/week x 1 week/7 days = 0.0753 mg/day.

The child has been prescribed chemotherapy. In order to properly calculate the child's dose, the nurse must first figure the child's body surface area (BSA). The child is 130 cm tall and weighs 27 kg. Calculate the child's BSA and round to the hundredths place. ______ BSA

0.99 Explanation: Square root of (height [cm] x weight [kg] divided by 3,600) = BSA. The child is 130 cm tall and weighs 27 kg: 130 x 27 = 3,510; 3,510/3,600 = 0.975; and the square root of 0.975 is 0.9874. The BSA would be 0.987, when rounded to the hundredths place = 0.99.

A woman carries a recessive gene for sickle cell anemia. If her sexual partner also has this recessive gene, the chance that her first child will develop sickle cell anemia is a) 0 in 4. b) 2 in 4. c) 1 in 4. d) 3 in 4.

1 in 4. Correct Explanation: Autosomal recessive inherited diseases occur at a 1-in-4 incidence in offspring.

What symptom assessed in the newborn shortly after delivery should be reported? a. Cyanosis of the hands and feet b. Irregular heart rate c. Mucus draining from the nose d. Sternal or chest retractions

nutritional needs of preterm

120- to 150- kcal/kg/day

The physician requests the nurse to calculate the child's ANC. The complete blood count indicates that the child's "segs" are 14%, bands are 9%, and white blood cells (WBC) are 15,000. Calculate the child's absolute neutrophil count. _____ ANC

3450 Correct Explanation: Bands + segs/100) x WBC = ANC 14 + 9 = 23% = 23/100 = 0.23 0.23 x 15,000 = 3,450

When collecting data on a child diagnosed with diabetes mellitus, the nurse notes that the child has had weight loss and other symptoms of the disease. The nurse would anticipate which of the following findings in the child's fasting glucose levels? a) 180 mg/dL b) 120 mg/dL c) 60 mg/dL d) 240 mg/dL

240 mg/dL Correct Explanation: If the blood glucose level is elevated or ketonuria is present, a fasting blood sugar (FBS) is performed. An FBS result of 200 mg/dL or higher almost certainly is diagnostic for diabetes when other signs such as polyuria and weight loss, despite polyphagia, are present.

51. A patient who has just returned from an abdominal panhysterectomy is at risk for impaired urninary elimination. At least how many milliliters should be in her catheter bag 8 hours postoperatively?

240. The patient should eliminate at least 30 mL per hour times 8 hours = 240 mL

term gestation

38 to 42 weeks``

A nurse is counseling a couple who have a 5-year-old daughter with Down syndrome. The nurse recognizes that their daughter's genome is represented by which of the following? a) 47XY21+ b) 46XX5p- c) 46XX d) 47XX21+

47XX21+ Correct Explanation: In Down syndrome, the person has an extra chromosome 21, so this is abbreviated as 47XX21+ (for a female) or 47XY21+ (for a male). 46XX is a normal genome for a female. The abbreviation 46XX5p- is the abbreviation for a female with 46 total chromosomes but with the short arm of chromosome 5 missing (Cri-du-chat syndrome).

A 25-year-old woman who recently underwent genetic testing has just learned that she is heterozygous dominant for Huntington disease. Her husband, however, who also underwent the testing, is free from the trait. What are the odds that the couple will have a child who will inherit the disorder? a) 25% b) 50% c) 75% d) 100%

50% Correct Explanation: If a person who is heterozygous or has a dominant illness gene opposing a recessive healthy gene mates with a person who is free of the trait, the chances are even (50%) a child born to the couple would have the disorder or would be disease and carrier free (that is, carrying no affected gene for the disorder).

The nurse is discussing the treatment for a child with attention deficit hyperactivity disorder with a group of school nurses. Which of the following would be an appropriate learning setting for a child with ADHD? a) A classroom with windows facing a playground. b) A classroom with tables and chairs rather than individual desks. c) A classroom with a plan of study that is followed each day. d) A classroom in which children self-select their activities.

A classroom with a plan of study that is followed each day. Correct Explanation: For the child with ADHD the learning situations should be structured so that the child has minimal distractions and a supportive teacher. Special arrangements can be made to provide an educational atmosphere that is supportive for the child without the need for the child to leave the classroom.

The nurse is teaching the parents of a 15-year-old boy who is being treated for acute myelogenous leukemia about the side effects of chemotherapy. For which of the following symptoms should the parents seek medical care immediately? a) Difficulty or pain when swallowing b) A temperature of 101°F (38.3° C) or greater

A temperature of 101°F (38.3° C) or greater Explanation: The parents should seek medical care immediately if the child has a temperature of 101°F (38.3° C) or greater. This is because many chemotherapeutic drugs cause bone marrow suppression; the parents must be directed to take action at the first sign of infection in order to prevent overwhelming sepsis. The appearance of earache, stiff neck, sore throat, blisters, ulcers, or rashes, or difficulty or pain when swallowing are reasons to seek medical care, but are not as grave as the risk of infection.

A pregnant client has heard about Down syndrome and wants to know about the risk factors associated with it. Which of the following would the nurse include as a risk factor? a) Advanced maternal age b) Recurrent miscarriages c) Advanced paternal age d) Family history of condition

Advanced maternal age Correct Explanation: Advanced maternal age is one the most important factors that increases the risk of an infant being born with Down syndrome. Down syndrome is not associated with advanced paternal age, recurrent miscarriages, or family history of Down syndrome.

The absence or suppression of mentruation

AMENORRHEA

Medication used to treat Herpes

ACYCLOVIR

20. Appendages, accessory organs (ovaries and tubes)

ADNEXA

1. Failure of an organ or part to develop or grow

AGENESIS

The nurse is caring for an infant with hydrocephalus. What nursing action is most important for this nurse to implement? a. Align the limbs. b. Support the head. c. Keep the head lower than the hip. d. Check intake and output

What would the nurse assess for in a preterm infant receiving an intravenous infusion containing calcium gluconate? a. Seizures b. Bradycardia c. Dysrhythmias d. Tetany

Uterus lies too far forward

ANTEVERSION

Surgery to increase the size of the breasts

AUGMENTATION

When reviewing information about the incidence of the various types of childhood cancer, nursing students demonstrate understanding of the information when they identify which of the following as having the highest incidence? a) Acute lymphocytic (lymphoblastic) leukemia b) Osteogenic sarcoma c) Neuroblastoma d) Non-Hodgkin's lymphoma

Acute lymphocytic (lymphoblastic) leukemia Correct Explanation: Acute lymphocytic leukemia accounts for approximately 32% of all childhood cancers. Neuroblastomas account for 8%; non-Hodgkin's lymphoma accounts for 6%; osteogenic sarcoma accounts for 3%

The drug most commonly abused by children and adolescents is which of the following? a) Alcohol b) Marijuana c) Ecstasy d) Percocet

Alcohol Correct Explanation: Alcohol abuse occurs when a person ingests a quantity sufficient to cause intoxication. It is also the most commonly abused drug among children and adolescents.

A woman in her third trimester has just learned that her fetus has been diagnosed with cri-du-chat syndrome. The nurse recognizes that this child will likely have which of the following characteristics? a) Small and nonfunctional ovaries b) Cleft lip and palate c) Rounded soles of the feet (rocker-bottom) d) An abnormal, cat-like cry

An abnormal, cat-like cry Correct Explanation: Cri-du-chat syndrome is the result of a missing portion of chromosome 5. In addition to an abnormal cry, which sounds much more like the sound of a cat than a human infant's cry, children with cri-du-chat syndrome tend to have a small head, wide-set eyes, a downward slant to the palpebral fissure of the eye, and a recessed mandible. They are severely cognitively challenged. Rounded soles of the feet are characteristic of trisomy 18 syndrome. Cleft lip and palate are characteristic of trisomy 13 syndrome. Small and nonfunctional ovaries are characteristic of Turner syndrome.

The nurse will use a special needle to start intravenous (IV) fluids through which central venous access device? a) A peripherally inserted central catheter b) An implanted port c) A multilumen catheter d) A tunneled central catheter

An implanted port Correct Explanation: An implanted port requires a special (Huber) needle placed through the skin into the port, which is implanted surgically under the skin and over a bony prominence. The peripherally inserted central catheter (PICC) and tunneled catheters (Broviac, Hickman, Groshong) do not require a special needle for access. A multilumen catheter has more than one lumen but is not a port.

A child with ADHD is placed on methylphenidate (Ritalin) therapy. Which of the following symptoms may children on Ritalin develop? a) Anorexia b) Sleepiness c) Rapid increase in height d) Hypotension

Anorexia Correct Explanation: Ritalin typically causes a loss of appetite. Weighing the child periodically to detect whether this has led to a loss of weight is important.

A nurse is reviewing information about the various types of insulin that are used to treat diabetes mellitus type 1. Integrating knowledge about the duration of action, place the types below in the order from shortest to longest duration. Glargine NPH Aspart Regular

Aspart Regular NPH Glargine Explanation: Aspart has a duration of action of 3 to 5 hours; regular insulin has a duration of 5 to 8 hours; NPH has a duration of 10 to 16 hours; and glargine has a duration of 12 to 24 hours.

The physician has ordered a thyroid scan to confirm the diagnosis. Before the procedure the nurse should: a) Give the client a bolus of fluids. b) Tell the client they will be asleep. c) Assess the client for allergies. d) Insert a urinary catheter.

Assess the client for allergies. Correct Explanation: A thyroid scan uses dye, so a client should be assessed for allergies to iodine and shellfish to prevent a possible reaction. The client will not be asleep, have a catheter, or receive a bolus of fluids.

A group of nursing students are reviewing medications used to treat attention deficit/hyperactivity disorder (ADHD). The group demonstrates understanding of the information when they identify which of the following as a nonstimulant norepinephrine reuptake inhibitor? 1) Atomoxetine 2) Methylphenidate 3) Lisdexamfetamine 4) Pemoline

Atomoxetine Explanation: Atomoxetine is a nonstimulant norepinephrine reuptake inhibitor used to treat ADHD. Methylphenidate is a psychostimulant used to treat ADHD. Lisdexamfetamine is a psychostimulant used to treat ADHD. Pemoline is a psychostimulant used to treat ADHD.

The nurse is preparing a presentation for a local health fair on autism spectrum disorders. Which of the following would the nurse include as part of the presentation? a) Autism cannot be cured. b) Scientific evidence supports the use of complementary therapies. c) Children respond best when the environment is less structured. d) Communication therapies are of little value in treating autism.

Autism cannot be cured. Correct Explanation: There are no medications or treatment available to cure autism. Behavioral and communication therapies are very important in caring for a child with autism. Children with autism spectrum disorder respond very well to highly structured educational environments. To date, complementary and alternative medical therapies have not been scientifically proven to improve autism.

A group of nursing students are studying information about childhood cancers in preparation for a class examination. They are reviewing how childhood cancers differ from adult cancers. The group demonstrates understanding of the information when they identify which of the following as an unlikely site for childhood cancer? a) Bladder b) Brain c) Blood d) Kidney

Bladder Correct Explanation: The most common sites for childhood cancer include the blood, lymph, brain, bone, kidney, and muscle. Bladder is a common site for adult cancer.

A 17-year-old is found after a high school football game wandering around. He is confused, sweaty, and pale. Which of the following tests is most likely to be performed first? a) Arterial blood gases b) Blood glucose level c) Blood cultures d) CT scan

Blood glucose level Correct Explanation: It is important to draw a blood glucose level on the child because he is exhibiting signs of hypoglycemia and he needs to be treated as soon as possible. Once the patient is stabilized, a complete health history will need to be taken to determine the extent of his illness.

What would the nurse consider an abnormal finding on a musculoskeletal assessment of a 4-year-old child? a. Has inward-turned knees while standing b. Walks on the toes c. Appears to have flat feet d. Swings his arms when walking

What would the nurse expect to find in a child admitted to the hospital for nonorganic failure to thrive? a. Cry to be picked up b. Be limp like a rag doll c. Be responsive to cuddling d. Weigh in the 10th percentile for age

What is one advantage of an implanted port (central venous access device) that the nurse will explain to an adolescent? a) Body appearance changes very little. b) Flushing of the device is not necessary. c) No tunneling is needed when the port is inserted. d) No special procedure is necessary for removal.

Body appearance changes very little. Correct Explanation: An implanted port has nothing extending through the skin and may be obvious only as a slight protrusion at the insertion site. Some tunneling from the port to a central vein is needed. Removal of the port requires a surgical procedure. Flushing of the port is necessary when used and on a regular basis.

The nurse is admitting to an examination room a child with the diagnosis of "probable acute lymphoblastic leukemia." What will confirm this diagnosis? a) History of leukemia in twin b) Lethargy, bruising, and pallor c) Bone marrow aspiration d) Complete white blood count

Bone marrow aspiration Correct Explanation: Bone marrow aspiration and biopsy are diagnostic. An abnormal white blood count and symptoms of lethargy, bruising, and pallor only create suspicion of leukemia; a twin may or may not be affected.

A group of students are reviewing information about delayed puberty in preparation for a class discussion. The students demonstrate understanding of this condition when they describe which of the following as occurring in girls? a) Growth spurt has not begun by age 12. b) Breast development has not occurred by age 13. c) Pubic hair has not appeared by age 16. d) Menarche has not occurred by age 14.

Breast development has not occurred by age 13. Explanation: Delayed puberty is a condition of delayed secondary sexual development. In girls, it exists if the breasts have not developed by age 13, pubic hair has not appeared by age 14 or menarche has not occurred by age 16. Growth spurt is not a criterion for the disorders.

10. Teenagers who are pregnant or breast feeding need 1300 mg of this daily

CALCIUM

3. Inflammation of the cervix

CERVICITIS

This procedure may be done to prevent infection in a newborn when the mother has active herpes

CESAREAN SECTION

4. A hard, syphilitic primary ulcer, the first sign of syphilis, appearing approximately 2 to 3 weeks after infection

CHANCRE

A newborn exhibits significant jittery movements, convulsions, and apnea. Hypoparathyroidism is suspected. Which of the following would the nurse expect to be administered? a) Hydrocortisone b) Desmopressin c) Levothyroxine d) Calcium gluconate

Calcium gluconate Correct Explanation: Intravenous calcium gluconate is used to treat acute or severe tetany. Hydrocortisone is used to treat congenital adrenal hyperplasia and Addison disease. Desmopressin is used to control diabetes insipidus. Levothyroxine is a thyroid hormone replacement used to treat hypothyroidism.

Which assessment would lead the nurse to suspect that a newborn infant has a ventricular septal defect? a. A loud, harsh murmur with a systolic thrill b. Cyanosis when crying c. Blood pressure higher in the arms than in the legs d. A machinery-like murmur

A child with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is: a) Check vital signs b) Encourage increased fluid intake c) Measure urine output d) Weigh the client

Check vital signs Correct Explanation: The large amount of fluid loss can cause fluid and electrolyte imbalance that should be corrected; the loss of electrolytes would be reflected in vital signs. Urine output is important but not the priority. Encouraging fluids will not correct the problem and weighing the patient is not necessary at this time.

Which type of genetic test would be used to detect the possibility of Down syndrome? a) Complete blood count (CBC) b) DNA analysis c) Hemoglobin electrophoresis d) Chromosomal analysis

Chromosomal analysis Correct Explanation: Chromosomal analysis is part of the genetic testing for Down syndrome. DNA analysis may be used in the detection of Huntington disease. Hemoglobin electrophoresis may be used in genetic testing for sickle cell anemia. A complete blood count (CBC) may be used as part of testing for a thalassemia

You care for a child with Down syndrome (trisomy 21). This is an example of which type of inheritance? a) Mendelian dominant b) Phase 2 atrophy c) Chromosome nondisjunction d) Mendelian recessive

Chromosome nondisjunction Correct Explanation: Down syndrome occurs when an ovum or sperm cell does not divide evenly, permitting an extra 21st chromosome to cross to a new cell.

What would the nurse include in a teaching plan about mouth care of a child receiving chemotherapy? a. Use commercial mouthwash. b. Clean teeth with a soft toothbrush. c. Avoid use of a Water-Pik. d. Inspect the mouth weekly for ulcerations

Hypothyroidism results from deficient production of thyroid hormone or a defect in the thyroid hormone receptor activity. Hypothyroidism caused during embryonic development of the gland is called: a) Autoimmune thyroiditis b) Congenital hypothyroidism c) Secondary hypothyroidism d) Acquired hypothyroidism

Congenital hypothyroidism Correct Explanation: Congenital hypothyroidism is most commonly caused by defective embryonic development of the gland. Acquired hypothyroidism usually refers to thyroid deficiency that becomes evident after a period of apparently normal thyroid function. The most common cause of acquired hypothyroidism in iodine-sufficient regions of the world is lymphocytic thyroiditis (also called Hashimoto's or autoimmune thyroiditis).

As a nurse, you know that which of the following is caused by excessive levels of circulating cortisol: a) Cushing syndrome b) Graves disease c) Addison disease d) Turner syndrome

Cushing syndrome Correct Explanation: CS is a characteristic cluster of signs and symptoms resulting from excessive levels of circulating cortisol. Addison disease is caused by autoimmune destruction of the adrenal cortex, which results in dysfunction of steroidogenesis. Grave disease is the most common form of hyperthyroidism. Turner syndrome is deletion of the entire X chromosome.

13. End to reproductive capabilities, menses must cease for 12 months

MENOPAUSE

17. Inflammation of the cervix producing mucus and purulent discharge

MUCOPURULENT CERVICITIS

The incidence of Down syndrome is 1:1600 in women older than 40 years of age, compared with 1:100 in women younger than 20 years. a) True b) False

False Correct Explanation: The incidence of Down syndrome is 1:100 in women older than 40 years of age, compared with 1:1600 in women younger than 20 years.

A nurse is conducting a physical examination of an adolescent girl with suspected bulimia. Which of the following assessment findings would the nurse expect to note? a) Eroded dental enamel b) Soft sparse body hair c) Dry sallow skin d) Thinning scalp hair

Eroded dental enamel Correct Explanation: The nurse should be sure to carefully assess the mouth and oropharynx for eroded dental enamel, red gums, and inflamed throat from self-induced vomiting. The other findings are typically noted with anorexia nervosa.

You are going in to see a new patient in the clinic and the chief complaints for the patient are polyuria and polydipsia. You know that these are indicative of which endocrine disorder? a) Hypopituitarism b) Precocious puberty c) Diabetes insipidus d) Syndrome of inappropriate antidiuretic hormone secretion

Diabetes insipidus Correct Explanation: The most common symptoms of central DI are polyuria (excessive urination) and polydipsia (excessive thirst). Children with DI typically excrete 4 to 15 L per day of urine despite the fluid intake. The onset of these symptoms is usually sudden and abrupt. Ask about repeated trips to the bathroom, nocturia, and enuresis. Other symptoms may include dehydration, fever, weight loss, increased irritability, vomiting, constipation, and, potentially, hypovolemic shock.

Which of the following diagnoses would be most appropriate for an infant with a large retinoblastoma after surgery? a) Disturbed sensory perception related to enucleation b) Pain related to retinal removal c) Anticipatory grieving related to change in body image d) Fear related to loss of normal vision

Disturbed sensory perception related to enucleation Explanation: The primary therapy for a large retinoblastoma is removal (enucleation) of the affected eye.

29. Enlargement and hardening of the penis caused by engorgement of blood

ERECTION

12. The expelling of semen from the urethra with force

EJACULATION

Which nursing objective is most important when working with neonates who are suspected of having congenital hypothyroidism? a) Promoting bonding b) Early identification c) Encouraging fluid intake d) Allowing rooming in

Early identification Correct Explanation: The most important nursing objective is early identification of the disorder. Nurses caring for neonates must be certain that screening is performed, especially in neonates who are preterm, discharged early, or born at home. Promoting bonding, allowing rooming in, and encouraging fluid intake are all important but are less important than early identification.

The nurse is preparing a plan to educate the parents of a 10-year-old boy with a learning disorder. Which of the following will be part of this plan? a) Explain the child's strengths and weaknesses. b) Encourage parents to give the child personal space. c) Tell parents to check on the child regularly. d) Have parents learn the child's facial expressions.

Explain the child's strengths and weaknesses. Correct Explanation: The nurse will explain the nature of the child's disorder but will also point out the strengths the child possesses as part of the plan. Encouraging parents to provide a personal space for the child is an intervention meant to promote autonomy and responsibility for a child with delayed growth and development. Regularly checking up on the child is a preventive measure to promote safety for a child with a developmental disorder. Learning facial expressions is important when a child has impaired communication skills.

Nursing students are reviewing information about the normal cell cycle. They demonstrate understanding of this process when placing phases in the proper sequence. Place the phases in the sequence that demonstrates understanding by the nursing students. Doubling of cell size Cell at rest Gap Duplication of DNA and chromosomes Cell division Period until DNA stabilization complete

Gap Cell at rest Period until DNA stabilization complete Duplication of DNA and chromosomes Doubling of cell size Cell division Explanation: The phases of the cell cycle include G or gap phase; G0 when the cell is at rest; G1, the period until DNA stabilization is complete; S(synthesis), DNA and chromosomes duplicate or cell readies for division; G2, the cell doubles in size in preparation for dividing; and mitosis or period of cell division.

A 12-year-old is being seen in the office and has hyperthyroidism; the nurse knows that the most common cause of hyperthyroidism is which of the following: a) Plummer disease b) Cushing disease c) Addison disease d) Graves disease

Graves disease Correct Explanation: Hyperthyroidism occurs less often in children than hypothyroidism. Graves' disease, the most common cause of hyperthyroidism in children, occurs in 1 in 5,000 children between 11 and 15 years of age. Hyperthyroidism occurs more often in females, and the peak incidence occurs during adolescence.

15. Pertaining to herpes

HERPETIC

A preschooler who received chemotherapy in the pediatric oncology outpatient department 1 week ago now has a temperature of 101.5°F (38.6°C). Which is the most appropriate response by the nurse? a) Ask whether any family members or other close associates are ill b) Tell the parent to administer acetaminophen every 4 hours until the fever dissipates c) Instruct the parent to immediately obtain and give the antibiotic that the oncologist will order d) Have the parent bring the child to the pediatric oncology clinic as soon as possible

Have the parent bring the child to the pediatric oncology clinic as soon as possible Correct Explanation: The preschooler is considered immune suppressed following recent chemotherapy. A fever can mean sepsis, which would require immediate investigation of blood and other body fluids to identify the organism, plus prompt treatment with an IV antibiotic. This can be accomplished only by seeing the pediatric oncologist and is likely to result in hospitalization.

A 6-month-old girl is seen with retinoblastoma. When taking a health history from her father, which symptom would you expect him to report he has noticed? a) His daughter tugs and pulls at one ear. b) His daughter's eye appears to be protruding. c) He has noticed one pupil appears white. d) The infant always keeps her eyes tightly closed.

He has noticed one pupil appears white. Explanation: As the tumor grows against the retina of the eye, the red reflex is no longer visible; the pupil appears white.

You have been working with an adolescent with an eating disorder for several days. Which of the following is an indication that she is developing trust in you? a) Her saying to you that she'll follow your orders but not those of the nurse on the next shift b) Her saying to you that she trusts you more than anyone else c) Her telling you that she is now ready to eat again d) Her telling you that she is still inducing vomiting after each meal

Her telling you that she is still inducing vomiting after each meal Correct Explanation: An adolescent has to be able to trust an adult before she can share confidences.

Without an opening

IMPERFORATE

A child with ALL is beginning treatment with methotrexate in an attempt to eradicate the leukemic cells. The stage of therapy represents which of the following? a) Delayed intensive-therapy phase b) Induction phase c) Consolidation phase d) Sanctuary phase

Induction phase Correct Explanation: An induction phase is the first attempt at eradicating the leukemic cells to induce or achieve a complete remission.

A child with rheumatic fever begins involuntary, purposeless movements of her limbs. What does the nurse recognize that this indicates? a. Seizure activity b. Hypoxia c. Sydenhams chorea d. Decreasing level of consciousness

Which behavior typical of children with autistic disorder requires you to maintain special care to keep them safe? a) A fascination with bright colors b) Insensitivity to pain c) Loss of hearing for high frequencies d) A craving for salt

Insensitivity to pain Correct Explanation: A number of children with autistic disorder demonstrate poor sensation of pain and, thus, bite their hands or bang their heads repeatedly.

Which statement about nondisjunction of a chromosome is true? a) Only the X chromosomes are affected. b) Only 4% of Down syndrome cases are attributed to this defect. c) It may result from genomic imprinting. d) It is failure of the chromosomal pair to separate.

It is failure of the chromosomal pair to separate. Correct Explanation: Nondisjunction simply means failure to separate. Nondisjunction can happen at any chromosome and is attributed to 95% of Down syndrome cases. Genomic imprinting is a different genetic disorder that is not related to nondisjunctioning.

Surgical opening of the abdomen; an abdominal operation

LAPAROTOMY

Rank the different types of insulin based on their duration of action beginning with the shortest to the longest duration. Humulin R Lispro Humulin N Lantus

Lispro Humulin R Humulin N Lantus Correct Explanation: Lispro is a rapid-acting insulin. Humulin R is a short-acting insulin. Humulin N is an intermediate-acting insulin. Lantus is a long-acting insulin.

Surgical modification of the breast

MAMMOPLASTY

Breast pain

MASTALGIA

A group of students are reviewing information about oral diabetic agents. The students demonstrate understanding of these agents when they identify which agent as reducing glucose production from the liver? a) Glyburide b) Metformin c) Glipizide d) Nateglinide

Metformin Correct Explanation: Metformin, a biguanide reduces glucose production from the liver. Glipizide stimulates insulin secretion by increasing the response of β cells to glucose. Glyburide stimulates insulin secretion by increasing the response of β cells to glucose. Nateglinide stimulates insulin secretion by increasing the response of β cells to glucose.

The nurse is caring for a 10-year-old recently diagnosed with attention deficit/hyperactivity disorder (ADHD). The nurse would expect to provide teaching regarding which of the following medications? a) Buspirone b) Methylphenidate c) Fluoxetine d) Trazodone

Methylphenidate Correct Explanation: Methylphenidate is a psychostimulant commonly prescribed for ADHD. Trazodone is used to treat depression. Buspirone is used for anxiety. Fluoxetine is used for depression.

A child with an intellectual disability is evaluated and found to have an intelligence quotient (IQ) of 65. The nurse interprets this as reflecting which category of intellectual disability? a) Mild b) Profound c) Moderate d) Severe

Mild Correct Explanation: Mild intellectual disability involves an IQ from 50 to 70. Moderate intellectual disability involves an IQ from 35 to 50. Severe intellectual disability involves an IQ from 20 to 35. A profound intellectual disability involves an IQ less than 20.

The nurse is caring for a child who has been hospitalized repeatedly at multiple hospitals. There is no clear medical diagnosis and the mother is threatening to leave the hospital against medical advice. The nurse suspects which of the following? a) Anxiety disorder b) Bipolar disorder c) Munchhausen syndrome by proxy d) Sexual abuse

Munchhausen syndrome by proxy Correct Explanation: Repeated hospitalizations that fail to produce a medical diagnosis, transfers to other hospitals, and discharges against medical advice are warning signs of Munchhausen syndrome by proxy.

When teaching parents of a child with encopresis, which of the following would you stress? a) Not punishing the child for encopresis b) Importance of cleaning the child immediately after an accident occurs c) Need for keeping the child close to bathroom facilities at all times d) Necessity for giving 4 to 6 tablespoons of Kaopectate per day

Not punishing the child for encopresis Correct Explanation: Encopresis (inappropriate soiling of stool) is a symptom of an underlying stress or disease. The child needs therapy to determine the cause.

An infant with craniosynostosis from Apert syndrome becomes lethargic and starts to vomit. What is the priority nursing intervention? a) Give IV dextrose b) Monitor intake and output c) Notify the doctor and prepare for surgery d) Reassess every hour and document findings

Notify the doctor and prepare for surgery Correct Explanation: The child is exhibiting signs and symptoms of increased intracranial pressure related to premature fusing of the skull joints. Surgery will be needed to relieve the pressure. IV dextrose is contraindicated with increased intracranial pressure. Waiting 1 hour to reassess may lead to brain damage and death. Monitoring intake and output is needed with a hospitalized child but is not the priority intervention based on presentation of symptoms.

18. Inflammation of the conjunctivae and deeper parts of the eye and can ultimately result in blindness

OPHTHALMIA NEONATORUM

Excision of the entire uterus, including the cervix uteri

PANHYSTERECTOMY

Following sexual intercourse

POSTCOITAL

14. Painful erection that lasts longer than 4 hours

PRIAPISM

20. Inflammation of the rectum nad anus that may be due to either nonsexually transmitted microbes or to STDs

PROCTITIS

16. Removal of entire prostate gland

PROSTATECTOMY

1. Inflammation of the prostate gland; can occur any time after puberty

PROSTATITIS

21. Concerning the puerperium, or period of 42 days after childbirth

PUERPERAL

The nurse is caring for a 10-year-old girl with an anxiety disorder. During a physical examination, which of the following physical findings would the nurse expect to find? a) Patches of hair loss b) Watery eyes c) Dilated eyes d) Absence of nasal hair

Patches of hair loss Correct Explanation: Patches of hair loss that occur with repetitive hair twisting or pulling are associated with anxiety. Watery, dilated eyes and the absence of nasal hair are often signs of substance abuse.

Three sisters decide to have genetic testing done because their mother and their maternal grandmother died of breast cancer. Each of the sisters has the BRCA1 gene mutation. The nurse explains that just because they have the gene does not mean that they will develop breast cancer. What does the nurse explain their chances of developing breast cancer depend on? a) Susceptibility b) Their lifestyles c) Penetrance d) What other gene mutations they have

Penetrance Correct Explanation: A woman who has the BRCA1 hereditary breast cancer gene mutation has a lifetime risk of breast cancer that can be as high as 80%, not 100%. This quality, known as incomplete penetrance, indicates the probability that a given gene will produce disease. The other answers are incorrect because lifestyles, other gene mutations, and susceptibility are not the deciding factor in getting breast cancer if you have the BRCA1 gene mutation.

Which of the following signs is consistent with autistic disorder in a 2-year-old boy? a) Has below-average intellectual function b) Possesses excellent language development c) Performs repetitive activity with toys d) Shows signs of losing attained skills

Performs repetitive activity with toys Correct Explanation: The repetitive behavior pattern with the toys, along with observation of communication and social impairment, would suggest autism. Below-average intellectual function is a sign of mental retardation. Loss of attained skills is a sign of Rett syndrome, which occurs only in girls. The presence of excellent language skills suggests Asperger syndrome.

The nurse is interviewing the caregivers of a child admitted with a diagnosis of Type 1 Diabetes Mellitus. The caregiver states, "She is hungry all the time and eats everything, but she is losing weight." The caregiver's statement indicates the child most likely has which of the following? a) Pica b) Polyphagia c) Polydipsia d) Polyuria

Polyphagia Correct Explanation: Symptoms of Type 1 Diabetes Mellitus include polyphagia (increased hunger and food consumption), polyuria (dramatic increase in urinary output, probably with enuresis), and polydipsia (increased thirst), and. Pica is eating nonfood substances.

Which intervention is best to use with the 6-year-old who has developed stomatitis as a side effect of chemotherapy? a) Limit foods to cool, clear liquids b) Use lidocaine rinses c) Have the child freely choose desired foods and beverages d) Practice frequent, gentle oral hygiene

Practice frequent, gentle oral hygiene Explanation: Frequent, gentle oral hygiene will keep the vulnerable oral mucosa clean and will prevent secondary infection. Offering only cool, clear liquids will limit nutrition. "Child freely choosing foods and beverages" gives some control to the 6-year-old but is likely to result in ingestion of foods that are irritating to the mouth, lips, and throat. Lidocaine used as a rinse can create risks for children younger than 8 years because often some is swallowed, and this inhibits the gag reflex.

Reva is an 8-year-old who is being seen today in the clinic for moodiness and irritability. She has begun to develop breasts and pubic hair and her parents are concerned that she is at too early an age for this to begin. As a nurse you know that the possible prognosis for her is: a) Pseudopuberty b) Adrenal hyperplasia c) Precocious puberty d) Neurofibromatosis

Precocious puberty Correct Explanation: The prognosis for a child with precocious puberty depends on the age at diagnosis and immediate treatment. Appropriate treatment can halt, and sometimes even reverse, sexual development and can stop the rapid growth that results in severe short adult stature caused by premature closure of the epiphysis. Treatment for precocious puberty allows the child to achieve the maximum growth potential possible. Mental development in children with precocious puberty is normal, and developmental milestones are not affected; however, the behavior may change to that of a typical adolescent. Girls may have episodes of moodiness and irritability, whereas boys may become more aggressive.

What is the priority action that the nurse should take when caring for a child newly diagnosed with Wilms' tumor (nephroblastoma)? a) Protact the abdomen from manipulation. b) Assess for constipation. c) Obtain a catheterized urine specimen. d) Control acute pain.

Protact the abdomen from manipulation. Explanation: Manipulation can release malignant cells into the abdominal cavity. Constipation may be a problem following surgical intervention. Pain is uncommon; obtaining a urine specimen is not a priority.

Portion of the rectum sags into the vagina because of inadequate support

RECTOCELE

Upper portion of the uterus bends backward

RETROFLEXION

Backward leakage of blood and tissue into the fallopian tubes during the menstrual period

RETROGRADE

17. Common side effect of prostate surgery; semen falls back into the bladder

RETROGRADE EJACULATION

Uterus lies too far backward

RETROVERSION

A child who has type 1 diabetes mellitus is brought to the emergency department and diagnosed with diabetic ketoacidosis. Which of the following would the nurse expect to administer? a) NPH b) Regular insulin c) Detemir d) Lispro

Regular insulin Correct Explanation: Insulin for diabetic ketoacidosis is given intravenously. Only regular insulin can be administered by this route.

A child with ALL is receiving methotrexate for therapy. Which nursing diagnosis below would best apply to him during therapy? a) Excess fluid volume related to effect of methotrexate on aldosterone secretion b) Risk for impaired skin integrity related to oral ulcerations associated with chemotherapy c) Risk for impaired mobility related to depressant effects of methotrexate d) Risk for self-directed violence related to effect of methotrexate on central nervous system

Risk for impaired skin integrity related to oral ulcerations associated with chemotherapy Explanation: Many chemotherapy agents cause oral ulcerations that interfere with nutrition because of pain and leave a portal of infection.

The nurse is performing an assessment of a 6-year-old girl with Turner syndrome. Which of the following would the nurse most likely assess? a) Pectus carinatum b) Enlarged thyroid gland c) Short stature and slow growth d) Short, stubby trident hands

Short stature and slow growth Correct Explanation: Short stature and slow growth are frequently the first indication of Turner syndrome. While children with Turner syndrome are more prone to thyroid problems, these problems are not as likely to occur as in other symptoms. Pectus carinatum is typical of children with Marfan syndrome. Short, stubby trident hands are typical of achondroplasia.

2. A type of hormonal therapy used to treat breast cancer

TAMOXIFEN

20. Compress

TAMPONADE

A congenital tumor containing one or more of the three primary embryonic germ layers

TERATOMA

The nurse working with the child diagnosed with Type 2 Diabetes Mellitus recognizes that most often the disorder can be managed by which of the following? a) Increasing protein in the diet, especially in the evening b) Decreasing amounts of daily insulin c) Conserving energy with rest periods during the day d) Taking oral hypoglycemic agents

Taking oral hypoglycemic agents Correct Explanation: If the child presents with diabetic ketoacidosis, initial treatment is insulin administration, but then oral hypoglycemic agents such as metformin are often effective for controlling blood glucose levels. Lifestyle changes such as weight loss and increased exercise are important aspects of treatment for the child.

Which of the following is an example of impaired adaptive functioning in a 9-year-old boy with a developmental disorder? a) The child cannot correctly copy a phone number. b) The child cannot correctly copy a sentence. c) The child cannot properly dress herself. d) The child's vision is fine but he is a poor reader.

The child cannot properly dress herself. Correct Explanation: A child with impaired adaptive functioning would not be able to dress himself properly, if at all. The inability to copy a phone number or sentence or to read well reflects learning disorders.

The nurse is assessing an 8-year-old boy who is performing at the second-grade level, complains of feeling tired and weak, and is only 45 inches tall. Which of the following findings would be specific to hypothyroidism? a) The child complains that the exam room is cold. b) The mother reports that the boy is always thirsty. c) The child has gained 20 pounds in the past year. d) Observation shows only two of the 6-year molars.

The child complains that the exam room is cold. Correct Explanation: Cold intolerance, manifested by the fact that the child was uncomfortably cold in the exam room, is a sign of hypothyroidism. Delayed dentition, with only two of the four 6-year molars having erupted, is typical of growth hormone deficiency. Complaints of thirst may signal diabetes or diabetes insipidus. The dramatic weight gain could be due to hypothyroidism, Cushing syndrome, or syndrome of inappropriate antidiuretic hormone.

The nurse is working with a child diagnosed with encopresis. After a complete medical workup has been done, no organic cause has been found for the disorder. The nurse will anticipate that which of the following will be done next? a) The child will be placed in a foster home. b) The child will be started on methylphenidate (Ritalin). c) The child will be put on a high-calorie, high-protein diet. d) The child will be referred for counseling.

The child will be referred for counseling. Correct Explanation: If no organic causes (e.g., worms, megacolon) exist, encopresis indicates a serious emotional problem and a need for counseling for the child and the family caregivers.

A baby is born with what the physician believes is a diagnosis of trisomy 21. This means that the infant has three number 21 chromosomes. What factor describes this genetic change? a) The mother also has genetic mutation of chromosome 21 b) The patient has a nondisjunction occurring during meiosis c) The patient will have a single X chromosome and infertility d) During meiosis, a reduction of chromosomes resulted in 23

The patient has a nondisjunction occurring during meiosis Correct Explanation: During meiosis, a pair of chromosomes may fail to separate completely, creating a sperm or oocyte that contains either two copies or no copy of a particular chromosome. This sporadic event, called nondisjunction, can lead to trisomy. Down syndrome is an example of trisomy. The mother does not have a mutation of chromosome 21, which is indicated in the question. Also, Trisomy does not produce a single X chromosome and infertility. Genes are packaged and arranged in a linear order within chromosomes, which are located in the cell nucleus. In humans, 46 chromosomes occur in pairs in all body cells except oocytes and sperm, which contain only 23 chromosomes.

A woman with both heart disease and osteoarthritis has come to the genetics clinic for genetic screening. What would the nurse know about these two diseases? a) They are direct result of the patient's lifestyle b) They are multifactorial c) They do not have a genetic basis d) They are caused by a single gene

They are multifactorial Correct Explanation: Genomic or multifactorial influences involve interactions among several genes (gene-gene interactions) and between genes and the environment (gene-environment interactions), as well as the individual's lifestyle.

What is the main purpose of nurses having basic genetic knowledge? a) To advocate for a cure for genetic disorders b) To provide support and education to families c) To understand all genetic disorders, allowing for improved quality of life d) To ensure proper medical diagnosis

To provide support and education to families Correct Explanation: The purpose of the nurse knowing about basic genetics is that it helps her to provide support and education to families. Nurses can advocate for a cure, but this is not the main purpose of attaining basic knowledge of genetics. Providing a medical diagnosis is beyond the scope of practice for a nurse. It would be impossible for the nurse to understand all genetic disorders; it is more reasonable for the nurse to be familiar with the most common genetic disorders

27. Inflammation of the urethra

URETHRITIS

22. Study of the holding or storage of urine in the bladder, the facility with which it empties, and the rate of movement of urine out of the bladder during urination

URODYNAMIC

7. Inflammation of the vagina

VAGINITIS

8. Inflammation of the vagina

VAGINITIS

Inflammation of the vagina caused by Gardnerella vaginalis

VAGINOSIS

37. Bag of worms; swelling of the veins of the spermatic cord. One of the most common problems associated with male infertility

VARICOCELE

23. Uses tiny clamps or cauterization to seal off the vas deferens to prevent sperm from reaching the outside of the body; permanent birth control for men

VASECTOMY

28. Wart-like with raised portions

VERRUCOUS

29. Pertaining to vesicles or small blisters

VESICULAR

30. Inflammation of the vulva and vagina and can be asymptomatic or involve redness, itching, burning, excoriation, pain, swelling of the vagina and labia, and discharge

VULVOVAGINITIS

. What nursing action will the nurse implement for a preterm infant who is being gavage fed and has a bloody stool? a. Assess for abdominal distention. b. Decrease the amount of the next feeding. c. Institute enteric precautions. d. Get a culture of the next stool.

How often should a child who has a continuous intravenous infusion should be assessed? a. Hourly b. Every 2 hours c. Every 3 hours d. Every 4 hours

Which statement by a mother may indicate a cause of her sons vitamin C deficiency? a. We get our fruits from homemade preserves. b. We use milk from our own goats. c. We grow all our own vegetables. d. Were not big meat eaters

What sign(s) indicate(s) moderate dehydration? (Select all that apply.) a. 10% weight loss b. Dry mucous membranes c. Normal anterior fontanel d. Increased urinary output e. Lethargy

a, b, c

The nurse is obtaining intake information on a new patient being seen for preconception care and notes a family history of neural tube defects. What interventions can the nurse suggest to this woman to help prevent neural tube anomalies in a developing fetus? (Select all that apply.) a. Avoid drug use. b. Follow a low-calorie, low-protein diet. c. Take a folic acid supplement every day. d. Exercise daily. e. Maintain bed rest during the first trimester

a, c

15. A patient who is 1 day post-transurethral resection of the prostate says he is having pain in his bladder, and the nurse notices urine leakage around his catheter. Which of the following responses by the nurse is the best? a. "Bladder spasms are common after your surgery. Take some deep breaths while I get a B&O suppository." b. "You should not be experiencing spasms. I will notify the RN right away." c. "Spasms can be very painful. Would you like an injection of Demerol?" d. "Your catheter is leaking; we weill need to replace it right away."

a. A B&O suppository will reduce bladder spasms, which often cause pain after TURP

8. A nurse has completed instruction related to STD risk reduction with a 17-year-old woman. Which statement by the patient indicates that teaching has been effective? a. "I should avoid drinking alcohol when I will be in situations with potential sex partners." b. "If I make sure my partners wear condoms, I will be protected from STDs." c. "Use of a barrier method of birth control will prevent infection with an STD." d. "As long as I know my partner well, I am safe."

a. Alcohol can cloud judgement

33. Which of the following medications can be used to treat vasovagal response during gynecological procedures? a. Atropine b. Morphine c.Epinephrine d. Norepinephrine

a. Atropine is an anticholinergic agent that will reverse the cholinergic response initiated by vagal stimulation

The nurse urges the mother of a 6-month-old to get her child inoculated with Haemophilus influenzae type B. What does this immunization protect against? a. Encephalitis b. Influenza c. Bacterial meningitis d. Otitis media

40. Which of the following is the least effective form of contraception? a. Douching b. Condom with spermicide c. Diaphragm with spermicide d. Oral contraceptive medication

a. Douching is ineffective because sperm may already be out of reach. It also may push sperm further upward

31. Which of the following pathogens causes syphilis? a. Treponema pallidum b. Chlamydia trachomatis c. Human papillomavirus d. Human immunodeficiency virus

a. Treponema pallidum causes syphilis

Signs of NEC

abdominal distention, bloody stools, diarrhea, bilious vomitus

Nursing Care of Infant With Immature Kidneys

accurate measurement of I&O, weigh diapers, urine output should be between 1 and 3 mL/kg/hr, observe for signs of dehydration and overhydration, document status of fontanelles, tissue turgor, weight and urinary output

gestational age

actual time from conception to birth that the fetus remains in the uterus

Necrotizing Enterocolitis

acute inflammation of the bowel that leads to bowel necrosis

When discussing care of an infant with congenital hypothyroidism, you would stress that the infant will need a) administration of levothyroxine for a lifetime. b) administration of vitamin C until after growth is complete. c) vitamin K administration until school age. d) an increased intake of calcium beginning in infancy.

administration of levothyroxine for a lifetime. Correct Explanation: Hypothyroidism occurs because the thyroid is not producing adequate thyroxine. The child will need a supplemental source for a lifetime.

postterm gestation

after 42 weeks

11. Which of the following is the most common cause of erectile dysfunction? a. Endocrine problems b. Circulatory problems c. Nervous system problems d. Excessive alcohol use

b. A good blood supply is essential for erection

21. Following a panhysterectomy, what should the nurse teach the patient to expect? a. Heavy bleeding for a week b. Symptoms of menopause c. Painful intercourse for approximately 6 months d. Monthly cramping but no menstrual flow

b. Because the ovaries are removed in a panhysterectomy, the patient should expect to experience menopause

18. A nurse working in a nursing home notes that it is difficult but not impossible to retract the foreskin for washing on an older gentleman. Which action is correct? a. Avoid retracting the foreskin for cleaning to prevent paraphimosis. the penis secretes an antibacterial substance that is self-cleaning. b. Gently retract the foreskin for cleaning, then replace it and notify the physician. c. Retract the foreskin for cleaning, and leave it retracted to prevent infection. d. Retract the foreskin and leave it retracted until the physician can evaluate it.

b. Cleaning is important, but be sure to replace the foreskin afterward to prevent paraphimosis

9. When obtaining the history of a 17-year-old male during a sports physical, what important screening practice should be discussed? a. Yearly DRE b. Monthly TSE c. Yearly PSA d. Bimonthly bimanual examination

b. Young men are at risk for testicular cancer, and so should be taught testicular self-examination

A couple just learned they are expecting their first child and are curious if they are having a boy or a girl. At what point of development can the couple first expect to see the sex of their child on ultrasound? a. 4 weeks gestational age b. 6 weeks gestational age c. 10 weeks gestational age d. 16 weeks gestational age

reasons for increased tendency to bleed in preterm

blood is deficient in prothrombin, fragile capillaries are particularly susceptible to injury

A 13-year-old girl has been hospitalized for the past week. When discussing the girls feelings about her illness, what would the nurse expect the girl to express as her biggest concern? a. Invasive procedures b. Loss of control c. Appearance d. Separation from her boyfriend

A 14-year-old boy is at the pediatric clinic for a checkup. What physical changes of puberty will the nurse indicate are related to the production of testosterone? a. Stimulation of production of white cells and platelets b. Promotion of growth of small bones c. Increase in muscle mass and strength d. Decrease in production of sebaceous gland secretions

What symptom reported by a pregnant patient would lead the nurse to suspect pyelonephritis? a. Frequency and urgency of urination b. Nausea and weight loss c. Burning sensation when voiding d. Tenderness in the flank area

11. A patient has just had a laparoscopy to investigate the causes of her infertility. Why should the nurse instruct her to lie flat in the bed for a few hours? a. She could rupture her abdominal incision b. Her blood pressure will be extremely low because of blood loss c. The carbon dioxide left over form the test will travel upward and cause pain d. Her uterus needs to be at the same level as her heart to prevent excessive swelling

c. Lying flat will reduce discomfort from the carbon dioxide used for insufflation

3. A patient who is breastfeeding her baby says "My doctor said I have mastalgia. What does that mean?" Which response by the nurse is the best? a. "That means you may have an infection in your breasts." b. "Mastalgia is just the normal discomfort that is associated with breastfeeding." c. "The word mastalgia just means breast pain; it can occur with monthly cycles of hormone levels." d. "Mastalgia is the medical term for fibrocystic breast disease. It is important to have it treated promptly."

c. Mastalgia can be broken down as mast-breast + algia-pain

2. Which of the following is the most commonly used surgical treatment for BPH? a. TUIP b. TUMA c. TURP d. TULIP

c. Transurethral resection of the prostate (TURP) is most common

causes of hypocalcemia

calcium is transported across placenta in higher quantities in third trimester, so early birth can result in lower calcium levels`

Preventing ROP

careful monitoring of O2sat in high-risk infants, avoiding excessive levels of O2; maintaining sufficient level of vitamin K

apnea

cessation of breathing for 20 sec. or longer

5. During an endometrial biopsy, for which of the following signs and symptoms of vasovagal response should the nurse observe? a. Pain in the chest and abdomen b. Cramping and diaphoresis c. High blood pressure and tachycardia d. Bradycardia and falling blood pressure

d. Bradycardia and falling blood pressure are signs that the vagus nerve has been stimulated

6. Which of the following is the usual site of fertilization? a. Ovary b. Uterus c. Vagina d. Fallopian tube

d. Fallopian tube

s/s of cold stress

decreased skin temp, increased respiratory rate with periods of apnea, bradycardia, mottling, lethargy

In the salt-losing form of congenital adrenogenital hyperplasia, the most important observation you would make in a newborn would be for a) excessive cortisone secretion. b) dehydration. c) bleeding tendencies. d) hypoglycemia.

dehydration. Correct Explanation: With this form of the disorder, children are unable to produce aldosterone. This leads to the inability to retain sodium and fluid.

Factors of NEC

diminished blood supply to bowel because hypoxia or sepsis causes decrease in protective mucus, resulting in bacterial invasion; formula or hypertonic gavage feeding is a source for bacterial growth

When an infant is born with a genetic disorder, it is appropriate to advise the parents that a) experiences the mother had during pregnancy are probably not related. b) not all genetic disorders are inherited. c) the disorder has probably occurred in the family before. d) it is likely that the mother drank alcohol during early cell division.

experiences the mother had during pregnancy are probably not related. Explanation: As genetic disorders occur at the moment of conception, events during pregnancy occur after the problem is already present.

interventions for apnea

gently rub infant's feet, ankles, back; if this fails, suction mouth and nose, raise head to semi-Fowler's; if breathing does not begin, an Ambu bag is used

Prognosis for Preterm Infant

growth rate of preterm nears term infants at abut 2nd year; growth and development are based on current age minus # of weeks before term the infant was born, which helps to prevent unrealistic expectations of newborn

A school-aged girl is diagnosed as having Cushing's syndrome from long-term therapy with oral prednisone. This means that the child a) appears pale and fatigued. b) has hypoglycemia. c) has purple striae on her abdomen. d) is excessively tall for her age.

has purple striae on her abdomen. Correct Explanation: An effect of a corticosteroid is to produce striae on the abdomen. Elevated levels of corticosteroids also cause these during pregnancy.

level of maturation

how well developed infant is at birth and the ability of organs to function outside the uterus

factors that lead to poor control of body temp in preterm newborn

lack of brown fat; radiation; immature heat-regulating center of brain; sweat glands don't function to capacity; preterm inactive with weak muscles that are less resistant to cold, unable to shiver; preterm body position is extension; high metabolism, prone to hypoglycemia

preterm gestation

less than 38 weeks

Children with ALL may need periodic lumbar punctures. You would teach the mother this is done to assess for a) early meningitis. b) leukemic cells. c) platelets. d) early development of septicemia.

leukemic cells. Correct Explanation: Leukemic cells in cerebrospinal fluid must be identified because, if present, they require additional therapy.

Physical Characteristics of Posterm

long and thin, weight may have been lost, skin is loose (esp. around butt and thighs), very little lanugo or vernix, skin is dry, cracked, and peeling, nails are long, may be meconium stained, thick head of hair, looks alert

monitoring preterm for bleeding

monitor neurological status, report bulging fontanelles, lethargy, poor feeding, and seizures

Rumination disorder is a poorly understood condition of young children. This refers to a) a habit of eating nonfood substances. b) rechewing undigested food. c) fear of moving objects. d) excessive worrying about friendships.

rechewing undigested food. Correct Explanation: Rumination is the rechewing of undigested food. It occurs primarily in infants.

physical characteristics of preterm infant

skin is transparent or loose; superficial veins visible on abdomen and scalp; lack of subcut fat; abundant lanugo and vernix; short extremities; few sole creases; protruding abdomen; short nails; small genitalia

Ballard score

standardized method to determine gestational age based on external characteristics and neurological development

Cause of ROP

thought to be caused by high oxygen levels of arterial blood

Kangaroo Care

uses skin-to-skin contact, infant wears only diaper and cap, rests on mother or father's bare chest, skin warms and calms infant, promote bonding

The parents of an adolescent are concerned about his mental health and have brought the adolescent into the physician's office for an evaluation. Which of the following statements by the child's parents indicates that the child may have a mental health disorder? Select all that apply. a) "He has lost 10 pounds over the last 4 months." b) "He used to be a straight-A student and now he's bringing home Cs and Ds." c) "He hangs out with the same kids he always has." d) "He still enjoys playing a lot of baseball." e) "He has started sleeping for only 3 hours each night."

• "He has lost 10 pounds over the last 4 months." • "He used to be a straight-A student and now he's bringing home Cs and Ds." • "He has started sleeping for only 3 hours each night." Correct Explanation: Altered sleep patterns, weight loss, and problems at school are commonly found in children with mental health disorders. There also may be alterations in friendships and changes in extracurricular activity participation.

Parents bring their daughter to the health care facility for evaluation. They report that lately the child seems rather pale and really tired. Which of the following would the nurse most likely find with further assessment if the child has acute lymphocytic leukemia? Select all that apply. a) Painless cervical lymphadenopathy b) Headache c) Low-grade fever d) Chest pain e) Bleeding from the oral mucous membranes

• Bleeding from the oral mucous membranes • Headache • Painless cervical lymphadenopathy • Low-grade fever Explanation: Assessment findings associated with acute lymphcytic leukemia include low-grade fever, lethargy, petechiae, bleeding from the oral mucous membranes, and easy bruising. As the spleen and liver begin to enlarge, abdominal pain, vomiting, and anorexia occur. Physical assessment reveals painless, generalized swelling of lymph nodes, especially the submaxillary or cervical nodes.

4. Term used to describe undescended testicles

CRYPTORCHIDISM

Removal of fluid from the cul-de-sac of Douglas, may be done during a culdoscopy

CULDOCENTESIS

27. Endoscope is introduced into the vagina and through a small incision in the vagina into the cul-de-sac of Douglas, a cavity behind the uterus, in order to observe for abnormalities

CULDOSCOPY

Incision into the upper posterior portion of the vagina

CULDOTOMY

22. Small spoon-shaped tool which is inserted into the cervix in order to scrape the uterus for endometrial biopsy specimens.

CURET

17. Fluid-filled

CYSTIC

Bladder sags into the vaginal space because of inadequate support

CYSTOCELE

7. Destructive to cells

CYTOTOXIC

A pregnant woman has a child at home who has been diagnosed with neurofibromatosis She asks the nurse what she should look for in the new baby that would indicate that it also has neurofibromatosis. What sign should the nurse instruct the woman to look for in the new baby? a) Projectile vomiting b) Café-au-lait spots c) Xanthoma d) Increased urination

Café-au-lait spots Correct Explanation: Physical assessment may provide clues that a particular genetic condition is present in a person and family. Family history assessment may offer initial guidance regarding the particular area for physical assessment. For example, a family history of neurofibromatosis type 1, an inherited condition involving tumors of the central nervous system, would prompt the nurse to carry out a detailed assessment of closely related family members. Skin findings such as café-au-lait spots, axillary freckling, or tumors of the skin (neurofibromas) would warrant referral for further evaluation, including genetic evaluation and counseling. A family history of familial hypercholesterolemia would alert the nurse to assess family members for symptoms of hyperlipidemias (xanthomas, corneal arcus, abdominal pain of unexplained origin). As another example, increased urination could indicate type 1 diabetes. Projectile vomiting is indicative of pyloric stensosis.

How can the nurse most simply describe for distressed parents a rhabdomyosarcoma that has been found in their 5-year-old? a) Indicate that the more commonly used name is Hodgkin's disease b) Explain that it develops in nerves outside the brain and spinal cord c) Describe it as a bone tumor d) Call it a tumor of muscle tissue

Call it a tumor of muscle tissue Correct Explanation: A rhabdomyosarcoma is a tumor of striated muscle that most commonly develops in the head, neck, arms, and legs, as well as in the genitourinary tract, of children. The other descriptors are incorrect.

The nurse is preparing a discharge teaching plan for the parents of an 8-year-old girl with leukemia. Which instruction would be the priority? a) Calling the doctor if the child gets a sore throat b) Keeping a written copy of the treatment plan c) Writing down phone numbers and appointments d) Using acetaminophen if the child needs an analgesic

Calling the doctor if the child gets a sore throat Correct Explanation: Calling the doctor if the child gets a sore throat is the priority. Because of the child's impaired immune system, any sign of potential infection, such as sore throat, must be evaluated by a physician. Using acetaminophen if the child needs an analgesic, writing down phone numbers and appointments, and keeping a written copy of the treatment plan are important teaching points but secondary to guarding against infection.

a patient with lung cancer in the left lung is acutely short of breath. which position should the patient assume? a. prone b. supine c. left side lying d. high fowlers

late hypocalcemia

occurs at about age 1 week in newborn/preterm infant fed cow's milk because cow's mile increases serum phosphate levels, causing calcium to fall

hypoglycemia

plasma glucose level less than 40 mg/dL in term infant and less than 30 mg/dL in preterm

It is documented in the medical record that a patient has gummas. For which sexually transmitted infection should the nurse plan care? a. Syphilis b. Gonorrhea c. Chlamydia d. Genital herpes

The nurse is collecting data from a patient who has returned from a dialysis session. After dialysis, the nurse should anticipate which patient finding? a. Weight loss b. Hypertension c. Increased energy d. Distended neck veins

What should the nurse closely assess in a child receiving a transfusion? a. Fever b. Lethargy c. Jaundice d. Bradycardia

A child diagnosed with epilepsy had a generalized tonic-clonic seizure that lasted 90 seconds. What would the nurse expect to assess after a generalized tonic-clonic seizure? a. Restlessness b. Sleepiness c. Nausea d. Anxiety

What will the nurse teach the parents of a child with a low platelet count to avoid? a. Ibuprofen b. Aspirin c. Caffeine d. Prednisone

An infant is delivered with the use of forceps. What should the nurse assess for in the newborn? a. Loss of hair from contact with forceps b. Sacral hematoma c. Facial asymmetry d. Shoulder dislocation

Approximately how old does the nurse assess a large green bruise on the thigh of a 4-year-old to be? a. 2 days b. 4 days c. 6 days d. 8 days

At her initial prenatal visit a woman asks, When can I hear the babys heartbeat? At what gestational age can the fetal heartbeat be auscultated with a specially adapted stethoscope or fetoscope? a. 4 weeks b. 12 weeks c. 18 weeks d. 24 weeks

At what point in prenatal development do the lungs begin to produce surfactant? a. 17 weeks b. 20 weeks c. 25 weeks d. 30 weeks

Because Trichomonas is relatively large, unusually shaped, and diagnosed quickly, the nurse is asked to assist the physician obtain which type of specimen? a. Culture b. Blood test c. Wet mount d. Litmus paper

The nurse is caring for a 4-year-old child. What will the nurse expect the childs daily urinary output to be? a. 400 to 500 mL b. 500 to 600 mL c. 600 to 700 mL d. 700 to 1000 mL

A woman is to undergo chorionic villus sampling as part of a risk assessment for genetic disorders. Which of the following would the nurse include when describing this test to the woman? a) "A needle will be inserted directly into your fetus's umbilical vessel to collect blood for testing." b) "An intravaginal ultrasound measures fluid in the space between the skin and spine." c) "A small piece of tissue from the fetal placenta will be removed and analyzed." d) "A small amount of amniotic fluid will be withdrawn and collected for analysis."

"A small piece of tissue from the fetal placenta will be removed and analyzed." Correct Explanation: Percutaneous umbilical cord sampling involves the insertion of a needle into the umbilical vessel. An amniocentesis involves the collection of amniotic fluid from the amniotic sac. Fetal nuchal translucency involves the use of intravaginal ultrasound to measure fluid collected in the subcutaneous space between the skin and cervical spine of the fetus. Chorionic villus sampling involves the removal of a small tissue specimen from the fetal portion of the placenta

Eve, 2 years old, and her parents are at the office for a follow-up visit. She has had excessive hormone levels in her recent blood work and her parents question why this was not found sooner. What is the best response of the nurse? a) "Have there been signs and symptoms that you should have reported to the doctor?" b) "As endocrine functions become more stable throughout childhood, alterations become more apparent." c) "Endocrine disorders are hard to detect and you are lucky that we have found it when we did." d) "It takes time to determine the level of functioning of endocrine glands."

"As endocrine functions become more stable throughout childhood, alterations become more apparent." Correct Explanation: The endocrine glands are all present at birth; however, endocrine functions are immature. As these functions mature and become stabilized during the childhood years, alterations in endocrine function become more apparent. Thus, endocrine disorders may arise at any time during childhood development.

Parents ask why their child just diagnosed with leukemia needs a "spinal tap." Which is the best response by the nurse? a) "Checking the cerebrospinal fluid will reveal whether leukemic cells have entered the central nervous system." b) "The spinal tap will help relieve pressure and headache for your child." c) "It will help rule out a second malignancy." d) "A sample of cerebrospinal fluid is needed to check for possible central nervous system infection."

"Checking the cerebrospinal fluid will reveal whether leukemic cells have entered the central nervous system." Correct Explanation: The cerebrospinal fluid is checked so the clinician can determine whether leukemic cells have invaded the central nervous system. It is common for a chemotherapy medication, usually methotrexate, to be administered immediately following lumbar puncture as treatment for potential infiltration. The other responses are incorrect.

You are meeting with a family that has learned that their 11-year-old daughter has some intellectual disabilities. They tell you that she is having trouble coping with different situations at school. Which of the following is the best response? a) "Coping and adaptation are often affected by intellectual disabilities." b) "Just give her some time, she will learn to adjust." c) "It takes time to learn to cope and adjust, give her some more time." d) "Maybe it would be best if she did not play with those kids at school."

"Coping and adaptation are often affected by intellectual disabilities." Correct Explanation: The child is at increased risk for adjustment disorders because the child's coping strategies are not understood or recognized and his or her range of adaptive strategies may be reduced. Coping, adaptation, and social skills development are greatly dependent on abstract thinking and the ability to generalize from one situation to another. Abstract thinking is impaired in intellectual disability. Children who have intellectual disability are often uncomfortable with unfamiliar surroundings and people. Time is needed to build relationships.

A child is prescribed glargine (Lantus) insulin. Which of the following would the nurse include when teaching the child and parents about this insulin? a) "Give the dose first thing in the morning." b) "Do not mix this insulin with other insulins." c) Discard any opened vials after a week. d) Store the insulin in the refrigerator until just before giving it.

"Do not mix this insulin with other insulins." Correct Explanation: Glargine (Lantus) is not mixed with other insulins. Glargine is usually given in a single dose at bedtime. Insulin should be kept at room temperature; insulin that is administered cold may increase discomfort with the injection. Any vial of insulin that is opened should be discarded after 1 month.

The nurse is interviewing a depressed 13-year-old girl. During the course of the interview, the girl reveals that her best friend is thinking about committing suicide. How should the nurse respond? 1) Are you the only one that knows? 2) Why do you think she wants to kill herself? 3) Do you know how she is planning to kill herself? 4) ?

"Do you know how she is planning to kill herself?" Explanation: Because the girl is depressed, the nurse suspects that the girl is indirectly talking about herself, not her best friend. When an adolescent raises the issue of suicide, it is important to find out exactly how he or she is envisioning suicide and take measures to prevent an attempted suicide. Therefore, the nurse should ask how the "friend" is contemplating suicide in order to gather this information and open a dialogue to encourage the girl to reveal she is talking about herself. The other questions would not elicit the critical information about the method of suicide.

A 15-year-old adolescent is scheduled for a pelvic ultrasound to evaluate for a possible ovarian cyst. Which instruction by the nurse would be most appropriate? a) "You need to remain very still for the entire test." b) "Limit your level of physical activity for one-half hour before the test." c) "You won't be able to drink any water before or during the test." d) "Drink plenty of fluids because you need to have a full bladder."

"Drink plenty of fluids because you need to have a full bladder." Explanation: A full bladder is needed for an ultrasound of the pelvic. The patient needs to remain still for a computed tomography or magnetic resonance imaging scan, not an ultrasound. Water is withheld during a water deprivation test used to detect diabetes insipidus. Limiting stress and physical activity for 30 minutes before the test is required for the growth hormone stimulation test.

The parent of a child diagnosed with Duchenne muscular dystrophy asks why gene therapy is not being used to treat her child. What is the best response by the nurse? a) "Clinical trials are very successful, and you should find one immediately." b) "Gene therapy remains experimental and is used only in clinical trials." c) "Genetic testing is unethical." d) "Gene therapy does not work for muscular dystrophy."

"Gene therapy remains experimental and is used only in clinical trials." Correct Explanation: Gene therapy in the United States is currently experimental and is used only in clinical trials. Clinical trials have resulted in minimal success. No documentation supports the statement that gene therapy would not work for muscular dystrophy. Genetic testing is used to diagnose illness; therefore, it is widely accepted as ethical when used to diagnose disorders. Gene therapy may be viewed by some as unethical, but the nurse should provide information in a nonjudgmental manner.

The nurse is conducting a well-child assessment of a 3-year-old. Which of the following statements by the parents would warrant further investigation? a) "He is very active and keeps very busy" b) "He spends hours repeatedly lining up his cars" c) "He would rather run around than sit on my lap and read a book" d) "He spends a lot of time playing with his little cars"

"He spends hours repeatedly lining up his cars" Correct Explanation: The nurse should pay particular attention to reports of a child spending hours in a repetitive activity, such as lining up cars rather than playing them. Most 3-year-olds are very busy and would rather play than sit on a parent's lap. The other statements are not outside the range of normal and do not warrant further investigation.

The nurse is teaching a 12-year-old girl with diabetes mellitus type 2 and her parents about dietary measures to control her glucose levels. Which comment by the child indicates a need for additional teaching? a) "I can eat two small cookies with each meal." b) "I can have an apple or orange for snacks." c) "We should give her nonfat milk to drink." d) "I will be eating more breads and cereals."

"I can eat two small cookies with each meal." Explanation: Cookies, cakes, candy, potato chips, and crackers are high in sugars and fats and should be eaten in moderation as special treats; they would not be included with each meal. An apple or orange makes a good snack. Nonfat milk is a better option than whole milk. Long-acting carbohydrates should be the largest category of foods eaten.

Which statement by an adolescent with anorexia nervosa would be most typical of an adolescent with this disorder? a) "I'd like to gain weight but just can't." b) "I'm afraid that someone is poisoning my food." c) "I'd like to grow up to be a model." d) "I feel chubby no matter what I wear."

"I feel chubby no matter what I wear." Correct Explanation: Children with eating disorders tend to think of themselves as overweight. This distorted body image leads them to diet excessively.

A young couple who underwent preconceptual genetic counseling and testing have learned that they are at high risk for having a child with Down syndrome. They have decided not to have children. Which of the following would be the most appropriate response for the nurse to give? a) "I think you made the right decision. After all, I never had children, and I'm perfectly happy." b) "I appreciate your decision, but I urge you to think through this further. Having a child, even one with Down syndrome, is so rewarding." c) "I understand. In case you would like to discuss this further with a genetic counselor, here is the contact information for the genetic counseling center." d) "I understand and support your decision. The risk is just not worth it."

"I understand. In case you would like to discuss this further with a genetic counselor, here is the contact information for the genetic counseling center." Correct Explanation: Even if a couple decides not to have more children, be certain they know genetic counseling is available for them should their decision change. It is never appropriate for a health care provider to impose his or her own values or opinions on others. Individuals with known inherited diseases in their family must face difficult decisions, such as how much genetic testing to undergo or whether to terminate a pregnancy that will result in a child with a specific genetic disease. Be certain couples have been told all the options available to them, and then leave them to think about the options and make their decision by themselves. Help them to understand nobody is judging their decision because they are the ones who must live with the decision in the years to come.

A couple has just learned that their son will be born with Down's syndrome. The nurse shows a lack of understanding when making which of the following statements? a) "I will alert your entire family about this so you don't have to." b) "We have counseling services available, and I recommend them to everyone facing these circumstances." c) "I will support you in any decision that you make." d) "I will give you as much information as I can about this condition."

"I will alert your entire family about this so you don't have to." Correct Explanation: It is necessary to maintain confidentiality at all times, which prevents healthcare providers from alerting family members about any inherited characteristic unless the family member has given consent for the information to be revealed.

The nurse is providing teaching about the potential side effects of lithium for the parents of a girl recently diagnosed with bipolar disorder. Which statement by the parents indicates a need for additional teaching? a) "She may notice an increase in urination" b) "If she loses weight, then we know the medication is working." c) "She will probably tell us that she is hungrier than usual." d) "Tremors and nausea are common side effects."

"If she loses weight, then we know the medication is working." Explanation: Weight gain, not weight loss, is a side effect of the drug. An increased appetite occurs with lithium. Lithium is associated with tremors and nausea. Polyuria occurs with lithium.

After teaching the parents of a child with Tourette syndrome about motor and vocal tics, the nurse determines that the teaching was successful when the parents state which of the following? a) "He can control the tics if he really concentrates on doing so." b) "Drugs are the primary method for controlling the symptoms." c) "Vocal tics are harder to control than the motor tics are." d) "If we get him focused on an activity, the tics will be less pronounced."

"If we get him focused on an activity, the tics will be less pronounced." Explanation: Tics become more noticeable or severe during times of stress and less pronounced when the child is focused on an activity such as watching TV, reading, or playing a video game. The tics are not under voluntary control and either type can be difficult to control. Management is highly individualized and involves psychopharmacology and behavioral therapy.

Which statement by a parent regarding mitochrondrial disorders requires further education? a) "It is passed from female to female. That's why my son cannot be affected." b) "The cells most affected are the ones that require high levels of energy." c) "My child can exhibit signs and symptoms of the disorder at any point in his life." d) "Mitochondrial disorders usually worsen over time."

"It is passed from female to female. That's why my son cannot be affected." Explanation: Mitochondrial disorders usually are inherited from the mother and affect offspring regardless of sex. Mitochondrial disorders are progressive, and onset of signs and symptoms can occur from infancy to adulthood. The disorder affects cells that require high levels of energy

What is the best response by the nurse to the parents of a child with leukemia who express guilt because they did not take immediate action when their child seemed to develop one respiratory infection after another? a) "Young children develop minor illness easily and often. Stop being hard on yourselves." b) "Don't feel bad. Children get lots of colds." c) "Keep in mind that the signs of leukemia are often subtle and difficult to recognize." d) "You need to focus on the present treatment now and not worry about the past."

"Keep in mind that the signs of leukemia are often subtle and difficult to recognize." Correct Explanation: Pointing out that the signs and symptoms of leukemia are often difficult to recognize indicates to the parents that they were not neglectful, while also providing information about the disease. The other responses minimize the parents' feelings or tell them how they should feel and are not therapeutic.

Kate and her parents are being seen in the office after discharge from the hospital with a new diagnosis of type 2 diabetes. Which of the following statements by the nurse is true? a) "This will rectify itself if you follow all of the doctor's directions." b) "Kids can usually be managed with an oral agent, meal planning, and exercise." c) "A weight-loss program should be implemented and maintained." d) "You are lucky that you did not have to learn how to give yourself a shot."

"Kids can usually be managed with an oral agent, meal planning, and exercise." Correct Explanation: Treating type 2 diabetes in children may require insulin at the outset if the child is acidotic and acutely ill. More commonly, the child can be managed initially with oral agents, meal planning, and increasing activity. Telling the child that she is lucky, she did not have to learn how to give a shot might scare her so it will inhibit her from seeking future healthcare. The condition will not rectify itself if all orders are followed. A weight-loss program might need to be implemented but that is not always the case.

A 10-year-old girl with ADHD has been on Ritalin for 6 months. The girl's mother calls and tells the nurse that the medication is ineffective and requests an immediate increase in the child's dosage. What should the nurse say? a) "Let me talk to the doctor about this." b) "Let's wait a few more weeks before we do anything." c) "Let's set up an appointment as soon as possible." d) "What does the teacher say?"

"Let's set up an appointment as soon as possible." Correct Explanation: The nurse plays a vital role in administering medicines and observing and reporting responses. A face-to-face appointment with the family and the doctor or advance practice mental health nurse can help uncover patient and parental factors that may be preventing success. Once it is established that the family is using the medication properly as well as instituting structure within the home, it can be determined if an increased dosage or alternate medicine would be appropriate. Deferring to the doctor will not elicit any information from the mother, and waiting will not address the current concerns. The teacher can only reveal partial information about the effectiveness of the medication, which can be reviewed once other factors have been addressed in a face-to-face visit with the family and patient.

A community health nurse is visiting her 16-year-old patient, a new mother. The nurse explains to the patient and her mother the genetic screening that is required by the state's law. The patient asks why it is important to have the testing done on the infant. What is the nurse's best response? a) "This testing is required and you will not be able to refuse it. It usually is free so there is no reason to refuse it." b) "Genetic testing is a way to determine the rate of infectious disease." c) "It is important to test newborns for PKU, congenital hypothyroidism, and galactosemia." d) "PKU, congenital hypothyroidism, and galactosemia are conditions that could result in disability or death if untreated."

"PKU, congenital hypothyroidism, and galactosemia are conditions that could result in disability or death if untreated." Correct Explanation: The first aim is to improve management, that is, identify people with treatable genetic conditions that could prove dangerous to their health if left untreated. The other answers are incorrect because genetic testing does not determine the rate of infectious disease. Answer B does not adequately explain the rationale for newborn testing. Answer D fails to inform the patient of the rationale for newborn testing.

A 10-year-old boy has been diagnosed with type 1 diabetes mellitus. He is curious about what the cause of his disease is and asks the nurse to explain it to him. Which of the following should the nurse say to the boy? a) "Special cells in a part of your body called the pancreas can't make a chemical called insulin, which helps control the sugar level in your blood." b) "Special cells in a part of your body called the pancreas cannot produce enough of a chemical called insulin, so there is too much sugar in your blood." c) "Your body does not produce enough a chemical called 'ADH,' which makes you really thirsty and have to go to the bathroom a lot." d) "A small part of your brain called the pituitary does not make enough of a chemical called growth hormone."

"Special cells in a part of your body called the pancreas can't make a chemical called insulin, which helps control the sugar level in your blood." Explanation: Type 1 diabetes is a disorder that involves an absolute or relative deficiency of insulin in contrast to type 2 where insulin production is only reduced. Insulin is produced by beta islet cells in the pancreas. Diabetes insipidus is caused by the pituitary gland not producing enough ADH and is characterized by extreme thirstiness and polyuria. Insufficient growth hormone is also related to dysfunction of the pituitary gland.

A nurse is caring for a 10-year-old intellectually disabled girl hospitalized for a scheduled cholecystectomy. The girl expresses fear related to her hospitalization and unfamiliar surroundings. How should the nurse respond? a) "Tell me about a typical day at home" b) "Have you talked to your parents about this?" c) "Do you want some art supplies?" d) "Don't worry, you will be going home soon"

"Tell me about a typical day at home" Correct Explanation: An IQ of 35 to 50 is classified as moderate. An IQ of 50 to 70 is classified as mild. An IQ of 20 to 35 is classified as severe, and an IQ less than 20 is considered profound

An 11-year-old boy has recently been prescribed Ritalin. The mother calls the pediatrician's office to speak with the advance practice pediatric nurse practitioner (APPNP). This mother has been extremely resistant to medication and insists that the medication is not working. How should the nurse respond? a) "Are you sure you are administering it properly?" b) "Tell me why you believe the medication is not working." c) "Do you want to increase the dosage?" d) "Do you want to try a different medication?"

"Tell me why you believe the medication is not working." Correct Explanation: Asking the mother to explain why she believes the medicine is not working will offer important insights into the mother's definition of effectiveness. It is important for both the mother and the advance practice pediatric nurse practitioner (APPNP) to develop a shared definition of effectiveness and improvement. Once this is established, the nurse can suggest the next step in the treatment plan. Asking if the mother wants to try a different medication or increase the dosage does not provide any information about the child's response to the current medication. Asking the mother whether she is administering it properly could cause her to take offense and does not provide the necessary information.

The nurse caring for a 14-year-old scheduled for magnetic resonance imaging (MRI) explains how the test works to the family. Which of the following responses accurately describes this test? a) "The MRI is a nuclear scanning test to rule out cancer involving the bones or determine extent of bone involvement." b) "The MRI uses radio waves and magnets to produce a computerized image of the body." c) "The MRI uses sound waves to create images that visualize body structures and locate masses." d) "The MRI uses radiation to examine soft tissue and bony structures of the body."

"The MRI uses radio waves and magnets to produce a computerized image of the body." Correct Explanation: The MRI uses radio waves and magnets to produce a computerized image of the body. The bone scan is a nuclear scanning test to rule out cancer involving the bones or determine extent of bone involvement. The ultrasound uses sound waves to create images that visualize body structures and locate masses. Radiography uses radiation to examine soft tissue and bony structures of the body.

The parents of a child diagnosed with Tay-Sachs inquire about progression of the disorder. Which statement by the nurse is accurate? a) "Anticonvulstants will be given to prolong life and prevent further brain damage." b) "Lifetime steroid therapy will reverse the blindness." c) "The child will experince decreased muscular and neurologic functioning until death occurs." d) "Symptoms can be controlled by eliminating dairy products."

"The child will experince decreased muscular and neurologic functioning until death occurs." Correct Explanation: This is an irreversible progressive disorder that affects the functioning of muscles and the neurologic system. Symptoms cannot be controlled by changes in the diet, and medication therapy will not reverse symptoms nor prolong life. Medication will be used to treat symptoms and provide comfort measures.

The nurse is counseling a couple who are concerned that their children might inherit sickle cell disease. Which of the following responses from the couple indicate a need for further teaching? a) "The disorder can be passed on to the children only if both parents have the gene." b) "If both parents have the gene, there is a 25% chance of the children having the disorder." c) "The father cannot pass the disorder onto his son or the mother to her daughter." d) "Even if the children do not get the disease they can still be carriers of the gene."

"The father cannot pass the disorder onto his son or the mother to her daughter." Correct Explanation: The father can pass the gene to his sons and the mother can pass the gene to her daughters. Sickle cell disease is an autosomal recessive disease. This means that both parents must have the disease or be carriers of the gene in order to pass it onto their children. If the parents are both carriers, then there is a 25% chance that they will pass it onto a child. The children can be carriers even if they don't have the disease.

The nurse is working with a group of caregivers of school-age children diagnosed with attention deficit hyperactivity disorder. Which of the following statements would be most appropriate for the nurse to make to this group of caregivers? a) "These children study better with quiet background music such as the radio or a CD." b) "These children function best if given a set of instructions and then left to do the task." c) "A frequent change in routine will be helpful so the child does not get bored." d) "The medications your child is on may cause a decreased appetite."

"The medications your child is on may cause a decreased appetite." Correct Explanation: Learning situations should be structured so that the child has minimal distractions. Structured, consistent guidance from the caregivers is needed. Medication is used for some children and these medications may suppress the appetite and affect the child's growth. The child should be given only one simple instruction at a time. Limiting distractions, using consistency, and offering praise for accomplishments are invaluable.

An advance practice pediatric nurse practitioner (APPNP) is conducting a mental status examination with a 6-year-old girl. Which of the following questions would be most appropriate? a) "Isn't it fun to play with dolls?" b) "Why does your pink doll hit all the other dolls?" c) "What is the name of the president of the United States?" d) "Do you like the doll with pink hair the best or the doll with green hair?"

"Why does your pink doll hit all the other dolls?" Correct Explanation: The nurse is trying to elicit the fantasies and feelings underlying the child's play. Asking an open-ended question is likely to reveal this information. A 6-year-old might know the name of the president but the meaning is ambiguous. The other questions would elicit "yes" or "no" answers.

Which statement by the nurse is most accurate when counseling a couple about transmitting Huntington's disease from father to child? a) "A daughter cannot be a carrier of the disease because it is an X-linked recessive disorder." b) "There is a 50% chance of transmission of the disorder because it is an autosomal dominant disorder." c) "You will transmit the disorder to a son because it is an X-linked dominant disorder." d) "There is a 75% chance that your offspring will express the disorder because it is an autosomal recessive disorder."

"There is a 50% chance of transmission of the disorder because it is an autosomal dominant disorder." Correct Explanation: An offspring of an autosomal dominant disorder has a 50% chance of acquiring the gene to be affected by the disorder. Huntington's is an autosomal dominant disorder. Female offspring of an X-linked recessive disorder have the possibility of being a carrier or of being afflicted with the disorder. With autosomal recessive disorders, there is only a 25% chance that the offspring will express the disorder.

A parent asks why a physical therapist is needed for the 6-month-old child diagnosed with Down syndrome. What is the best response by the nurse? a) "To optimize the child's development and functioning" b) "The earlier the intervention, the more likely we are to cure the problem." c) "To prevent contractures" d) "To ensure that the child meets all developmental milestones on time"

"To optimize the child's development and functioning" Correct Explanation: Interventional therapy is started early to promote the child's development and optimize functioning. The Down syndrome child usually meets developmental milestones at a slower pace. There is no cure for genetic disorders. Range-of-motion activities can prevent contractures; Down syndrome does not require physical therapy.

A nurse is teaching about autosomal dominant and recessive genetics. Which statement by the nurse is accurate? a) "Two abnormal genes, one from each parent, are required to produce the phenotype in an autosomal recessive disorder." b) "An autosomal dominant disorder is classified as X-linked." c) "One abnormal autosomal recessive gene is needed for outward presentation of the disorder." d) "An autosomal dominant disorder has a lower risk of phenotyping than an autosomal recessive disorder."

"Two abnormal genes, one from each parent, are required to produce the phenotype in an autosomal recessive disorder." Correct Explanation: An autosomal recessive disorder requires two abnormal genes to outwardly express the disorder. Recessive disorders have a lower risk of phenotyping than dominant disorders. X-linked and autosomal disorders are two different classifications.

A child is to receive an oral corticosteroid as part of the treatment regimen for leukemia. After teaching the child and family about this drug, the nurse determines the need for additional teaching when they state which of the following? a) "We should administer the drug on an empty stomach." b) "We will need to gradually decrease the dosage." c) "We should check our son's urine for glucose." d) "He might develop a rounded face from this drug."

"We should administer the drug on an empty stomach." Correct Explanation: Corticosteroids are commonly administered with food to decrease the risk for gastrointestinal upset. Corticosteroids can disrupt glucose balance, so urine should be checked for glucose. A moon face is an adverse effect of corticosteroids. Corticosteroids need to be tapered gradually to reduce the risk of adrenal insufficiency.

A 9-year-old child with leukemia is scheduled to undergo an allogenic hematopoietic stem cell transplant. When teaching the child and parents, which of the following would the nurse include? a) "The risk for rejection is much less with this type of transplant." b) "You'll need to have an incision in your hip area to instill the cells." c) "We'll need to have a match to a donor." d) "You won't need to receive the high doses of chemotherapy before the transplant."

"We'll need to have a match to a donor." Correct Explanation: An allogenic hematopoietic stem cell transplantation (HSCT) refers to transplantation using stem cells from another individual that are harvested from the bone marrow, peripheral blood, or umbilical cord blood. With this type of transplant, human leukocyte antibody (HLA) matching must occur. Therefore, the lesser the degree of HLA matching in the donor, the higher the risk for graft rejection and graft-versus-host disease (GVHD). Regardless of the type of transplant, a period of purging of abnormal cells in the child is necessary and accomplished through high-dose chemotherapy or irradiation. The procedure is accomplished by intravenously infusing hematopoietic stem cells into the child.

A 16-year-old recently diagnosed with Marfan syndrome states, "I feel fine. Why do I need to have this testing done?" What is the best response by the nurse? a) "You want to live a long time, right?" b) "You are at risk of rupturing your aorta, and the echocardiogram will let us know if there are any problems." c) "This is routine. Nothing to worry about." d) "The lab work will let us know if you are developing diabetes as a complication."

"You are at risk of rupturing your aorta, and the echocardiogram will let us know if there are any problems." Correct Explanation: Marfan sydrome is a disorder that affects connective tissue. The aorta is susceptible to weakening because of the connective tissue disorder, leading to sudden death from aortic dissection. Diabetes is not a complication of Marfan. The other two choices offer no information and dismiss the teen's concerns.

The nurse is describing some of the developmental milestones the mother of a 3-month-old boy with Down syndrome can expect to see in her child. Which statement describes the milestones that are expected in a child with Down syndrome? a) "He will be speaking in sentences at 21 months of age." b) "Bladder training can be expected by 2.5 to 3 years of age." c) "You can expect him to eat with his hands by age 12 months." d) "He'll be crawling all over the house by 9 months of age."

"You can expect him to eat with his hands by age 12 months." Correct Explanation: Children with Down syndrome will accomplish eating with their hands by about 12 months of age. They will develop the skills of typical children, but at an older age. The child with Down syndrome will speak in sentences at 24 months rather than 21 months. Bladder training would occur by 48 months rather than 32 months. A child with Down syndrome will crawl at 11 months rather than 9 months.

The mother of a 10-year-old boy with attention deficit hyperactivity disorder (ADHD) contacts the school nurse. She is upset because her son has been made to feel different by his peers because he has to visit the nurse's office for a lunch time dose of medication. The boy is threatening to stop taking his medication. How should the nurse respond? a) "You may want to talk to your physician about an extended release medication" b) "He should ignore the children, he needs this medication" c) "I can have the teacher speak with the other children" d) "Remind him that his schoolwork may deteriorate"

"You may want to talk to your physician about an extended release medication" Correct Explanation: The nurse should encourage the family to explore with their physician the option of one of the newer extended-release or once daily ADHD medications. The other statements are not helpful and do not address the mother's or boy's concerns.

When explaining the procedure of bone marrow aspiration to a child with leukemia, what would be the best explanation? a) "You will have to lie on your back and hold your breath." b) "You won't feel any pain at all, because you will be asleep." c) "You will feel pressure on your hip from the needle." d) "You will need to lie still afterward to prevent a headache."

"You will feel pressure on your hip from the needle." Correct Explanation: Bone marrow aspiration requires hard pressure to allow the needle to puncture the bone. It is usually done under local anesthesia or conscious sedation.

A woman who has a recessive gene for sickle cell anemia marries a man who also has a recessive gene for sickle cell anemia. Their first child is born with sickle cell anemia. The chance that their second child will develop this disease is a) 0 in 4. b) 3 in 4. c) 1 in 4. d) 2 in 4.

1 in 4. Explanation: Autosomal recessive inherited diseases occur at a 1-in-4 incidence in offspring. The possibility of a chance happening does not change for a second pregnancy.

An adolescent patient at a pediatric clinic presents with a butterfly rash. What diagnosis does the nurse suspect? a. Tuberous sclerosis b. Eczema c. Psoriasis d. Systemic lupus erythematosus

An infant is admitted to the hospital with severe isotonic dehydration. For what is this child at the highest risk? a. Metabolic alkalosis b. Hypocalcemia c. Sepsis d. Shock

The nurse is caring for a macrosomic newborn of a diabetic patient. What complications will the nurse assess for in the newborn? a. Meconium ileus b. Diarrhea c. Hypoglycemia d. Muscle tremors e. Urine retention

The nurse recognizes that which individual or couple would most benefit from obtaining genetic counseling? a) 30-year-old female with a normal alpha-fetoprotein screening b) 23-year-old female, 25-year-old-male, both with family history of sickle cell disorder c) 25-year-old female, 40-year-old male, both with no significant past medical history d) 32-year-old female, 25-year-old male with one pregnancy loss

23-year-old female, 25-year-old-male, both with family history of sickle cell disorder Correct Explanation: A family history of sickle cell disorder increases the risk of passing the disorder to offspring; genetic counseling would benefit this couple most. The usual standard for counseling for pregnancy loss is two or more, not a single loss. A normal alpha-fetoprotein screening is not a criterion for genetic counseling. All ages listed here do not exceed the criterion for advanced maternal or paternal age.

What is the result of a deficiency of factor IX? a. Thalassemia b. Idiopathic thrombocytopenic purpura c. Hemophilia A d. Christmas disease

You prepare a couple to have a karyotype performed. Which of the following describes a karyotype? a) The gene carried on the X or Y chromosome b) A visual presentation of the chromosome pattern of an individual c) The dominant gene that will exert influence over a correspondingly located recessive gene d) A blood test that will reveal an individual's homozygous tendencies

A visual presentation of the chromosome pattern of an individual Correct Explanation: A karyotype is a photograph of a person's chromosomes aligned in order.

14. Enlargement of the liver and spleen

HEPATOSPLENOMEGALY

Causes condylomata acuminate (genital warts)

HUMAN PAPILLOMAVIRUS (HPV)

35. Fluid-filled mass found in scrotum/testes

HYDROCELE

8. Collection of fluid in the scrotal sac

HYDROCELE

An increase in the size of an organ or structure, or of the body, owing to growth rather than tumor formation

HYPERTROPHY

Underdevelopment of a tissue organ or body

HYPOPLASIA

32. Urethral opening is on the underside of the shaft

HYPOSPADIAS

Surgical removal of the uterus through the abdominal wall or vagina

HYSTERECTOMY

23. Dye is injected into the uterus until it comes out the ends of the fallopian tubes

HYSTEROSALPINGOGRAM

25. Performed to see the inside of the uterus

HYSTEROSCOPY

Removal of the uterine contents through an abdominal incision in the same manner as a cesarean section; RARELY done for pregnancy termination

HYSTEROTOMY

The school nurse notes that a child diagnosed with diabetes mellitus is experiencing an insulin reaction and is unable to eat or drink. Which of the following actions would be the most appropriate for the school nurse to do? a) Request that someone call 911 b) Administer subcutaneous glucagon c) Anticipate that the child will need intravenous glucose d) Dissolve a piece of candy in the child's mouth

Administer subcutaneous glucagon Correct Explanation: If the child having an insulin reaction cannot take a sugar source orally, glucagon should be administered subcutaneously to bring about a prompt increase in the blood glucose level. This treatment prevents the long delay while waiting for a physician to administer IV glucose or for an ambulance to reach the child.

The school nurse notes that a child diagnosed with diabetes mellitus is experiencing an insulin reaction and is unable to eat or drink. Which of the following actions would be the most appropriate for the school nurse to do? a) Request that someone call 911 b) Administer subcutaneous glucagon c) Dissolve a piece of candy in the child's mouth d) Anticipate that the child will need intravenous glucose

The school nurse notes that a child diagnosed with diabetes mellitus is experiencing an insulin reaction and is unable to eat or drink. Which of the following actions would be the most appropriate for the school nurse to do? a) Request that someone call 911 b) Dissolve a piece of candy in the child's mouth c) Anticipate that the child will need intravenous glucose d) Administer subcutaneous glucagon

Antiemetics are ordered to control nausea and vomiting in the child undergoing chemotherapy. How can the nurse most effectively use these medications? a) Provide the antiemetic as needed (PRN) when nausea and vomiting are reported b) Start the antiemetic on a scheduled basis when the chemotherapy begins to cause nausea c) Administer the antiemetic before starting chemotherapy d) Use the antiemetic after it is clear that nonpharmacologic methods are not effective

Administer the antiemetic before starting chemotherapy Correct Explanation: Antiemetics are most effective when given before chemotherapy begins and then on a regular schedule to prevent nausea and vomiting throughout administration of chemotherapy. Nonpharmacologic measures can be used in conjunction with antiemetics but not in place of them.

The nurse is caring for a 6-year-old boy with an abdominal neuroblastoma prior to having a magnetic resonance imaging (MRI) scan without contrast done. Which of the following interventions would the nurse expect to perform? a) Encouraging fluid intake to increase radionuclide uptake b) Administering a sedative as ordered to keep the child still c) Applying EMLA to the injection site prior to inserting the IV d) Advising the physician that the child is allergic to shellfish

Administering a sedative as ordered to keep the child still Explanation: The nurse would expect to administer a sedative as ordered to keep the child still because the machine makes a loud thumping noise that could frighten the child. The child must lie without moving while the MRI is being done. Encouraging fluid intake to increase radionuclide uptake is necessary for a bone scan. Advising the physician that the child is allergic to shellfish is an intervention for a computed tomograph (CT) scan with contrast. If the child did not have an IV prior to the MRI and contrast was going to be used, then an IV would need to be inserted for the contrast after the noncontrast MRI was finished. Applying EMLA to an injection site prior to inserting an IV would be appropriate for both the CT and bone scans.

The nurse is caring for a 14-year-old boy with hyperpituitarism. Which of the following would be the priority? a) Assessing the child's self-image due to the disorder b) Teaching the child and family about proper treatment c) Administering octreotide acetate as ordered d) Treating the child according to his chronological age

Administering octreotide acetate as ordered Explanation: Administering octreotide acetate as ordered is the priority intervention and treatment for acromegaly. Assessing the child's self-image is appropriate but would not be the priority Treating the child according to his chronological age would be appropriate but not the priority. Teaching the child and family about proper treatment is appropriate and important but not the immediate priority.

The toddler with a cancer diagnosis is seen for a well-child checkup. Which health maintenance activity will the nurse exclude? a) Assessing dietary intake by addressing "picky eating" and "food jags" b) Plotting height and weight on a growth chart c) Administering the measles, mumps, rubella (MMR) vaccine d) Teaching the importance of taking water safety measures

Administering the measles, mumps, rubella (MMR) vaccine Correct Explanation: Live vaccines (viral or bacterial) should not be administered to an immune suppressed child because of the risk of causing disease. The other health maintenance activities are important for the health maintenance of the toddler and should be included during the well-child visit.

The parents of a child who was diagnosed with diabetes insipidus ask the nurse, "How does this disorder occur?" When responding to the parents, the nurse integrates knowledge that a deficiency of which hormone is involved? a) Insulin b) Antidiuretic hormone c) Growth hormone d) Thyroxine

Antidiuretic hormone Explanation: Diabetes insipidus results from a deficiency in the secretion of antidiuretic hormone (ADH). This hormone, also known as vasopressin, is produced in the hypothalamus and stored in the pituitary gland. Hypopituitarism or dwarfism involves a growth hormone deficiency. Diabetes mellitus involves a disruption in insulin secretion. Thyroxine is a thyroid hormone that if deficient leads to hypothyroidism.

The nurse is providing preoperative care for a 7-year-old boy with a brain tumor and his parents. Which of the following is the priority intervention? a) Assessing the child's level of consciousness b) Having him talk to a child who has had this surgery c) Educating the child and parents about shunts d) Providing a tour of the intensive care unit

Assessing the child's level of consciousness Explanation: The priority intervention is to monitor for increases in intracranial pressure because brain tumors may block cerebral fluid flow or cause edema in the brain. A change in the level of consciousness is just one of several subtle changes that can occur indicating a change in intracranial pressure. Lower priority interventions include providing a tour of the ICU to prepare the child and parents for after the surgery, and educating the child and parents about shunts.

Cystic fibrosis is an example of which type of inheritance? a) Multifactorial b) Autosomal dominant c) X-linked recessive d) Autosomal recessive

Autosomal recessive Correct Explanation: Cystic fibrosis is an autosomal recessive inherited condition. Huntington disease would be an example of an autosomal dominant inherited condition. Hemophilia is an X-linked recessive inherited condition. Cleft lip is a multifactorial inherited condition.

A 4-year-old child diagnosed with Wilms tumor is admitted for surgery. Which of the following would be most important for the nurse to include in the child's preoperative plan of care? a) Preparing the child for amputation b) Avoiding further abdominal palpation c) Administering analgesics for pain d) Performing dressing changes to the affected area

Avoiding further abdominal palpation Explanation: After the initial assessment is performed on a child with Wilms tumor, further palpation of the abdomen should be avoided because the tumor is highly vascular and soft. Therefore, excessive handling of the tumor may result in tumor seeding and metastasis. Preoperatively, the child with Wilms tumor does not have a wound; therefore, dressing changes are not necessary. Although the child may experience abdominal pain, avoiding further abdominal palpation would be the priority. Surgical removal of the tumor and affected kidney is the treatment of choice for Wilms tumor. Amputation would be more likely for a child with osteosarcoma.

The nurse is providing care for a patient with genital herpes who has vesicular lesions. What term should the nurse use to describe these lesions to the patient? a. Warts b. Rashes c. Blisters d. Papules

Any process, device, or method that prevents conception

CONTRACEPTIVE

4. This secretes progesterone and estrogen after ovulation

CORPUS LUTEUM

Freezing therapy

CRYOTHERAPY

The nurse is assessing an 11-year-old girl diagnosed with acute myelogenous leukemia (AML) who came to the emergency department. Which of the following would alert the nurse to the need for immediate intervention? a) CBC indicates hyperleukocytosis. b) Palpation reveals lymphadenopathy in the axillae. c) Observation discloses weight loss and muscle wasting. d) Child complains of headache and vision problems.

CBC indicates hyperleukocytosis. Explanation: About 25% of children with acute myelogenous leukemia present with blood counts greater than 100,000. This is called hyperleukocytosis, and it is a medical emergency requiring leukapheresis to decrease hyperviscosity by quickly decreasing the number of circulating blasts. Lymphadenopathy, headache, visual disturbance, weight loss, and muscle wasting are signs and symptoms common to both types of leukemia. Lymphadenopathy is a common manifestation associated with AML and does not require immediate intervention. Headache and vision problems are common manifestations associated with AML. They do not require immediate intervention. Weight loss and muscle wasting are common manifestations associated with AML. They do not require immediate intervention.

34. Surgical removal of the foreskin

CIRCUMCISED

Surgical repair of the anterior portion of the vagina

COLPORRHAPHY

26. A binocular microscope is used with an endoscope that is introduced into the vagina to closely study lesions of the cervix

COLPOSCOPY

5. Genital warts; common sexually transmitted viral disease

CONDYLOMATA ACUMINATA

1. Wart-like

CONDYLOMATOUS

21. Collection of cells by removing a small cone-shaped sample from the cervical canal

CONIZATION

6. Inflammation of the conjunctiva of the eye

CONJUCTIVITIS

The nurse is caring for a girl with anorexia who has been hospitalized with unstable vital signs and food refusal. The girl requires enteral nutrition. The nurse is alert for which of the complications that signal re-feeding syndrome? a) Bradycardia with ectopy b) Hypothermia and irregular pulse c) Cardiac arrhythmias, confusion, seizures d) Orthostatic hypotension

Cardiac arrhythmias, confusion, seizures Correct Explanation: The nurse should be aware that rapid nutritional replacement in the severely malnourished can lead to refeeding syndrome. Refeeding syndrome is characterized by cardiovascular, hematologic, and neurologic complications such as cardiac arrhythmias, confusion, and seizures. Orthostatic hypotension, hypertension, and irregular and decreased pulses are complications of anorexia but do not characterize refeeding syndrome.

The father of an 8-year-old boy who is receiving radiation therapy is upset that his son has to go through 6 weeks of treatments. He doesn't understand why it takes so long. In explaining the need for radiation over such a long time, which of the following should the nurse mention? a) Insurance companies typically allow only a short radiation treatment per week, to contain costs b) It is difficult to locate where the cancer cells are in the body, so the entire body must be irradiated c) Cells are only susceptible to treatment by radiation during certain phases of the cell cycle d) Radiation therapy is very weak, and therefore it takes a long time to achieve therapeutic doses

Cells are only susceptible to treatment by radiation during certain phases of the cell cycle Correct Explanation: Radiation is not effective on cells that have a low oxygen content (a proportion of cells in every tumor), nor is it effective at the time of cell division (mitosis). Therefore, radiation schedules are designed so that therapy occurs over a period of 1 to 6 weeks and includes time intervals when cells will be in a susceptible stage.

The nurse is assessing a 10-year-old girl with acute lymphoblastic leukemia. Which of the following would lead the nurse to suspect that the cancer has infiltrated the central nervous system? a) Observing petechiae, purpura, or unusual bruising b) Child complains of facial palsy and vision problems c) Noting adventitious breath sounds during auscultation d) Palpation of abdomen reveals enlarged liver and spleen

Child complains of facial palsy and vision problems Correct Explanation: The presence of facial palsy and vision problems indicates that the central nervous system has been infiltrated by leukemia cells. The petechiae, purpura, or unusual bruising results from decreased platelet levels and may be present regardless of metastasis. Adventitious breath sounds may indicate pneumonia, and may be present whether the disease has metastasized or not. Hepatomegaly and splenomegaly result from infection, not metastasis.

A nursing student compares and contrasts childhood and adult cancers. Which statement does so accurately? a) Adult cancers are more responsive to treatment than are those in children. b) Little is known regarding cancer prevention in adults, although much prevention information is available for children. c) Environmental and lifestyle influences in children are strong, unlike those in adults. d) Children's cancers, unlike those of adults, often are detected accidentally, not through screening.

Children's cancers, unlike those of adults, often are detected accidentally, not through screening. Correct Explanation: Children's cancers are often found during a routine checkup, following an injury, or when symptoms appear---not through screening procedures or other specific detection practices. A very small percentage of children may be followed closely because they are known to be at high risk genetically. Most children's cancers are highly responsive to therapy. Few prevention strategies are available for children, although many are known to be effective for adults. Several lifestyle and environmental influences regarding children's cancers are suspect, but few have been scientifically documented. The reverse is true in the adult population.

A nursing student is reviewing information about inheritance and genetic disorders. The student demonstrates understanding of the information by identifying which of the following as an example of a disorder involving multifactorial inheritance? a) Cystic fibrosis b) Hypophosphatemic rickets c) Hemophilia d) Cleft palate

Cleft palate Correct Explanation: Cleft palate is attributed to multifactorial inheritance. Hemophilia follows an X-linked recessive inheritance pattern. Hypophosphatemic rickets follows an X-linked dominant inheritance pattern. Cystic fibrosis follows an autosomal recessive inheritance pattern.

For which of the following clients is preimplantation genetic diagnosis (PGD) a viable option? a) Clients carrying cystic fibrosis gene b) Prevention of Pyloric stenosis c) Prevention of DiGeorge syndrome d) Client in the second week of pregnancy

Clients carrying cystic fibrosis gene Correct Explanation: Preimplantation genetic diagnosis (PGD) is a viable option for clients carrying the cystic fibrosis gene. PGD does not help prevent DiGeorge syndrome or pyloric stenosis. PGD is not a viable option for pregnant clients.

Upon assessment, the nurse notices that the infant's ears are low-set. What is the priority action by the nurse? a) Inform the parents that low-set ears are a sign of Down syndrome b) Place the infant on a cardiac monitor c) Continue to assess the infant to look for other abnormalities d) Give a vitamin B12 injection to combat the metabolic disorder

Continue to assess the infant to look for other abnormalities Correct Explanation: Continue to assess for major and minor congenital anomalies because major anomalies may require immediate medical attention. Three or more minor anomalies increase the chance of a major anomaly. Low-set ears can be a symptom of a variety of genetic disorders. Mentioning Down syndrome without further investigation can cause undue stress in parents. The infant may not need cardiac monitoring; further assessment will provide clues. Diagnostic testing is needed to determine whether the child is afflicted with a metabolic disorder.

As a nurse, you know that which of the following is caused by excessive levels of circulating cortisol: a) Cushing syndrome b) Addison disease c) Turner syndrome d) Graves disease

What should the nurse explain to the parent of a child with exercise-induced asthma about when to inhale Cromolyn? a. Before exercise to prevent attacks b. At the initial onset of the attack c. During the attack to relieve symptoms d. As often as 4 times a day

Resembling the skin

DERMOID

3. Done to palpate the prostate

DIGITAL RECTAL EXAMINATION

A surgical procedure that expands the cervical canal of the uterus so that the surface lining of the uterine wall can be scraped

DILATION AND CURETTAGE

2. Difficult or painful menstruation

DYSMENORRHEA

4. Difficult or painful menstruation

DYSMENORRHEA

Pain with intercourse

DYSPAREUNIA

Cell changes that may become cancerous

DYSPLASIA

A child with a primary growth hormone deficiency is to receive biosynthetic growth hormone. The nurse would explain to the child and parents that this hormone would be given at which frequency? a) Monthly b) Weekly c) Bi-monthly d) Daily

Daily Explanation: Biosynthetic growth hormone, derived from recombinant DNA, is given by subcutaneous injection. The weekly dosage is 0.2 to 0.3 mg/kg, divided into equal doses given daily for best growth.

A 15-year-old girl is brought to the clinic by her mother because the girl has been experiencing irregular and sporadic menstrual periods and excessive body hair growth. Polycystic ovary syndrome is suspected. Which additional assessment finding would help to support this suspicion? a) Body mass index as normal b) Darkened pigmentation around the neck area c) Short stature d) Decreased serum levels of free testosterone

Darkened pigmentation around the neck area Explanation: Acanthosis nigricans (darkened, thickened pigmentation, particularly around the neck or in the axillary region) is associated with polycystic ovary syndrome. Serum levels of free testosterone typically are elevated with polycystic ovary syndrome. With polycystic ovary syndrome, body mass index indicates overweight or obesity. Short stature typically is associated with growth hormone deficiency.

A woman in her first trimester of pregnancy has just been diagnosed with acquired hypothyroidism. The nurse is alarmed because she knows that this condition can lead to which of the following pregnancy complications? a) Gestational diabetes in the mother b) Spina bifida in the fetus c) Decreased cognitive development of the fetus d) Congenital heart defects in the fetus

Decreased cognitive development of the fetus Correct Explanation: If acquired hypothyroidism exists in a woman during pregnancy, her infant can be born cognitively challenged because there was not enough iodine present for fetal growth. It is important, therefore, that girls with this syndrome be identified before they reach childbearing age.

Removed just the tumor and a margin around it

LUMPECTOMY

16. Any disorder of the lymph nodes

LYMPHADENOPATHY

The nurse is caring for a child with diabetes mellitus type 1. The nurse notes that the child is drowsy, has flushed cheeks and red lips, a fruity smell to the breath, and there has been an increase in the rate and depth of the child's respirations. The nurse recognizes that these symptoms indicate the child has which of the following? a) Diabetic ketoacidosis b) Polyphagia c) Insulin reaction d) Cheyne stokes respiration

Diabetic ketoacidosis Correct Explanation: Diabetic ketoacidosis is characterized by drowsiness, dry skin, flushed cheeks and cherry-red lips, acetone breath with a fruity smell, and Kussmaul breathing (abnormal increase in the depth and rate of the respiratory movements).

Insulin deficiency, increased levels of counterregulatory hormones, and dehydration are the primary cause of which of the following: a) Ketone bodies b) Ketonuria c) Glucosuria d) Diabetic ketoacidosis

Diabetic ketoacidosis Correct Explanation: Insulin deficiency, in association with increased levels of counterregulatory hormones (glucagon, growth hormone, cortisol, catecholamines) and dehydration, is the primary cause of diabetic ketoacidosis (DKA), a life-threatening form of metabolic acidosis that is a frequent complication of diabetes. Liver converts triglycerides (lipolysis) to fatty acids, which in turn change to ketone bodies. The accumulation and excretion of ketone bodies by the kidneys is called ketonuria. Glusosuria is glucose that is spilled into the urine.

Nondisjunction of a chromosome results in which of the following diagnoses? a) Duchenne muscular dystrophy b) Down syndrome c) Marfan syndrome d) Huntingon disease

Down syndrome Correct Explanation: When a pair of chromosomes fails to separate completely (nondisjunction) the resulting sperm or oocyte contains two copies of a particular chromosome. Nondisjunction can result in a fertilized egg having trisomy 21 or Down syndrome. Huntington disease is one example of a germ-line mutation. Duchenne muscular dystrophy, an inherited form of muscular dystrophy, is an example of a genetic disease caused by structural gene mutations. Marfan syndrome is a genetic condition that may occur in a single family member as a result of spontaneous mutation.

A pregnant woman undergoes maternal serum alpha-fetoprotein (MSAFP) testing at 16 to 18 weeks' gestation. Which of the following would the nurse suspect if the woman's level is decreased? a) Cardiac defects b) Open neural tube defect c) Down syndrome d) Sickle-cell anemia

Down syndrome Explanation: Decreased levels might indicate Down syndrome or trisomy 18. Sickle cell anemia may be identified by chorionic villus sampling. MSAFP levels would be increased with cardiac defects, such as tetralogy of Fallot. A triple marker test would be used to determine an open neural tube defect.

What situation would concern the nurse about the presence of Rh incompatibility? a. Rh-negative mother, Rh-positive fetus b. Rh-positive mother, Rh-negative fetus c. Rh-negative mother, Rh-negative fetus d. Rh-positive mother, Rh-positive fetus

A 7-year-old child is diagnosed with a learning disability involving reading, writing, and spelling. The nurse identifies this as which of the following? a) Dyslexia b) Dyspraxia c) Dyscalculia d) Dysgraphia

Dyslexia Correct Explanation: Dyslexia is a learning disability that involves reading, writing, and spelling. Dyscalculia is a learning disability that involves mathematics and computation. Dyspraxia is a learning disability that involves problems with manual dexterity and coordination. Dysgraphia is a learning disability that involves problems producing the written word.

9. Cauterization using platinum wires heated to red or white heat by an electric current, either direct or alternating

ELECTROCAUTERY

10. Coagulation of tissue by means of a high-requency electric current

ELECTROCOAGULATED

11. Inflammation/infection of the endometrium

ENDOMETRITIS

12. Study of the distribution and determinants of health related states and events in populations and the application of this study to the control of health problems

EPIDEMIOLOGICAL

5. Inflammation or infection of the epididymis that can be caused by bacteria, viruses, parasites, chemicals, or trauma

EPIDIDYMITIS

33. Urethral opening is on the dorsum of the shaft

EPISPADIAS

7. Impotence; cannot obtain or keep a usable erection that is firm enough and long-lasting enough for satisfactory sexual intercourse

ERECTILE DYSFUNCTION

A 45-year-old man has just been diagnosed with Huntington disease. He and his wife are concerned about their four children. What will the nurse explain about the children's possibility of inheriting the gene for the disease? a) Each child will have no chance of inheriting the disease b) Each child will have a 50% chance of inheriting the disease c) Each child will have a 25% chance of inheriting the disease d) Each child will have a 75% chance of inheriting the disease

Each child will have a 50% chance of inheriting the disease Correct Explanation: Huntington disease is an autosomal dominant disorder. Autosomal dominant inherited conditions affect female and male family members equally and follow a vertical pattern of inheritance in families. A person who has an autosomal dominant inherited condition carries a gene mutation for that condition on one chromosome pair. Each of that person's offspring has a 50% chance of inheriting the gene mutation for the condition and a 50% chance of inheriting the normal version of the gene. Based on this information, the choices of 25%, 75%, or no chance of inheriting the disease are incorrect.

The nurse is caring for a 1-year-old boy with Down syndrome. Which of the following would the nurse be least likely to include in the child's plan of care? a) Promoting annual vision and hearing tests b) Describing the importance of a high-fiber diet c) Explaining developmental milestones to parents d) Educating parents about how to deal with seizures

Educating parents about how to deal with seizures Correct Explanation: It is unlikely that the parents will need to know how to deal with seizures. It will be helpful to provide parents with growth and developmental milestones that are unique to children with Down syndrome. More than 60% of children with Down syndrome have hearing loss, so promoting annual vision and hearing tests is the priority intervention. Special diets are usually not necessary; however, a balanced, high-fiber diet and exercise are important because constipation is frequently a problem.

The nurse is collecting data from the caregiver of an 8-year-old child who recently started soiling his underwear each day rather than using the toilet to defecate. This behavior indicates a symptom of which of the following? a) Echolalia b) Encephalopathy c) Encopresis d) Enuresis

Encopresis Correct Explanation: Encopresis is chronic involuntary fecal soiling beyond the age when control is expected (about 3 years of age).

The nurse is caring for a 13-year-old girl with a nursing diagnosis of ineffective coping related to inability to deal with life stressors as evidenced by few or no meaningful friendships and low self-esteem. Which intervention would be the priority to promote coping skills? a) Set clear limits on behavior. b) Role model appropriate social and conversation skills. c) Encourage her to discuss her thoughts and feelings. d) Demonstrate unconditional acceptance of the child as a person.

Encourage her to discuss her thoughts and feelings. Explanation: The priority intervention is to encourage her to discuss her thoughts and feelings, as this is an initial step toward learning to deal with them appropriately. The other interventions are appropriate, but the priority intervention is to encourage discussion and obtain information from the child. This way the nurse can develop and refine the interventions based on the child's thoughts and feelings.

A 10-year-old girl has been referred for evaluation due to difficulties integrating with her peers at her new school. The counselor believes she is at risk for situational low self-esteem due to problematic relationships with both family members and peers. Which of the following is the best approach? a) Engage the girl in dialogue regarding feelings about self/personal appearance. b) Explore the girl's feelings about changes in her body with the onset of puberty. c) Remind her of the importance of good hygiene for better appearance. d) Introduce the concept of accepting differences to reduce conflict.

Engage the girl in dialogue regarding feelings about self/personal appearance. Correct Explanation: Engaging the child in dialogue about self and personal appearance may reveal self-perceptions and allow discussion of reality versus perception; this enables discussion of methods to address perceived weaknesses and to focus on strengths. Appearance may reflect self-perception, and a comment regarding hygiene might be poorly received. While pubertal changes can be stressful, a 10-year-old girl may not have entered puberty and the question may not be relevant. The concept of accepting differences is secondary to engaging child in dialogue about self and appearance.

A newborn girl is discovered to have congenital adrenogenital hyperplasia. When assessing her, you would expect to find which physical characteristic? a) Abnormal facial features b) Small for gestational age c) Divergent vision d) Enlarged clitoris

Enlarged clitoris Correct Explanation: Lack of production of cortisol by the adrenal gland leads to overproduction of androgen. This leads to female infants developing an enlarged clitoris.

When counseling potential parents about genetic disorders, which of the following statements would be appropriate? a) Genetic disorders primarily follow Mendelian laws of inheritance. b) Environmental influences may affect multifactorial inheritance. c) All genetic disorders involve a similar number of abnormal chromosomes. d) The absence of genetic disorders in both families eliminates the possibility of having a child with a genetic disorder.

Environmental influences may affect multifactorial inheritance. Correct Explanation: It is difficult to predict with certainty the incidence of genetic disorders because in some disorders, more than one gene is involved and environmental insults may play a role (cleft palate, for example).

A child receiving chemotherapy is experiencing significant reduction in red blood cells secondary to myelosuppression. Which agent would the nurse most likely expect to be ordered? a) Epoetin alfa b) Filgrastim c) Gamma interferon d) Sargramostim

Epoetin alfa Correct Explanation: Epoetin alfa is a colony-stimulating factor used to stimulate production of red blood cells. Filgrastim is a colony-stimulating factor used to stimulate production of granulocytes. Sargramostim is a colony-stimulating factor used to stimulate production of granulocytes. Gamma interferon is used to stimulate macrophage production to fight bacteria and fungus.

The pediatric nurse examines the radiographs of a patient that show that there are lesions on the bone. This finding is indicative of: a) Neuroblastoma b) Hodgkin disease c) Ewing sarcoma d) Non-Hodgkin lymphoma

Ewing sarcoma Correct Explanation: Radiographs that show lesions on the bone may indicate tumors (e.g., Ewing sarcoma, osteosarcoma) or metastasis of tumors and warrant further investigation by bone scan, CT, or MRI. Positron emission tomography is the most effective test to diagnose Hodgkin disease, non-Hodgkin lymphoma, a neuroblastoma, bone tumors, lung and colon cancers, and brain tumors.

While instructing a new mother on formula preparations, the nurse would include what types? (Select all that apply.) a. Ready-to-feed formula b. Concentrated liquid formula c. Powdered formula d. Cows milk e. Canned evaporated milk

a, b, c

The nurse explains to the teenager that which alterations may occur when steroids are added to the cancer therapy regimen? a) Facial changes b) Nighttime itching c) Loss of appetite d) Urinary incontinence

Facial changes Correct Explanation: Facial changes are common and include a round face with full cheeks, often reddened, described as "moon face." Weight gain and fat pads may appear in various areas of the body. Appetite is likely to increase. Urinary incontinence and nighttime itching are not related to steroid therapy.

Children who are free of acute lymphocytic anemia for 2 years following treatment are considered cured. a) False b) True

False Correct Explanation: Children who are free of disease for 4 years are considered cured, and their maintenance therapy can then be stopped.

Tay-Sachs disease is found primarily in the Asian population. a) True b) False

False Correct Explanation: Tay-Sachs disease is found primarily in the Ashkenazi Jewish population (Eastern European Jewish ancestry).

The parathyroid glands regulate serum levels of glucose in the body. a) False b) True

False Correct Explanation: The four parathyroid glands, located posterior and adjacent to the thyroid gland, regulate serum levels of calcium in the body by controlling the rate of bone metabolism.

13. Tumors of a rubbery consistency that can break down and ulcerate, leaving holes in body tissues

GUMMAS

After teaching a class of students about genetics and inheritance, the instructor determines that the teaching was successful when the students identify which of the following as the basic unit of heredity? a) Allele b) Autosome c) Chromosome d) Gene

Gene Correct Explanation: A gene is the basic unit of heredity of all traits. A chromosome is a long, continuous strand of DNA that carries genetic information. An allele refers to one of two or more alternative versions of a gene at a given position on a chromosome that imparts the same characteristic of that gene. An autosome is a non-sex chromosome.

A client who is 37 years of age presents to the health care clinic for her first prenatal check up. Due to her advanced age, the nurse should prepare to talk with the client about her increased risk for what complication? a) Incompetent cervix b) Genetic disorders c) Gestational diabetes d) Preterm labor

Genetic disorders Correct Explanation: Women over the age of 35 are at increased risk of having a fetus with an abnormal karyotype or other genetic disorders. Gestational diabetes, an incompetent cervix, and preterm labor are risks for any pregnant woman.

After hospital discharge, the mother of a child newly diagnosed with type 1 diabetes mellitus telephones you because her daughter is acting confused and very sleepy. Which emergency measure would you suggest the mother carry out before she brings the child to see her doctor? a) Give her a glass of orange juice. b) Give her a glass of orange juice with one unit regular insulin in it. c) Give her one unit of regular insulin. d) Give her nothing by mouth so that a blood sugar can be drawn at the doctor's office.

Give her a glass of orange juice. Correct Explanation: These are typical symptoms of hypoglycemia. Administering a form of glucose would help relieve them. Insulin cannot be absorbed when taken orally.

The nurse is caring for a 4-year-old boy following surgical removal of a stage I neuroblastoma. Which of the following interventions will be most appropriate for this child? a) Applying aloe vera lotion to irradiated areas of skin b) Giving medications as ordered via least invasive route c) Maintaining isolation as prescribed to avoid infection d) Administering antiemetics as prescribed for nausea

Giving medications as ordered via least invasive route Explanation: Giving medications as ordered using the least invasive route is a postsurgery intervention focused on providing atraumatic care and is appropriate for this child. Since the child has a stage I tumor, it can be treated by surgical removal, and does not require chemotherapy or radiation therapy. Applying aloe vera lotion is good skin care following radiation therapy. Administering antiemetics and maintaining isolation are interventions used to treat side effects of chemotherapy.

A child with Addison disease has been admitted with a history of nausea and vomiting for the past three days. The client is receiving IV glucocorticoids (e.g., Solu-Medrol). Which of the following interventions would the nurse implement? a) Daily weights b) Monitoring of sodium and potassium levels c) Glucometer readings as ordered d) Intake and output measurements

Glucometer readings as ordered Explanation: IV glucocorticoids raise the glucose levels and often require coverage with insulin. Measuring the intake and output at this time is not necessary. Sodium and potassium would be monitored when the client is receiving mineral corticoids. Daily weights are not necessary at this time.

The nurse knows that disorders of the pituitary gland depend on the location of the physiologic abnormality. Caring for a child that has issues with the anterior pituitary, the child has issues with which hormone? a) Oxytocin b) Antidiuretic hormone c) Vasopressin d) Growth hormone

Growth hormone Correct Explanation: Disorders of the pituitary gland depend on the location of the physiologic abnormality. The anterior pituitary, or adrenohypophysis, is made up of endocrine glandular tissue and secretes growth hormone (GH), adrenocorticotropic hormone (ACTH), TSH, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and prolactin. The posterior lobe is called the neurohypophysis because it is formed of neural tissue. It secretes antidiuretic hormone (ADH; vasopressin) and oxytocin. Usually, several target organs are affected when there is a disorder of the pituitary gland, especially the adrenohypophysis

You care for a 12-month-old with autistic disorder. Which of the following descriptions would you expect to elicit from his mother on history-taking? a) He stares at a rotating wheel on his crib mobile. b) He already speaks in complete sentences. c) He sleeps at least 12 out of every 24 hours. d) He responds warmly to his father but not to his mother.

He stares at a rotating wheel on his crib mobile. Explanation: Children with autistic disorder seem fascinated by whirling or spinning toys or objects. They are nonverbal and have difficulty forming close relationships.

A child is diagnosed with hyperthyroidism. Which of the following would the nurse expect to assess? a) Weight gain b) Facial edema c) Constipation d) Heat intolerance

Heat intolerance Correct Explanation: Hyperthyroidism is manifested by heat intolerance, nervousness or anxiety, diarrhea, weight loss and smooth, velvety skin. Constipation, weight gain, and facial edema are associated with hypothyroidism.

The nurse is assessing a 16-year-old boy who has had long-term corticosteroid therapy. Which of the following findings, along with the use of the corticosteroids, would indicate Cushing disease? a) Observing delayed dentition b) History of rapid weight gain c) Observing a round, child-like face d) Observing high weight to height ratio

History of rapid weight gain Explanation: A history of rapid weight gain and long-term corticosteroid therapy suggests this child may have Cushing disease, which could be confirmed using an adrenal suppression test. A round, child-like face is common to both Cushing and growth hormone deficiency. Observing high weight to height ratio and delayed dentition are findings with growth hormone deficiency.

In teaching the parents of an infant diagnosed with diabetes insipidus, the nurse should include which treatment? a) Antihypertensive medications b) Fluid restrictions c) The need for blood products d) Hormone replacement

Hormone replacement Correct Explanation: The usual treatment for diabetes insipidus is hormone replacement with vasopressin or desmopressin acetate (DDAVP). Blood products shouldn't be needed. No problem with hypertension is associated with this condition, and fluids shouldn't be restricted.

When describing genetic disorders to a group of childbearing couples, the nurse would identify which as an example of an autosomal dominant inheritance disorder? a) Phenylketonuria b) Cystic fibrosis c) Huntington's disease d) Sickle cell disease

Huntington's disease Correct Explanation: Huntington's disease is an example of an autosomal dominant inheritance disorder. Sickle cell disease, phenylketonuria, and cystic fibrosis are examples of autosomal recessive inheritance disorders.

When discussing congenital adrenogenital hyperplasia with a child's parents, you would advise them that administration of which of the following drugs will probably be indicated? a) Calcium b) Hydrocortisone c) Vitamin D d) Growth hormone

Hydrocortisone Correct Explanation: The basic defect in congenital adrenogenital hyperplasia is the lack of cortisol. Administering hydrocortisone supplements this.

An 18-year-old male patient is diagnosed with Klinefelter syndrome. What signs and symptoms are consistent with this diagnosis? a) Hypergonadism and decreased pubic hair b) Hypogonadism and gynecomastia c) Long torso and decreased facial hair d) Enlaged testes and tall stature

Hypogonadism and gynecomastia Correct Explanation: Klinefelter syndrome affects males, causing only testosterone deficiency. Males may develop female-like characteristics such as gynecomastia and may experience hypogonadism. Decreased pubic and facial hair, along with tall stature, are characteristic of the disorder. The corresponding signs and symptoms listed in the other answer selections are not signs and symptoms of the disorder.

A 6-year-old girl visits the pediatrician with complaints of excessive thirst, frequent voiding, weakness, lethargy, and headache. The nurse suspects diabetes insipidus. Which of the following hormonal conditions is characteristic of this disease? a) Hypersecretion of somatotropin b) Hyposecretion of somatotropin c) Hyposecretion of antidiuretic hormone d) Hypersecretion of antidiuretic hormone

Hyposecretion of antidiuretic hormone Correct Explanation: Diabetes insipidus is a disease in which there is decreased release of antidiuretic hormone (ADH) by the pituitary gland. The child with diabetes insipidus experiences excessive thirst (polydipsia) that is relieved only by drinking large amounts of water; there is accompanying polyuria. Symptoms include irritability, weakness, lethargy, fever, headache, and seizures. Overproduction of antidiuretic hormone by the posterior pituitary gland results in a decrease in urine production and water intoxication and features weight gain, concentrated urine (increased specific gravity), nausea, and vomiting. As the hyponatremia grows more severe, coma or seizures occur from brain edema. Hyposecretion of somatotropin, or growth hormone, results in undergrowth; hypersecretion results in overgrowth.

Bringing ova and sperm together outside the bodies of the participants

IN VITRO FERTILIZATION

28. Inflation of the adbomen during laparoscopic or endoscopic procedures to enhance visualization of structures

INSUFFLATION

On admission, a child with leukemia has widespread purpura and a platelet count of 19,000/mm3. What is the priority nursing intervention? a. Assessing neurological status b. Inserting an intravenous line c. Monitoring vital signs during platelet transfusions d. Providing family education about how to prevent bleeding

The nurse is teaching an 11-year-old boy and his family how to manage his diabetes. Which of the following does not focus on glucose management? a) Promoting higher levels of exercise than previously maintained b) Encouraging the child to maintain the proper injection schedule c) Instructing the child to rotate injection sites to decrease scar formation d) Teaching that 50% of daily calories should be carbohydrates

Instructing the child to rotate injection sites to decrease scar formation Explanation: Instructing child to rotate injection sites to decrease scar formation is important, but does not focus on managing glucose levels. Teaching the child and family to eat a balanced diet, encouraging the child to maintain the proper injection schedule, and promoting a higher level of exercise all focus on regulating glucose control.

In interpreting the negative feedback system that controls endocrine function, the nurse correlates how _______ secretion is decreased as blood glucose levels decrease. a) Glucagon b) Insulin c) Adrenocorticotropic hormone d) Glycogen

Insulin Correct Explanation: Feedback is seen in endocrine systems that regulate concentrations of blood components such as glucose. Glucose from the ingested lactose or sucrose is absorbed in the intestine and the level of glucose in blood rises. Elevation of blood glucose concentration stimulates endocrine cells in the pancreas to release insulin. Insulin has the major effect of facilitating entry of glucose into many cells of the body; as a result, blood glucose levels fall. When the level of blood glucose falls sufficiently, the stimulus for insulin release disappears and insulin is no longer secreted.

You care for a 10-year-old boy with growth hormone deficiency. Which therapy would you anticipate will be prescribed for him? a) Oral administration of somatotropin b) Short-term aldosterone provocation c) Intramuscular injections of growth hormone d) Long-term blocking of beta cells

Intramuscular injections of growth hormone Correct Explanation: Growth hormone deficiency occurs when the pituitary is unable to produce enough hormone for usual growth. Administering IM growth hormone supplements this.

A nurse is observing a 10-year-old boy who is in the waiting room of a pediatrician's office. Another child on the other side of the room removes the lid from a toy box, and the 10-year-old boy screams and then cries briefly. Noticing his shoe laces, he begins laughing and untying them. The nurse recognizes this behavior as an example of which of the following? a) Labile mood b) Catatonia c) Flat affect d) Echolalia

Labile mood Correct Explanation: Children with autistic spectrum disorder are said to have a labile mood (crying occurs suddenly and is followed immediately by giggling or laughing or vice versa). Echolalia (repetition of words or phrases spoken by others) and concrete interpretation are also common findings. Children with schizophrenia experience hallucinations (hear or see people or objects that other people cannot) and may display rambling or illogical speech patterns. They may not be responsive (have a flat affect), may withdraw into themselves so completely they are stuporous (catatonia) or be so extremely suspicious that others want to harm them (paranoia) it is difficult for them to function.

A couple wants to start a family. They are concerned that their child will be at risk for cystic fibrosis because they each have a cousin with cystic fibrosis. They are seeing a nurse practitioner for preconceptual counseling. What would the nurse practitioner tell them about cystic fibrosis? a) It is an X-linked inherited disorder b) It is an autosomal dominant disorder c) It is an autosomal recessive disorder d) It is passed by mitochondrial inheritance

It is an autosomal recessive disorder Correct Explanation: Cystic fibrosis is autosomal recessive. Nurses also consider other issues when assessing the risk for genetic conditions in couples and families. For example, when obtaining a preconception or prenatal family history, the nurse asks if the prospective parents have common ancestors. This is important to know because people who are related have more genes in common than those who are unrelated, thus increasing their chance for having children with autosomal recessive inherited condition such as cystic fibrosis. Mitochondrial inheritance occurs with defects in energy conversion and affects the nervous system, kidney, muscle, and liver. X-linked inheritance, which has been inherited from a mutant allele of the mother, affects males. Autosomal dominant is an X-linked dominant genetic disease

The mother of an 8-year-old boy is concerned that her son has attention-deficit/hyperactivity disorder. She describes the symptoms he demonstrates. Which of the following behaviors should the nurse recognize as an example of impulsiveness? a) Constantly fidgeting in his chair and shaking his foot b) Repeating words or phrases spoken by others c) Jumping out of his seat in the middle of class and running to the bathroom without the teacher's permission d) Inability to answer a question posed by his teacher because he was daydreaming

Jumping out of his seat in the middle of class and running to the bathroom without the teacher's permission Correct Explanation: The disorder is characterized by three major behaviors: inattention, impulsiveness, and hyperactivity. Inattention makes children become easily distracted and often may not seem to listen or complete tasks effectively. Impulsiveness causes them to act before they think and therefore to have difficulty with such tasks as awaiting turns. With hyperactivity, children may shift excessively from one activity to another, exhibit excessive or exaggerated muscular activity, such as excessive climbing onto objects, constant fidgeting, or aimless or haphazard running. Repeating words or phrases spoken by others is echolalia and is associated with autistic spectrum disorder.

A nurse is giving instructions to the father of a boy who is receiving chemotherapy including methotrexate regarding how best to care for the boy during this period of treatment. Which of the following should she mention to him? a) Give him aspirin to help manage pain b) Give the boy folic acid supplements c) Be sure that the boy receives only live-virus vaccines d) Keep him away from people with known infections

Keep him away from people with known infections Correct Explanation: Caution parents, while children are receiving chemotherapy, not to give them aspirin for pain as, in addition to increasing the child's susceptibility to Reye syndrome, aspirin may interfere with blood coagulation, a problem that may already be present because of lowered thrombocyte levels. A parent who wants to give a child vitamins should check with the primary health care provider to be certain the vitamin preparation will not interfere with a chemotherapeutic agent. Administration of a vitamin that contains folic acid, for example, could interfere with the effectiveness of methotrexate, a folic acid antagonist. A child receiving chemotherapy is particularly susceptible to contracting an infection so should be kept away from people with known infections. Caution parents that live-virus vaccines should not be given during chemotherapy as, if the child's immune mechanism is deficient, these vaccines could cause widespread viral disease.

The nurse realizes that the chemotherapy agents and radiation that a child is receiving are likely to irritate the bladder. What are the best measures that the nurse can take to diminish this risk? a) Administer chemotherapy during sleep periods, including naps and overnight b) Keep intravenous (IV) fluids running to maintain excellent hydration and frequent voids c) Have the child wait to void until the bladder becomes full d) Promote drinking of cranberry juice, making it an attractive oral fluid option

Keep intravenous (IV) fluids running to maintain excellent hydration and frequent voids Correct Explanation: IV fluids are given before, during, and after radiation and chemotherapy drugs; bladder irritation results from the need to dilute and remove them from the body. This reduces the need for the child to drink large quantities. Administering the drug during sleep and having the child retain urine would cause irritating chemicals to be kept in contact with the bladder mucosa. No benefit is associated with providing cranberry juice.

Fibroid tumors, benign, made up of endometrial cells that have implanted on or within the walls of the uterus

LEIOMYOMA

14. Sexual desire

LIBIDO

Which of the following is a well-defined risk management technique that the nurse can teach children and parents to prevent cancer? a) Incorporate more preservative-free foods into the diet b) Eliminate aerosol sprays from the living area c) Avoid artificial colors, flavors, and fragrances in foods, cosmetics, and household items d) Limit sun exposure throughout childhood and adolescence

Limit sun exposure throughout childhood and adolescence Explanation: Limiting sun exposure by using shade, clothing, and sunscreen applied correctly will reduce the risk of skin cancer. Sun exposure is cumulative throughout life; the greatest exposure tends to occur in childhood and adolescence. Tanning booths should not be used. The other choices could have some merit, but none has been scientifically confirmed.

Which results would indicate to the nurse the possibility that a neonate has congenital hypothyroidism? a) Low T4 level and high TSH level b) Normal TSH level and high T4 level c) Normal T4 level and low TSH level d) High thyroxine (T4) level and low thyroid stimulating hormone (TSH) level

Low T4 level and high TSH level Correct Explanation: Screening results that show a low T4 level and a high TSH level indicate congenital hypothyroidism and the need for further tests to determine the cause of the disease.

The nurse is examining a child with fetal alcohol syndrome (FAS). Which of the following assessment findings would the nurse expect to note? a) Low nasal bridge with short upturned nose b) Macrocephaly c) Clubbing of fingers d) Short filtrum with thick upper lip

Low nasal bridge with short upturned nose Correct Explanation: Typical FAS facial features include a low nasal bridge with short upturned nose, flattened midface, and a long filtrum with narrow upper lip. Microcephaly rather than macrocephaly is associated with FAS. Clubbing of fingers is associated with chronic hypoxia.

When assessing newborns for chromosomal disorders, which assessment would be most suggestive of a problem? a) Low-set ears b) Bowed legs c) Short neck d) Slanting of the palpebral fissure

Low-set ears Correct Explanation: A number of common chromosomal disorders, such as trisomies, include low-set ears.

18. Radiographic (x-ray) examination of the breasts; spreads and flattens the breast tissue

MAMMOGRAPHY

Surgical formation of a pouch around an opening made into a gland to facilitate drainage

MARSUPIALIZATION

Can be partial (removes only part of the breast), simple (removing the breast tissue of one or both breasts), or radical (removing breast tissue, underlying muscle, and surrounding lymph nodes).

MASTECTOMY

Breast infection with inflammation, result of injury and introduction of bacteria into the breast

MASTITIS

The removal of some skin and fat with subsequent resuturing so that the breast tissues are held higher on the chest to corect sagging breasts

MASTOPEXY

5. The initial menstrual period, normally occurring between the 9th and 17th year

MENARCHE

Removal of only the fibroid tumor and may be chosen to preserve fertility

MYOMECTOMY

The nurse is performing a physical assessment of 16-year-old girl who is cognitively challenged. This client attended her local public elementary school through fifth grade and has since been enrolled at a special education school where she has received social and vocational training. She plans on getting a job in the coming month and on living independently in a few years. The nurse recognizes this client's level of cognitive challenge as which of the following? a) Moderate b) Severe c) Profound d) Mild

Mild Correct Explanation: About 85% of children who are cognitively challenged have an IQ of 50 to 70 and may be referred to as "educable" by a school system. During early years, these children learn social and communication skills and are often not too distinguishable from average infants or toddlers. They continue to learn academic skills up to about a sixth-grade level. As adults, they can usually achieve social and vocational skills adequate for minimum self-support. They're able to live independently but need guidance and assistance when faced with new situations or unusual stress.

A nurse is caring for a child with intellectual disability. The medical chart indicates an IQ of 37. The nurse understands that the degree of disability is classified as which of the following? a) Mild b) Profound c) Severe d) Moderate

Moderate Correct Explanation: An IQ of 35 to 50 is classified as moderate. An IQ of 50 to 70 is classified as mild. An IQ of 20 to 35 is classified as severe, and an IQ less than 20 is considered profound.

The nurse is caring for a 4-year-old boy during a growth hormone stimulation test. Which of the following is a priority task for the care of this child? a) Providing a wet washcloth to suck on b) Monitoring blood glucose levels c) Educating family about side effects d) Monitoring intake and output

Monitoring blood glucose levels Correct Explanation: Monitoring blood glucose levels during this study is the priority task along with observing for signs of hypoglycemia since insulin is given during the test to stimulate release of growth hormone. Providing a wet washcloth would be more appropriate for a child who is on therapeutic fluid restriction, such as with syndrome of inappropriate antidiuretic hormone. Monitoring intake and output would not be necessary for this test but would be appropriate for a child with diabetes insipidus. While it is important to educate the family about this test, it is not the priority task.

A nurse teaching a couple says that when X-linked recessive inheritance is present in a family, the genogram will reveal which of the following? a) Only males in the family have the disorder. b) Sons of an affected man are also affected. c) A history of boys dying at birth for unknown reasons often exists. d) The parents of the affected man have the disorder.

Only males in the family have the disorder. Correct Explanation: When X-linked recessive inheritance is in a family, a genogram will reveal only males in the family with the disorder, a history of girls dying at birth for unknown reasons, unaffected sons of affected men, and parents of affected children not having the disorder

The nurse is caring for a 6-year-old boy with non-Hodgkin lymphoma who is being treated with monoclonal antibodies. Which of the following would the nurse include in the child's plan of care? a) Monitoring for complaints of bone pain b) Assessing the child's hydration status secondary to vomiting c) Monitoring for allergic reactions or anaphylaxis d) Assessing for signs of capillary leak syndrome

Monitoring for allergic reactions or anaphylaxis Correct Explanation: The nurse would monitor for infusion-related reactions and anaphylaxis if monoclonal antibodies were administered and would have epinephrine, antihistamines, and steroids available at the bedside for treatment if a reaction occurred. Assessing the level of hydration due to vomiting would be necessary if tumor necrosis factor was administered. The flu-like symptoms produced by interferons require hydration maintenance also. Monitoring for complaints of bone pain is appropriate when administering colony-stimulating factors such as filgrastim or sargramostim. Assessing for signs of capillary leak syndrome within 2 to 12 hours of the start of treatment is necessary when interleukins are used.

The nurse is caring for a 13-year-old girl with delayed puberty. When developing the plan of care for this child, which of the following would be the priority? a) Encouraging the parents to discuss their concerns about the disorder b) Helping the child discuss her feelings about her condition c) Involving the child in her therapy to give her a sense of control d) Monitoring for therapeutic and side effects of medication

Monitoring for therapeutic and side effects of medication Explanation: The child will be receiving hormone supplementation; therefore, monitoring for therapeutic results and possible side effects of medications is key. The physiological effects of the medications take priority over the psychosocial needs of the family or the child. Encouraging the parents to discuss their concerns about the disorder, involving the child in her therapy to give her a sense of control, and helping the child discuss her feelings about her condition would also be included in the plan of care but they would be addressed later on.

9. Removal of one or both testicles; a treatment for prostate cancer

ORCHIECTOMY

10. Rare inflammation or infection of the testicles

ORCHITIS

30. Pleasurable physical release sensation related to physical, sexual, and psychological stimulation

ORGASM

The nurse is performing a physical examination on a 1-week-old girl with trisomy 13. Which of the following would the nurse expect to assess? a) Inspection reveals hypoplastic fingernails. b) Observation discloses severe hypotonia. c) Inspection shows a clenched fist with overlapping fingers. d) Observation reveals a microcephalic head.

Observation reveals a microcephalic head. Correct Explanation: Children with trisomy 13 have microcephalic heads with malformed ears and small eyes. Severe hypotonia, hypoplastic fingernails, and clenched fists with index and small fingers overlapping the middle fingers are typical symptoms of trisomy 18.

The nurse is assessing a 5-year-old boy who has had several convulsions. The nurse continues to assess the child and suspects that he may have hypoparathyroidism. Which of the following would support this suspicion? a) Observation reveals tetany. b) Slight exophthalmos is observed. c) Auscultation reveals an irregular heart rate. d) The child acts sleepy and unresponsive.

Observation reveals tetany. Explanation: Tetany occurs in children with hypoparathyroidism due to decreased serum calcium levels. Sleepiness and lack of responsiveness would suggest hyperthyroidism Exophthalmos is associated with hyperthyroidism Irregular heart rate is associated with hyperthyroidism.

A female patient has the Huntington's disease gene. She and her husband want to have a child but are apprehensive about possibly transmitting the disease to their newborn child. They have strong views against abortion. They would also like to have their "own" child and would consider adopting only as a last resort. Which of the following would be most appropriate in this situation? a) Chancing the conception and birth of a child b) Using donor gametes for conception of a child c) Opting for a preimplantation genetic diagnosis d) Undergoing prenatal diagnosis with prenatal choice of continuing pregnancy

Opting for a preimplantation genetic diagnosis Correct Explanation: The most appropriate choice would be opting for a preimplantation genetic diagnosis (PGD). A PGD is a genetic evaluation of the embryo created through IVF which will reveal whether the Huntington's disease gene is present in the embryo. Undergoing prenatal diagnosis with prenatal choice of continuing pregnancy is not an option because the client and her husband are against abortion. Chancing the conception and birth of a child involves the risk of passing the gene to the newborn child. Using donor gametes may reduce the risk, but it is against the client's preferences.

16. Births, whether alive or stillborn after 20 weeks' gestation

PARA

12. The uncircumcised foreskin is pulled back, during intercourse or bathing, and not immediately replaced in a forward position; causes constriction of the doral veins, which leads to edema and pain

PARAPHIMOSIS

Medication used to treat syphilis

PENICILLIN

The phase before the onset of menopause, during which the cycle of a woman with regular menses changes, perhaps abruptly, to a pattern of irregular cycles and increased periods of amenorrhea

PERIMENOPAUSAL

13. Condition in which the foreskin of an uncircumcised male becomes so tight that it is difficult or impossible to pull back away from the head of the penis

PHIMOSIS

Natruallly occurring plant sterols that have an estrogen-like effect; in soy, tofu, flax seeds, black cohosh, and dong quai

PHYTOESTROGENS

The nurse is assessing a 14-year-old girl with a tumor. Which of the following findings would indicate Ewing's sarcoma? a) Child complains of persistent pain from minor ankle injury b) Palpation reveals swelling and redness on the right ribs c) Child complains of dull bone pain just below her knee d) Palpation discloses asymptomatic mass on the upper back

Palpation reveals swelling and redness on the right ribs Correct Explanation: Ewing sarcoma may result in swelling and erythema at the tumor site. Common sites are chest wall, pelvis, vertebrae, and long bone diaphyses. Dull bone pain in the proximal tibia is indicative of osteosarcoma. Persistent pain after an ankle injury is not indicative of Ewing's sarcoma. An asymptomatic mass on the upper back suggests rhabdomyosarcoma.

Which of the following conditions is a part of normal newborn screening? a) Down syndrome b) Cystic fibrosis c) Sickle cell anemia d) Phenylketonuria

Phenylketonuria Correct Explanation: Phenylketonuria is part of normal newborn screening. Prenatal screening includes Down syndrome. Preconception screening includes sickle cell anemia and cystic fibrosis.

The nurse is interviewing the caregivers of a child admitted with a diagnosis of Type 1 Diabetes Mellitus. The caregiver states, "The teacher tells us that our child has to use the restroom many more times a day than other students do." The caregiver's statement indicates the child most likely has which of the following? a) Polyphagia b) Polydipsia c) Pica d) Polyuria

Polyuria Correct Explanation: Symptoms of Type 1 Diabetes Mellitus include polyuria (dramatic increase in urinary output, probably with enuresis), polydipsia (increased thirst), and polyphagia (increased hunger and food consumption). Pica is eating nonfood substances.

A nurse is assessing a child diagnosed with Sturge-Weber syndrome. Which of the following would the nurse expect to find when assessing the skin? a) Pigmented nevi b) Café-au-lait spots c) Port wine stain d) Tumors

Port wine stain Correct Explanation: Facial nevus or port wine stain is most often seen on the forehead and on one side of the face. Café-au-lait spots are commonly associated with neurofibromatosis. Tumors are associated with tuberous sclerosis and neurofibromatosis. Pigmented nevi are associated with neurofibromatosis.

The nurse is caring for a 3-year-old diagnosed with diabetes mellitus. The child's eating patterns are unpredictable. One day the child will eat almost nothing, the next day the child eats everything on her tray. The nurse recognizes that which of the following types of insulin would most likely be used in treating this child? a) Regular insulin b) Rapid-acting insulin c) Intermediate-acting insulin d) Long-acting insulin

Rapid-acting insulin Explanation: The introduction of rapid-acting insulin, such as lispro or humalog, has greatly changed insulin administration in children. The onset of action of rapid-acting insulin is less than 15 mi nutes. Rapid-acting insulin can even be used after a meal in children with un predic table eating habits. Regular, intermediate, and long-acting insulin all have a longer onset, peak, and duration than rapid acting insulin, and are more difficult to regulate in the child with unpredictable eating patterns.

The nurse is caring for a child admitted to the emergency center in diabetic ketoacidosis. Which of the following clinical manifestations would the nurse most likely note in this child? a) Hyperactive and restless behavior b) Slow pulse and elevated blood pressure c) Red lips and fruity odor to breath d) Pale and moist skin

Red lips and fruity odor to breath Correct Explanation: Diabetic ketoacidosis is characterized by drowsiness, dry skin, flushed cheeks and cherry-red lips, acetone breath with a fruity smell, and Kussmaul breathing (abnormal increase in the depth and rate of the respiratory movements). Nausea and vomiting may occur. If untreated, the child lapses into coma and exhibits dehydration, electrolyte imbalance, rapid pulse, and subnormal temperature and blood pressure.

A nurse is caring for a 12-year-old girl who is recovering from surgery for removal of a brain tumor. Which of the following interventions should the nurse implement to avoid increasing intracranial pressure? a) Place a sterile towel under wet dressings b) Regulate the rate of IV fluid infusions carefully c) Apply saline eye drops, as prescribed d) Sponge the client's face

Regulate the rate of IV fluid infusions carefully Correct Explanation: Be certain to regulate the rate of IV fluid infusions carefully because an increase in the infusion rate has the potential to increase intracranial pressure. The other answers refer to other interventions, unrelated to intracranial pressure.

The neonatal nurse caring for children with inborn errors of metabolism explains to the student nurse that prompt treatment is an essential intervention to successful management of the diseases. Which of the following is a recommended treatment for these conditions? a) Undergoing liver or bone marrow transplant to increase deficient enzymes b) Replacing deficient enzymes through intravenous administration c) Eliminating the deficient product from the child's diet d) Increasing substrates preceding the enzymatic block

Replacing deficient enzymes through intravenous administration Correct Explanation: Prompt treatment for metabolic disorders may include replacing deficient enzymes through intravenous administration. Other interventions are decreasing substrates preceding the enzymatic block (e.g., avoiding a particular amino acid or carbohydrate), administering a supplement of the deficient product that should have been produced, providing an enzymatic cofactor, using medications to remove accumulated substrates, undergoing liver or bone marrow transplantation to eliminate all deficient enzymes, and providing somatic gene therapy (a future option).

24. Inflammation/infection of the fallopian tubes

SALPINGITIS

Removal of uterus, fallopian tubes and ovaries

SALPINGO-OOPHORECTOMY

24. Performed to see the inside of the fallopian tubes

SALPINGOSCOPY

25. Study of substances present in blood serum

SEROLOGICAL

19. Area at the lower abdomen; at the bladder

SUPRAPUBIC

A mother is telling the school nurse about her concerns regarding her 13-year-old daughter, who complains of headaches. Her grades have dropped, and she is sleeping late and going to bed early every night. The nurse advises the mother that the first priority should be which of the following: a) Schedule an immediate history and physical examination. b) Call for an appointment with a psychologist. c) Discuss the situation with her teacher. d) Ask the school psychologist to do psychometric testing.

Schedule an immediate history and physical examination. Correct Explanation: The first step is to conduct a physical examination to rule out or identify illnesses or physical problems that might cause depression. Once any physical causes have been ruled out, the healthcare team can determine the most appropriate approach to assess the girl's symptoms. (less)

An African American couple presents for a genetic counseling appointment. They are pregnant and are concerned about their child. What would a patient of African American heritage have genetic carrier testing for? a) Sickle cell anemia b) Asthma c) Rubella d) Meckel's diverticulum

Sickle cell anemia Correct Explanation: Assessing ancestry and ethnicity is important to help identify individuals and groups who could benefit from genetic testing for carrier identification, such as African Americans routinely offered testing for sickle cell anemia. The other answers are incorrect because they are not identified with the African American race

Steve, a 15-year-old Vietnamese boy, has been referred by his homeroom teacher to the school nurse for evaluation. The teacher is concerned that Steve may be suffering from major depression. Who should be the primary source of information to investigate the concerns about Steve? a) Steve's homeroom teacher b) Steve c) Steve's parents d) Steve's school nurse

Steve Correct Explanation: Steve is the primary historian, and the nurse should first elicit his perspective on the problem to establish a therapeutic alliance. The school nurse might have some input, but his or her contact with Steve may have been minimal. Steve's parents can provide insight and assistance, but they may not be willing to do so because of cultural differences. The teacher will provide a valuable timeline and observations as the individual who referred this case; however, Steve is still the primary historian.

A number of inherited diseases can be detected in utero by amniocentesis. Which of the following diseases can be detected by this method? a) Diabetes mellitus b) Phenylketonuria c) Trisomy 21 d) Impetigo

Trisomy 21 Correct Explanation: Karyotyping for chromosomal defects can be carried out using amniocentesis.

A nurse is teaching a child with type 1 diabetes mellitus how to self-inject insulin. Which of the following methods should she recommend to the child for regular doses? a) Subcutaneously in the outer thigh b) Intradermally in the outer arm c) Intramuscularly in the abdomen d) Intravenously in the chest

Subcutaneously in the outer thigh Correct Explanation: Insulin is always injected SC except in emergencies, when half the required dose may be given IV. SC tissue injection sites used most frequently in children include those of the upper outer arms and the outer aspects of the thighs. The abdominal SC tissue injection sites commonly used in adults can be adequate sites but most children dislike this site as abdominal skin is tender.

The nurse is conducting an examination of a boy with Tourette's syndrome. Which of the following would the nurse expect to observe? a) Sudden, rapid stereotypical sounds b) Spinning and hand flapping c) Toe walking d) Lack of eye contact

Sudden, rapid stereotypical sounds Correct Explanation: Sudden, rapid, stereotypical sounds are a hallmark fi ding with Tourette's syndrome. Toe walking and unusual behaviors such as hand-flapping and spinning are indicative of autism spectrum disorder (ASD). Lack of eye contact is associated with ASD but is also noted in children without a mental health disorder.

A 12-year-old boy arrives at the emergency room experiencing nausea, vomiting, headache, and seizures. He is diagnosed with bacterial meningitis. Other findings include a decrease in urine production, hyponatremia, and water intoxication. Which pituitary gland disorder would be most associated with these symptoms? a) Hypersecretion of somatotropin b) Syndrome of inappropriate antidiuretic hormone c) Diabetes insipidus d) Hyposecretion of somatotropin

Syndrome of inappropriate antidiuretic hormone Explanation: Syndrome of inappropriate antidiuretic hormone (SIADH) is a rare condition in which there is overproduction of antidiuretic hormone by the posterior pituitary gland. This results in a decrease in urine production and water intoxication. As sodium levels fall in proportion to water, the child develops hyponatremia or a lowered sodium plasma level. It can be caused by central nervous system infections such as bacterial meningitis. As the hyponatremia grows more severe, coma or seizures occur from brain edema. Diabetes insipidus is characterized by polyuria, not decreased urine production. Hyposecretion of somatotropin, or growth hormone, results in undergrowth; hypersecretion results in overgrowth.

36. Noninvasive test where a flashlight held behind the scrotum is used to determine if a mass is fluid filled or solid

TRANSILLUMINATION

Surgical removal of enlarged prostatic tissue using a scope

TURP

The nurse is caring for a 6-year-old girl with leukemia who is having an oncological emergency. Which of the following signs and symptoms would indicate hyperleukocytosis? a) Wheezing and diminished breath sounds b) Tachycardia and respiratory distress c) Respiratory distress and poor perfusion d) Bradycardia and distinct S1 and S2 sounds

Tachycardia and respiratory distress Explanation: Increased heart rate, murmur, and respiratory distress are symptoms of hyperleukocytosis (high white blood cell count) which is associated with leukemia. Increased heart rate and blood pressure are indicative of tumor lysis syndrome, which may occur with acute lymphoblastic leukemia, lymphoma, and neuroblastoma. Wheezing and diminished breath sounds are signs of superior vena cava syndrome related to non-Hodgkin's lymphoma or neuroblastoma. Respiratory distress and poor perfusion are symptoms of massive hepatomegaly which is caused by a neuroblastoma filling a large portion of the abdominal cavity.

A Caucasian female client of Jewish ancestry is pregnant. The nurse is aware that the client may be a carrier for which of the following conditions? a) Tay Sachs disease b) Phenylketonuria c) Dupuytrens d) Krabbe disease

Tay Sachs disease Correct Explanation: Because the client is of Jewish ancestry, there is an increased risk of her being a carrier of the Tay Sachs disease gene. Norwegians are at a greater risk for Dupuytrens and Phenylketonuria, while Icelanders have an increased risk for Phenylketonuria.

The nurse is preparing an education plan to help the family to learn about their child's developmental disorder and its treatment. Which of the following interventions will be part of the plan? a) Linking the family to support groups b) Providing education to build social skills c) Conducting developmental assessments of the child d) Teaching how to plan schedules and routines

Teaching how to plan schedules and routines Correct Explanation: Teaching how to plan schedules and routines would be part of the education plan. Providing education to build social skills, conducting developmental assessments of the child, and linking the family to support groups are all nursing interventions for providing services to the child.

Which of the following signs and symptoms suggest that a 5-year-old boy who does not maintain eye contact or speak may be autistic? a) The child constantly opens and closes his hands. b) The child has a long face and prominent jaw. c) The child has a slight decrease in head circumference. d) The child is highly active and inattentive.

The child constantly opens and closes his hands. Correct Explanation: Repetitive motor mannerisms such as constantly opening and closing the hands are a typical behavior pattern for autistic disorder. A high level of activity and inattentiveness are typical symptoms of mental retardation. Decrease in head circumference suggests malnutrition or decelerating brain growth. A long face and prominent jaw are symptoms of fragile X syndrome.

Which of the following signs and symptoms suggest that a 5-year-old boy who does not maintain eye contact or speak may be autistic? a) The child constantly pats his legs. b) The child has a long face and prominent jaw. c) The child has a slight decrease in head circumference. d) The child is highly active and inattentive.

The child constantly pats his legs. Correct Explanation: Repetitive motor mannerisms such as the boy constantly patting his legs are a typical behavior pattern for autistic disorder. A high level of activity and inattentiveness are typical symptoms of mental retardation. A decrease in head circumference suggests malnutrition or decelerating brain growth. A long face and prominent jaw are symptoms of fragile X syndrome.

The nurse is collecting data on an 18-month-old old child with a diagnosis of autism. Which of the following clinical manifestations would likely have been noted in the child with this diagnosis? a) The child smiles when the caregiver shows her a stuffed animal. b) The child does not respond or talk to the nurse when asked simple questions. c) The child cries and runs to the door when the caregiver leaves the room. d) The child sits quietly in the caregivers lap during interview.

The child does not respond or talk to the nurse when asked simple questions. Correct Explanation: Children with autism often have blank expressions and a lack of response to verbal stimulation. They do not develop a smiling response to others nor an interest in being touched or cuddled. In fact, they can react violently to attempts to hold them. They do not show the normal fear of separation from parents that most toddlers exhibit. Often they seem not to notice when family caregivers are present.

The nurse is assessing a 4-year-old girl whose mother complains that she is not eating well, is losing weight, and has started vomiting after eating. Which of the following risk factors from the health history would suggest the child may have a Wilm tumor? a) The child has Down syndrome b) The child has Schwachman syndrome c) There is a family history of neurofibromatosis d) The child has Beckwith-Wiedemann syndrome

The child has Beckwith-Wiedemann syndrome Correct Explanation: Along with the symptoms reported by the mother, the fact that the child has Beckwith-Wiedemann syndrome suggests that the child could have a Wilm tumor. Down syndrome would point to leukemia or brain tumor. Schwachman syndrome would suggest leukemia. A family history of neurofibromatosis is a risk factor for brain tumor, rhabdomyosarcoma, or acute myelogenous leukemia.

The nurse is caring for 1-month-old girl with thyrotoxicosis. Which of the following would the nurse expect to assess? a) The child is hypoactive and hypotonic. b) Skin is cool, dry, and scaly to the touch. c) Observation reveals lethargy and irritability. d) The child has a strong appetite but fails to thrive.

The child has a strong appetite but fails to thrive. Explanation: Infants with thyrotoxicosis may display hyperphagia but fail to gain weight. A combination of lethargy and irritability suggests congenital hypothyroidism. Cool, dry skin that is scaly to the touch suggests congenital hypothyroidism. Hypoactivity and hypotonicity are findings that suggest congenital hypothyroidism.

The nurse in the well-child clinic observes that a 5-year-old child in the waiting room is having trouble using a crayon to color. During the visit, the same child climbs off the table several times even after the nurse has asked him to stay on the table. Each time the nurse reminds him he says, "Oh, yeah," and happily climbs back up. The nurse suspects that which of the following applies to this child? a) The child is autistic. b) The child has failure to thrive. c) The child has attention deficit hyperactive disorder. d) The child has an addicted caregiver.

The child has attention deficit hyperactive disorder. Correct Explanation: The child with ADHD may have these characteristics: Impulsiveness, easy distractibility, frequent fidgeting or squirming, difficulty sitting still, problems following through on instructions despite being able to understand them, inattentiveness when being spoken to, frequent losing of things, going from one uncompleted activity to another, difficulty taking turns, frequent excessive talking, and engaging in dangerous activities without considering the consequences.

Which of the following characteristics are commonly noted in the child with anorexia nervosa? a) The child is impulsive and inattentive when spoken to. b) The child has rigid study skills and ritualistic behavior. c) The child is inactive and participates in sedentary activites. d) The child has trouble sitting still and is figety.

The child has rigid study skills and ritualistic behavior. Correct Explanation: Anorexic children often are described as successful students who tend to be perfectionists and are always trying to please parents, teachers, and other adults. They may make demands on themselves for cleanliness and order in their environment, or they may engage in rigid schedules for studying and other ritualistic behavior.

Which of the following would suggest that a 5-year-old boy might have a developmental disorder? a) The child has trouble with r, l, and y sounds. b) The child knows what a dog and a cat sound like. c) The child must be supervised when brushing his teeth. d) The child is not able to follow directions.

The child is not able to follow directions. Correct Explanation: A 5-year-old child should be able to follow simple directions. If he is unable to this, he has not yet achieved a developmental milestone. Brushing his teeth with supervision and knowing cat and dog sounds are normal for this age. Having trouble with r, l, and y sounds is not unusual and may continue until age 7.

The child has been diagnosed with leukemia. Rank the following medications used to treat leukemia in order based on the stage of treatment. The child is receiving chemotherapy through an intrathecal catheter. The child is receiving vincristine through an intravenous line and oral steroids. The child is receiving low doses of mercaptopurine and methotrexate. The child is receiving high doses of mercaptopurine and methotrexate.

The child is receiving vincristine through an intravenous line and oral steroids. The child is receiving high doses of mercaptopurine and methotrexate. The child is receiving low doses of mercaptopurine and methotrexate. The child is receiving chemotherapy through an intrathecal catheter. Explanation: During induction, the child receives oral steroids and IV vincristine. During consolidation, the child receives high doses of methotrexate and mercaptopurine. During maintenance, the child receives low doses of methotrexate and mercaptopurine. During central nervous system prophylaxis, the child receives intrathecal chemotherapy.

The nurse is working with school-age children who are having enuresis or encopresis. Which of the following will most likely be the first step in this child's treatment? a) The child will be given a strict daily schedule. b) The child will have a complete physical exam. c) The child will be given medications. d) The child will be taken to a therapist.

The child will have a complete physical exam. Correct Explanation: The child with enuresis or encopresis may have a physiologic or psychological cause and may indicate a need for further exploration and treatment. A complete physical exam and assessment is done first to rule out any physical cause.

The most common mixture of insulin used with children with type 1 diabetes mellitus is a combination of an intermediate-acting insulin and a regular insulin, usually in a 2:1 ratio or 0.75 units of the intermediate-acting insulin to 0.33 units regular insulin, and given in the same syringe. a) False b) True

True

Women having in vitro fertilization (IVF) can have both the egg and sperm examined for genetic disorders of single gene or chromosome concerns before implantation. a) True b) False

True

As many as 50% of children with autistic spectrum disorder are also cognitively challenged. a) False b) True

True Explanation: As many as 50% of children with autistic spectrum disorder are also cognitively challenged; many have a coexistent mental health diagnoses.

The nurse is assessing a 6-year-old with attention deficit/hyperactivity disorder (ADHD). The nurse observes the boy making repeated clicking noises and notes he has a slight grimace. The nurse recommends the boy receive further evaluation for which of the following? a) Asperger syndrome b) Tourette syndrome c) Autism spectrum disorder d) Anxiety disorder

Tourette syndrome Correct Explanation: Repeated vocal tics such as sniffling, grunting, clicking, or word utterances are associated with Tourette syndrome. The syndrome consists of multiple motor tics and one or more motor tics occurring simultaneously at different times. ADHD and obsessive-compulsive disorder occur in 90% of children with Tourette syndrome. Vocal and motor tics are not typical indicators of Asperger syndrome, anxiety disorder, or autism spectrum disorder.

A 6-year-old boy has a moon-faced, stocky appearance but with thin arms and legs. His cheeks are unusually ruddy. He is diagnosed with Cushing syndrome. The nurse knows that which of the following is the most likely cause of this condition in this child? a) Tumor of the parathyroids b) Tumor of the adrenal cortex c) Tumor of the pancreas d) Tumor of the thyroid

Tumor of the adrenal cortex Explanation: Cushing syndrome is caused by overproduction of the adrenal hormone cortisol; this usually results from increased ACTH production due to either a pituitary or adrenal cortex tumor. The peak age of occurrence is 6 or 7 years. The overproduction of cortisol results in increased glucose production; this causes fat to accumulate on the cheeks, chin, and trunk, causing a moon-faced, stocky appearance. Cortisol is catabolic, so protein wasting also occurs. This leads to muscle wasting, making the extremities appear thin in contrast to the trunk, and loss of calcium in bones (osteoporosis). Yet other effects are hyperpigmentation (the child's face to be unusually red, especially the cheeks).

To feed lunch to a child with autistic disorder, which of the following actions would be most important to take? a) Allow the child to ask questions about the procedure. b) Don't allow him to see the spoon approach his mouth. c) Use a repetitive series of movements. d) Use an authoritarian manner to gain control.

Use a repetitive series of movements. Correct Explanation: Children with autistic disorder typically enjoy repetitive movements or the same action over and over.

A comatose patient is admitted to the emergency department after an automobile accident. The nurse notes a Medic-Alert identification bracelet that states the patient has hemophilia. What should the nurse do first? a. Notify the physician of the bracelet. b. Tape the bracelet to the patients arm. c. Call the phone number on the bracelet. d. Remove the bracelet, and give it to the patients family member.

The nurse is observing a group of two and three year olds in a play group setting. Which of the following behaviors noted in one of the children indicates to the nurse that the child may be autistic? a) While the other children are eating a snack, the child walks around the room feeling the walls and ignores the caregiver who offers him a snack. b) A child flips the light switch off and on until the caregiver asks her to stop and join the other children in playing. c) A child playing in the kitchen area pretends to pour a glass of milk and repeats this over and over. d) After another child takes a toy, the child cries and stomps his feet.

While the other children are eating a snack, the child walks around the room feeling the walls and ignores the caregiver who offers him a snack. Explanation: autistic children become completely absorbed in strange repetitive behaviors such as spinning an object, flipping an electrical switch on and off, or walking around the room feeling the walls. If these movements are interrupted or if objects in the environment are moved, a violent temper tantrum may result. These tantrums may include self-destructive acts such as hand biting and head banging. Although infants and toddlers normally are self-centered, ritualistic, and prone to displays of temper, autistic children show these characteristics to an extreme degree coupled with an almost total lack of response to other people.

A nurse is conducting a mental status examination with a 5-year-old boy who is playing with trains and blocks of different colors. He repeats the same actions with the trains over and over again throughout the examination. Which of the following questions would be most appropriate? a) Are you having fun now? b) What year is it? c) Why does that red train keep crashing into all of the other trains? d) Do you like playing with trains and blocks?

Why does that red train keep crashing into all of the other trains? Correct Explanation: Asking about the red train is an open-ended question that could help the nurse elicit the fantasies and feelings underlying the boy's play. A 5-year-old may not know what year it is. Questions allowing yes or no answers do not open a dialogue.

A patient is diagnosed with a parasitic infection caused by close contact with another persons genitals. For which infection should the nurse plan care? a. Phthirus pubis b. Treponema pallidum c. Neisseria gonorrhoeae d. Chlamydia trachomatis

A 2-day-old infant is noted to have small pustules on her skin. What is the best nursing action? a. Report it immediately because it may be a staphylococcus infection. b. Keep the affected area dry and clean. c. Teach the parents how to care for seborrheic dermatitis. d. Chart the finding because it may be the beginning of a strawberry nevus.

A 2-year-old child has been crying constantly for his mother since he was hospitalized 3 days ago. What does this behavior suggest? a. The toddler feels abandoned by his mother. b. The child still has not adjusted to his hospitalization. c. The child is not separated from his mother often. d. There is a poor mother-child bond.

A 2-year-old child has been diagnosed with hemophilia A. What information should the nurse include in a teaching plan about home care? a. If bleeding occurs, apply pressure, ice, elevate, and rest the extremity. b. Childrens aspirin in lowered doses may be given for joint discomfort. c. A firm, dry toothbrush should be used to clean teeth at least twice a day. d. Do not permit interactive play with other children.

A 3-month-old infant is diagnosed with developmental hip dysplasia. The nurse knows that what is the usual treatment for an infant with this diagnosis? a. A Pavlik harness b. A body spica cast c. Traction d. Triple-diapering

A 42-year-old woman is tearful after a hysterectomy. What information should the nurse use to respond appropriately to the patient? a. Loss of reproduction function may cause grieving. b. Most women are done bearing children by age 42. c. Hysterectomy is more traumatic for younger women. d. Most women are happy not to have periods after a hysterectomy.

A 6-year-old child with daytime enuresis complains of dysuria and urgency. What does the nurse recognize these signs and symptoms indicate? a. Urinary tract infection b. Nephrotic syndrome c. Acute glomerulonephritis d. Vesicoureteral reflux

A 6-year-old sustained a fractured femur and was put in Russell traction 2 days ago. She screams in pain when she raises herself onto the bedpan. Which nursing diagnosis takes highest priority for this child? a. Pain resulting from tissue trauma b. High risk for impaired skin integrity resulting from immobility c. Altered growth and development related to separation from family d. Altered urinary elimination related to immobility and traction

A 6-year-old with leukemia asks, Who will take care of me in heaven? What is the best response by the nurse? a. Who do you think will take care of you? b. Your grandparents and God will take care of you. c. Your mom will know more about that than I do. d. Why are you asking me that?

A 7-month-old infant is admitted to the hospital with a diagnosis of acute gastroenteritis. What will be the nursess priority goal of the infants care? a. Prevent fluid and electrolyte imbalance. b. Prevent nutritional deficiency. c. Prevent skin breakdown. d. Prevent malabsorption.

A 7-year-old child with acute glomerulonephritis has gross hematuria and has been confined to bed. What is the most appropriate nursing intervention for this child? a. Providing activities for the child on restricted activity b. Feeding the child a protein-restricted diet c. Carefully handling edematous extremities d. Observing the child for evidence of hypotension

A child has sustained a second-degree deep thermal burn to the hand. What is the best first action to take? a. Immerse the burned area in cold water. b. Apply ice to the burned area. c. Break any blisters that are present. d. Apply petroleum jelly to the burned skin.

A child is brought to the emergency department with burns on the face and chest. What is the nurses first priority? a. Assess respiratory status. b. Administer pain medication. c. Remove clothing. d. Insert a Foley catheter.

A father asks why his child with tetralogy of Fallot seems to favor a squatting position. What is the nurses best response? a. Squatting increases the return of venous blood back to the heart. b. Squatting decreases arterial blood flow away from the heart. c. Squatting is a common resting position when a child is tachycardic. d. Squatting increases the workload of the heart.

A female patient is embarrassed because of not being able to walk to the bathroom in time before become incontinent of urine. Which type of incontinence should the nurse plan care for this patient? a. Urge b. Total c. Stress d. Functional

A female patients hematocrit level is 50% and oxygen saturation is 98% on room air. What should the nurse suspect as being the cause for this patients hematocrit level? a. Dehydration b. Chronic renal failure c. Bone marrow suppression d. Bleeding esophageal varices

A frustrated patient in labor has been affected by decreased uterine muscle tone and reports, My doctor wont induce my labor because of some silly score. He said I was a 4. What kind of magic number do I need? What is the lowest Bishop score the patient should have prior to induction? a. 6 b. 8 c. 10 d. 12

A group of nursing students plans to teach a class of sixth-grade girls about menstruation. What correct information will the nursing students teach to the class? a. Menarche usually occurs around 12 years of age. b. Ovulation occurs regularly from the very first cycle. c. A regular cycle is established by the third period. d. Typically, menstrual flow is heavy and lasts up to 10 days.

A hospitalized toddler was drinking from a cup at home but now refuses to drink from anything except his favorite bottle. What is the most likely reason for this behavior? a. He is dealing with the anxiety of hospitalization by regressing. b. He is demonstrating attention-seeking behaviors because of an overabundance of attention in the hospital. c. He is attempting to refocus the attention of the adults around him to avoid further painful procedures. d. He is exhibiting normal behavior for his age, as children often stop new behaviors after they believe they have mastered them.

A labor dysfunction due to decreased uterine muscle tone occurs in a patient who is dilated to 5 cm with membranes intact. What action by the physician will the nurse anticipate? a. Perform an amniotomy. b. Initiate tocolytic drugs. c. Order a sedative for the patient. d. Plan to do an emergency cesarean section

A mother is anxious about her ability to breastfeed after her child is born because of her small breast size. What would be an important point to teach this mother? a. Milk is produced in ducts and lobules regardless of breast size. b. Supplementing breastfeeding with formula allows the infant to receive adequate nutrition. c. Breast size can be increased with exercise. d. Drinking extra milk during pregnancy allows breasts to produce adequate amounts of milk.

A mother reports that her child has been scratching the anal area and complaining of itching. What does the nurse suspect based on this information? a. Pinworms b. Giardiasis c. Ringworm d. Roundworm

A new mother has decided not to breastfeed her newborn. What information will the nurse include when planning to teach the mother about formula feeding? a. Positioning the bottle so that the nipple is full of formula during the entire feeding b. Heating the infant formula in a microwave c. Burping the infant after 4 ounces and again when the bottle is empty d. Propping a bottle for a feeding

A new mother states her preference to formula feed her newborn. What will the nurse planning discharge instructions tell her to help suppress lactation and promote comfort? a. Wear a well-fitting bra continuously for several days. b. Stand in a warm shower, letting the water spray over the breasts. c. Express small amounts of milk from the breasts several times a day. d. Massage the breasts when they ache

A nurse is assisting with data collection on a newly admitted patient with a history of hemophilia. Which assessment finding indicates that the patient has experienced some severe episodes of bleeding in the past? a. Joint deformities b. Distended abdomen c. Ecchymoses on the extremities d. Elevated WBC count

A nurse is providing prenatal education. The nurse will explain that pregnancy affects glucose metabolism in what way? a. Placental hormones increase the resistance of cells to insulin. b. Insulin cells cannot meet the bodys demands as the womans weight increases. c. There is a decreased production of insulin during pregnancy. d. The speed of insulin breakdown is decreased during pregnancy.

A parent reports that her child has begun to do poorly at school and experiences episodes where he appears to be staring into space. Of which type of seizure is this behavior a characteristic? a. Absence b. Akinetic c. Myoclonic d. Complex partial

A patient asks for the best way to prevent contracting a sexually transmitted infection (STI). What response should the nurse make to this patients question? a. Abstinence b. Oral contraceptives c. Condom with spermicide d. Prophylactic oral antibiotics

A patient asks the nurse when her infants heart will begin to pump blood. What will the nurse reply? a. By the end of week 3 b. Beginning in week 8 c. At the end of week 16 d. Beginning in week 24

A patient has a platelet count of 75,000 /mm3. What action should the nurse take to support this patient? a. Restrict blood draws. b. Place in protective isolation. c. Wear a mask when entering the room. d. Document rectal temperatures to be taken.

A patient has just received a new prescription for a transurethral suppository for erectile dysfunction. What instructions should the nurse provide about this medication? a. Urinate before you insert the suppository into your urethra. b. Remove the suppository after you are finished having intercourse. c. Lubricate the suppository well, and insert it into your rectum before intercourse. d. Insert the suppository into the urethra at least 2 hours before anticipated intercourse.

A patient hourly urine output is recorded. Which output rates should be brought to the attention of the registered nurse (RN) immediately? a. 15 mL/hr b. 40 mL/hr c. 60 mL/hr d. 80 mL/hr

A patient is admitted to determine why red blood cells are being quickly destructed in the body. What finding should the nurse associate with this patients health problem? a. Jaundice b. Bleeding c. Diarrhea d. Cyanosis

A patient is diagnosed with anemia and asks the nurse what nutrients are important for RBC formation. The nurse bases an answer on the understanding that which nutrients are essential for production of healthy red cells? a. Iron, folic acid, and vitamin B12 b. Vitamin C, vitamin D, and selenium c. Vitamin A, calcium, and phosphorus d. Aluminum, vitamin E, and beta carotene

A patient is diagnosed with polycystic ovary syndrome. When preparing teaching for this patient, which hormone should the nurse explain as being too abundant in the patients body? a. Insulin b. Thyroxine c. Growth hormone (GH) d. Antidiuretic hormone (ADH)

A patient is diagnosed with urticaria. For which type of hypersensitivity reaction should the nurse plan care for this patient? a. Type I b. Type II c. Type III d. Type IV

A patient is receiving a transfusion of packed RBCs. Ten minutes after the infusion begins the patient reports low back pain and a headache. Which action should the nurse take first? a. Stop the blood infusion. b. Notify the physician STAT. c. Start the new 0.9% normal saline infusion. d. Prepare a new 0.9% normal saline infusion.

A patient is stabilized after having an allergic reaction. Which preventive instructions should the nurse reinforce with the patient? a. Wear Medic-Alert identification. b. Stay indoors as much as possible. c. Wear insect repellent when outdoors. d. Take corticosteroids before going outdoors.

A patient recovering from radiological studies of the renal system has a nursing diagnosis of Impaired Urinary Elimination. Which outcome indicates that the nursing interventions have been effective? a. Patient voids 35 mL/hour of clear urine. b. Patient voids 30 mL/hour of cloudy urine. c. Patient voids 10 mL/hour of reddish urine. d. Patient voids an average of 15 mL/hour of dark-colored urine.

A patient reports severe abdominal cramping and diarrhea. Assessment reveals a temperature of 102F (38.8C) and pulse of 82 beats/min. Results of a complete blood count reveal lower than normal segmented and banded neutrophils and higher than normal lymphocytes. Which type of infection does the nurse suspect this patient is most likely experiencing? a. Viral b. Fungal c. Parasitic d. Bacterial

A patient who has had a splenectomy complains of malaise. The nurse checks the patients temperature and finds it is 102F (39C). Which action by the nurse should take priority? a. Notify the physician. b. Encourage fluids to reduce fever and prevent dehydration c. Administer acetaminophen to reduce fever and relieve discomfort. d. Explain to the patient that low-grade fevers are common after splenectomy because the spleen is part of the immune system.

A patient who is 28 weeks pregnant presents with consistent hypertension. What need would the home health nurse make the first priority? a. Activity restriction b. Balanced nutrition c. Increased fluid intake to ensure adequate hydration d. Instruction about the effect of diuretics

A patient with a bleeding disorder is prescribed an infusion of plasma. What should the nurse explain as being the purpose of this infusion? a. Contains clotting factors b. Carries oxygen to the tissues c. Supports cellular metabolism d. Removes waste products from cells

A patient with chronic kidney disease is very weak due to low hemoglobin. What should the nurse understand as the best explanation for the anemia? a. Secretion of erythropoietin by the diseased kidney is reduced. b. There is loss of red blood cells in the urine with kidney disease. c. Chronic hypertension associated with chronic kidney disease suppresses the bone marrow. d. Metabolic acidosis associated with chronic kidney disease increases red blood cell fragility.

A patient with iron-deficiency anemia has been taking oral iron supplements. Which test should the nurse review to determine the effectiveness of this intervention? a. Hemoglobin and hematocrit b. WBC and platelet counts c. Electrolytes, blood urea nitrogen (BUN), and creatinine d. Thrombin clotting time (TCT) and prothrombin time (PT)

A patient with multiple myeloma is at risk for hypercalcemia. Which nursing intervention is most important for the patient with hypercalcemia? a. Encourage fluids. b. Offer citrus juices and fruits. c. Place the patient on a low-sodium diet. d. Discourage intake of alcoholic beverages.

A patient with multiple myeloma is being cared for at home. Which nursing diagnosis should guide the nurse when teaching the family how to provide care for the patient? a. Risk for Injury related to compromised bone integrity b. Ineffective Tissue Perfusion related to vascular occlusion c. Risk for Deficient Fluid Volume related to bleeding disorder d. Ineffective Airway Clearance related to cervical lymphadenopathy

A patient with pneumonia has a blood urea nitrogen (BUN) of 32 mg/dL and creatinine of 0.8 mg/dL. What should the nurse realize is the most probable explanation for this finding? a. The patient is dehydrated. b. The patient has septicemia. c. The patient is malnourished. d. The patient has kidney damage.

A patient with terminal lymphoma says to the nurse, Im tired of being so fatigued all the time. Cant you just give me a big shot of morphine and help me end this suffering? Which response by the nurse is most appropriate? a. You sound frustrated. It must be difficult to feel so tired all the time. b.Are you sure that is what you want me to do? Maybe you should think about it first. c. That is really not appropriate to ask. Would you like a shot just to take away the pain? d. You have orders for morphine 10 to 15 mg. I dont think thats enough to end your suffering.

A postpartum woman is not immune to rubella. What will the nurse expect? a. The rubella virus vaccine should be administered before discharge. b. The woman should receive the rubella virus vaccine at her 6-week postpartum checkup. c. The woman should be instructed not to get pregnant until she receives the rubella vaccine. d. No intervention is indicated at this time because the woman is not at risk for rubella

A pregnant woman asks the nurse, Will I be able to have a vaginal delivery? The nurse knows that which is the most favorable pelvic type for vaginal birth? a. Gynecoid b. Android c. Anthropoid d. Platypelloid

In what situation will the physician order RhoGAM? a. An unsensitized Rh-negative mother has an Rh-positive infant. b. An Rh-negative mother becomes sensitized. c. A sensitized infant has a rising bilirubin level. d. An unsensitized infant exhibits no outward signs

A pregnant woman comes to the clinic stating that she has been exposed to hepatitis B. She is afraid that her infant will also contract hepatitis B. What will the nurse explain to this woman? a. The infant will be given a single dose of hepatitis immune globulin after birth. b. The infant will be able to use the antibodies from the immunizations given to the patient before delivery. c. The infant will not have hepatitis B because the virus does not pass through the placental barrier. d. The infant will be immune to hepatitis B because of the mothers infection.

A woman 2 weeks past her expected delivery date is receiving an oxytocin infusion to induce labor and begins to have contractions every 90 seconds. What is the nurses initial action? a. Stop the oxytocin infusion. b. Continue the infusion and report the findings to the physician. c. Turn her on her left side and reassess the contractions. d. Administer oxygen by mask.

A woman had a vaginal delivery two days ago and is preparing for discharge. What will the nurse plan to teach the woman to report to help prevent postpartum complications? a. Fever b. Change in lochia from red to white c. Contractions d. Fatigue and irritability

A woman pregnant for the first time asks the nurse, When will I begin to feel the baby move? What is the nurses best response? a. You may notice the baby moving around the 4th or 5th month. b. Quickening varies with every woman. c. Youll feel something by the end of the first trimester. d. The baby will be big enough for you to feel in your 8th month.

A woman who is 25 weeks pregnant asks the nurse what her fetus looks like. What does the nurse explain is one physical characteristic present in a 25-week-old fetus? a. Lanugo covering the body b. Constant motion c. Skin that is pink and smooth d. Eyes that are closed

A woman who is 33 weeks pregnant is admitted to the obstetric unit because her membranes ruptured spontaneously. What complication should the nurse closely assess for with this patient? a. Chorioamnionitis b. Hemorrhage c. Hypotension d. Amniotic fluid embolism

A woman who is 37 weeks pregnant reports feeling dizzy when lying on her back. What does the nurse explain as the most likely cause of this symptom? a. Supine hypotension syndrome b. Gestational diabetes c. Pregnancy-induced hypertension d. Malnutrition

Although the nurse has massaged the uterus every 15 minutes, it remains flaccid, and the patient continues to pass large clots. What does the nurse recognize these signs indicate? a. Uterine atony b. Uterine dystocia c. Uterine hypoplasia d. Uterine dysfunction

An 18-month-old child had a surgical repair of a cleft palate and is now allowed to eat a regular diet. What nursing action is the most appropriate? a. Feed solid foods with the spoon at the side of the mouth. b. Puree foods and offer them through a straw. c. Place small bites of food in the mouth with a tongue blade. d. Offer small, frequent meals of finger foods.

An 8-year-old child will be hospitalized for several weeks in skeletal traction to treat a fractured femur. What does the nurse realize immobilization in this age-group can generate feelings of in planning care of this child? a. Loss of control b. Altered body image c. Shame and guilt d. Fear of bodily harm

An adolescent has just had a generalized seizure and collapsed in the school nurses office. When should the nurse should call 911? a. The seizure lasts more than 5 minutes. b. The child is sleepy and lethargic after the seizure. c. The child fell at the onset of the seizure. d. The child is confused and has slurred speech after the seizure.

An adolescent is at the pediatricians office because he has been experiencing intense itching, particularly in the axilla and between the fingers. The itching is worse during the night and he has not been sleeping well. With what is this symptom associated? a. Scabies b. Pediculosis capitis c. Tinea corporis d. Eczema

An infant is admitted to the hospital with severe dehydration. Laboratory results show pH 7.32, PaCO2 40, HCO3 21. How does the nurse interpret these values? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

An infant is experiencing dyspnea related to patent ductus arteriosus (PDA). What does the nurse understand regarding why dyspnea occurs? a. Blood is circulated through the lungs again, causing pulmonary circulatory congestion. b. Blood is shunted past the pulmonary circulation, causing pulmonary hypoxia. c. Blood is shunted past cardiac arteries, causing myocardial hypoxia. d. Blood is circulated through the ductus from the pulmonary artery to the aorta, bypassing the left side of the heart.

An ultrasound confirms that a 16-year-old girl is pregnant. How does the need for prenatal care and counseling for adolescents different from other age populations? a. A pregnant adolescent is experiencing two major life transitions at the same time. b. Adolescents who get pregnant are more likely to have other chronic health problems. c. Adolescents are at greater risk for multifetal pregnancies. d. At this age, a pregnant adolescent will accept the nurses advice.

During a postpartum assessment, a woman reports her right calf is painful. The nurse observes edema and redness along the saphenous vein in the right lower leg. Based on this finding, what does the nurse explain the probable treatment will involve? a. Anticoagulants for 6 weeks b. Application of ice to the affected leg c. Gentle massage of the affected leg d. Passive leg exercises twice a day

During an ultrasound, two amnions and two placentas are observed. What will be the most likely result of this pregnancy? a. Dizygotic twins b. Monozygotic twins c. Conjoined twins d. High birth-weight twins

During the physical examination for the first prenatal visit, it is noted that Chadwicks sign is present. What is Chadwicks sign? a. Bluish or purplish discoloration of the vulva, vagina, and cervix b. Presence of early fetal movements c. Darkening of the areola and breast tenderness d. Palpation of the fetal outline

Gentamicin ear drops are prescribed for a 4-year-old child. How would the nurse position the auricle when administering the ear drops? a. Up and back b. Down and back c. Up and out d. Down and out

Human papillomavirus (HPV) produces verrucous growths. What term should the nurse use to describe these lesions to the patient? a. Warts b. Rashes c. Blisters d. Papules

On entering the room of a child in Bucks traction, the nurse makes all of the following observations. Which observation requires a nursing intervention? a. Childs heels are placed firmly against the foot of the bed. b. Head of bed is elevated 20 degrees. c. Weights are hanging freely. d. Ropes are on pulleys.

On the second day of hospitalization for a 3-month-old brought in for treatment for gastroenteritis, the nurse makes all of the assessments listed below. Which assessment finding indicates ineffectiveness of treatment? a. Weight loss of 4 ounces b. Dry mucous membranes c. Decreased skin turgor d. Depressed fontanelle

One day after discharge, the postpartum patient calls the clinic complaining of a reddened area on her lower leg, temperature elevation of 37 C (99.8 F), rust-colored lochia, and sore breasts. What does the nurse suspect from these symptoms? a. Phlebitis b. Puerperal infection c. Late postpartum hemorrhage d. Mastitis

Parents are speaking with the urologist about their sons undescended testicle. Which statement by the childs father causes the nurse to determine he understands the information presented? a. An undescended testicle can reduce fertility. b. The testicle usually descends spontaneously during the first month of life. c. Surgical correction reduces the risk for testicular tumors. d. The optimal time to surgically correct the condition is at diagnosis.

Parents of a 10-year-old child diagnosed with an intellectual deficit are sharing multiple approaches they implement in dealing with various challenges. Which of the following a statements by the parents alerts the nurse that they need further instruction? a. We dress our son every morning for school. b. Our son participates in the Special Olympics every year. c. Our son attends play therapy at a center close to home. d. We attend a support group once a week.

The most recent blood count for a child who received chemotherapy last week shows neutropenia. What is the priority nursing diagnosis for this child? a. Risk for infection b. Risk for hemorrhage c. Altered skin integrity d. Disturbance in body image

The mother is upset to learn that her sons testes have not descended into the scrotum. At what age should the mother consider surgery for her sons health problem? a. 1 b. 2 c. 3 d. 4

The mother of a 2-week-old infant tells the nurse that she thinks he is sleeping too much. What is the most appropriate nursing response to this mother? a. Tell me how many hours per day your baby sleeps. b. It is normal for newborns to sleep most of the day. c. Newborns generally sleep 12 to 15 hours per day. d. You will find as the baby gets older, he sleeps less.

The mother of a postterm infant asks the nurse why the infant is being watched so closely. What is the nurses most appropriate response? a. The placenta does not function adequately as it ages. b. Infants born postmaturely are generally large. c. Delivery of the postterm infant is more difficult. d. There is less amniotic fluid

The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. What should the nurses next assessment be? a. Fullness of the bladder b. Amount of lochia c. Blood pressure d. Level of pain

The nurse caring for a preterm infant will record the intake and output. The nurse is aware that what is the optimum output for this infant? a. 1 to 3 mL/kg/hr b. 4 to 6 mL/kg/hr c. 7 to 9 mL/kg/hr d. 10 to 14 mL/kg/hr

The nurse compared the birth weight of a 3-day-old with her current weight and determined the infant had lost weight. What is the most appropriate intervention by the nurse? a. Do nothing because this is a normal occurrence. b. Report the discrepancy to the pediatrician immediately. c. Decrease the interval between the infants feedings. d. Try feeding the infant a different type of formula

The nurse encourages the members of a prenatal class to seriously consider breastfeeding. What does breast milk provide in addition to nourishment for the infant? a. Maternal antibodies b. Stimulus for red blood cell production c. Endorphins that soothe the infant d. Hormones that stimulate growth

The nurse explained how to position an infant with tetralogy of Fallot if the infant suddenly becomes cyanotic. Which statement by the father leads the nurse to determine he understood the instructions? a. If the baby turns blue, I will hold him against my shoulder with his knees bent up toward his chest. b. If the baby turns blue, I will lay him down on a firm surface with his head lower than the rest of his body. c. If the baby turns blue, I will immediately put the baby upright in an infant seat. d. If the baby turns blue, I will put the baby in supine position with his head elevated.

The nurse is administering terbutaline (Brethine) to a pregnant woman to prevent preterm labor. The nurse would assess for which adverse effect? a. Maternal tachycardia b. Maternal hypertension c. Fetal bradycardia d. Fetal hypokalemia

The nurse is assessing a patient with a bleeding disorder and finds large purplish areas in the skin and oral mucosa. Which term should the nurse use to document this finding? a. Purpura b.Bleeding c. Petechiae d. Hemorrhage

The nurse is assisting in the development of a care plan for a patient with anemia. Which nursing diagnosis is most common in a patient with anemia? a. Activity Intolerance related to tissue hypoxia b. Ineffective Airway Clearance related to dyspnea c. Chronic Pain related to bone marrow dysfunction d. Risk for Infection related to reduction in circulating WBC

The nurse is assisting in the planning of care for a patient with chronic serum sickness. Which action should be a priority for this patient? a. Assessing for a decrease in urine output b. Administration of immunosuppressive medications c. Closely monitoring the patient during the transfusion of blood products d. Discussing with the patient and significant other the need for genetic counseling

The nurse is assisting with the admission of a known intravenous drug abuser to a medical unit. In addition to drug abuse, which disorder in the patients history is most consistent with a diagnosis of hepatitis? a. Jaundice b. Diabetes mellitus c. Bowel obstruction d. Chronic headaches

The nurse is checking for capillary refill on a child in Bryants traction. How long does it take for the toe to regain color if adequate perfusion is assessed? a. 3 seconds b. 4 seconds c. 5 seconds d. 6 seconds

The nurse is assisting with the preparation of a blood transfusion for a patient. Which type of fluid should the nurse select to transfuse with the blood? a. 0.9% normal saline b. Dextrose 5% and water c. Dextrose 5% and 0.9% normal saline d. Dextrolse 5% and 0.45% normal saline

The nurse is aware that the diagonal conjugate is 12 centimeters. What is the measurement in centimeters of the obstetric conjugate? a. 10 to 10.5 b. 11 to 11.5 c. 12.5 to 13 d. 14 to 14.5

The nurse is caring for a 76-year-old retired man who is undergoing evaluation for dementia. What would be an important part of the mans history to report to the physician? a. The patient has a history of syphilis. b. The patient was exposed to Chlamydia. c. The patient has a history of hepatitis B. d. The patient has a history of genital warts.

The nurse is caring for a child with a diagnosis of Kawasaki disease. The childs parent asks the nurse, How does Kawasaki disease affect my childs heart and blood vessels? On what understanding is the nurses response based? a. Inflammation weakens blood vessels, leading to aneurysm. b. Increased lipid levels lead to the development of atherosclerosis. c. Untreated disease causes mitral valve stenosis. d. Altered blood flow increases cardiac workload with resulting heart failure.

The nurse is caring for a macrosomic newborn whose mother has diabetes. What should the nurse assess for with this neonate? a. Hypoglycemia b. Erythroblastosis fetalis c. Intracranial hemorrhage d. Pancreatic failure

The nurse is caring for a man diagnosed with prostatitis. What symptom should the nurse expect when collecting data from the patient? a. Dysuria b. Polyuria c. Hematuria d. Glycosuria

The nurse is caring for a newborn who is being breastfed. What will the nurse expect the stool color to be 2 days after birth? a. Yellow b. Brown c. Greenish brown d. Black and tarry

The nurse is caring for a patient at risk for infection. Which immunoglobulin should the nurse consider as being the cause of this patients infection risk? a. IgA b. IgE c. IgG d. IgM

The nurse is caring for a patient having a bone marrow biopsy. What nursing action is the most important following the biopsy? a. Observe for bleeding. b. Encourage oral fluids. c. Administer an analgesic for pain. d. Monitor the puncture site for infection.

The nurse is caring for a patient recovering from a hysterectomy earlier in the day. Four hours later, the woman is unable to urinate. What assessment should the nurse use to determine bladder distention and be comfortable for the patient? a. Perform a scratch test. b. Palpate for bladder distention. c. Palpate for rebound tenderness. d. Percuss the bladder for fullness.

The nurse is caring for a patient who has a nephrostomy tube. What action should the nurse take to maintain the integrity of this device? a. Ensure tube is not kinked or clamped. b. Limit fluids to 1000 mL per 24 hours. c. Keep collection bag taped to abdomen. d. Remove and clean the tube once daily.

The nurse is caring for a patient who has renal calculi. Which action is essential for the nurse to take? a. Strain all urine. b. Limit fluids at night. c. Record blood pressure. d. Obtain a sterile urine specimen.

The nurse is caring for a patient who is stung by a wasp. Which manifestation should the nurse expect if an allergic reaction develops? a. Hives b. Retinal hemorrhage c. Jugular vein distention d. Pallor around the sting sites

The nurse is caring for a patient with PV. Which laboratory study should the nurse monitor to help evaluate the effectiveness of treatment for this patient? a. Hematocrit b. Total protein c. Blood urea nitrogen (BUN) d. WBC differential

The nurse is caring for a patient with a bleeding disorder. Which medication order should the nurse question? a. Aspirin b. Morphine c. Digoxin (Lanoxin) d. Thyroid hormone (Synthroid)

The nurse is caring for a patient with idiopathic autoimmune hemolytic anemia. Which action should the nurse include in the plan of care for this patient? a. Assist with ambulation. b. Teach good hand hygiene. c. Avoid intramuscular injections. d. Obtain manual blood pressures.

The nurse is caring for a patient with primary dysmenorrhea. Which medication should the nurse anticipate being prescribed because it blocks prostaglandin synthesis? a. NSAIDs b. Antacids c. Vitamins d. Morphine

The nurse is caring for a pregnant woman diagnosed with preeclampsia. What will the nurse explain is the objective of magnesium sulfate therapy for this patient? a. To prevent convulsions b. To promote diaphoresis c. To increase reflex irritability d. To act as a saline cathartic

The nurse is caring for a pregnant woman receiving an intravenous infusion with magnesium sulfate. What is the most appropriate nursing intervention? a. Count respirations and report a rate of less than 12 breaths/min. b. Count respirations and report a rate of more than 20 breaths/min. c. Check blood pressure and report a rate of less than 100/60 mm Hg. d. Monitor urinary output and report a rate of less than 100 mL/hr.

The nurse is caring for a toddler with acute laryngotracheobronchitis. Which assessment finding would indicate the child is experiencing increased respiratory obstruction? a. Restlessness b. Tachycardia c. Brassy cough d. Expiratory wheezing

The nurse is caring for a woman of Middle Eastern descent on the first postpartum day. Education is provided regarding instruction on use of a sitz bath. What documentation best indicates that the woman has understood the provided instruction? a. Patient correctly performed return demonstration. b. Patient indicated understanding by nodding head with instruction. c. Patient verbalizes I understand. d. Family member indicates patient understands procedure.

The nurse is caring for an infant born at 43 weeks. What would the physical assessment reveal? a. Dry, peeling skin b. Minimal hair on the head c. Short, rough nails d. Abundant lanugo on the body

The nurse is catheterizing a patient after voiding to determine the amount of residual urine in the bladder. What should the nurse consider as being the normal amount of urine within the bladder after urination? a. 50 mL b. 75 mL c. 100 mL d. 150 mL

The nurse is contributing to a group of patients care plans. Which patient should the nurse identify as being at risk for developing serum sickness? a. A patient who receives intravenous (IV) penicillin for an infection b. A patient who has a transfusion with packed red blood cells (RBCs) c. A patient who is given cryoprecipitate and factor IX after an abdominal injury d. A patient given steroids and immunosuppressant therapy after organ transplantation

The nurse is counseling a lactating mother about diet. What would the nurse include with this information? a. Consume 500 more calories than her usual prepregnancy diet. b. Eat less meat and more fruits and vegetables. c. Drink 3 to 4 tall glasses of fluid daily. d. Eat 1000 more calories than her usual prepregnancy diet.

The nurse is educating high school students about puberty. What will the nurse indicate regulates the production of sperm and secretion hormones? a. Testes b. Vas deferens c. Ejaculatory ducts d. Prostate gland

The nurse is emptying the bedside commode of a patient with chronic leukemia and notes that the stool is very dark. Which assumption should guide the nurses action? a. The patient may be bleeding. b. The patient may be dehydrated. c. The patient is most likely on iron supplements. d. The patient ate something that turned the stool a dark color.

The nurse is explaining the role of red blood cells with oxygen transport in the body with a nursing student. Which term should the nurse use to describe hemoglobin that has given up its oxygen to the bodys cells? a. Reduced b. Detached c. Oxyhemoglobin d. Hypoxyhemoglobin

The nurse is identifying ways for a young adult to reduce the risk of contracting a sexually transmitted infection (STI). What should the nurse teach about the relationship between consumption of alcohol and immediate risk of contracting an STI? a. Alcohol may reduce inhibitions. b. Alcohol increases risk for liver disease. c. Alcohol lowers the bodys resistance to infection. d. Alcohol impairs the integrity of the mucous membranes, providing a portal of entry for infection.

The nurse is making a visit to the home of a patient with functional incontinence. Which observation indicates that teaching about the disorder has been effective? a. Patient wearing sweat pants b. Patient drinking a cup of coffee c. Patient sitting with the legs elevated d. Patient restricting fluid intake after 6 pm.

The nurse is monitoring a patient with AIDS. Which manifestation should the nurse expect to observe in this patient? a. Diarrhea b. Chest pain c. Hypertension d. Pustular skin lesions

The nurse is preparing teaching for a patient with Hodgkins disease. Which beverage should the nurse instruct this patient to avoid? a. Wine b. Coffee c. Ginger ale d. Orange juice

The nurse is preparing to care for a patient who is HIV positive. Which action should the nurse take when following standard precautions for protection from HIV exposure? a. Put on gloves before touching body fluids. b. Recap intramuscular needles after injection. c. Wash own open skin lesion after providing care. d. Remove one finger on a glove during venipuncture.

The nurse is preparing to provide care to a patient recovering from surgery. What nursing action is the best way to prevent infection in a postoperative patient? a. Practice good hand washing. b. Encourage 2 L of fluid daily. c. Change wound dressings daily. d. Assess vital signs every 4 hours.

The nurse is preparing to start an IV on an infant admitted to the pediatric unit. What intervention is appropriate for the nurse to implement? a. Involve the parents. b. Provide a simple explanation to the child. c. Let the child examine the equipment. d. Suggest coping techniques.

The nurse is providing instructions about how to treat a sprained ankle. What statement by the mother does the nurse recognize as indicative of a need for additional teaching? a. Apply warm compresses to the ankle for the first 24 hours. b. Put an ice pack on the ankle, alternating 30 minutes on with 30 minutes off. c. Wrap the ankle in an Ace bandage for support. d. Keep the leg elevated when sitting.

The nurse is reinforcing teaching about the most serious side effect of peritoneal dialysis with a patient scheduled for the first treatment. Which side effect should the patient state that indicates correct understanding? a. Peritonitis. b. Paralytic ileus. c. Respiratory distress. d. Cramps in the abdomen.

The nurse is reinforcing teaching provided to a patient with Hashimotos thyroiditis. What should the nurse explain as occurring initially in this health problem? a. Thyroid hormone production increases. b. Thyroid hormone production decreases. c. Thyroid-stimulating hormone production increases. d. Thyroid-stimulating hormone production decreases.

The nurse is reviewing a patients history and physical report. What term should the nurse recognize is being used to describe waste products building up in the blood? a. Uremia b. Septicemia c. Nitrosemia d. Proteinemia

The nurse is reviewing fetal circulation with a pregnant patient and explains that blood circulates through the placenta to the fetus. What vessel(s) carry blood to the fetus? a. One umbilical vein b. Two umbilical veins c. One umbilical artery d. Two umbilical arteries

The nurse is reviewing laboratory results for a patient who has HIV. Which result would be strongly suggestive of a diagnosis of AIDS? a. CD4+ = 180/L b. CD4+ percentage = 68% c. CD8+ = 650/L d. CD4+/CD8+ ratio = 1.5

The nurse is reviewing the medical records for a couple who have been trying to conceive. How long must a couple attempt to conceive unsuccessfully before they are considered infertile? a. 1 year b. 2 years c. 3 months d. 6 months

The nurse is staying with a patient who has been started on a blood transfusion. Which assessment should the nurse perform during a blood product infusion to detect a reaction? a. Vital signs b. Skin turgor c. Bowel sounds d. Pupil reactivity

What should the nurse suggest before a 17-year-old girl starts a protocol of isotretinoin (Accutane) for her acne? a. Get a prescription for oral contraceptives. b. Increase the dose of the present medication. c. Limit intake of chocolate, cola, and peanuts. d. Increase exposure to sunlight.

The nurse is teaching a patient how to use a daily vaginal suppository. Which statement indicates that teaching has been effective? a. I should put the suppository in at night after I get into bed. b. I should put the suppository in each morning before I get out of bed. c. It is best to insert the suppository each morning after a shower or bath. d. The suppository should be put in late in the day when Im less likely to be active.

The nurse learns that a patient has a urine pH of 7.9. What question should the nurse ask the patient after learning of this laboratory value? a. Are you a vegetarian? b. Are you lactose intolerant? c. How much protein do you eat each day? d. How much acetaminophen do you take each day?

The nurse notes that a 4-year-old childs gums bleed easily and he has bruising and petechiae on his extremities. Which lab value is consistent with these symptoms? a. Platelet count of 25,000/mm3 b. Hemoglobin level of 8 g/dL c. Hematocrit level of 36% d. Leukocyte count of 14,000/mm3

The nurse notes that a female patient has been treated for vaginal yeast infections 6 times in one year. For which additional health problem should the nurse suspect the patient should be evaluated? a. HIV b. Hepatitis B c. Tuberculosis d. Chronic inflammation

The nurse offers a variety of fluids to a 5-year-old asthmatic child to compensate for the fluid loss through dyspnea. Which fluids are most appropriate? a. Room temperature water b. Carbonated beverages c. Iced fruit juice d. Cold milk

The nurse provides teaching on nevirapine (Viramune) for a patient who is HIV positive. Which patient statement indicates that teaching has been effective? a. Monitor for rash. b. Observe urine color. c. Report extremity pain. d. Monitor for flulike symptoms.

The nurse shares the information and timelines recorded on the interdisciplinary outline of care for a child. What is this document? a. Clinical pathway b. Comprehensive nursing care plan c. Holistic care approach d. Incorporated cost analysis

The nurse would observe a child for frequent swallowing after a tonsillectomy and adenoidectomy (T&A). What might this indicate? a. Bleeding from the surgical site b. Pain at the incision area c. Sore throat from postnasal drip d. Potential vomiting

The nurse, caring for a child receiving chemotherapy, notes that the childs abdomen is firm and slightly distended. There is no record of a bowel movement for the last 2 days. What do these assessment findings suggest? a. Peripheral neuropathy b. Stomatitis c. Myelosuppression d. Hemorrhage

What assessment made by the nurse would lead the nurse to suspect hip dysplasia? a. Asymmetrical gluteal folds b. Limited adduction of the affected side c. Foot turned inward d. Deep inguinal creases

What description of a childs stool characteristic leads the nurse to suspect intussusception? a. Currant jelly b. Black and tarry c. Green liquid d. Greasy and foul-smelling

What does the nurse explain is used to soften the cervix with a cervical ripening agent? a. Prostaglandin gel insertion b. Intravenous oxytocin c. Warm saline douches d. Nipple stimulation

What does the nurse explain that a ventricular septal defect will allow? a. Blood to shunt left to right, causing increased pulmonary flow and no cyanosis b. Blood to shunt right to left, causing decreased pulmonary flow and cyanosis c. No shunting because of high pressure in the left ventricle d. Increased pressure in the left atrium, impeding circulation of oxygenated blood in the circulating volume

What instruction will the nurse give to parents about preventing the spread and reinfection of pinworms? a. Keep childrens nails short. b. Dress child in loose-fitting underwear. c. Clean the bathroom with bleach solution. d. Wash bed linens in cold water.

What intervention is appropriate for a nurse assessing a preadolescent child for scoliosis? a. Ask the child to bend forward at the waist and observe the childs back for asymmetry. b. Observe the gait while the child is walking forward heel to toe. c. Have the child flex the knees and look for uneven knee height. d. Look at the childs shoulders and hips while fully clothed.

What is it important to assess in a child receiving prednisone to treat nephrotic syndrome? a. Infection b. Urinary retention c. Easy bruising d. Hypoglycemia

What is the best choice for fluid replacement that the nurse can offer a child who has just had a tonsillectomy? a. A popsicle b. Chocolate milk c. Orange juice d. Cola drink

What is the correct nursing response to a mother who asks, How can I get rid of the babys cradle cap? a. Rub baby oil on the infants head at night and shampoo the hair the next morning. b. Use a brush with firm bristles to loosen the scales on the babys head several times a day. c. Wash the babys head every night with a dandruff-control shampoo. d. Lubricate the babys head every morning with a small amount of olive oil

What is the treatment of choice for a child with intussusception? a. A barium enema b. Immediate surgery c. IV fluids until the spasms subside d. Gastric lavage

What might the nurse explain as a common treatment for amblyopia? a. Patching the good eye to force the brain to use the affected eye b. Patching the affected eye to allow the refractory muscles to rest c. Using glasses that will slightly blur the image for the good eye d. Using corticosteroids to treat inflammation of the optic nerve

What nursing action is appropriate to prevent possible retinopathy in a preterm infant requiring oxygen therapy? a. Monitor arterial oxygen levels with a pulse oximeter. b. Position the head slightly lower than the body. c. Administer low concentrations of oxygen. d. Keep the infants eyes covered at all times.

What nursing action will significantly decrease the risk of serious complications for a child in Bryants traction? a. Neurovascular checks are done frequently. b. Bandages are wrapped tightly. c. The child is restrained from rolling over. d. The childs buttocks are resting on the bed

What organ does the ductus venosus shunt blood away from in fetal circulation? a. Liver b. Heart c. Lungs d. Kidneys

What statement by the parent of a hospitalized toddler leads the nurse to determine the parent understands a hospitalized toddlers need for transitional objects? a. This stuffed animal makes him feel secure. b. He insisted on bringing this dirty old blanket with him. c. Im going to buy him a big stuffed animal from the gift shop. d. Id like to get him some toys from the playroom.

What will the nurse caution the parents of a child who has had a nephrectomy that he will have to avoid? a. Contact sports b. Horseback riding c. Alcohol d. Diuretic medications

What will the nurse teach the child with cystic fibrosis to take in order to facilitate digestion and absorption of nutrients? a. Pancreatic enzymes b. Water-soluble minerals c. Fat-soluble vitamins d. Salt supplements

What would the nurse expect to find when assessing the fundus of the uterus immediately after delivery? a. Well-contracted with its upper border at or just below the umbilicus b. Well-contracted with its upper border three or four fingerbreadths above the umbilicus c. Relaxed with its upper border level with the umbilicus d. Relaxed with its upper border two or three fingerbreadths below the umbilicus

When assessing a preterm infant, the nurse observes nasal flaring, sternal retractions, and expiratory grunting. What do these findings indicate? a. Respiratory distress syndrome b. Postmaturity syndrome c. Apneic episode d. Cold stress

When the newborns crib was moved suddenly, the nurse noticed that his legs flexed and arms fanned out, and then both came back toward the midline. How would the nurse interpret this behavior? a. The Moro reflex b. The grasp reflex c. An abnormality of the musculoskeletal system d. A neurological abnormality

Where is the usual location for implantation of the zygote? a. Upper section of the posterior uterine wall b. Lower portion of the uterus near the cervical os c. Inner third of the fallopian tube near the uterus d. Lateral aspect of the uterine wall

Which assessment finding in a child with meningitis should be reported immediately? a. Irregular respirations b. Tachycardia c. Slight drop in blood pressure d. Elevated temperature

Which assessment of the newborn should be reported? a. Head circumference is 5 cm greater than the chest circumference b. Hands and feet are warm with a blue color c. Temperature is 36.6 C (97.8 F) d. Head has a longer than normal shape to it

Which observation may cause the nurse to consider the possibility of child abuse when a mother says that her young child fell down the basement stairs? a. Red, green, and yellow bruises on his body b. Bruises are dispersed on his head, arms, and legs c. A broken arm last year, and the child being described as accident-prone d. The mother is very anxious for her son to get medical attention

Which statement by a mother may indicate a cause for her 9-month-olds iron deficiency anemia? a. Formula is so expensive. We switched to regular milk right away. b. She almost never drinks water. c. She doesnt really like peaches or pears, so we stick to bananas for fruit. d. I give her a piece of bread now and then. She likes to chew on it

Which statement indicates that parents understand how to feed their infant who had a surgical repair for a cleft lip? a. We are feeding the baby with a dropper for 2 weeks. b. We resumed bottle feeding after discharge. c. We started the baby on solid food yesterday. d. The baby is drinking well from a straw.

Which statement indicates the new mother is breastfeeding correctly? a. I will alternate breasts when feeding the baby. b. I keep the baby on a 4-hour feeding schedule. c. I let the baby stay on the first breast only 5 minutes. d. I put only the nipple in the babys mouth when I am breastfeeding.

Which statement indicates to the nurse on a postpartum home visit that the patient understands the signs of late postpartum hemorrhage? a. My discharge would change to red after it has been pink or white. b. If I have a postpartum hemorrhage, I will have severe abdominal pain. c. I should be alert for an increase in bright red blood. d. I would pass a large clot that was retained from the placenta

Which statement made by a parent indicates an understanding of the topical application of medications for a skin condition? a. I apply the medication after I give my child a bath. b. I rub the ointment in a circular motion over the rash. c. I increased the amount of cream because the rash was not improving. d. I use powder and cornstarch to keep the skin dry

Which statement made by a parent indicates the need for further teaching about strategies to control itching for the infant with eczema? a. Wool is the best fabric for the infants clothing. b. I should avoid laundry detergents with fragrances. c. I put cotton gloves on the infants hands. d. The infants fingernails are kept short.

While caring for a postpartum patient who had a vaginal delivery yesterday, the nurse assesses a firm uterine fundus and a trickle of bright blood. How does the nurse most likely feel and react to this finding? a. Concerned and reports a probable cervical laceration b. Attentive and massages the uterus to expel retained clots c. Distressed and reports a possible clotting disorder d. Satisfied with the normal early postpartum finding

Why does a 4-day-old infant born at 33 weeks of gestation possibly need to be fed by gavage during the first few days of life? a. Weak or absent sucking or swallowing reflex b. Inability to digest food properly c. Refusal to take formula by mouth d. Need for a larger quantity of formula at each feeding

a patient asks why the physician wouldnt prescribe antibiotics for influenza. how should the nurse respond? a. antibiotics are not effective against viruses b. antibiotics have too many serious side effects c. antibiotics interact with other medications used for the flu d. most cases of the flu are caused by antibiotic resistant bacteria

an older adult who reports difficulty breathing and productive cough and has a low grade fever is admitted to the hospital for diagnosis and treatment. intervention for which new onset symptoms should take priority? a. confusion b. crackles on lung auscultation c. blood tinged sputum d. fatigue

most common complication of influenza? a. pneumonia b. common cold c. meningitis d. abscess

nurse is providing care to a patient who experienced an ischemic stroke and now requires respiratory support with mechanical ventilation. the nurse realizes the stroke most likely occured in which part of the brain? a. medulla b. cerebrum c. cerebellum d. hypothalamus

nurse is providing discharge teaching to a patient with newly diagnosed asthma. which should be included in the teaching? a. symptoms are caused by inflammation in the lining of your airways b. fluid fills the tiny sacs in the lungs and makes breathing difficult c. you may notice large amounts of pus like sputum that has a foul odor d. the chest wall becomes stiff and air movement is restricted in individuals with asthma

oxygen saturation is 89%. what has highest priority? a. raise head of bed b. no action; normal oxygen saturation c. call respiratory therapist d. place patient in supine position

what structure sweeps mucus and pathogens from the nasal cavities and trachea to the pharnyx? a. cilliated epithelium b. simple squamous epithelium c. alveolar macrophages d. elastic connective tissue

when caring for a patient with a new laryngectomy, the nurse is asked by the family why the patient cannot be given higher doses of narcotics. which is the best response? a. narcotics can depress the respiratory rate and cough reflex b. narcotics can increase respiratory tract secretions c. narcotics are constipating d. narcotics can be addicting

which lab tests would best help the nurse to monitor the condition of a patient wit pneumonia? a. white blood cell count, arterial blood gases (ABGs) b. complete blood count, urinalysis c. electrolytes, serum creatinine d. partial thromboplastin time (PTT), serum potassium

which symptom does the nurse anticipate when assessing a patient with a sinus infection? a. facial tenderness b. chest pain c. photophobia d. hypoxemia

A newborn was diagnosed as having hypothyroidism at birth. Her mother asks you how the disease could be discovered this early. Your best answer would be a) her child is already severely impaired at birth, and this suggests the diagnosis. b) hypothyroidism is usually detected at birth by the child's physical appearance. c) children have a typical rash at birth that suggests the diagnosis. d) a simple blood test to diagnose hypothyroidism is required in most states.

a simple blood test to diagnose hypothyroidism is required in most states. Explanation: Hypothyroidism is diagnosed by a screening procedure a few days after birth.

A patient in labor is diagnosed with mucopurulent cervicitis. For which health problems should the nurse anticipate providing care to the newborn? (Select all that apply.) a. Pneumonia b. Conjunctivitis c. Irregular heart rate d. Flaccid extremities e. Cyanotic extremities

a, b

The nurse cautions the patient that, because of hormonal changes in late pregnancy, the pelvic joints relax. What does this result in? (Select all that apply.) a. Waddling gait b. Joint instability c. Urinary frequency d. Back pain e. Aching in cervical spine

a, b

The nurse is collecting data from a patient with a vascular access graft in the right arm for dialysis. What should the nurse do when assessing this patient? (Select all that apply.) a. Auscultate for a bruit over the site. b. Palpate for a thrill in the right arm. c. Observe the tubing for bright red blood. d. Feel for a brachial pulse on the affected arm. e. Redress the arm daily, keeping the site sterile at all times.

a, b

A 7-year-old child has a BUN of 25 mg/dL. What is the nurse aware this lab value might indicate? (Select all that apply.) a. Dehydration b. Renal disease c. Need for steroid therapy d. Diabetes e. Pituitary malfunction

a, b, c

A nurse is teaching a lesson on fetal development to a class of high school students and explains the primary germ layers. What are the germ layers? (Select all that apply.) a. Ectoderm b. Endoderm c. Mesoderm d. Plastoderm e. Blastoderm

a, b, c

A woman is preparing for administration of a cervical ripening agent. What nursing actions will the nurse anticipate implementing? (Select all that apply.) a. Insert IV. b. Record a baseline fetal heart rate. c. Explain procedure to patient. d. Instruct patient to ambulate immediately afterward. e. Ensure a tocolytic is available.

a, b, c

The nurse in the newborn nursery is watchful for neonatal abstinence syndrome in the newborn of a crack-addicted mother. What would be the manifestations of this syndrome? (Select all that apply.) a. Body tremors b. Excessive sneezing c. Hyperirritability d. Drowsiness e. Excessive appetite

a, b, c

The nurse is caring for a woman who gave birth to a preterm infant. The nurse is aware that what are possible causes of preterm delivery? (Select all that apply.) a. Placenta previa b. Gestational diabetes c. Pregnancy-induced hypertension d. Hyperemesis gravidarum e. Chloasma

a, b, c

The nurse reviews care orders written by the HCP for a patient recovering from a transurethral resection of the prostate. These orders include bladder irrigation, antispasmodic medication, and intravenous antibiotics every 6 hours. For which potential complications are these orders specifically addressing? (Select all that apply.) a. Infection b. Blood clots c. Bladder spasms d. Urinary retention e. Nausea and vomiting

a, b, c

The nurse speaking to a group of junior high school students informs them that acne can be exacerbated by which drug(s)? (Select all that apply.) a. Steroids b. Phenytoin c. Phenobarbital d. Aspirin e. Oral contraceptives

a, b, c

The nurse would suggest the parents of an asthmatic child to encourage participation in which sport(s)? (Select all that apply.) a. Swimming b. Gymnastics c. Baseball d. Cross-country skiing e. Distance running

a, b, c

What manifestations of increasing ICP in the hydrocephalic child should the nurse be aware of? (Select all that apply.) a. High-pitched cry b. Inequality of pupils c. Bulging fontanelles d. Diarrhea e. Hiccups

a, b, c

Which interventions could a nurse apply to help stimulate contractions? (Select all that apply.) a. Encouraging the patient to sit upright b. Assisting the patient to ambulate c. Stimulating the nipples d. Offering emotional support e. Allowing the patient to vent frustration

a, b, c

While providing a bath the nurse suspects that an older female patient has a Trichomonas infection. What type of discharge did the nurse observe to come to this conclusion? (Select all that apply.) a. Frothy discharge b. Foul-smelling discharge c. Yellow-green discharge d. Open sores on the labia majora e. Wart-like growths on the labia minora

a, b, c

A female patient is diagnosed with mild uterine prolapse into the vagina. For which areas should the nurse prepare to reinforce teaching to help this patient? (Select all that apply.) a. Avoid weight gain b. Take care of the pessary c. Consume a healthy diet d. Perform Kegel exercises e. Perform vaginal douches

a, b, c, d

A patient who is 30 weeks pregnant delivers a stillborn child in the emergency department (ED). What should the ED nurse offer the patient? (Select all that apply.) a. Privacy b. An opportunity to hold the infant c. Materials about support groups d. A memento (footprint or lock of hair) e. A warm beverage

a, b, c, d

A woman is diagnosed with a urinary tract infection in the postpartum period. What foods can the nurse encourage to increase the acidity of urine? (Select all that apply.) a. Apricots b. Cranberry juice c. Plums d. Prunes e. Apples

a, b, c, d

During a home visit, the nurse becomes concerned that a child is developing idiopathic thrombocytopenic purpura (ITP). Which health problems could have precipitated the development of this disorder in the child? (Select all that apply.) a. HIV b. Rubella c. Hepatitis C d.Chickenpox e. Cystic fibrosis

a, b, c, d

The nurse is assessing Apgar score on a newborn. What will be evaluated? (Select all that apply.) a. Reflexes b. Color c. Heart rate d. Respiration e. Weight

a, b, c, d

The nurse is assisting with the preparation of materials for a patient who is at risk for prostatitis. What should the nurse include in this teaching? (Select all that apply.) a. Practice safe sex b. Ensure good personal hygiene c. Avoid urinary catheterizations d. Avoid excessive intake of citrus juices e. Avoid excessive intake of animal products

a, b, c, d

The nurse is aware that genitourinary surgery is especially stressful for preschool children. What factor(s) lend to this stress? (Select all that apply.) a. They may perceive the treatment as punishment. b. They are especially prone to separation anxiety. c. They are sexually curious and developmentally fixated on their genitals. d. They have a fear of castration. e. They fear death

a, b, c, d

The nurse is caring for a child with a low platelet count. What skin assessments would alert the nurse to bleeding? (Select all that apply.) a. Petichiae b. Purpura c. Ecchymosis d. Hematoma e. Lymphadenopathy

a, b, c, d

The nurse is collecting data for a patient who has suspected kidney disease. What health problems should the nurse consider as being associated with a high urine specific gravity? (Select all that apply.) a. Nephrosis b. Dehydration c. Heart failure d. Diabetes mellitus e. Diabetes insipidus f. Fluid volume excess

a, b, c, d

What are the classic symptoms of thalassemia major (Cooleys anemia)? (Select all that apply.) a. Hepatomegaly b. Jaundice c. Protruding teeth d. Pathological fractures e. Renal failure

a, b, c, d

What nursing interventions are appropriate for the prenatal patient in terms of prenatal care? (Select all that apply.) a. Offer nutritional counseling. b. Reinforce responsibility of parenthood. c. Reduce risk factors. d. Improve health practices. e. Make financial arrangements for delivery.

a, b, c, d

What postpartum exercises should the nurse teach a patient who had a vaginal delivery yesterday? (Select all that apply.) a. Abdominal tighteners b. Head lift c. Pelvic tilt d. Kegel exercises e. Leg lifts

a, b, c, d

What should be included in the nursing care of a 12-year-old child receiving radiation therapy for Hodgkins disease? (Select all that apply.) a. Application of sunblock b. Appetite stimulation c. Conservation of energy d. Provision for expressions of anger e. Preparation for premature sexual development

a, b, c, d

What will the nurse include when documenting the discharge of a pediatric patient? (Select all that apply.) a. Time of discharge b. Adult(s) accompanying the child and the relationship to the child c. Condition of the child d. Method of transportation e. Instructions that were given to physician

a, b, c, d

Which factor(s) activate the herpes simplex virus type I? (Select all that apply.) a. Stress b. Sun c. Menses d. Fever e. Food allergies

a, b, c, d

The nurse is aware that a full-term infant is born with which reflexes? (Select all that apply.) a. Blinking b. Sneezing c. Gagging d. Sucking e. Grasping

a, b, c, d, e

What assessment(s) would lead a nurse to suspect Hirschsprungs disease in a 1-month-old infant? (Select all that apply.) a. Ribbon-like stools b. Fever c. Failure to thrive d. Vomiting e. Diminished peristalsis

a, b, c, d, e

26. What signs and symptoms of STDs should nurses assess for in all patients? Select all that apply. a. Itching b. Discharge c. Dysuria d. Genital ulcers e. Genital warts f. Rectal pain

a, b, c, d, e, f. All symptoms can occur with sexually transmitted diseases and should be assessed

The nurse is reinforcing teaching on the rising incidence of HIV in adults over the age of 50 with a group of senior community members. Which factors should the nurse include? (Select all that apply.) a. Older adults are less likely to use condoms than younger at-risk adults. b. At-risk individuals over the age of 50 are less likely to be tested for HIV. c. Society continues to age with larger numbers of people entering this age group. d. A decline in the function of the immune system increases the risk of HIV infection. e. Decreased vaginal dryness and friability of tissues increases the risk of HIV in older women. f. Treatments for erectile dysfunction have increased the number of older individuals who are sexually active.

a, b, c, d, f

A patient is diagnosed with a folic acid deficiency. On what dietary changes should the nurse instruct this patient? (Select all that apply.) a. Snack on peanuts. b. Eat breads fortified with folic acid. c. Add green leafy vegetables to meals. d. Increase the intake of milk each day. e. Prepare soups with dried peas and beans.

a, b, c, e

A patient with AIDS is planning a trip to Mexico. What teaching should the nurse provide to this patient to prevent the development of an opportunistic infection? (Select all that apply.) a. Use beach towels. b. Do not walk barefoot. c. Do not eat raw fruits or vegetables. d. Clean bathroom supplies with bleach. e. Take an antimicrobial agent if diarrhea occurs.

a, b, c, e

A patient with a UTI is concerned about the expectation to void every three hours. What should the nurse explain to the patient about voiding this frequently? (Select all that apply.) a. Empties the bladder b. Reduces urine stasis c. Prevents reinfection d. Cleanses the perineum e. Lowers bacterial counts

a, b, c, e

A postpartum patient is experiencing hypovolemic shock. What interventions can the nurse anticipate? (Select all that apply.) a. Provision of IV fluids b. Placement of an indwelling Foley catheter c. Assessment of oxygen saturation d. Administration of anticoagulants e. Blood transfusion

a, b, c, e

How would the nurse caring for an infant with congestive heart failure (CHF) modify feeding techniques to adapt for the childs weakness and fatigue? (Select all that apply.) a. Feeding more frequently with smaller feedings b. Using a soft nipple with enlarged holes c. Holding and cuddling the child during feeding d. Substituting glucose water for formula e. Offering high-caloric formula

a, b, c, e

The family of a child receiving chemotherapy for leukemia should be taught to focus on which aspect(s) of the childs care? (Select all that apply.) a. Using a support group b. Stimulating appetite c. Maintaining adequate hydration d. Continuing with scheduled immunizations e. Reporting exposure to infectious diseases

a, b, c, e

The nurse describes the allergic salute as a cluster of what signs related to chronic allergy? (Select all that apply.) a. Mouth breathing b. Transverse nasal crease c. Dark circles under the eyes d. Productive cough e. Reddened conjunctiva

a, b, c, e

The nurse is caring for a patient with an indwelling catheter. What should the nurse include in this patients routine care? (Select all that apply.) a. Encourage fluid intake. b. Maintain a closed system. c. Secure the catheter to the patients leg. d. Clamp the catheter for 1 hour each shift. e. Remove the catheter as soon as possible. f. Use sterile technique when emptying the drainage bag.

a, b, c, e

The nurse is contributing to the plan of care for a patient who has chronic kidney disease. What possible effects of this condition should the nurse consider? (Select all that apply.) a. Anemia b. Cardiac dysrhythmias c. Peripheral neuropathy d. Increased bone density e. Anorexia, nausea, vomiting f. Increase in function of oil and sweat glands

a, b, c, e

The nurse is participating in care planning for a patient with urge incontinence. What should the nurse recommend be included in this patients plan of care? (Select all that apply.) a. Void every 2 hours. b. Practice relaxation breathing. c. Use urge inhibition techniques. d. Reduce fluid intake for several hours before sleep. e. Gradually increase length of time between voidings.

a, b, c, e

The nurse recognizes which behavior characteristic(s) of women in their first trimester of pregnancy? (Select all that apply.) a. Showing off her sonogram photos b. Ambivalence about pregnancy c. Emotional and labile mood d. Focusing on her infant e. Fatigue

a, b, c, e

The nurse suggests to parents that they use the outpatient surgical center for their childs upcoming surgery. What advantage(s) does this type of facility have to offer? (Select all that apply.) a. Lower cost b. Less incidence of health careassociated infections c. Reduction of parent-child separation d. Ample time for recuperation at the facility e. Decreased emotional impact of illness

a, b, c, e

What are considered to be functions of the fallopian tubes? (Select all that apply.) a. Passage for sperm to meet ova b. Passage for ovum to uterus c. Safe environment for zygote d. Restriction for only one ovum to enter uterus e. Site for fertilization

a, b, c, e

What assessment(s) in a child with tetralogy of Fallot would indicate the child is experiencing a paroxysmal hypercyanotic episode? (Select all that apply.) a. Spontaneous cyanosis b. Dyspnea c. Weakness d. Dry cough e. Syncope

a, b, c, e

What would be included in the plan of care for a child just returned to the floor from surgery in which a clubfoot was repaired? (Select all that apply.) a. Keep cast uncovered to allow drying. b. Check toes for capillary refill. c. Circle with a pen any area of bleeding on the cast. d. Keep casted leg lowered. e. Observe for skin irritation

a, b, c, e

The nurse is contributing to a nutrition and hydration teaching plan for a patient who has AIDS. What recommendations should the nurse include in this plan? (Select all that apply.) a. Avoid soft cheeses. b. Avoid Caesar salad. c. Avoid public drinking fountains. d. Avoid all beers and all soft drinks. e. Avoid leftovers or heat until steaming. f. Cook red meat until internal temperature is 165F with no trace of pink

a, b, c, e, f

The nurse is reinforcing teaching provided to a patient with chronic kidney disease who is receiving hemodialysis three times a week at a hemodialysis center. Which statements should be included? (Select all that apply.) a. You may feel weak and fatigued after the treatment. b. You may not be able to eat before the treatment session. c. You will need to be weighed before and after the session. d. Your medication schedule will be the same on dialysis days. e. Report any numbness, swelling, redness, or drainage from the dialysis access site. f. You may experience some bleeding from the puncture site or a nosebleed. Report it if it doesnt stop within a few minutes.

a, b, c, e, f

A nurse is teaching a patient how to avoid contracting influenza and secondary bacterial infection. Which measures should be included in the instruction? (Select all that apply) a. influenza vaccination b. avoiding crowds during flu season c. good hand washing d. prophylactic antibiotics e. increased intake of vitamin B f. avoiding sharing of eating or drinking utensils

a, b, c, f

The nurse is participating in a teaching plan to address Risk for Impaired Skin Integrity for a patient with contact dermatitis. Which information should the nurse recommend be included in this plan? (Select all that apply.) a. Keep fingernails short. b. Take baths with an oatmeal solution. c. Use oil-in-water lubricants for skin dryness. d. Rub affected area roughly, but do not scratch. e. Avoid washing affected area with brown soap. f. Use cool washcloths over affected area to ease itching.

a, b, c, f

A patient with an autoimmune disorder asks, What might cause my body to do this to itself? What should the nurse state as reasons for the body to have lost the ability to recognize self? (Select all that apply.) a. Drugs b. Hormones c. Vaccinations d. Viral infections e. Bacterial infections

a, b, d

LPN is providing csre for an 88 year old patient. which of the following age related assessment findings would the nurse expect? a. weakened cough due to atrophied respiratory muscles b. increased risk of respiratory infection due to decreased ciliary activity c. large peak expiratory flow rate due to increased lung elasticity d. decreased gas exchange due to decreased number of alveoli e. increased nasal discharge due to increased number of cilia f. peripheal cyanosis due to reduced gas exchange

a, b, d

The nurse explains that testosterone is responsible for males exceeding females in which aspects? (Select all that apply.) a. Strength b. Height c. Mental concentration d. Hematocrit levels e. Agility

a, b, d

The nurse is contributing to a staff education program about nursing care for hypersensitivity reactions. Which should the nurse include as examples of type I hypersensitivity reactions? (Select all that apply.) a. Anaphylaxis b. Angioedema c. Serum sickness d. Allergic rhinitis e. Contact dermatitis f. Hypogammaglobulinemia

a, b, d

The nurse is monitoring a patient with chronic kidney disease. Which findings should the nurse realize indicates fluid overload? (Select all that apply.) a. Periorbital edema b. Crackles in the lungs c. Postural hypotension d. Increased blood pressure e. Decreased pulse pressure f. Auditory wheezes on inspiration

a, b, d

The nurse is providing care for a woman experiencing premenstrual syndrome (PMS). Which nursing actions should be included in the plan of care? (Select all that apply.) a. Encourage the client to stop smoking. b. Teach client to limit alcohol consumption. c. Provide small, frequent meals to reduce food cravings. d. Encourage the client to develop a regular exercise regimen. e. Provide food that promotes increased intake of simple sugars. f. Instruct client to increase intake of products containing caffeine

a, b, d

What would the nurse teaching an asthmatic child the technique of pursed-lip breathing include? (Select all that apply.) a. Inhale deeply through nose with mouth closed. b. Make exhalation twice as long as inhalation. c. Use medicated inhaler prior to performing breathing exercise. d. Exhale through mouth as if whistling. e. Exhale forcefully.

a, b, d

The nurse is assisting in the preparation of an educational seminar about breast pathology. What characteristics of cancerous breast lesions should the nurse include in this teaching? (Select all that apply.) a. They tend to be harder. b. They tend to be less mobile. c. They tend to be more painful. d. They tend to be more irregularly shaped. e. They tend to have more clearly defined borders.

a, b, d,

A 16-year-old patient is diagnosed with primary hypertension. What risk factors does the nurse mention when providing education on this diagnosis to the patient and his family? (Select all that apply.) a. Heredity b. Stress c. Congenital defect d. Obesity e. Poor diet

a, b, d, e

After collecting data the nurse suspects that a young female patient is experiencing manifestations of toxic shock syndrome. What findings did the nurse use to make this decision? (Select all that apply.) a. Sore throat b. Skin peeling c. Fluid retention d. Red palm and soles of feet e. Muscle pain and weakness

a, b, d, e

How has synthetic recombinant antihemophilic factor improved the management of hemophilia? (Select all that apply.) a. Eliminates the need for frequent transfusions b. Can be administered by family at home c. Prevents hemorrhage d. Reduces cost of care of the hemophiliac e. Reduces risk of HIV and hepatitis A and B transmission

a, b, d, e

Informed consent for a minor guarantees that the parent or legal guardian understands what aspect(s) of a procedure? (Select all that apply.) a. Purpose of the procedure b. Risks associated with the procedure c. That no suit can be brought for damages d. That the document must be signed and witnessed e. That information was given

a, b, d, e

The nurse caring for a child with nephrotic syndrome is alert to which classic symptoms of this disorder? (Select all that apply.) a. Proteinuria b. Grossly bloody urine c. Hyperalbuminemia d. Fatigue e. Generalized edema

a, b, d, e

The nurse conducting a sex education class for junior high students describes some cultural rites celebrating the entry to adulthood. What information would the nurse include? (Select all that apply.) a. Bar mitzvah b. Displays of bravery c. Receiving part of their inheritance d. Ritual circumcision e. Displays of self-defense

a, b, d, e

The nurse demonstrates which similarities among all traction devices? (Select all that apply.) a. Pull the limb into extension b. Decrease muscle spasm c. Reduce pain d. Align two bone fragments e. Immobilize the limb

a, b, d, e

The nurse emphasizes to a patient with a high-risk pregnancy that the impact of such a pregnancy might result in which problems? (Select all that apply.) a. Disruption of family roles b. Financial pressures c. Excessive attachment to infant d. Frustration with activity restriction e. Alteration in child care practices

a, b, d, e

The nurse explains that the COPP medical regimen for the treatment of Hodgkins disease uses a combination of which drugs? (Select all that apply.) a. Vincristine b. Cyclophosphamide c. Methotrexate d. Prednisone e. Procarbazine hydrochloride

a, b, d, e

The nurse is collecting a medication history from a man with erectile dysfunction. For what medication classes and lifestyle substances should the nurse assess because they can cause erectile dysfunction? (Select all that apply.) a. Alcohol b. Caffeine c. Antibiotics d. Antihistamines e. Beta-blocking agents f. Oral hypoglycemic agents

a, b, d, e

What are the four structural heart anomalies that make up the tetralogy of Fallot? (Select the four that apply.) a. Hypertrophied right ventricle b. Patent ductus arteriosus c. Ventral septal defect d. Narrowing of pulmonary artery e. Dextroposition of aorta

a, b, d, e

What characteristics are typical in a child diagnosed with Down syndrome? (Select all that apply.) a. Close-set eyes b. Simian creases c. Wide-spaced front teeth d. Protruding tongue e. Curved, small fingers

a, b, d, e

Which aspect(s) of a childs development does the nurse caution parents that hearing impairment can affect? (Select all that apply.) a. Speech clarity b. Language development c. Immunity to disease d. Personality development e. Academic achievement

a, b, d, e

Which specific drug(s) should be checked with a second licensed nurse prior to administration? (Select all that apply.) a. Insulin b. Digoxin c. Vasodilators d. Calcium salts e. Anticoagulants

a, b, d, e

While receiving a unit of packed red blood cells, the patient begins to experience hives around the neck and upper chest. What actions should the nurse perform because of this reaction? (Select all that apply.) a. Stop the transfusion. b. Notify the health care provider (HCP). c. Return the blood to the blood bank. d. Administer prescribed antihistamines. e. Restart the infusion and carefully monitor.

a, b, d, e

Why would the nurse urge the family of a dying 12-year-old boy to include his 8-year-old sister in care? (Select all that apply.) a. She will feel less neglected by the parents. b. She can make amends for past hostilities to her brother. c. She will feel increased helplessness. d. She can express her feelings through care. e. She can experience being supportive of her parents and brother

a, b, d, e

An LPN is helping prepare a patient for a thoracentesis. Which of the following would be included in teaching? (select all that apply) a. the doctor will collect fluid from the space between your lung and chest wall b. you will assume a sitting position at the end of the bed c. you will need to be NPO for 6 hours d. you will need to sign a consent form for this procedure e. you will need to take frequent deep breaths during the procedure f. this is a sterile procedure, so the site will be covered with a drape

a, b, d, f

A patient is being seen by her health care provider for a suspected vaginal infection. What will the nurse include when educating this patient on factors that affect the vaginal pH? (Select all that apply.) a. Antibiotic therapy b. Frequent douching c. Exercise d. Jet lag e. Use of vaginal sprays

a, b, e

The nurse applies clean white cotton socks over the hands of a patient with contact dermatitis. What should the nurse explain to the patient about the purposes of this intervention? (Select all that apply.) a. Cotton allows air movement. b. White cotton has no dye in the material. c. White cotton prevents the wounds from spreading. d. The cotton will absorb the drainage from the wounds. e. Scratching is less during sleep when the area is covered.

a, b, e

The nurse is assisting with teaching a patient who has been exposed to hepatitis B. Which symptoms should the nurse explain may occur before jaundice appears? (Select all that apply.) a. Rash b. Nausea c. Confusion d. Dark-colored urine e. Muscle or joint pain f. Elevated blood glucose

a, b, e

The nurse is reading a pregnant patients history and physical. What information does the nurse recognize might indicate the need for a cesarean delivery? (Select all that apply.) a. History of childhood rickets b. Immobile coccyx c. Prepregnant weight of 100 pounds d. Avid horse rider e. Pelvic fracture 3 years ago

a, b, e

The nurse is teaching a patient about the use of condoms to prevent sexually transmitted infections (STIs). Which information should the nurse include in this teaching? Select all that apply. a. Condoms can decrease the risk of transmitting STDs. b. Latex condoms are less likely to break than other types. c. Inflating the condom prior to use allows for effective inspection. d. Condoms should be used no more than twice and then discarded properly. e. Use of a water-soluble lubricant with a condom increases its effectiveness in preventing the spread of an STD. f. Use of a petroleum-based lubricant with a condom increases its effectiveness in preventing the spread of an STD.

a, b, e

The nurse knows that a postterm infant may experience which potential problems? (Select all that apply.) a. Seizures b. Asphyxia c. Paralysis d. Visual defects e. Polycythemia

a, b, e

The nurse notes that a patient is diagnosed with vulvovaginitis. What should the nurse expect when assessing this patient? (Select all that apply.) a. Vaginal edema b. Vaginal discharge c. Areas of ecchymosis d. Dark brown vaginal bleeding e. Complaints of vaginal itching and burning

a, b, e

The nurse reports which assessments that suggest a meconium ileus in a newborn? (Select all that apply.) a. Abdominal distention b. Vomiting c. Hiccoughing d. Jaundice e. Absence of stool

a, b, e

The nurse takes into consideration that newborns are especially prone to dehydration because of which aspects of their physiology? (Select all that apply.) a. Small glomeruli b. Minimal renal blood flow c. Inactive gastrointestinal (GI) tract d. Excessive fluid loss from the sweat glands e. Immature renal tubules that do not concentrate urine

a, b, e

What complications of overstimulation of uterine contractions may occur? (Select all that apply.) a. Water intoxication b. Impaired placental exchange of oxygen and nutrients c. Increased blood pressure d. Convulsions e. Uterine rupture

a, b, e

What information will the nurse include when taking a developmental history? (Select all that apply.) a. Previous experience with hospitalization b. Cultural needs c. History of illness d. Allergies e. Childs nickname

a, b, e

What will the nurse include in the plan of care when caring for an infant with an intracranial hemorrhage? (Select all that apply.) a. Keep positioned with head elevated. b. Feed slowly to reduce possibility of vomiting. c. Stimulate often to maintain level of consciousness. d. Hold and coddle frequently to stimulate. e. Observe for increased intracranial pressure.

a, b, e

A patient with a bleeding disorder is considering surgery to have the spleen removed. What should the nurse explain as being functions of the spleen in a healthy adult? (Select all that apply.) a. Storage of platelets b. Formation of bilirubin c. Production of red blood cells d. Production of neutrophils and eosinophils e. Production of lymphocytes and monocytes f. Phagocytosis of worn blood cells and platelets

a, b, e, f

The nurse is caring for a patient scheduled for tests to confirm the diagnosis of lymphoma. For which diagnostic tests should the nurse prepare the patient? (Select all that apply.) a. CT scan b. Cerebral angiogram c. Lymph node biopsy d. Lymphangiography e. Complete blood count

a, c, d, e

The nurse is caring for a patient who is breastfeeding and receiving antibiotics for mastitis. What should be included in the patients teaching? (Select all that apply.) a. Wash hands before handling the breast. b. NSAIDs may be used to help control pain. c. Apply cool packs to the breast to ease pain. d. Stop breastfeeding, and switch to bottle feeding. e. Wear a bra to support the swollen painful breast. f. Change the infants feeding position on the breast frequently

a, b, e, f

The nurse is caring for a woman who has just had an uncomplicated abortion. What instructions should the nurse provide? (Select all that apply.) a. Call if you bleed for more than 3 days. b. Call if you have more bleeding than you would during a heavy period. c. The discharge often has a foul odor due to the procedure. d. Dont be surprised if you pass clots. Call if they are larger than a golf ball. e. You can expect moderate bleeding and a low-grade fever for about a week. f. You should abstain from sexual intercourse as directed by your physician.

a, b, f

The nurse is contributing to the plan of care for a patient with systemic lupus erythematosus (SLE). Which interventions should the nurse recommend for this patient? (Select all that apply.) a. Eat a balanced diet. b. Report foamy urine to physician. c. Take cool showers or baths to relieve joint stiffness. d. Avoid naps and obtain a minimum of 6 hours of sleep. e. Exercise when pain and inflammation in joints is increased. f. Use a daily personal schedule to plan activities to reduce fatigue.

a, b, f

The nurse is contributing to the teaching plan for a patient diagnosed with Hashimotos thyroiditis who has progressed to hypothyroidism with a goiter. Which self-care instructions should the nurse recommend? (Select all that apply.) a. Eat a soft diet. b. Increase activity slowly. c. Eat more foods high in iodine. d. Keep home at a cool temperature. e. Eat a high-carbohydrate, high-protein diet. f. During low-energy periods, use anti-embolism stockings.

a, b, f

The nurse is preparing to obtain a throat culture on a toddler patient. What interventions are appropriate for the nurse to implement? (Select all that apply.) a. Model desired behavior. b. Instruct patient not to yell. c. Use distractions. d. Explain the procedure in detail. e. Encourage the child to ask questions

a, c

The nurse reminds new parents that newborns must be protected from environments that are too cold or too hot because of which aspects of the newborns physiology? (Select all that apply.) a. Very little subcutaneous fat b. Low metabolic rates c. Ineffective sweat glands d. Small fluid reserves e. Low red blood cell counts

a, c

Which assessments would lead the nurse to determine the gestational age of the infant as preterm? (Select all that apply.) a. Thin, transparent skin b. Vernix only in the body creases c. Folded ear springs back slowly d. Breast tissue under the nipple e. Creases over entire sole

a, c

A female patient asks what can be done to reduce symptoms associated with menopause. What should the nurse suggest to this patient? (Select all that apply.) a. Eat a healthy diet. b. Reflect on past experiences and challenges. c. Dress in layers so clothing can be removed. d. Reduce intake of caffeine, sugar, and alcohol. e. Use an oil-based vaginal lubricant to ease vaginal dryness

a, c, d

A patient receiving a unit of packed red blood cells as treatment for anemia begins to vomit and experience extreme gastrointestinal cramping. What should the nurse do? (Select all that apply.) a. Stop the transfusion. b. Administer intravenous (IV) heparin. c. Prepare to provide cardiopulmonary resuscitation (CPR) if necessary. d. Stay with the patient and call for help. e. Flush the blood tubing with normal saline.

a, c, d

A patient who is 6 weeks pregnant is contemplating having an abortion. What methods of abortion should the nurse explain as most commonly used to terminate a pregnancy of less than 14 weeks? (Select all that apply.) a. Vacuum suction b. Saline induction c. Menstrual extraction d. Dilation and curettage (D&C) e. Dilation and evacuation (D&E)

a, c, d

The nurse is educating parents on prevention of eyestrain in their 5-year-old child. What information will the nurse include? (Select all that apply.) a. Encourage books with large type. b. Words in books should be closely spaced. c. Provide adequate lighting without glare. d. Be sure desks and chairs are adequate height. e. Instruct child to squint when reading.

a, c, d

The nurse is reinforcing teaching about potential triggers with a patient experiencing allergic rhinitis. What should the nurse include in the teaching? (Select all that apply.) a. Dust b. Penicillin c. Ragweed d. Pet dander e. Topical lotion f. Oral multivitamin

a, c, d

`The nurse is obtaining history and physical information on a new patient attending her first prenatal visit. After recording current height, weight, and BMI, it is determined that the patient is obese. What complications related to obesity will the nurse assess this patient for during pregnancy? (Select all that apply.) a. Gestational diabetes b. RH Incompatibility c. Hypertension d. Pre-eclampsia e. Infection

a, c, d

A male patient explains that manifestations of benign prostatic hyperplasia (BPH) have been occurring for several years. For which adverse effects of this health problem should the nurse consider when planning this patients caring? (Select all that apply.) a. Urosepsis b. Bladder cancer c. Renal insufficiency d. Evidence of hydronephrosis e. Recurrent urinary tract infections

a, c, d, e

During a home visit, the nurse becomes concerned that a patient recovering from a splenectomy is at risk for infection. What did the nurse observe to come to this conclusion? (Select all that apply.) a. Received a manicure and pedicure b. Washed hands before preparing lunch c. Poured a cup of tea after petting the cat d. Had a hot tub installed on the back patio e. Planting tomato plants in an outside garden

a, c, d, e

The nurse educates prenatal patients about the threat of TORCH infections. Which infections are included in this classification? (Select all that apply.) a. Toxoplasmosis b. Toxemia c. Cytomegalovirus d. Rubella e. Herpes simplex

a, c, d, e

The nurse is assisting in the care of a patient with ankylosing spondylitis. What should the nurse expect to find in the patients collaborative plan of care? (Select all that apply.) a. Physical therapy daily b. Sitz baths three times daily c. Tylenol #3 every 4 hours prn pain d. Administer Remicade as prescribed e. Activity as tolerated; up with assistance

a, c, d, e

The nurse is caring for a patient with an elevated uric acid level. Which health problems should the nurse consider as potentially causing this patients elevation? (Select all that apply.) a. Leukemia b. Steroid use c. Malnutrition d. Kidney disease e. Use of thiazide diuretics f. Gastrointestinal bleeding

a, c, d, e

The nurse is reviewing prescribed laboratory tests for a patient demonstrating manifestations of syphilis. What diagnostic tests should the nurse expect to be prescribed for this patient? (Select all that apply.) a. RPR b. NAT c. VDRL d. ELISA e. Culture f. CD4 counts

a, c, d, e

The school nurse suspects a first grade student has sinusitis. Which symptoms might lead the nurse to this suspicion? (Select all that apply.) a. Child reports tooth pain. b. Severe wheezing is auscultated on inspiration. c. Child reports, I have had a cold for 2 weeks. d. Nurse observes periorbital swelling. e. Halitosis is present.

a, c, d, e

What intervention(s) would the nurse caring for a child with infectious meningitis include? (Select all that apply.) a. Isolation precautions b. Provision of brightly lit room c. Observation for increasing intracranial pressure d. Preparation for spinal tap e. Seizure precautions

a, c, d, e

What will the nurse include then documenting a grand mal seizure? (Select all that apply.) a. Presence of incontinence b. Current dose of antispasmodic medication c. Activity level prior to and following seizure d. Level of consciousness following seizure e. Length of seizure

a, c, d, e

What would the nurse teach parents to do in order to avoid diaper rash? (Select all that apply.) a. Use ointments. b. Keep perineum covered at all times. c. Use disposable diapers. d. Avoid plastic bloomers or pants. e. Change diaper frequently.

a, c, d, e

The nurse is collecting information about sickle cell disease for an upcoming seminar. What should the nurse include as common triggers for a sickle cell crisis? (Select all that apply.) a. Anesthesia b. Chemotherapy c. Severe infection d. Strenuous exercise e. Use of nasal oxygen f. Blood loss during surgery

a, c, d, f

The nurse is providing care for a patient after a hysterectomy. Which interventions are appropriate to prevent constipation? (Select all that apply.) a. Encourage ambulation. b. Increase protein intake. c. Increase oral fluid intake. d. Provide a high-fiber diet. e. Withhold pain medication. f. Provide stool softener as ordered.

a, c, d, f

How does the pediatric skeletal system differ from that of the adult? (Select all that apply.) a. Lower mineral content b. More ossification c. Open epiphyses d. Less porosity e. Greater strength

a, c, e

The nurse instructs the postpartum patient that her nutritional intake should include which food(s) particularly supportive to healing? (Select all that apply.) a. Legumes b. Potatoes and pasta c. Citrus fruits d. Rice e. Cantaloupe

a, c, e

The nurse is providing an inservice to students beginning their obstetric clinical rotation. Using a diagram, the nurse points out parts of the female pelvis. What will the nurse include? (Select all that apply.) a. Two innominates b. Obstetric conjugate c. Sacrum d. Perimetrium e. Coccyx

a, c, e

What are the basic fears of a young child being hospitalized? (Select all that apply.) a. Separation b. Permanent scarring c. Pain d. Cost e. Body intrusion

a, c, e

The nurse notes it is time to administer prescribed gentamicin (Garamycin) for a patient with acute kidney injury and suspected streptococcal pneumonia. Which action should the nurse take at this time? (Select all that apply.) a. Hold medication. b. Administer drug as ordered. c. Administer half of the prescribed dose. d. Consult physician about medication order. e. Flush the tubing with heparin before infusing.

a, d

The nurse takes into consideration that the patient with placenta previa is at risk for postpartum infection for what reasons? (Select all that apply.) a. Vaginal organisms can invade the placenta. b. The undernourished placenta becomes necrotic. c. The amniotic fluid can become infected. d. The placenta is an excellent growth medium. e. The misplaced placenta weakens the uterine wall.

a, d

What will the nurse discourage when providing education to parents of a child with asthma? (Select all that apply.) a. Stuffed toys b. Pet ownership c. Gymnastics d. Basketball e. Cotton blankets

a, d

Which interventions would be included in the nursing care of the newly circumcised infant? (Select all that apply.) a. Wash penis with warm water. b. Wipe with alcohol swab. c. Gently remove the yellow crust formation. d. Apply diaper loosely. e. Dress with simple bandage.

a, d

which of the following are common causes of respiratory acidosis? (select all that apply) a. chronic lung disease b. hyperventilation c. anxiety d. shallow respirations e. uncontrolled diabetes f. kidney failure

a, d

The nurse assesses a preterm infant in the NICU. What signs should be reported to the physician? (Select all that apply.) a. Paleness b. Transparent skin c. Superficial scalp veins d. Vomiting e. Bulging fontanelles

a, d, e

The nurse has been discussing actions to prevent AIDS-related wasting syndrome with a patient being treated for AIDS. Which patient statements indicate an understanding of this teaching? (Select all that apply.) a. Eat a low-residue diet. b. Drink liquids before meals. c. Enjoy food odors to stimulate appetite. d. Numb painful oral sores with ice or popsicles. e. Eat three high-calorie, high-protein meals a day, plus snacks. f. Increase consumption of caffeine-containing foods and fluids.

a, d, e

The nurse is reviewing a patients prescribed medications. Which medications are used to treat cancer by suppressing or blocking testosterone? (Select all that apply.) a. Leuprolide (Lupron) b. Finasteride (Proscar) c. Dutasteride (Avodart) d. Diethylstilbesterol (DES) e. Goserelin (Zoladex)

a, d, e

What should the nurse assess to determine the method of transportation for a pediatric patient? (Select all that apply.) a. Age b. Race c. Vital signs d. Distance to travel e. Level of consciousness

a, d, e

A child develops carditis from rheumatic fever. Which areas of the heart are affected by carditis? a. Coronary arteries b. Heart muscle and the mitral valve c. Aortic and pulmonic valves d. Contractility of the ventricles

What would the nurse include in a teaching plan for the pregnant patient who has iron deficiency anemia and has been placed on iron supplements? (Select all that apply.) a. Citrus fruits enhance absorption of iron. b. Bran products support iron deficiency. c. Milk will disguise the taste of the iron. d. The iron therapy will continue for about 3 months. e. Tea should be avoided while taking iron

a, d, e

Which congenital cardiac defect(s) cause(s) increased pulmonary blood flow? (Select all that apply.) a. Atrial septal defects (ASDs) b. Tetralogy of Fallot c. Dextroposition of aorta d. Patent ductus arteriosus e. Ventricular septal defects (VSDs)

a, d, e

A patient is prescribed tamsulosin (Flomax) for treatment of benign prostatic hypertrophy. What instructions should be provided to this patient? (Select all that apply.) a. Dizziness may occur. b. Chew or crush tablets. c. Avoid unnecessary sunlight. d. Avoid the use of heavy machinery. e. Dry mouth and gastrointestinal upset may occur. f. Be careful when going from a sitting to a standing position.

a, d, e, f

The nurse is concerned that a female patient is at risk for developing cervical cancer. What risk factors for cervical cancer did the nurse assess in the patient? (Select all that apply.) a. Smoking b. Being nulliparous c. Using barrier contraceptives d. Having multiple sexual partners e. Being infected with herpes simplex virus type II f. Being infected with human papillomavirus

a, d, e, f

The nurse is reinforcing teaching provided to a patient about caring for a new fistula in the left arm for dialysis. Which patient statements indicates correct understanding? (Select all that apply.) a. Do not sleep on my arm. b. Keep my arm elevated at all times. c. Keep a firm bandage on my arm. d. Wear loose clothing on my left arm. e. Avoid carrying heavy things with my left arm. f. Do not allow blood pressures to be taken on my left arm.

a, d, e, f

The nurse is reinforcing teaching provided to a patient with polycystic kidney disease. Which patient statements indicate a correct understanding of the teaching? (Select all that apply.) a. It is a hereditary disease. b. It affects women more than men. c. Symptoms appear in early childhood. d. Genetic counseling is appropriate for individuals with this diagnosis. e. There is no effective treatment to stop the progression of the disease. f. It is characterized by the formation of multiple grapelike cysts in the kidney.

a, d, e, f

3. What are common complications of varicocele? Select all that apply a. Infertility b. Infection c. Erectile dysfunction d. Pain e. Priapism f. Cancer

a, d. Varicocele is like a varicose vein in the scrotum. It can cause pain and infertility

The nurse is providing education to an individual with sickle cell anemia. Which activities should the nurse instruct the patient to avoid? (Select all that apply.) a. Scuba diving b. Contact sports c. Sexual activity d. Long-distance driving e. Skiing in the mountains f. Standing for long periods

a, e

What are the functions of amniotic fluid? (Select all that apply.) a. Maintaining an even temperature b. Impeding excessive fetal movement c. Lubricating fetal skin d. Acting as a reservoir for nutrients e. Acting as a cushion for the fetus

a, e

What special considerations are related to long-term prednisone therapy in preschoolers? (Select all that apply.) a. Delayed immunization b. Hypertension c. Enlargement of the sex organs d. Alteration in nutrition e. Increased risk for infection

a, e

6. A patient is admitted to a medical unit for complications of diabetes. The nurse asks if he is satisfied with his level of sexual functioning, and he becomes tearful. Which initial response by the nurse is best? a. "You seem upset with my question. Are you having a problem you would like to talk about?" b. "Impotence is common with diabetes. Don't let it worry you." c. "What kind of sexual dysfunction are you experiencing?" d. "I am sorry you are having problems with your sexual functioning. Would you like a referral to a sex therapist?"

a. Reflecting back and asking the patient if he would like to talk more will identify if there is a concern that should be followed up by a physician or care provider

38. A 66-year-old woman is seen in an outpatient clinic for routine care. What teaching should the nurse provide related to bone health? a. "You should be taking in at least 1200 mg of calcium and 400 international units of vitamin D a day to protect your bones." b. "The benefit of eating red meat outweighs the risk as you age. You should eat 6 ounces three times a week." c. "Your bones are protected by the calcium you ate in your younger years; increasing intake now will not help your bones." d. "You can easily protect your bones by drinking milk twice a day."

a. The National Institutes of Health recommends 1200 mg calcium and 400 international units vitamin D for women ages 51 to 70

jaundice

also called icterus, contributed by immature liver; causes skin and whites of eyes to assume yellow-orange cast; liver is unable to clear bilirubin, the higher the bilirubin level, the higher the jaundice and the greater the risk for neurological damage

A child is to receive radiation therapy this morning. A drug you would expect to see prescribed for him prior to this would be an a) antineoplastic. b) analgesic. c) antipyretic. d) antiemetic.

antiemetic. Correct Explanation: Radiation therapy causes nausea because it destroys rapid-growing cells. Among these are the cells of the stomach lining, the reason that nausea occurs.

A 10-year-old girl asks the nurse, What is the first sign of puberty? What is the correct nursing response? a. An increase in height b. Breast development c. Appearance of axillary hair d. The first menstrual period

A 13-year-old girl is diagnosed with functional scoliosis. What does the nurse explain as the cause of this spinal curvature defect? a. Juvenile rheumatoid arthritis b. Poor posture c. Heredity d. Myelomeningocele

A 15-year-old patient returns to the pediatric unit following a lumbar puncture. What initial position will the nurse maintain for this patient? a. Left side-lying b. Supine c. Prone d. Semi-Fowlers

A 4-year-old asks tearfully if the IM injection will hurt. What is the nurses most effective response? a. No. It is over before you know it. b. Yes. It will sting a little. c. No. Would you like to see the syringe? d. Yes. Your mom and I are going to hold you to help you be still

A child had a burn, evidenced by pink skin and blistering. The child complains of pain and is crying. How does the nurse classify this burn when documenting? a. First-degree b. Second-degree superficial c. Second-degree deep dermal d. Third-degree

A child has an elevated antistreptolysin O (ASO) titer. Which combination of symptoms, in conjunction with this finding, would confirm a diagnosis of rheumatic fever? a. Subcutaneous nodules and fever b. Painful, tender joints and carditis c. Erythema marginatum and arthralgia d. Chorea and elevated sedimentation rate

A child has been diagnosed with ascariasis (roundworm). Which statement made by her mother that may suggest a cause for her condition? a. Ive been airing out the house on these nice breezy days. b. My child often goes out to the garden and pulls up a carrot to eat. c. She runs barefoot so much I have to wash her feet at least twice a day. d. We just remodeled our bathroom at home.

A child hospitalized for treatment of osteomyelitis complains that he is tired of being sick and wants to know when the antibiotic protocol will end. How long will the nurse indicate that antibiotic therapy will probably last? a. 2 weeks b. 6 weeks c. 2 months d. 3 months

A child is brought to the emergency department because he ingested an unknown quantity of acetaminophen (Tylenol). What does the nurse expect this child to receive following gastric lavage? a. Activated charcoal b. N-acetylcysteine c. Vitamin K d. Syrup of ipecac

A child is diagnosed with iron deficiency anemia. What will the nurse explain can occur if this disorder goes untreated? a. Hemorrhage b. Heart failure c. Infection d. Pulmonary embolism

A child is diagnosed with nonparalytic strabismus. How will this disorder most likely be corrected? a. Patching the unaffected eye b. Corrective lenses c. Laser treatment d. Surgery

A first-time mother reports that she is experiencing difficulty breastfeeding her newborn. Which neonatal reflex would the nurse teach the mother to elicit to facilitate breastfeeding? a. Sucking b. Rooting c. Grasping d. Tonic neck

A frightened mother calls the pediatricians office because her child swallowed dishwashing detergent. What is the most appropriate action? a. Induce vomiting by giving the child syrup of ipecac. b. Take the child to the local emergency department. c. Give the child activated charcoal mixed with juice. d. Give the child milk to soothe affected mucous membranes

A health care provider (HCP) is anticipating the use of RU-486 to provide a chemically induced abortion for a patient. What information should the nurse obtain from the patient before this medication is provided? a. Type of contraception used b. Date of the first day of the patients last period c. Date of the first day of the patients first missed period d. Average number of times the bladder is emptied in one day

A health care worker is exposed to blood from a patient who has HIV. What action should the worker take after the exposure? a. Apply alcohol to the site. b. Cleanse the site with soap and water. c. Flush the site with hot running water. d. Apply a topical antibiotic to the site.

A male client comes into the emergency department experiencing a painful prolonged erection. What term should the nurse use to document this patients problem? a. Orchitis b. Priapism c. Paraphimosis d. Peyronies disease

A male patient has infertility caused by an endocrine problem. For which type of problem should the nurse plan care for this patient? a. Testicular b. Pretesticular c. Post-testicular d. Chronic testicular

A newly married couple tells the nurse they would like to wait a few years before starting a family. Which statement made by the man indicates an understanding about sexual activity and pregnancy? a. My wife cant get pregnant if I withdraw before climax. b. A man can secrete semen before ejaculation. c. If we dont have intercourse very often, my wife wont get pregnant. d. It is safe to ejaculate outside the vagina.

A nurse encourages a school-age child to draw a picture after a painful procedure. What is the best rationale for this nursing intervention? a. Attempting to re-establish rapport b. Providing a way for the child to express his feelings c. Encouraging quiet play d. Distracting the child from thinking about the pain

A nurse is planning to teach couples about the physiology of the sex act. What correct information will the nurse provide? a. Fertilization of an ovum requires penetration by several sperm. b. An ovum must be fertilized within 24 hours of ovulation. c. It takes 4 to 5 days for sperm to reach the fallopian tubes. d. Sperm live for only 24 hours following ejaculation.

A patient has a bone marrow aspiration from the posterior iliac crest. Before the procedure, the patients vital signs were: blood pressure 132/82 mm Hg and pulse 88 beats/min. One hour after the procedure, the blood pressure is 108/70 mm Hg and pulse is 96 beats/min. Which assessment is the least important for the patient at this time? a. Observe the puncture site. b. Check the patients most recent complete blood count report. c. Ask the patient about feelings of lightheadedness or dizziness. d. Determine if the patient had any medications before the procedure

A patient is being evaluated for renal dialysis. What creatinine clearance value should the nurse realize this patient must have to live without needing dialysis treatments? a. 5 mL b. 10 mL c. 20 mL d. 50 mL

A patient is being seen for the urinary bladder sagging into the vagina. How should the nurse document this health problem? a. Rectocele b. Cystocele c. Dyspareunia d. Bladder fistula

A patient is diagnosed with excessive fluid in the scrotal sac. What term should the nurse use when discussing the health problem with the patient? a. Orchitis b. Hydrocele c. Varicocele d. Epididymitis

A patient is diagnosed with hypogammaglobulinemia. Which of immune cell should the nurse realize is defective in this disorder? a. T cells b. B cells c. Mast cells d. Plasma cells

A 3-year-old child with sickle cell disease is admitted to the hospital in sickle cell crisis with severe abdominal pain. Which type of crisis is the child most likely experiencing? a. Aplastic b. Hyperhemolytic c. Vaso-occlusive d. Splenic sequestration

A patient is discharged home after a prostatectomy. Two days later, he calls the nurse and says his bleeding has increased. The nurse asks what he has been doing since discharge. Which activity reported by the patient indicates the need for teaching by the nurse? a. The patient took an opioid for pain. b. The patient raked leaves in the yard. c. The patient took a walk around the block. d. The patient has been sitting in a recliner watching television.

A patient is scheduled for a hysterectomy and bilateral salpingo-oophorectomy. She asks what this means. How should the nurse respond? a. You will have your uterus removed and your bladder suspended. b. You are going to have your uterus, fallopian tubes, and ovaries removed. c. You will have your uterus removed and your fallopian tubes and ovaries sutured in place. d. You will have your uterus and fallopian tubes removed, but your ovaries will remain intact.

A patient is seen in a clinic for contact vaginitis. What information from her history helps the nurse to plan teaching for the patient? a. She has been under stress at work. b. She takes bubble baths every night. c. She has had a urinary tract infection (UTI). d. She has been on oral antibiotics for a sinus infection.

A patient is suspected as having a blood transfusion reaction. Which laboratory test should the nurse expect to be done to confirm this diagnosis? a. Skin testing b. Direct Coombs test c. White blood cell count d. C-reactive protein level

A patient who developed hemolytic anemia related to the administration of penicillin asks for an explanation of this condition. What is the most appropriate response by the nurse? a. The red blood cells are being produced inappropriately. b. An antigenantibody reaction is causing destruction of red blood cells. c. An allergy to penicillin is destroying your platelets for unknown reasons. d. Allergens are invading the bone marrow and interfering with red blood cell production.

A patient who has AIDS expresses concern about telling others about the illness. Which response would be appropriate by the nurse? a. It would be best to tell everyone you know. b. You should tell those who have a reason to know. c. Your diagnosis will be discovered anyway by those you know. d. Secrecy is a poor idea because it will erode your self-esteem.

A patient who has just returned from a transurethral resection of the prostate (TURP) asks the nurse why he needs a urinary catheter. What is the correct explanation? a. The catheter keeps your bladder empty to reduce risk for infection. It is important to leave it in for at least 72 hours. b. The catheter is keeping pressure on the area to prevent bleeding. We will remove it when the risk for bleeding has passed. c. We can take the catheter out when you are able to urinate on your own. Ill ask the physician if we can remove it later today. d. The catheter is being used to irrigate your bladder with antibiotics. It is important to continue this until you can take antibiotics orally.

A patient with abdominal injuries from a motor vehicle crash is scheduled for surgery to remove the spleen. What bodily function will be affected by the removal of this organ? a. Filtration of waste products b. Removal of old red blood cells from circulation c. Clearance of mucous in the tracheobronchial tree d. Facilitation of glucose to be used by the cell for energy

A patient with glomerulonephritis asks, How could I have gotten this? How should the nurse respond? a. Has anyone in your family had glomerulonephritis? b. Have you had a sore throat or skin infection recently? c. Glomerulonephritis almost always follows a bladder infection. d. Glomerulonephritis often results from having unprotected sex.

A patients urinalysis results are: white blood cells (WBC) 100+/hpf; red blood cells (RBC) 4/hpf; bacteria, moderate amount; nitrite, positive; specific gravity, 1.025; urine, cloudy. What should the nurse recognize these findings indicate? a. Dehydration b. Urinary tract infection c. Contamination from menstruation d. Contamination of the specimen from bacteria on the perineum

A pregnant patient tells the nurse that she has been nauseated and vomiting. How will the nurse explain that hyperemesis gravidarum is distinguished from morning sickness? a. Hyperemesis gravidarum usually lasts for the duration of the pregnancy. b. Hyperemesis gravidarum causes dehydration and electrolyte imbalances. c. Sensitivity to smells is usually the cause of vomiting in hyperemesis gravidarum. d. The woman with hyperemesis gravidarum will have persistent vomiting without weight loss.

A pregnant woman is attending her second postpartum visit. Prenatal lab work indicates she is not immune to the rubella virus. What is the most appropriate nursing intervention? a. Provide the rubella vaccine as ordered by the physician immediately. b. Inform the woman she should receive the vaccine in the hospital after delivery. c. Hold all immunizations until 1 month postpartum. d. Encourage the patient to decide whether or not to get the rubella vaccine prenatally.

A pregnant womans membranes ruptured prematurely at 34 weeks. She will be discharged to her home for the next few weeks. What would the nurse planning discharge instruction teach the woman to do? a. Report any increase in fetal activity. b. Notify her obstetrician if she has a temperature above 37.8 C (100 F). c. Massage her breasts to promote uterine relaxation. d. Rest in a side-lying Trendelenburg position with hips elevated.

A student nurse questions the instructor regarding what alteration should be made for the assessment of the fundus of a new postoperative cesarean section patient. What is the best response? a. The fundus is not assessed until the second postoperative day. b. The fundus is assessed by walking fingers from the side of the uterus to the midline. c. The fundus is assessed only if large clots appear in lochia. d. The fundus is assessed only once every shift.

A woman asks about resumption of her menstrual cycle after childbirth. What should the nurse respond? a. A woman will not ovulate in the absence of menstrual flow. b. Most nonlactating women resume menstruation about 2 months postpartum. c. Generally, a woman does not ovulate in the first few cycles after childbirth. d. The return of menstruation is delayed when a woman does not breastfeed.

A woman calls her health care provider to schedule prenatal visits in an uncomplicated pregnancy. How frequently will the nurse assist the patient to schedule these appointments? a. Every 3 weeks until the 6th month, then every 2 weeks until delivery b. Every 4 weeks until the 7th month, after which appointments will become more frequent c. Monthly until the 8th month d. Every 2 to 3 weeks for the entire pregnancy

A woman is 9 weeks pregnant and experiencing heavy bleeding and cramping. She reports passing some tissue. Cervical dilation is noted on examination. What is the most likely cause of these symptoms? a. Inevitable abortion b. Incomplete abortion c. Complete abortion d. Missed abortion

A woman tells the nurse, I am having terrible pain with my period. This has never happened before. What should I do? What is the best response by the nurse? a. Sometimes getting into a kneechest position is helpful. b. You should notify your doctor if this is a new experience for you. c. Dysmenorrhea is a common occurrence; NSAIDs or aspirin may help. d. The best way to combat painful menses is to exercise and drink plenty of fluids.

After a prolonged labor, a woman vaginally delivered a 10 pound, 3 ounce infant boy. What complication should the nurse be alert for in the immediate postpartum period? a. Cervical laceration b. Hematoma c. Endometritis d. Retained placental fragments

After delivery, a mother asks the nurse about newborn screening tests. The nurse explains that what is the optimal time for testing for phenylketonuria? a. In the first 24 hours of life b. After 2 to 3 days c. At 4 to 6 weeks of age d. At 2 months of age

After delivery, the nurses assessment reveals a soft, boggy uterus located above the level of the umbilicus. What is the most appropriate nursing intervention? a. Notify the physician. b. Massage the fundus. c. Initiate measures that encourage voiding. d. Position the patient flat

After several hours of labor, a nursing assessment reveals that a womans cervix is 5 cm dilated but contractions are becoming shorter and less frequent. What is this labor pattern considered? a. Normal b. Hypotonic c. Hypertonic d. False

An adolescent comes into the emergency department requesting the morning-after pill. What should the nurse assess in this patient? a. Age of the patient b. Time of intercourse c. Use of contraception d. Location of the parents

An infant is hospitalized with RSV bronchiolitis. What is the priority nursing diagnosis? a. Fatigue related to increased work of breathing b. Ineffective breathing pattern related to airway inflammation and increased secretions c. Risk for fluid volume deficit related to tachypnea and decreased oral intake d. Fear and/or anxiety related to dyspnea and hospitalization

An infant receives surfactant via endotracheal (ET) tube at birth for symptoms of respiratory distress syndrome (RDS). When will the nurse anticipate seeing improvement of lung function? a. Immediately b. Within 3 days c. 1 to 2 weeks d. At least 1 month

An infants dry diaper weighs 2.5 grams. The wet diaper weighs 47 grams. How would the nurse record the infants urine output? a. 47 mL b. 44.5 mL c. 43.5 mL d. 40.5 m

An older adult patient is receiving a transfusion of packed red blood cells after being injured in a car accident. On assessment, the nurse notes a new finding of bounding pulse, crackles, and increasing dyspnea. What should the nurse do first, after stopping the transfusion? a. Assess vital signs. b. Raise the head of the bed. c. Encourage the patient to deep breathe and cough. d. Administer prn diphenhydramine (Benadryl) as ordered.

An older male patient is upset to learn about the diagnosis of benign prostatic hyperplasia. What should the nurse explain to the patient about this health problem? a. This health problem is a precursor to prostate cancer. b. 75% of men over the age of 70 have this health problem. c. 50% of men with this health problem need the prostate removed. d. 25% of men with this health problem will have erectile dysfunction.

At a 2-month well-child visit, parents ask the nurse about the red area on the infants neck. They tell the nurse that the mark appeared a few weeks after birth. What does the nurse recognize this skin lesion as? a. A port wine nevus b. A strawberry nevus c. Exanthem d. Intertrigo

At her 6-week postpartum checkup, a woman mentions to the nurse that she cannot sleep and is not eating. She feels guilty because sometimes she believes her infant is dead. What does the nurse recognize as the cause of this womans symptoms? a. Bipolar disorder b. Major depression c. Postpartum blues d. Postpartum depression

During a strenuous labor, the woman asks for some pain remedy for the sudden pain between her scapulae that seems to occur with every breath she takes. What is the best nursing action? a. Give the pain remedy. b. Notify the charge nurse immediately. c. Turn the patient to her back and flex her knees. d. Suggest that the coach give her a back rub.

During an assessment, the nurse notes that a patient has crystals deposited on the skin. What should this finding indicate to the nurse? a. Gout b. Uremic frost c. Poor hygiene d. Metabolic alkalosis

During data collection the nurse notes the presence of a chancre on a male patients penis. For which sexually transmitted infection should the nurse focus additional data collection? a. Herpes b. Syphilis c. Gonorrhea d. Chlamydia

How often will the nurse caring for a preterm infant in an incubator record the temperature of the infant and the incubator? a. Every hour b. Every 2 hours c. Every 4 hours d. Every 8 hours

On the first day following a severe burn, the bodys fluid reserves have left the circulating volume and entered the interstitial space, causing massive edema. What should the nurse monitor for very closely in the burn victim? a. Increasing intracranial pressure b. Reduced urine output c. Eschar formation d. Fluid overload

On the second postpartum day, a mother bathed her newborn for the first time. She tells the nurse, I dont think I did it right. What postpartum psychological stage is this woman most likely in based on this comment? a. Taking in b. Taking hold c. Letting go d. Settling down

Parents of a 2-month-old infant with Down syndrome are attending a well visit at the pediatric clinic. What should they be instructed to provide special attention to in regard to the generalized hypotonicity of the child? a. Preventing hyperthermia b. Respiratory care c. Prevention of diarrhea d. Incontinence care

Parents of a newborn with a unilateral cleft lip are concerned about having the defect repaired. The nurse explains that a child with a cleft lip usually undergoes surgical repair at which time? a. Immediately after birth b. By 3 months of age c. After 12 months of age d. Varies in every case

The 1-day postpartum patient shows a temperature elevation, cough, and slight shortness of breath on exertion. What action should the nurse implement based on these symptoms? a. Notify the charge nurse of a possible upper respiratory infection. b. Notify the physician of a possible pulmonary embolism. c. Document expected postpartum mucous membrane congestion. d. Medicate with antipyretic remedy for elevated temperature.

The apnea monitor indicates that a preterm infant is having an apneic episode. What is the most appropriate nursing action in this situation? a. Administer oxygen via a nasal cannula. b. Gently rub the infants feet or back. c. Ventilate with an Ambu bag. d. Perform nasopharyngeal suctioning.

The mother of a 3-year-old tells the nurse that she will be in to visit tomorrow around 12:00 PM. The next morning, the child asks the nurse, When is my mommy coming? What is the nurses best response? a. Your mommy will be here around noon. b. Your mommy will be here when you have lunch. c. Mommy will be here very soon. d. Your mommy is coming in 4 hours

The mother of a hospitalized toddler states, He cries when I visit. Maybe I should just stay away. What is the nurses best response? a. Perhaps you are right. He only gets upset when you have to leave. b. It is important that you are here. This is a common reaction in children when they are separated from their parents. c. It might be easier for your child if you would stay with him, but this decision is up to you. d. We take good care of him and he seems fine when you are not here.

The nurse caring for an infant born at 36 weeks of gestation assesses tremors and a weak cry. The nurse is aware that these symptoms indicate what? a. Respiratory distress syndrome b. Hypoglycemia c. Necrotizing enterocolitis d. Renal failure

The nurse contributed to the teaching plan for a patient with a history of allergies to pollen. Which patient action indicates an understanding of how to control this disease? a. Gardening outdoors on dry, windy days b. Wearing a mask when mowing the lawn c. Driving the car with the windows open during high pollen counts d. Taking frequent walks outside in spring when the weather is warm

The nurse explains to the parents of a hospitalized child that their child will receive fentanyl for an upcoming procedure. What advantage of fentanyl will the nurse explain? a. It is specifically designed for children. b. It has a rapid onset. c. It is nonaddicting. d. It has a long duration

The nurse has explained physiological changes that occur during pregnancy. Which statement indicates that the woman understands the information? a. Blood pressure goes up toward the end of pregnancy. b. My breathing will get deeper and a little faster. c. Ill notice a decreased pigmentation in my skin. d. There will be a curvature in the upper spine area.

The nurse in a pediatricians office is preparing to do a developmental assessment on a 3-month-old infant who was born at 36 weeks. The nurse knows that the infant should be evaluated in what month of achievement to adjust for the preterm birth? a. 1 b. 2 c. 3 d. 4

The nurse instructed an adolescent female about collecting a clean-catch urine specimen. What statement made by the adolescent led the nurse to determine she understood the instructions? a. I should wash my perineum with soap and water, then begin to urinate. b. I clean the perineum from front to back with an antiseptic wipe before I urinate. c. Ill collect the first stream of urine in a sterile container. d. I will discard the first void and collect a freshly voided specimen 30 minutes later.

The nurse is assessing a patient after a mastectomy and thinks the patients affected arm appears swollen. What is the best way to verify this finding? a. Measure and document the circumference of the arm. b. Measure and compare the circumferences of both arms. c. Press a finger into the arm and measure the indentation. d. Ask the patient to hang the arm down for 3 minutes and check for increased swelling.

The nurse is assisting in a teaching plan for the family of a patient with HIV. Which explanation about the transmission of HIV should the nurse include in this plan? a. HIV is spread by casual contact with others. b. HIV spreads by contact with infected blood. c. HIV can be spread by sharing eating utensils. d. HIV is commonly transmitted by tears or saliva

The nurse is assisting with a urology clinic intake assessment on a patient who reports erectile dysfunction. He has tried several treatments without success. He states, Im pretty useless to my wife now. I might as well become a monk. Which nursing diagnosis should take priority in guiding the nurses care? a. Anxiety related to uncertain future b. Powerlessness related to inability to fulfill role functions c. Noncompliance related to use of treatments for erectile dysfunction d. Knowledge Deficit related to lack of knowledge about treatments for erectile dysfunction

The nurse is assisting with pelvic inlet measurements on a pregnant woman. What measurement will provide the nurse with information about whether the woman can deliver vaginally? a. Diagonal conjugate b. Obstetric conjugate c. Transverse diameter d. Anteroposterior diameter

The nurse is caring for a 3-year-old with a head injury. Which assessment would lead the nurse to report the probability of increasing intracranial pressure (ICP)? a. Temperature increase from 37.2 C (99 F) to 37.7 C (100 F) b. Increase in blood pressure with an attendant decrease in pulse c. Increase in respirations d. Equilateral pupils

The nurse is caring for a male patient with functional incontinence. What action should the nurse take to help prevent incontinence? a. Teach the patient how to do Kegel exercises. b. Ensure that the patient has ready access to the urinal. c. Teach the patient to increase the time between voiding. d. Give the patient cranberry juice to keep the urine acidic.

The nurse is caring for a patient recovering from a renal biopsy. For which complication should the nurse monitor the patient during the 24 hours after the procedure? a. Polyuria b. Bleeding c. Infection d. Urinary obstruction

The nurse is caring for a patient who had a left mastectomy earlier in the day and informs the nurse of several concerns. Which should the nurse attend to first? a. Bowels have not moved in 48 hours. b. Pain level of is 7 on a 0-to-10 scale. c. A 3-cm area of blood is on the wound dressing. d. Feels anxious about how her husband will react to the surgery.

The nurse is caring for a patient who has had a portion of stomach removed. Which manifestations should the nurse expect to determine if the patient has a vitamin B12 deficiency? a. Fever, malaise, muscle soreness, and diarrhea b. Numbness and tingling, weakness, and glossitis c. Urticaria, angioedema, anorexia, pruritus, and blistered lesions d. Frequent infections, fever, malaise, vertigo, and lymphadenopathy

The nurse is caring for a patient who is scheduled for a cystoscopy (C&P) with basket extraction of a stone. What is the most important postoperative care for the nurse to provide? a. Limiting fluid intake b. Measuring urine output c. Monitoring daily weights d. Observing for acute kidney injury

The nurse is caring for a patient who is threatening preterm labor and has been given glucocorticoids. What is the purpose of glucocorticoid administration? a. Prevent infection. b. Increase fetal lung maturity. c. Increase blood flow from placenta. d. Relax the cervix.

The nurse is caring for a patient with a kidney infection. When providing prescribed medications, the nurse should recall that which structure is the capillary network in each nephron? a. Corpuscles b. Glomerulus c. Renal tubules d. Bowmans capsule

The nurse is caring for a patient with a severe allergic reaction. Which medication and route should the nurse anticipate being ordered for this patient? a. Intramuscular morphine b. Subcutaneous epinephrine c. IV diphenhydramine d. Oral diphenhydramine (Benadryl)

The nurse is caring for a patient with continuous bladder irrigation after a transurethral resection of the prostate (TURP). Which assessment finding should take priority? a. Pink-tinged urine b. 10-mL urine output in an hour c. Patient report of bladder spasms d. Leakage of small amounts of urine around the catheter

The nurse is caring for a patient with kidney disease. How should the nurse end a 24-hour urine test at the end of the 24 hours? a. The final voiding before 24 hours is discarded. b. The patient voids at the end of 24 hours, adding it to the collection container. c. One hundred milliliters of collected urine is placed into a specimen cup and sent to the laboratory. d. The patient voids, and the first and last specimens from 24 hours are sent to the laboratory.

The nurse is caring for a patient with prostatitis. Which manifestation should the nurse attend to immediately? a. Shaking chills b. Inability to urinate c. Fever 101F (38.3C) d. Low back pain rated 9 on a 0-to-10 scale

The nurse is caring for a patient with thrombocytopenia. Which activity should be avoided? a. Ambulation b. Intramuscular injections c. Visits from family members d. Eating fresh fruits and vegetables

The nurse is caring for a pregnant woman who is fearful that her unborn child will be born blind because of having a sexually transmitted infection (STI). For which STI should the nurse plan care to prevent ophthalmia neonatorum in the newborn? a. Syphilis b. Gonorrhea c. Genital warts d. Genital herpes

The nurse is caring for a prenatal patient diagnosed with a placenta previa. What is the best position for this patient? a. Flat on her back with knees flexed to help prevent hemorrhage b. On her side to prevent supine hypotension c. In the semi-Fowlers position to prevent supine hypotension d. In the knee-chest position to reduce pressure on the placenta

The nurse is caring for an Rh-negative mother on the postpartum unit. What scenario indicates the need to administer RhoGAM to this patient? a. She has had one Rh-negative child and is pregnant with an Rh-negative child. b. She has had an Rh-positive infant and is pregnant with an Rh-positive fetus. c. She has had an O-negative child and is pregnant with a B-negative child. d. She is a primipara with an O-negative child.

The nurse is collaborating on discharge teaching needed for a patient recovering from a splenectomy. What follow-up care is most important for the nurse to emphasize with this patient? a. Monthly coagulation studies b. Yearly influenza vaccination c. Oral analgesics for pain control d. Routine transfusion of packed RBCs to prevent anemia

The nurse is collecting data for a patient with kidney disease. When reviewing a urinalysis report, which range should the nurse recognize as normal specific gravity of urine? a. 0.080 to 0.100 b. 1.002 to 1.035 c. 2.600 to 3.000 d. 4.612 to 5.030

The nurse is collecting data for a patient with suspected exposure to HIV. Which symptoms would be most concerning in this patient? a. Tremors, edema, coughing b. Fever, diarrhea, sore throat c. Urticaria, sneezing, pruritus d. Abdominal pain, anorexia, and vomiting

The nurse is collecting data from a patient with kidney disease. Which adventitious lung sound should the nurse recognize as being caused by fluid overload? a. Stridor b. Crackles c. Wheezes d. Pleural friction rub

The nurse is collecting data from a patient with skin eruptions. What should the nurse recall to differentiate urticaria from angioedema? a. It is less pruritic. b. It lasts a shorter period of time. c. It includes mucous membrane edema. d. It causes more widespread skin lesions.

The nurse is collecting data from a patient with suspected cancer of the bladder. What finding should the nurse recognize as the most common symptom of cancer of the bladder? a. Pain b. Hematuria c. Urine retention d. Burning on urination

The nurse is concerned that a patient is demonstrating signs of red blood cell production. What laboratory value did the nurse most likely use to make this decision? a. Iron b. Bilirubin c. Thrombin d. Intrinsic factor

The nurse is contributing to the plan of care for a patient who is having an intravenous pyelogram (IVP) done to diagnose possible bladder cancer. Which intervention should the nurse recommend be included for the patient after the procedure? a. Document heart rhythm. b. Monitor creatinine level. c. Monitor arterial blood gases (ABGs). d. Review thyroid-stimulating hormone (TSH) and T4 levels.

The nurse is contributing to the teaching plan for a patient who is allergic to dust. Which environmental modification should the nurse recommend be included in the teaching plan to help control symptoms? a. Installing a hot air heater b. Cover heating ducts with filters c. Installing wall-to-wall carpeting d. Using heavy draperies on sunny windows

The nurse is educating a class of expectant parents about fetal development. What is considered fetal age of viability? a. 14 weeks b. 20 weeks c. 25 weeks d. 30 weeks

The nurse is helping to prepare a patient for a renal biopsy. In which position should the nurse help the patient assume? a. Sims b. Prone c. Supine d. Fowlers

The nurse is interviewing parents of an infant with pyloric stenosis. What would the nurse expect the parents to report? a. Diarrhea b. Projectile vomiting c. Poor appetite d. Constipation

The nurse is measuring the vital signs of a full-term newborn. Which finding is abnormal? a. An axillary temperature of 36.6 C (98 F) b. An apical pulse rate of 178 beats/min c. Respirations of 35 breaths/min d. Blood pressure of 80/50 mm Hg

The nurse is preparing a poster presentation identifying the frequency of sexually transmitted infections (STIs) in the United States. Which STI should the nurse highlight as being the most commonly diagnosed? a. Gonorrhea b. Chlamydia c. Trichomoniasis d. Human papillomavirus

The nurse is presenting information on the congentital disorder of hemophilia A. What fact will the nurse include? a. It is seen in males and females equally. b. It is transmitted by symptom-free females. c. It is a sex-linked dominant trait. d. It is a defective gene located on the Y chromosome

The nurse is providing care for a newborn. Which intervention should the nurse make to prevent development of ophthalmia neonatorum? a. Interferon injection b. Antibiotic eyedrops c. Vitamin K injection d. Hepatitis B virus (HBV)-immune globulin

The nurse is providing care to a patient who has had diagnostic testing for HIV. Which test should the nurse review to monitor the response to antiretroviral therapy? a. Western blot b. Viral load testing c. P24 antigen testing d. Enzyme-linked immunosorbent assay

The nurse is providing education to parents of a child with cleft palate. What will the nurse instruct the parents to report immediately? a. Facial paralysis b. Ear infections c. Increasing intracranial pressure (ICP) d. Drooling

The nurse is reinforcing teaching on chloroquine side effects for a patient with systemic lupus erythematosus. Which adverse effect should the nurse encourage the patient to report when taking this medication? a. Tarry stools b. Vision changes c. Any weight gain d. Changes in joint movement

The nurse is reinforcing teaching provided to a patient with pernicious anemia. Which patient statement indicates that teaching has been effective? a. I can miss a month or two of injections if I am feeling better. b. I will need to take vitamin B12 injections for the rest of my life. c. I will take the vitamin B12 injections until my strength returns. d. I can take a vitamin B12 injection when I feel tired or fatigued.

The nurse is reviewing data collected on several patients. Which patient should the nurse identify as being most likely to exhibit signs and symptoms of systemic lupus erythematosus? a. A 16-year-old Caucasian man b. A 20-year-old Hispanic woman c. A 45-year-old Caucasian woman d. A 42-year-old Asian American man

The nurse is reviewing the characteristics of Ewings sarcoma. Which statement if made by the nurse indicates correct understanding of this disease? a. Amputation is the accepted treatment. b. The disease is sensitive to radiation and chemotherapy. c. Metastasis is rare. d. The disease is more prevalent among toddlers and preschoolers.

The nurse is teaching a male patient the early warning signs of testicular cancer. What should this instruction include? a. Skin of scrotal sac red in color b. Small painless lump on the testicle c. Presence of rugae on the scrotal sac d. Skin of scrotal sac cooler in temperature

The nurse is teaching a patient with sickle cell anemia how to prevent crises. Which foods should the nurse teach the patient to avoid? a. Citrus fruits b. Alcoholic beverages c. Chocolates and colas d. Whole grain products

The nurse is teaching the parents of a young child with iron deficiency anemia about nutrition. What food would the nurse emphasize as being a rich source of iron? a. An egg white b. Cream of Wheat c. A banana d. A carrot

The nurse needs to obtain a urine specimen from a female patient. What action should the nurse take when obtaining this specimen? a. Obtain the first voided urine of the day. b. Direct the patient to wash her perineum before collecting the urine specimen. c. Have the patient urinate into a bedpan, then pour the urine into the specimen container. d. Have the patient void, throw that urine away, and then collect another specimen at least 1 hour later.

The nurse notes that a patients gaping wound is developing a blood clot. Which body substance is responsible for this clot formation? a. Plasma b. Platelets c. Red blood cells d. White blood cells

The nurse teaches a woman who is 8 weeks pregnant about how rubella can affect the developing fetus. What can result from maternal rubella during pregnancy? a. Facial abnormalities b. Mental retardation c. Liver failure d. Limb deformities

The parent of a child with osteomyelitis asks why his child is in so much pain. What will the nurse respond causes the pain experienced with osteomyelitis? a. Pressure of inelastic bone b. Purulent drainage in the bone marrow c. The cast applied on the extremity d. Circulatory congestion of the skin

The parents of a 3-month-old infant with cystic fibrosis (CF) want to know how their child got this disease, because no one in either of their families has CF. What is the nurses best response based on the understanding of CF? a. Only one parent carries the CF gene. b. Both parents are carriers of the CF gene. c. The inheritance pattern is multifactorial. d. The result is probably a genetic mutation.

The parents of a child diagnosed with cystic fibrosis ask the nurse what caused this disorder. What is the most appropriate response? a. Cystic fibrosis is a chromosomal defect. b. Cystic fibrosis is a metabolic defect. c. Cystic fibrosis is a malformation present at birth. d. Cystic fibrosis is a blood disorder.

The parents of a newborn girl express concern about the infants vaginal discharge, which appears to be bloody mucus. What does the nurse explain as the cause? a. Premature stimulation of the ovarian hormones by the pituitary system b. Cessation of female sex hormones transferred in utero from mother to infant c. The increased amount of circulating blood from the mother throughout pregnancy d. Trauma to the genitalia during the birth process

The pediatric nurse completes an assessment on all patients assigned during evening shift at the hospital. Which patient assessment requires immediate intervention? a. Toddler with an axillary temperature of 99 F b. School-age child with widening pulse pressure c. Infant pulse rate of 100 beats per minute d. Adolescent with a respiratory rate of 28 breaths per minute

The prescription for a 4-month-old is penicillin G 150,000 units intramuscularly bid. The drug is supplied as a unit dose of 600,000 units in a 5-mL vial. How many milliliters (mL) should the nurse provide? a. 1.25 b. 1.4 c. 1.6 d. 1.8

The school nurse is counseling a group of adolescent girls. What does the nurse explain about sperm ejaculated near the cervix? a. They are destroyed by the acidic pH of the vagina. b. They survive up to 5 days and can cause pregnancy. c. They lose their motility in about 12 hours after intercourse. d. They are usually pushed out of the vagina by the muscular action of the vaginal wall.

What assessment made by the school nurse would lead to the suspicion of strabismus? a. Reddened sclera in one eye b. Child covers one eye to read the chalkboard c. Child complains of a headache d. Copious tears while watching TV

What does the nurse explain can affect the survival of the X- and Y-bearing sperm after intercourse? a. Age b. Estrogen level c. Body temperature d. Level of feminine hygiene

What emergency action should be implemented for airway obstruction in the infant? a. Six to 10 midsternal thrusts b. Five back blows followed by five chest thrusts c. Five chest thrusts followed by five back blows d. Abdominal thrusts until the object is expelled

What instruction should the nurse teach the postpartum woman about perineal self-care? a. Perform perineal self-care at least twice a day. b. Cleanse with warm water in a squeeze bottle from front to back. c. Remove perineal pads from the rectal area toward the vagina. d. Use cool water to decrease edema of the perineum.

What intervention will the nurse caring for a child in Bucks skin traction implement? a. Position in high Fowlers position. b. Assist the child to be pulled up in bed. c. Keep childs heel on the bed surface. d. Maintain childs feet against the foot of the bed.

What is an appropriate intervention for the edematous child with reduced mobility related to nephrotic syndrome? a. Reach the child to minimize body movements. b. Change the childs position frequently. c. Keep the head of the childs bed flat. d. Keep edematous areas moist and covered.

What is an appropriate nursing action when a child is experiencing a generalized tonic-clonic seizure? a. Guide the child to the floor if the child is standing, and then go for help. b. Move objects out of the childs immediate area. c. Stick a padded tongue blade between the childs teeth. d. Manually restrain the child.

What is an initial sign of nephrosis that the nurse might note in a child? a. Raspberry-like rash b. Periorbital edema c. Temperature elevation d. Abdominal pain

What is the appropriate technique for the application of a topical treatment for a child with eczema? a. Apply skin lotions in a circular motion. b. Apply prescribed ointments with a gloved hand. c. Apply as much and as frequently as relieves the symptoms. d. Choose lanolin-based ointments

What is the best pulse location for the nurse to use when assessing the pulse rate on a 12-month-old infant? a. Brachial b. Apical c. Radial d. Femoral

What is the most common site for fertilization? a. Lower segment of the uterus b. Outer third of the fallopian tube near the ovary c. Upper portion of the uterus d. Area of the fallopian tube farthest from the ovary

What is the total number of chromosomes contained in a mature sperm or ovum? a. 22 b. 23 c. 44 d. 46

What nursing care should be provided to a woman with a third-degree laceration immediately after delivery? a. Warm compresses to the perineum b. Cold pack to the perineum c. Warm sitz bath d. Elevation of hips to prevent edema

What sign(s) of infection should the nurse assess for after an amniotomy? (Select all that apply.) a. Oral temperature of 37 C (99.8 F) b. Increase of fetal heart rate (FHR) from 160 to 174 beats/minute c. Flecks of vernix in the amniotic fluid d. Low back pain e. Edematous labia

What statement by the patient leads the nurse to determine a woman with mastitis understands treatment instructions? a. I will apply cold compresses to the painful areas. b. I will take a warm shower before nursing the baby. c. I will nurse first on the affected side. d. I will empty the affected breast every 8 hours.

What statement indicates a woman has correct information about oogenesis? a. Women make fewer ova as they age. b. Women have all of their ova at the time they are born. c. Ova production begins at birth and continues until puberty. d. New ova are made every month from puberty to climacteric.

What term describes the age of a neonate that is based on the actual time in utero? a. Maturational age b. Gestational age c. Neurological age d. Chronological age

What type of lochia will the nurse assess initially after delivery? a. Serosa b. Rubra c. Alba d. Vaginalis

What will the nurse administer with ferrous sulfate drops when providing them to a child on the pediatric unit? a. With milk b. With orange juice c. With water d. On a full stomach

What will the nurse tell parents of a child with a positive throat culture for group A hemolytic streptococcus that the treatment is most likely to be? a. Acetaminophen and plenty of fluids b. Oral penicillin for 10 days c. Penicillin until his sore throat is gone d. Streptococcus immunization

What would help the child with a serious burn meet nutritional needs during the subacute phase of recovery? a. Decrease calories because the child will be on bed rest and will not need as many. b. Increase calories and protein to compensate for the healing process. c. Increase fat to replace the layer of fat next to the burned skin. d. Decrease carbohydrates and starches because the pancreas is strained by the healing process.

When a 2-year-old returns to her hospital room following a diagnostic procedure, her parents are not available, and the child is crying loudly. Which technique is most appropriate to alleviate the childs distress? a. Rock the child gently to sleep. b. Play with the child using pop-up toys. c. Role play with the child to act out her feelings. d. Ask the child to draw a picture about her feelings.

When a woman is admitted to the labor and delivery unit, she tells the nurse that she is anxious about delivery, the welfare of her infant, and how quickly she will recover. How can anxiety affect labor? a. By decreasing a womans pain sensitivity b. By reducing blood flow to the uterus c. By increasing the ability to tolerate pain d. By enhancing maternal pushing through greater muscle tension

When asked about correcting the hypospadias of a newborn, what does the nurse explain about this condition? a. No intervention is necessary as the defect will correct itself over time. b. Surgical repair of the hypospadias is done before 18 months of age. c. Corrective surgery is usually delayed until the preschool age. d. Repairing the defect will increase the risk of testicular cancer

When bathing an infant, what sign does the nurse recognize as a sign of developmental hip dysplasia? a. Hypotonicity of the leg muscles b. One leg is shorter than the other c. Broadening and flattening of the buttocks d. Two skinfolds on the back of each thigh

When describing the female reproductive tract to a pregnant woman, the nurse would explain that which uterine layer is involved in implantation? a. Perimetrium b. Endometrium c. Myometrium d. Internal os

When preparing to teach a class about prenatal development, the nurse would include information about folic acid supplementation. What is folic acid known to prevent? a. Congenital heart defects b. Neural tube defects c. Mental retardation d. Premature birth

When the nurse tells a pregnant woman that she needs 1200 mg of calcium daily during pregnancy, the woman responds, I dont like milk. What dietary adjustments could the nurse recommend? a. Increase intake of organ meats. b. Eat more green leafy vegetables. c. Choose more fresh fruits, particularly citrus fruits. d. Include molasses and whole-grain breads in the diet.

Which child would have the most difficulty in coping with separation from parents because of hospitalization? a. 3-month-old child b. 16-month-old child c. 4-year-old child d. 7-year-old child

Which comment made by a parent of a 1-month-old would alert the nurse about the presence of a congenital heart defect? a. He is always hungry. b. He tires out during feedings. c. He is fussy for several hours every day. d. He sleeps all the time.

Which finding in a newborn is suggestive of tracheoesophageal fistula? a. Failure to pass meconium in 24 hours b. Choking on the first feeding c. Palpable mass in the sternal area d. Visible peristalsis across abdomen

Which hormone initiates the maturation of the ovarian follicle? a. Estrogen b. Follicle-stimulating hormone c. Progesterone d. Luteinizing hormone

Which intervention would be helpful in relieving morning discomfort associated with juvenile rheumatoid arthritis? a. Wearing splints at night to prevent extension contractures b. Applying moist heat packs upon awakening c. Taking a warm tub bath the evening before d. Sleeping with two pillows under the head

Which is the most appropriate nursing action related to the administration of digoxin (Lanoxin) to an infant? a. Counting the apical rate for 30 seconds before administering the medication b. Withholding a dose if the apical heart rate is less than 100 beats/min c. Repeating a dose if the child vomits within 30 minutes of the previous dose d. Checking respiratory rate and blood pressure before each dose

Which nursing action would facilitate rapport with a child and the childs parents during the admission process? a. Direct the parents to undress the child. b. Answer questions in a calm and matter-of-fact way. c. Perform assessments and ask questions as quickly as possible. d. Express concern about the seriousness of the childs condition.

Which observation on entering the hospital room lets the nurse know that there is a need for the parents to receive safety education to prevent unintentional injury? a. The blanket is not tucked into the mattress. b. Diapers and wipes are stacked at the foot of the crib. c. The crib side is locked in the up position. d. Pillows are stacked on the bedside table.

Which physical assessment technique will the nurse omit when caring for a 2-year-old diagnosed with Wilms tumor? a. Performing range-of-motion exercises on lower extremities b. Palpating the abdomen c. Assessing for bowel sounds d. Percussing ankle and knee reflexes

Which statement best corresponds to a preschoolers understanding of hospitalization? a. A germ made me get sick. b. I got sick because I was mad at my brother. c. My tonsils are sick and they have to come out. d. I have a cast because I broke my leg.

Which statement indicates a woman understands activity limitations for the management of preterm labor? a. After my shower in the morning, I do the laundry and straighten up the house; then I rest. b. I pack a picnic basket and put it next to the sofa so I do not have to get up for food during the day. c. I have a 2-year-old to care for, but I try to rest as much as I can. d. I get really bored at home, so I go to the shopping mall for just a little while.

Which statement made by a parent indicates an understanding of health maintenance of a child with sickle cell disease? a. I should give my child a daily iron supplement. b. It is important for my child to drink plenty of fluids. c. He needs to wear protective equipment if he plays contact sports. d. He shouldnt receive any immunizations until he is older.

Which urinary diversion procedure is the least damaging to the body image of the adolescent? a. Urostomy b. Ileal conduit c. Nephrostomy d. Suprapubic placement

While assisting with care, the nurse counsels the patient diagnosed with a sexually transmitted infection (STI) about notification of sexual partners. Which patient statement indicates the need for further teaching? (Select all that apply.) a. I can contact my sexual partners myself. b. Reporting regulations are the same throughout the country. c. A report form will be completed in my chart that includes a list of my sexual contacts. d. The public health authority can notify a list of sexual contacts without including my identity.

Why does the woman taking oral hypoglycemic agents to control diabetes mellitus need to take insulin during pregnancy? a. Insulin can cross the placental barrier to the fetus. b. Insulin does not cross the placental barrier to the fetus. c. Oral agents do not cross the placenta. d. Oral agents are not sufficient to meet maternal insulin needs.

a patient with pleural effusion is dyspneic. what procedure should be anticipated? a. tracheostomy b. thoracentesis c. bronchoscopy d. pericardiocentesis

nurse enters room of a COPD patient who is acutely short of breath. which of the following actions should the nurse take first? a. assist patient into sims position b. encourage use of pursed lip breathing c. ask patient what caused the dyspnea d. teach patient use of accesory muscles

nurse is providing care for a patient diagnosed with asthma. which of the following sounds is anticipated? a. crackles b. wheezes c. diminished breath sounds d. pleural friction rub

what emergency equipment should the nurse have available at the bedside for a patient who has just had a tonsillectomy? a. sterile hemostats b. suction c. sterile gauze packing d. irrigation set

when reinforcing discharge teaching for a patient with emphysema, which of the following patient statements would indicate effective teaching? a. my disease is caused by spasm of the smooth muscles in my breathing pipes b. air gets trapped when damage to the air sacs makes it hard for air to move in and out c. emphysema causes swelling in the airways and an increase in mucus production d. there are bacteria in my lungs so my body is trying to wall of the infection

which of the following instructions is appropriate when teaching a dyspneic patient how to breathe effectively? a. take four quick panting breaths and blow out for 6 seconds b. use deep breathing and exhale as forcfully as you are able c. breathe using abdominal muscles and blow out slowly through pursed lips d. hold your breath for 3 seconds after each exhalation to empty all alveoli

What intervention(s) would the nurse preparing a teaching plan for the care of a child with infantile eczema include? (Select all that apply.) a. Bathe the child using products with a light fragrance. b. Use oatmeal and baking soda as bath additives. c. Add bath oil to bath water after the child has soaked. d. Apply lanolin-based lotions after the bath. e. Bathe child several times a day.

b, c

A toddler must maintain bed rest for the diagnosis of pneumonia. What actions will the nurse implement? (Select all that apply.) a. Maintain strict bed rest. b. Consider age. c. Assess developmental level. d. Implement light play activities. e. Provide hypnotic medication as ordered

b, c, d

How might the nurse instruct the patient to stimulate her nipples in an attempt to increase the quality of uterine contractions? (Select all that apply.) a. Place a warm, moist washcloth over the breast. b. Brush the nipples with a dry washcloth. c. Gently pull on the nipples. d. Apply suction to the nipples with a breast pump. e. Press the palms of her hands down on her breasts.

b, c, d

Parents have adopted a child with the diagnosis of kwashiorkor. What is most likely to be observed when assessing this child? (Select all that apply.) a. Hyperactivity b. White streak in hair c. Edematous abdomen d. Slowed growth e. Thick, oily hair

b, c, d

Parents of a child show the nurse that their child has a flat strawberry nevus. What information can the nurse provide in educating the parents regarding strawberry nevus? (Select all that apply.) a. It is a rare skin variation. b. It is harmless. c. It gradually becomes raised. d. Laser treatment is available. e. Sometimes it can disappear spontaneously

b, c, d

The nurse is instructing a woman at 6 months postpartum on weaning her infant from breastfeeding. What interventions will the nurse suggest? (Select all that apply.) a. Omit newborns favorite feeding first. b. Eliminate one feeding at a time. c. Expect the need for comfort feeding. d. Formula will need to be provided to substitute for feeding. e. Pump breasts in place of eliminated feeding.

b, c, d

The nurse is providing care for a patient diagnosed with bacterial prostatitis who is being treated on an outpatient basis with oral antibiotic therapy. In addition to the medication, which interventions should the nurse include in discharge teaching? (Select all that apply.) a. Bedrest b. Stool softeners c. Warm sitz baths d. Anti-inflammatory agents e. Self-catheterization every 2 hours

b, c, d

The nurse is reviewing the contents of blood plasma prior to participating in a seminar for nursing students. What should the nurse include as proteins in the plasma? (Select all that apply.) a. Iron b. Albumin c. Globulin d. Fibrinogen e. Electrolytes f. Hemoglobin

b, c, d

What interventions will the nurse perform when feeding a child with pyloric stenosis? (Select all that apply.) a. Give a formula thinned with water. b. Burp the infant before and during feeding. c. Give the feeding slowly. d. Refeed if the infant vomits. e. Position infant on left side after feeding.

b, c, d

A nurse is discussing risk factors for postpartum shock with a childbirth preparation class. What will the nurse include in this education session? (Select all that apply.) a. Hypertension b. Blood clotting disorders c. Anemia d. Infection e. Postpartum hemorrhage

b, c, d, e

A patient with AIDS is prescribed the nucleoside reverse transcriptase inhibitor lamivudine (Epivir). What information should the nurse ensure that the patient receives about this medication? (Select all that apply.) a. Report any onset of bleeding. b. Report any yellowing of the skin. c. Report any change in urine output. d. Report any symptoms similar to having the flu. e. Report any numbness or tingling of the hands or feet.

b, c, d, e

A patient with lupus erythematosis is prescribed a corticosteroid. What side effects of this medication should the nurse review with the patient? (Select all that apply.) a. Tinnitus b. Facial hair c. Moon face d. Mood changes e. Increased weight f. Rash and pruritus

b, c, d, e

A woman, gravida 3, para 2, is attending her fourth prenatal visit and confides in the nurse that she is battered by her husband. She is assessed to have multiple bruises at various stages of healing. What nursing actions are appropriate for the nurse to implement? (Select all that apply.) a. Tell the husband that authorities will be notified immediately. b. Provide privacy for the assessment. c. Determine if children are being hurt. d. Communicate in a non-judgmental way. e. Determine factors that increase the risk of injury.

b, c, d, e

An 8-year-old near-drowning victim is rushed into the ED. What priorities of care will be implemented? (Select all that apply.) a. Parental education regarding prevention b. Respiratory support c. Cardiovascular support d. Controlled rewarming e. Adequate cerebral oxygenation

b, c, d, e

The HCP suggests that a patient with benign prostatic hyperplasia have an invasive procedure to reduce the symptoms of the disorder. For which procedures should the nurse prepare materials for the patient? (Select all that apply.) a. Lithotripsy b. Prostatic stents c. Transurethral needle ablation d. Transurethral microwave therapy e. High intensity focused ultrasound

b, c, d, e

The nurse is experiencing severe skin blisters after wearing latex gloves at work. Which treatment should the nurse expect to be prescribed by the health care provider for these skin lesions? (Select all that apply.) a. Oral antibiotics b. Topic drying agent c. Oral antihistamines d. Topical corticosteroid e. Topical immunomodulators

b, c, d, e

The nurse is giving a shower to a patient who had a cesarean section 2 days previously. What interventions should be included before, during, and after the shower? (Select all that apply.) a. Leave abdominal dressing open to air. b. Position patient with back to water stream. c. Cover infusion site with rubber glove. d. Provide a shower chair. e. Confirm ambulation ability.

b, c, d, e

The nurse is reviewing normal kidney function with a patient experiencing an acute kidney injury. Which hormones should the nurse include that affect kidney function? (Select all that apply.) a. Estrogen b. Aldosterone c. Parathyroid hormone d. Antidiuretic hormone (ADH) e. Atrial natriuretic hormone (ANH) f. Thyroid-stimulating hormone (TSH)

b, c, d, e

The nursing home administrator for a skilled nursing facility is concerned because a large number of older residents are developing UTIs. What should the staff nurse explain about the development of UTIs in this population? (Select all that apply.) a. Overuse of antibiotics b. Diminished immune function c. Enlarged prostate in older men d. Presence of neurogenic bladder e. Decline in estrogen in older women

b, c, d, e

What will the nurse caring for a newborn with exstrophy of the bladder include in the care? (Select all that apply.) a. Diaper infant tightly. b. Protect skin around bladder. c. Position infant on back. d. Prepare for surgical closure. e. Cover exposed bladder with shield

b, c, d, e

What will the nurse teach a nursing mother to do to reduce the risk of mastitis? (Select all that apply.) a. Limit fluid intake to 1 liter per day. b. Empty both breasts with each feeding. c. Take warm showers. d. Wear a supportive bra. e. Pump breasts to ensure emptying.

b, c, d, e

While collecting admission data, the nurse suspects a patient with AIDS is experiencing an HIV-associated neurocognitive disorder. What observations did the nurse make to come to this conclusion? (Select all that apply.) a. Audible bowel sounds b. Inappropriate laughter c. Inability to state home address d. Knee buckling while walking e. Asking if the bugs could be removed from the walls

b, c, d, e

31. Which of the following items should be set up in preparation for a Pap smear? Select all that apply. a. 50-mL syringe b. Vaginal speculum c. Lubricant d. Clean gloves e. Slides and fixative spray

b, c, d, e. A speculum with lubricant for the examination; gloves for the examiner; slides and fixative to send the sample to the lab

The nurse is contributing to the plan of care for a patient with chronic kidney disease. The nurse has recognized a growing body of evidence related to restricting protein intake. Which evidence should the nurse use to develop the plan of care? (Select all that apply.) a. Protein requirements should be based on ideal body weight. b. Increased protein is recommended for patients on hemodialysis. c. Protein calorie malnutrition should be avoided for patients on hemodialysis. d. Optimum nutritional status should be maintained for all patients with kidney disease. e. All patients with renal compromise should limit protein intake to less than 0.5 g/kg/day. f. Protein energy malnutrition is a predictor of mortality and morbidity for patients on dialysis.

b, c, d, f

A 24-year-old woman diagnosed with Chlamydia has been prescribed doxycycline. What should be included in the nurses teaching about the drug treatment? (Select all that apply.) a. Take this drug with a meal. b. Do not take with dairy products. c. Avoid unnecessary exposure to sunlight. d. Abstain from alcohol for at least 48 hours after treatment. e. Use birth control methods to ensure you do not become pregnant.

b, c, e

A 3-year-old patient is admitted to the pediatric unit with a fever of 103 F. Which actions will the nurse implement? (Select all that apply.) a. Assess rectal temperature every 4 hours. b. Administer Acetaminophen as ordered. c. Assess skin turgor. d. Restrict fluids. e. Assess level of consciousness.

b, c, e

A child is brought into the ED with suspected appendicitis. What signs and symptoms does the nurse expect to assess? (Select all that apply.) a. Left lower quandrant pain b. Guarding c. Rebound tenderness d. Decreased C-reactive protein e. Pain on lifting thigh when supine

b, c, e

A patient is being treated for prostatitis. What instructions should the nurse provide to help this patient? (Select all that apply.) a. Avoid tub baths. b. Empty your bladder frequently. c. Avoid products that contain caffeine. d. Try to increase the amount of fiber in your diet. e. Increase your fluid intake to nearly 3000 mL/day. f. Take your antibiotics until your symptoms have completely resolved.

b, c, e

The home health nurse is educating parents on home phototherapy. What will the nurse include when providing information to these parents? a. Cover the infants eyes when under the light. b. Use a three-prong plug. c. Keep a diaper in place. d. Place the light source on an absorbent surface. e. Expose as much skin as possible.

b, c, e

The nurse is assisting in the development of a program to instruct female high school students on ways to prevent the development of toxic shock syndrome. What should the nurse include in this program? (Select all that apply.) a. Increase oral fluid intake. b. Change tampons every 4 hours. c. Wash hands before inserting a new tampon. d. Take over-the-counter aspirin while menstruating. e. Use sanitary pads instead of tampons overnight when menstruating.

b, c, e

The nurse is caring for a 4-year-old child diagnosed with H. influenzae type B. Which signs and symptoms exhibited by the child would alert the nurse to suspect epiglottitis? (Select all that apply.) a. Harsh cough b. Restlessness c. Edematous epiglottis d. Child insists on lying down e. Drooling

b, c, e

The nurse is caring for a patient with an indwelling urinary catheter. Which instructions should the nurse provide to help prevent development of a urinary tract infection? (Select all that apply.) a. Limit fluid intake to decrease the flow of urine. b. Position the tubing to allow free flow of the urine. c. Use aseptic technique when emptying the drainage bag. d. Wash the perineum with an antibacterial soap every 8 hours. e. Keep the catheter securely taped to prevent catheter movement. f. Empty the urinary bag every 4 hours to prevent stagnation of urine.

b, c, e

The nurse is contributing to a staff education program about the risks of smoking and conditions related to smoking. Which statements by a staff member indicate correct understanding of the teaching? (Select all that apply.) a. Kidney stones b. Kidney cancer c. Bladder cancer d. Hydronephrosis e. Diabetic nephropathy f. UTI

b, c, e

A woman is 37 weeks pregnant and questioning the nurse about possible induction of labor at term. What conditions would contraindicate labor induction? (Select all that apply.) a. Maternal gynecoid pelvis b. Placenta previa c. Horizontal cesarean incision d. Prolapsed cord e. Gestational diabetes

b, d

The nurse assesses the progress from the announcement stage of fatherhood to the acceptance stage when the patient reports which actions by the father? (Select all that apply.) a. Goes fishing every afternoon b. Has revised his financial plan c. Spends leisure time with his friends d. Traded his sports car for a sedan e. Helped select a crib

b, d, e

The nurse is assisting in an educational seminar on common allergens. What should the nurse include as the most common irritant causing contact dermatitis? (Select all that apply.) a. Bleach b. Rubber c. Fire ants d. Poison ivy e. Poison oak

b, d, e

The nurse is caring for a macrosomic newborn of a woman diagnosed with gestational diabetes immediately after birth. What assessment findings can the nurse anticipate? (Select all that apply.) a. High blood glucose levels b. Weight of 9 pounds or more c. Decreased subcutaneous fat d. Hypocalcemia e. Hyperbilirubinemia

b, d, e

The nurse suspects a patient is experiencing manifestations of Hodgkins disease. Which are characteristics of this health disorder? (Select all that apply.) a. Visual changes occur. b. It is the most curable of all lymphomas. c.Skeletal pain is a common symptom. d. It is distinguished by the presence of Reed-Sternberg cells. e. Painless swelling of cervical, axillary, or inguinal nodes occurs. f. It is distinguished by the presence of Philadelphia chromosome.

b, d, e

Which assessments would cause the pediatric nurse to suspect the probability of an ear infection in a 6-month-old child? (Select all that apply.) a. Hypersensitivity to noise b. Irritability c. Reddened ear canal d. Rolls head from side to side e. Temperature of 39.4 C (103 F)

b, d, e

The nurse is reinforcing teaching provided to a patient with a history of calcium oxalate kidney stones. The nurse recognizes that teaching has been effective if the patient avoids which foods? (Select all that apply.) a. Bread b. Cocoa c. Lettuce d. Spinach e. Chicken f. Instant coffee

b, d, f

The nurse assesses the perineal pad placed on a 3-hour postdelivery patient and finds that there is no lochia on it. What would the nurse expect to find on further assessment? (Select all that apply.) a. A firm fundus the size of a grapefruit b. A full bladder c. Retained placental fragments d. Vital signs indicative of shock e. A soft, boggy fundus

b, e

The nurse is collecting admission data from a patient recently diagnosed with benign prostatic hyperplasia. Which symptoms should the nurse expect the patient to report? (Select all that apply.) a. Low back pain b. Dribbling after urination c. Difficulty initiating an erection d. Difficulty maintaining an erection e. Difficulty starting the urine stream

b, e

The nurse is collecting data for a patient with kidney disease. Which information should the nurse identify as being normal urinalysis findings? (Select all that apply.) a. pH 3.5 b. Amber color c. Small amount of nitrite d. Red blood cells of 8/hpf e. Specific gravity of 1.010 f. Small quantities of enzymes

b, e, f

The nurse is preparing to provide education related to HIV transmission at a local community health fair. Which statements should the nurse recommend for inclusion in the teaching? (Select all that apply.) a. Use oil-based lubricants. b. Use a new condom for each sex act. c. Use condoms that are not made of latex. d. Fit condom tightly over the tip of the penis. e. Check condom package for expiration date. f. Apply the condom before touching partner with the penis.

b, e, f

The nurse is evaluating laboratory values for a group of patients. Which values should the nurse identify as being within normal limits? (Select all that apply.) a. An adult male with Hct = 35% b. An adult female with Hct = 40% c. An adult male with Hgb = 12.8 g/100 mL d. An adult female with Hgb = 11.5 g/100 mL e. An adult male with RBC = 4 million/mm3 f. An adult female with RBC = 5 million/mm3

b, f

A 54-year-old patient is admitted to the hospital in the final stage of chronic lymphocytic leukemia (CLL). Which manifestations of CLL should the nurse expect to find while collecting admission data? a. Nausea and vomiting b. Hypotension and alopecia c. Fever and abnormal bleeding d. Cervical lymphadenopathy and chest pain

A 70-year-old male arrives in the emergency department and says, I havent urinated in 24 hours. I feel like I have to go, but I cant. What care should the nurse anticipate providing first? a. STAT administration of IV fluids b. Emergency preparation for a cystoscopy c. STAT insertion of an indwelling catheter d. Emergency preparation for an intravenous pyelogram (IVP)

A child is admitted to the hospital because she had a seizure. Her parents report that for the past few weeks she has had headaches, with vomiting, that are worse in the morning. What does the nurse suspect? a. Meningitis b. Reyes syndrome c. Brain tumor d. Encephalitis

A child is brought to the emergency department after he fell and hit his head on the ground. Which nursing assessment suggests the child has a concussion? a. Sleepy but easily arousable b. Complaining of a stiff neck c. Cannot remember what happened to him d. Pupils react sluggishly to light

A child is sent to the school nurse for assessment because she comes to school every day disheveled, unbathed, and hungry. The assessment does not indicate any bruises or marks on the body. What do these finding indicate? a. Sexual abuse b. Physical abuse c. Physical neglect d. Emotional abus

A group of football players is taking oral griseofulvin for tinea pedis. What should the school nurse caution them to avoid? a. Citrus fruit and juice b. Eating shellfish c. Alcohol consumption d. Taking corticosteroids

A mother reports that her 2-year-old child experiences constipation frequently. Which food would the nurse recommend to include in the childs diet? a. Cooked vegetables b. Pretzels c. Whole-grain cereal d. Yogurt

A newborn was just admitted to the neonatal intensive care unit with a meningomyelocele. What is the priority preoperative nursing care of this newborn? a. Keep the sac dry. b. Diaper snugly. c. Position prone in an incubator. d. Move from side to side every hour

A newly married couple is seeking genetic counseling because they are both carriers of the sickle cell trait. How can the nurse best explain the childrens risk of inheriting this disease? a. Every fourth child will have the disease; two others will be carriers. b. All of their children will be carriers, just as they are. c. Each child has a one in four chance of having the disease and a two in four chance of being a carrier. d. The risk levels of their children cannot be determined by this information.

A nurse is preparing to assist with a bone marrow biopsy. Which anatomical site should the nurse anticipate will be used to obtain the specimen? a. Ribs b. Humerus c. Posterior iliac crest d. Long bones in the legs

A parent tells the nurse that her child is scheduled for an x-ray of the bladder and urethra that is done while the child is urinating. What is this test known as? a. Cystometrogram b. Cystoscopy c. Voiding cystourethrogram d. Intravenous pyelogram

A parent tells the nurse, Im not sure how to give this medicine to my infant. How would the nurse teach the parent to best administer an oral suspension? a. Pour the medication into a small cup and allowing the infant to drink it. b. Place the medication in a nipple and having the infant suck the nipple. c. Use an oral syringe and placing the medication in the side of the infants mouth. d. Administer the medication with a dropper onto the back of the infants tongue

A patient comes to an outpatient clinic because of premenstrual syndrome (PMS) symptoms. What advice from the nurse may help her reduce her symptoms? a. There is no treatment for PMS other than rest and fluids. b. Ask the physician about a mild antianxiety agent. c. Avoidance of alcohol and caffeine may help reduce your discomfort. d. Avoid strenuous exercise for several days before and after your period.

A patient diagnosed with Trichomonas asks the nurse how the diagnosis will affect her risk for cervical cancer. Which response by the nurse is best? a. Wet-mount slides should be done yearly to help detect cervical cancer. b. Serological testing will be done to detect tumor proteins and screen for cervical cancer. c. Papanicolaou smears should be done more frequently because results may be altered by Trichomonas. d. Culture and sensitivity testing is done with Papanicolaou (Pap) smears every other year to determine if you have cervical cancer.

A patient diagnosed with benign prostatic hyperplasia is prescribed the alpha-blocking medication terazosin (Hytrin) to reduce symptoms. For which side effect should the nurse monitor this patient? a. Dry mouth b. Headaches c. Hypotension d. Urinary frequency

A patient diagnosed with genital warts asks how they developed. Which pathogen should the nurse explain as causing genital warts? a. Sarcoptes scabiei b. Hepatitis A and B c. Human papillomavirus d. Chlamydia trachomatis

A patient has an altered level of T and B cells. The nurse realizes that these cells are members of which cell type? a. Platelets b. Eosinophils c. Lymphocytes d. Red blood cells

A patient hospitalized for orthopedic surgery had a urinary catheter inserted. The patient later develops a urinary tract infection (UTI) and asks the nurse what caused it. What is the appropriate response by the nurse? a. There was a change in the pH of your urine. b. You probably did not void frequently enough. c. Bacteria probably ascended the catheter, causing the infection. d. There are always bacteria on your perineum that enter your urine.

A patient is admitted in sickle cell crisis with symptoms of dyspnea and leg pain. The patients significant other asks, I dont really understand why he is hurting so badly. Which response by the nurse is best? a. The pain is due to a disturbance in cellular metabolism. b. The bone marrow is expanding with the sickled cells and that causes pain. c. Clumping of abnormal red blood cells blocks the flow of blood through the capillaries. d. Bleeding in the joints occurs because red blood cells are being rapidly destroyed by the bone marrow.

A patient is admitted to the hospital with hypertension and vertigo related to polycythemia vera (PV). For which treatment should the nurse prepare the patient? a. Myelogram b. Splenectomy c. Therapeutic phlebotomy d. Injection of colony-stimulating factors

A patient is being prepared for splenectomy. What is the purpose of the order for a vitamin K injection? a. It corrects a dietary deficiency. b. It helps correct underlying anemia. c. It corrects clotting factor deficiencies. d. It replaces vitamin K lost during night sweats.

A patient is being started on a blood transfusion. For how many minutes should the nurse stay with the patient during this transfusion? a. 5 b. 10 c. 15 d. 20

A patient is being tested for possible leukemia. With which diagnostic test should the nurse anticipate assisting? a. Liver biopsy b.Thoracentesis c. Bone marrow biopsy d. Arterial blood gas analysis

A patient is experiencing an episode of urticaria. Which intervention should the nurse recommend to include in the teaching plan to assist the patient in controlling the symptoms of urticaria? a. Avoiding tub baths b. Taking one aspirin daily c. Using relaxation techniques d. Drinking decaffeinated coffee

A patient is prescribed a transfusion of washed packed red blood cells. What should the nurse realize as being the rationale for the using this type of blood? a. Reduces the risk of hypothermia b. Cleans the blood cells of impurities c. Reduces the risk of a febrile reaction d. Removes potential harmful particles from the blood

A patient is prescribed to receive 2 units of packed red blood cells. What approach should the nurse use to ensure that the correct blood will be provided to this patient? a. Check the patients arm band. b. Check the order on the medical record. c. Follow the organizations verification process. d. Assume the correct blood was provided by the blood bank.

A patient is scheduled for an intravenous pyelogram (IVP). What care should the nurse provide before the patient has this procedure? a. IV antibiotics b. Opioid pain medication c. Enema evening before the test d. Bedrest for 16 hours before the test

A patient is to receive a transfusion of packed RBCs. Before administering the transfusion, which action should the nurse take? a. Verify the patients kidney function. b. Verify the patients hematocrit level. c. Verify blood type of the patient and donor. d. Verify the patients admitting medical diagnosis.

A patient is using a suction device and penile ring to treat erectile dysfunction. What instructions must the patient receive to prevent tissue damage? a. Loosen the penile ring before having intercourse. b. Remove the penile ring as soon as an erection occurs. c. Remove the penile ring within 15 to 20 minutes of putting it on. d. Leave the penile ring on no more than an hour after intercourse.

A patient must prevent pregnancy while receiving chemotherapy that could harm a fetus. About which type of birth control should the nurse anticipate teaching the patient? a. Condom b. Depot medication c. Oral contraceptive d. Diaphragm with spermicide

A patient receiving blood begins complaining of severe chest pain and a feeling of warmth. What should the nurse do first? a. Call the physician. b. Administer diuretics as ordered. c. Discontinue the blood transfusion. d. Assess vital signs and cardiovascular status.

A patient receiving chemotherapy for chronic myelocytic leukemia has irritated mucous membranes. Which mouth care intervention should the nurse include in the plan of care? a. Brush teeth twice a day with a firm toothbrush. b. Use waxed floss between meals and at bedtime. c. Use sponge Toothettes to clean teeth after meals. d. Swab teeth and mucous membranes four times daily with lemon-glycerin swabs.

A patient walks into the urgent care clinic, stating that he has hemophilia and that he is bleeding. The triage nurse does a quick assessment and sees no signs of active bleeding. Several patients are already in the waiting area. Which action by the nurse is most appropriate? a. Palpate the suspected area for tenderness and edema. b. Ask the patient to sit in the waiting room until his name is called. c. Place the patient in an examination room and tell the physician that the patient may be bleeding. d. Send the patient for routine x-rays according to clinic protocol to look for a source of bleeding, and then place him in an examination room.

A patient with HIV asks the nurse if thinking about dying frequently is common with HIV. What is an appropriate response by the nurse? a. HIV is a serious disease that results in death. b. Thinking about death will not change the prognosis. c. HIV is now considered a chronic disease with treatment. d. HIV has a very high mortality rate, so it is realistic to plan for death.

A patient with Hodgkins disease has cervical lymph node enlargement. Which symptom should the nurse attend to first? a. Pain b. Fever c. Stridor d. Fatigue

A patient with anemia and a nursing diagnosis of activity intolerance due to tissue hypoxia and dyspnea is attempting to increase activity tolerance. What percentage of increase in pulse and respiratory rate should the nurse use to determine if the activity is too strenuous for the patient? a. 5% b. 10% c. 20% d. 30%

A patient with aplastic anemia is to receive an injection of erythropoietin (Epogen). The patient asks what the injection is intended to do. Which should the nurse respond to the patient? a. It will inhibit the protein that is attacking your blood cells. b. It works like a blood transfusion to give you extra red blood cells. c. It will stimulate your body to produce more of its own red blood cells. d. It will increase your energy while your body is recovering from the anemia.

A patient with gestational hypertension is exhibiting all of the signs below. What should the nurse report immediately? a. Diarrhea b. Urticaria c. Blurred vision d. Backache

A patient with glomerulonephritis develops acute kidney injury. Which form of kidney injury should the nurse realize has occurred with this patient? a. Prerenal b. Postrenal c. Intrarenal d. Suprabladder

A patient with hemophilia A is bleeding. Which treatment should the nurse anticipate being prescribed for this patient? a. IV infusion of factor IX b. IM injection of factor IX c.IV infusion of factor VIII d. IM injection of factor VIII

A patient with lymphoma wants to attend a family members wedding but is extremely fatigued. The nurse develops a plan for Activity Intolerance related to symptoms of lymphoma. How will the nurse know if the plan has been effective? a. The patient is able to sleep 8 hours at night. b. The patient can list three ways to combat fatigue. c. The patient attends the family members wedding. d. The patient verbalizes understanding of the importance of gradually increasing activity.

A pediatric nurse is assisting with the care of a child diagnosed with a fractured femur. What type of fracture would be the most likely to alert the nurse to the possibility of physical abuse? a. Stress fracture b. Compound fracture c. Spiral fracture d. Greenstick fracture

A postpartum patient experiences anaphylactic shock. What is the most likely cause? a. Pulmonary embolism b. Hypertension c. Allergy d. Blood clotting disorder

A pregnant woman inquires about exercising during pregnancy. What information should the nurse include when planning to educate this woman? a. Exercise elevates the mothers temperature and improves fetal circulation. b. Exercise increases catecholamines, which can prevent preterm labor. c. A regular schedule of moderate exercise during pregnancy is beneficial. d. Pregnant women should limit water intake during exercise.

A pregnant woman is experiencing nausea in the early morning. What recommendations would the nurse offer to alleviate this symptom? a. Eat three well-balanced meals per day and limit snacks. b. Drink a full glass of fluid at the beginning of each meal. c. Have crackers handy at the bedside, and eat a few before getting out of bed. d. Eat a bland diet and avoid concentrated sweets.

A preterm infant has a yellow skin color and a rising bilirubin level. The nurse knows that this infant is at risk for what? a. Skin breakdown b. Renal failure c. Brain damage d. Heart failure

A primigravida in her first trimester is Rh negative. What will this woman receive to prevent anti-Rh antibodies from forming? a. Rh immune globulin during labor b. Intrauterine transfusions with O-negative blood c. Rh immune globulin at 28 weeks and within 72 hours after the birth of an Rh-positive infant d. Rh immune globulin now and again in the last trimester

A primipara tells the nurse, My afterpains get worse when I am breastfeeding. What is the most appropriate nursing response? a. Ill get you some aspirin to relieve the cramping that you feel. b. Afterpains are more intense with your first baby. c. Breastfeeding releases a hormone that causes your uterus to contract. d. A change of position when youre breastfeeding might help.

A pulsating structure is felt during a vaginal examination of a woman in labor. How would the nurse position the woman to prevent compression of a prolapsed cord? a. On her right side with knees flexed b. On her left side with a pillow placed between her legs c. On her back with her head lower than the rest of her body d. Supine with her legs elevated and bent at the knee

A woman has given birth to an unresponsive newborn that NICU staff are attempting to revive. The patient and her husband are grief stricken and request the child be baptized immediately. What is the nurses most appropriate action? a. Contact the hospital chaplain. b. Request the couples clergy. c. Baptize the newborn. d. Ask the physician to baptize the newborn.

A woman has had persistent lochia rubra for 2 weeks after her delivery and is experiencing pelvic discomfort. What does the nurse explain is the usual treatment for subinvolution? a. Uterine massage b. Oxytocin infusion c. Dilation and curettage d. Hysterectomy

A woman missed her menstrual period 1 week ago and has come to the doctors office for a pregnancy test. Which placental hormone is measured in pregnancy tests? a. Progesterone b. Estrogen c. Human chorionic gonadotropin d. Human placental lactogen

A woman reports that her last normal menstrual period began on August 5, 2013. What is this womans expected delivery date using Ngeles rule? a. April 30, 2014 b. May 5, 2014 c. May 12, 2014 d. May 26, 2014

A woman who is 24 weeks pregnant is placed on an intravenous infusion of magnesium sulfate. What side effect should the nurse inform the patient that she might experience? a. Nausea and vomiting b. Headache c. Warm flush d. Urinary frequency

A woman who is 35 weeks pregnant has a total placenta previa. She asks the nurse, Will I be able to deliver vaginally? What explanation by the nurse is the most appropriate? a. Yes, you can deliver vaginally until 36 weeks. b. A vaginal delivery can be attempted, but if bleeding occurs, a cesarean section will be done. c. A cesarean section is performed when the mother has a total placenta previa. d. There is no reason why you cannot have a vaginal delivery.

A woman who is 7 weeks pregnant tells the nurse that this is not her first pregnancy. She has a 2-year-old son and had one previous spontaneous abortion. How would the nurse document the patients obstetric history using the TPALM system? a. Gravida 2, para 20120 b. Gravida 3, para 10011 c. Gravida 3, para 10110 d. Gravida 2, para 11110

A woman will be discharged 48 hours after a vaginal delivery. When planning discharge teaching, the nurse would include what information about lochia? a. Lochia should disappear 2 to 4 weeks postpartum. b. It is normal for the lochia to have a slightly foul odor. c. A change in lochia from pink to bright red should be reported. d. A decrease in flow will be noticed with ambulation and activity.

A womans prepregnant weight is determined to be average for her height. What will the nurse advise the woman regarding recommended weight gain during pregnancy? a. 10 to 20 pounds b. 15 to 25 pounds c. 25 to 35 pounds d. 28 to 40 pounds

An adolescent is diagnosed with Hodgkins disease. Lymph nodes on both sides of her diaphragm have been found to be involved, including cervical and inguinal nodes. Which disease stage is this? a. I b. II c. III d. IV

An adolescent male is admitted to the ED with severe acute scrotal pain. When documenting medical history the nurse notes cryptorchidism at birth. What diagnosis does the nurse expect? a. Urinary tract infection b. Nephrosis c. Torsion d. Phimosis

During a physical assessment of a hospitalized 5-year-old, the nurse notes that the foreskin has been retracted and is very tight on the shaft of the penis; the nurse is unable to return it over the head of the penis. What action should the nurse implement? a. Forcibly push the foreskin down over the head of the penis. b. Place a warm compress on the penis. c. Notify the charge nurse. d. Wait a few hours and try again.

During the second prenatal visit, the nurse attempts to locate the fetal heartbeat with an electronic Doppler device. How early might fetal heart tones be detected with an electronic Doppler device? a. 4 weeks b. 8 weeks c. 10 weeks d. 14 weeks

Five days after a spontaneous vaginal delivery, a woman comes to the emergency room because she has a fever and persistent cramping. What does the nurse recognize as the possible cause of these signs and symptoms? a. Dehydration b. Hypovolemic shock c. Endometritis d. Cystitis

How long should a 4-year-old child recovering from rheumatic fever need to receive monthly injections of penicillin G? a. 1 year b. 2 years c. 5 years d. 10 years

How will the nurse safely ensure tube placement when preparing to initiate a gavage feeding? a. Check tube placement by injecting air into the stomach. b. Weigh the infant before the feeding. c. Aspirate stomach contents. d. Check serum glucose level.

How would the nurse advise a mother to clear the nostrils when her infant has a cold? a. Clear the nasal passages after the infant has a feeding. b. Use over-the-counter nose drops to clear passages. c. Remove nasal secretions with a bulb syringe. d. Instill saline nose drops after clearing away secretions.

In the recovery room, the nurse checks the newly delivered womans fundus following a cesarean section. How would the nurse proceed with this assessment? a. Palpate from the midline to the side of the body. b. Palpate from the symphysis to the umbilicus. c. Palpate from the side of the uterus to the midline. d. Massage the abdomen in a circular motion.

Massage and putting the infant to the breast of a postpartum patient have been ineffective in controlling a boggy uterus. What will the nurse anticipate might be ordered by the physician? a. Ritodrine b. Magnesium sulfate c. Oxytocin d. Bromocriptine

Of what is the normal umbilical cord comprised? a. 1 artery carrying blood to the fetus and 1 vein carrying blood away from the fetus b. 1 artery carrying blood to the fetus and 2 veins carrying blood away from the fetus c. 2 arteries carrying blood away from the fetus and 1 vein carrying blood to the fetus d. 2 arteries carrying blood to the fetus and 2 veins carrying blood away from the fetus

Parents ask the nurse how their infant developed a Meckels diverticulum. What condition, will the nurse explain, is present causing this diagnosis? a. The yolk sac remains connected to the intestine. b. There is inflammation of the ileocecal valve. c. A pouch forms when the vitelline duct fails to disappear. d. There is a weakness in the abdominal wall.

Parents of a preterm infant come to the NICU every day to see their infant, who is being gavage fed. What will the nurse teaching about stimulating the infant tell the parents? a. To bring in colorful pictures and toys to place in the incubator b. That stimulating the infant during feedings increases intake c. To stroke the infant during feeding to increase intake d. Not to disturb the infant between feedings

Phototherapy is instituted for an infant. What is the most appropriate nursing action for the infant having phototherapy? a. Cover the infants head with a hat. b. Dress the infant lightly in a T-shirt. c. Keep the infants eyes covered. d. Reposition the infant at least every 4 to 8 hours.

Postoperative nursing care of the infant following surgical repair of a cleft lip would include: a. Feeding the infant with a spoon to avoid sucking b. Positioning the infant on the abdomen to facilitate drainage c. Applying elbow restraints to protect the surgical area d. Providing minimal stimulation to prevent injury to the incision

The 6-year-old scheduled for an orchiopexy shyly asks the nurse, What are they going to do to me down there? What is the nurses best response? a. They are going to fix you up down there. b. They will move your testicle from your abdomen to your scrotum. c. What do you think your doctor is going to do? d. You shouldnt worry. Your doctor knows exactly what to do.

The anxious parent asks if there is a danger of her 2-year-old child becoming addicted to the opioid pain reliever. What is the nurses most helpful response? a. Although this drug is addictive, the doctor monitors the dose very carefully. b. Dont worry. Addicted children are very easy to wean off the drug. c. Addiction is rare in children when opiates are given for pain. d. Addictive behaviors are easy to assess. The drug will be stopped if that happens.

The daughter of a male patient with hemophilia is concerned about transmitting the genetic disorder to any future children. What percentage of chance of transmitting the gene to future children should the nurse instruct the daughter? a. 10% b. 25% c. 50% d. 100%

The first child of a couple is being treated for bronchopulmonary dysplasia (BPD). They ask how to prevent this from happening with the child they are currently expecting. What will the nurse explain as the best way to prevent BPD? a. Maternal intake of folic acid b. Exercise c. Prevention of preterm birth d. Provision of oxygen therapy to the newborn

The home health nurse discovers a family infected with pediculosis. What information can the nurse provide to the mother to start eradication of the lice? a. Cover the hair with Vaseline. b. Apply a soda-vinegar solution to the hair. c. Comb through the hair with a vinegar-water solution. d. Shampoo the hair with dish detergent

The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. The panicked woman begs the nurse, Please give me something. What is the most appropriate pain relief intervention for a woman in precipitate labor? a. Get an order for an intravenous narcotic. b. Notify the anesthesiologist for an epidural block. c. Stay and breathe with her during contractions. d. Tell her to bear with it because she is close to delivery.

The nurse arrives at the start of a shift on the labor unit to find a census of four patients in active labor. Which laboring patient should the nurse attend to first? a. 18-year-old primigravida with a fetal breech presentation b. 25-year-old multigravida with history of previous cesarean section c. 35-year-old multigravida with history of precipitate birth d. 16-year-old primigravida with a twin pregnancy

The nurse assesses a pregnant woman for pregnancy-induced hypertension. What is the first sign of fluid retention suggestive of this complication? a. Abdominal enlargement b. Facial swelling c. Sudden weight gain d. Swelling of the feet and ankles

The nurse assessing a child with juvenile rheumatoid arthritis notes the childs right knee and ankle are swollen, warm, and tender. The child has a temperature of 38.8 C (102 F) and abdominal pain. What type of juvenile rheumatoid arthritis do these findings suggest? a. Psoriatic b. Enthesitis c. Systemic d. Acute febrile

The nurse contributed to a staff education program about transmission precautions to use when caring for a patient who has AIDS. Which statement by a staff member indicates a correct understanding of the teaching? a. Wear a mask for any patient contact. b. Wear a waterproof gown at all times. c. Wear clean gloves for body fluid contact. d. Wear sterile gloves for any patient contact.

The nurse contributes to the plan of care for a patient with edema. Which action should the nurse take as the best indicator of this patients fluid volume status? a. Vital signs b. Skin turgor c. Daily weight d. Intake and output

The nurse discussed strategies with a parent to prevent a recurrence of urinary tract infection in the child. Which statement made by the parent indicates a need for further teaching? a. My daughter should wash and wipe the perineal area from front to back. b. I am only going to have my daughter wear cotton underwear. c. It is acceptable to take frequent bubble baths. d. She needs to drink lots of fluids and void frequently.

The nurse enters the room of a patient with a new mastectomy and finds her crying. After confirming that the patient is crying because of the loss of her breast, which response by the nurse is best? a. At least they got all the cancer. You are fortunate. b. I know how you feel. It is difficult to lose a breast. c. How have you coped with other problems in your life? Do you have someone you can talk to? d. Here, have a tissue. I know you feel like crying now, but before you know it, you will feel much better, and this will all be behind you.

The nurse finds a woman crying after she has undergone a dilation and evacuation (D&E) for a missed abortion. What is the most appropriate statement by the nurse? a. There is usually something wrong with the fetus when this happens early in pregnancy. b. Now there. You can try to conceive on your next cycle. c. Im here if you need to talk. d. You are young and strong. I know you can have a healthy pregnancy.

The nurse has been caring for a patient with pernicious anemia. Which finding should indicate to the nurse that treatment has been successful? a. Decreased folic acid level and an increase in enlarged RBCs b. A decrease in intrinsic factor and increased vitamin B12 excreted in the urine c. An increase in vitamin B12 levels and decrease in number of enlarged RBCs d. A decrease in hydrochloric acid levels in gastric secretion and decrease in production of RBCs

The nurse has explained menstruation to a 13-year-old girl. What statement indicates the girl needs additional education? a. Periods last about 5 days. b. My cycle should get regular in 6 months. c. I should expect heavy bleeding with clots. d. Periods come about every 4 weeks.

The nurse instructed a postpartum woman about storing and freezing breast milk. What statement by the woman leads the nurse to determine that the teaching was effective? a. I can thaw frozen breast milk in the microwave. b. Ill put enough breast milk for one day in a container. c. Breast milk can be stored in glass containers. d. Breast milk can be kept in the refrigerator for up to 3 months.

The nurse is assessing a patient with chronic lung disease. Which finding indicates long-term hypoxia? a. Pallor b. Dyspnea c. Clubbed fingertips d. Pulmonary crackles

The nurse is assisting with a community education class on breast cancer prevention. Which risk factors should the nurse include in this training? a. History of breastfeeding b. Large or pendulous breasts c. High-fat diet and alcohol intake d. Early first pregnancy and late menarche

The nurse is assisting with teaching a 22-year-old female patient who is diagnosed with a sexually transmitted infection (STI). She says, I dont understand. My boyfriend always wears a condom. Which understanding by the nurse should guide teaching in this situation? a. Condoms are a reliable source of protection against STIs. b. It is a myth that condoms provide any protection against STIs. c. Condoms can decrease the risk of STIs, but they are not foolproof. d. Condoms must be used with a spermicide to guarantee protection against STIs.

The nurse is assisting with teaching a 56-year-old office manager who reports engaging in a variety of activities. Which one should the nurse explain most likely increased his risk for developing prostatitis? a. Sitting for long periods in his office b. Bowling once a week with the office team c. Drinking three to four martinis each night after work d. Having sexual intercourse with his wife once a week

The nurse is assisting with teaching a patient who has been placed on metronidazole (Flagyl) for bacterial vaginosis. What instruction by the nurse is appropriate? a. Take the Flagyl whenever you feel vaginal itching or irritation. b. Take the Flagyl until the discharge is gone for at least 24 hours. c. Take the Flagyl as prescribed, even if your symptoms are gone. d. You will need to take Flagyl for an extended period. This prescription has several refills.

The nurse is bathing an older male patient who has never been circumcised. What is proper care of the uncircumcised penis? a. Do not retract the foreskin; leave it in its natural position at all times. b. Use alcohol and a cotton swab to clean gently underneath the foreskin. c. Retract the foreskin, wash with soap and water, and replace the foreskin to its original position. d. Retract the foreskin, wash with soap and water, and leave the foreskin retracted to prevent collection of debris

The nurse is caring for a patient who had a mastectomy for breast cancer 2 days ago and is now developing pulmonary congestion. Why is a mastectomy patient at risk for pulmonary complications? a. Breast cancer has often spread to the lungs before diagnosis. b. Pathogens may have been introduced during the surgical procedure. c. The chest incision makes the patient hesitant to deep breathe and cough. d. Mastectomy patients must remain on bedrest for 48 to 72 hours postoperatively.

The nurse is caring for a patient who has AIDS. Which outcome should receive priority? a. Remain socially active. b. Report high self-esteem. c. Remain free of infection. d. Maintain baseline weight.

The nurse is caring for a patient who has an acute kidney injury. Which diagnostic test result should the nurse identify as most supporting this diagnosis? a. Hematocrit 20% (normal 38% to 47%) b. Uric acid 8 ng/dL (normal 2.5 to 5.5 ng/dL) c. 24-hour creatinine clearance 5 mL/min (normal 100 mL/min) d. Blood urea nitrogen 20 mg/100 mL (normal 8 to 25 mg/100 mL)

The nurse is caring for a patient with HIV. For which common opportunistic infection should the nurse observe when caring for this patient? a. Toxoplasmosis b. Cryptococcosis c. Candida albicans d. Cryptosporidiosis

The nurse is caring for a patient with a severe allergic reaction. Which medication should the nurse anticipate being administered to control the itching? a. Morphine b. Epinephrine c. Diphenhydramine (Benadryl) d. Hydrocortisone sodium succinate (Solu-Cortef)

The nurse is caring for a patient with anemia. Which blood component is deficient in this patient? a. Plasma b. Platelets c. Red blood cells (RBCs) d. White blood cells (WBCs)

The nurse is caring for a patient with chronic kidney disease. Which data collection technique is the best one for the nurse to use to determine this patients fluid volume status? a. Vital signs b. Skin turgor c. Daily weight d. Intake and output

The nurse is caring for a patient with severe ankylosing spondylitis. What nursing action would be most appropriate? a. Provide tepid tub soaks. b. Encourage a high-fiber diet. c. Provide activity every 2 hours. d. Administer narcotic analgesics.

The nurse is caring for a young woman who is newly diagnosed with genital warts. She states, I heard you can get cancer from STIs. Is that true? Which response by the nurse is correct? a. No, you cannot get cancer from STIs. b. Yes, most STIs can lead to cancerous changes if not treated promptly. c. Yes, some STIs have been linked to cancer, so adequate treatment is very important. d. No, that is not true, but a diagnosis of cancer does increase the risk of contracting an STI.

The nurse is dealing with a preschool-age child with a life-threatening illness. What should the nurse remember the childs concept of death is at this age? a. That it is final b. Only a fear of separation from her parents c. That a person becomes alive again soon after death d. An understanding based on simple logic

The nurse is explaining to a 17-year-old female the actions to prevent urinary tract infection. Which is the best beverage for the nurse to recommend to keep urine acidic? a. Milk b. Grape juice c. Apple juice d. Orange juice

The nurse is going to use a bulb syringe to clear mucus from a newborns nose and mouth. What is the nurses first action? a. Place the tip in the nose and squeeze the bulb gently. b. Suction secretions from the nose before the mouth. c. Depress the bulb before inserting the syringe tip into the mouth. d. Insert the tip into the back of the mouth to reach mucus.

The nurse is instructing a patient on the use of Kegel exercises. How many times a day should the nurse recommend that these exercises be performed? a. 10 to 20 b. 15 to 30 c. 30 to 80 d. 85 to 100

The nurse is planning a hypertension-prevention program. What should be the main focus of the nurse when presenting information? a. Pharmacological treatment b. Surgical interventions available c. Patient education d. Reduction of aerobic exercise

The nurse is planning a parent education program about lead poisoning prevention. What will be included regarding primary sources of lead in the community? a. Increased lead content of air b. Use of aluminum cookware c. Deteriorating paint in older buildings d. Inhaling smog

The nurse is planning to teach parents about prevention of Reyes syndrome. What information would the nurse include in this teaching? a. Use aspirin instead of acetaminophen for children with viral illness. b. Advise parents to have their children immunized against Reyes syndrome. c. Avoid giving salicylate-containing medications to a child who has viral symptoms. d. Get the child tested for Reyes syndrome if the child exhibits fever, vomiting, and lethargy.

The nurse is preparing a pregnant patient for an abdominal ultrasound at 8 weeks gestation. What intervention will the nurse implement before this diagnostic test? a. Instruct the patient to take nothing by mouth after midnight the night before the test. b. Initiate an IV. c. Encourage the patient to drink 1 to 2 quarts of water before the test. d. Instruct the patient to remove all jewelry.

The nurse is preparing teaching materials for a patient with PV. How many liters of fluid should the nurse instruct the patient to consume each day? a. 1 b. 2 c. 3 d. 4

The nurse is presenting a conference on gene dominance. What does the nurse report as the percentage of children carrying the dominant gene if one parent has a dominant gene and the other parent does not? a. 10% b. 25% c. 50% d. 100%

The nurse is providing care for a patient admitted with epididymitis. Which intervention is most appropriate? a. Frequent ambulation b. Pressure to the scrotum c. Elevation of the scrotum d. Warm packs to the scrotum

The nurse is providing care for a patient who has had a splenectomy. Which nursing action has the highest priority? a. Assess pain every shift. b. Provide a diet rich in fruits and vegetables. c. Teach the patient to cough and deep breathe every hour. d. Encourage the patient to look at the incision during dressing changes

The nurse is providing care to a child with Down syndrome. What body system has the highest risk of congenital anomaly in a child with Down syndrome? a. Reproductive system b. Genitourinary system c. Cardiovascular system d. Gastrointestinal system

The nurse is providing dietary teaching to an individual with iron-deficiency anemia. Which patient statement indicates that teaching has been effective? a. I know I need to eat more green vegetables and dairy products. b. Berries and natural cereals are good for me because of my low iron levels. c. Im going to drink orange juice for breakfast and increase red meats in my diet. d. Yellow vegetables and green tea will be important to help build up my blood levels.

The nurse is reinforcing 24-hour fluid intake teaching for a patient to prevent further UTIs. Which amount should the patient state that indicates that teaching has been effective? a. 1000 mL. b. 1500 mL. c. 3000 mL. d. 5000 mL.

The nurse is reinforcing teaching provided to a patient about antibiotics prescribed for a UTI. Which patient statement indicates teaching has been effective? a. I will take the antibiotics until my urine is no longer cloudy. b. I will take the antibiotics whenever I feel discomfort from urinating. c. I will take the antibiotics until they are gone regardless of symptoms. d. I will take the antibiotics until my temperature has been normal for 3 days.

The nurse is reinforcing teaching provided to a patient with chronic kidney disease. Which patient statement indicates the need for further teaching? a. I do not use salt substitute. b. My fluid intake is restricted. c. As long as I dont eat protein, Ill be okay. d. Since Im on dialysis, I cannot eat just anything I want.

The nurse is reviewing a urinalysis report. What should the nurse recognize as the normal average pH of urine? a. 2 b. 4.2 c. 6 d. 7.4

The nurse is reviewing the activated partial thromboplastin time for a patient receiving heparin. Which value indicates that the medication is within the therapeutic range? a. 2.5 to 9.5 minutes b. 9.5 to 11.3 seconds c. 1.5 to 2.0 times normal d. 2.0 to 3.0 times normal

The nurse is reviewing the care plan for a patient with disseminated intravascular coagulation. Which nursing intervention is most likely to cause an acute complication in this patient? a. Placing the patient on strict bedrest b. Providing a diet that is high in fat and sodium c. Administering intramuscular meperidine (Demerol) for pain d. Allowing a family member with a respiratory infection to visit

The nurse is reviewing the current patient census on a care area. Which individual is most likely to present with signs or symptoms of sickle cell anemia? a. A 1-month-old boy who is Hispanic b. A 5-year-old girl of Hispanic origin c. A 1-year-old boy who is African American d. A 3-month-old girl who is African American

The nurse is reviewing the results of a patients arterial blood gas analysis. What should the nurse recognize as being a normal blood pH? a. 7.29 b. 7.31 c. 7.38 d. 7.48

The nurse is speaking to the parent of a 3-year-old child who has mild diarrhea. What dietary modification would the nurse advise? a. Soft foods with rice, bananas, toast, and applesauce b. Small amounts of clear fluids such as gelatin c. An oral rehydrating solution, such as Pedialyte d. Chicken soup because it is high in sodium

The nurse is teaching a parent about pyrvinium (Povan). What would be included in regard to potential side effects? a. Diarrhea b. Skin rash c. Red stool d. Metallic taste

The nurse is teaching a patient the importance of completing treatment for gonorrhea. On which information is the nurse basing this teaching? a. Gonorrhea is not treatable. b. Only men experience symptoms; women are usually asymptomatic. c. Men and women may be asymptomatic and still transmit the infection. d. Treatment is associated with many serious side effects, so compliance is low.

The nurse is teaching a woman with a menstrual disorder how to measure menstrual flow. Which instruction should the nurse include? a. Use a perineal collection system. b. Use a vaginal catheter and collection bag. c. Weigh her perineal pads before and after use. d. Weigh the woman before and after her menses.

The nurse is to obtain orthostatic blood pressure measurements for a patient on dialysis for end-stage renal disease. What should the nurse do when measuring this patients blood pressure? a. Take blood pressure before and after dialysis treatments. b. Check blood pressure every minute three times for four readings. c. Obtain blood pressure while the patient is lying, sitting, and standing. d. Monitor blood pressure before and after an antihypertensive medication is given.

The nurse must bathe a patient with herpes. What is the nurses best protection against contracting sexually transmitted infections (STIs) from patients while providing perineal hygiene? a. Wearing gloves at all times b. Washing hands following care c. Practicing standard precautions d. Avoiding touching patients who have STIs

The nurse must make a room assignment for a 16-year-old with cystic fibrosis. Which roommate would be the most appropriate for this patient? a. A 4-year-old child who had an appendectomy b. A 10-year-old child with sickle cell disease in vaso-occlusive crisis c. A 15-year-old with type 1 diabetes mellitus d. To assign the adolescent to a private room

The nurse observes a childs position is supine with his arms and legs rigidly extended and the hands pronated. How does the nurse identify this posture? a. Correct anatomical position b. Decorticate c. Decerebrate d. Opisthotonos

The nurse observes a tarry stool from a 16-year-old burn victim who has been in the ICU for 2 weeks. Which complication does the nurse document and report? a. Diverticulitis b. Stress diarrhea c. Curlings ulcer d. Perforated bowel

The nurse observes that the legs of a child with cerebral palsy cross involuntarily, and the child exhibits jerky movements with his arms as he tries to eat. The nurse recognizes that he has which type of cerebral palsy? a. Athetoid b. Ataxic c. Spastic d. Mixed

A patient reports long, heavy, irregular menses accompanied by headache and back pain for the past several months. How should the nurse document these symptoms? a. Polymenorrhea b. Oligomenorrhea c. Hypermenorrhea d. Menometrorrhagia

The nurse preparing to administer medication to a 2-month-old infant discovers there is no ID bracelet on the child. What should be the next action by the nurse? a. Give the medication after confirming the childs name from the foot of the crib. b. Ask the charge nurse to give the medicine. c. Confirm the identity with the charge nurse, make a new bracelet, and give the medicine. d. Delay the medication until the admissions office can supply a new ID bracelet.

The nurse recommends the diagnosis Disturbed Body Image for a patient with systemic lupus erythematosus. What would be an appropriate long-term outcome for this patient? a. Engages in diversional activities b. Uses normal coping mechanisms c. Returns to previous social involvement d. Verbalizes feelings about body changes

The nurse reviews the ways to prevent condom breakage with a patient. Which patient statement indicates that more teaching is necessary? a. Condoms should never be reused. b. I should use a water-soluble lubricant. c. Before I use a condom, I should inflate it and check it for holes and leaks. d. I should make sure to leave a half inch extra space at the end of the condom.

The nurse uses a diagram to demonstrate the fimbriae when teaching nursing students about the female anatomy. What is true about fimbriae? a. They form the passageway for the sperm to meet the ovum. b. They are the site of fertilization. c. They are fingerlike projections that capture the ovum. d. They propel the egg through the fallopian tube.

The parents of a hospitalized toddler are upset because she seems more interested in her toys when they come to visit her. In which stage of separation anxiety is the toddler? a. Protest b. Despair c. Denial d. Attachment

The parents of a newborn are concerned that their sons scrotum is enlarged and swollen on one side. What is the nurses best response? a. It is very common in the newborn that one gonad is larger than the other. b. Birth trauma caused bruising to the scrotum. It will reduce in size in a few days. c. It is a collection of fluid that will most likely correct itself in a year. d. The doctor will drain this collection of blood before your baby is discharged.

The patient remarks that she has heard some foods will enhance brain development of the fetus. The nurse replies that foods high in docosahexaenoic acid (DHA) are thought to enhance brain development. What food can the nurse recommend? a. Fried fish b. Olive oil c. Red meat d. Leafy green vegetables

The patient who is 28 weeks pregnant shows a 10-pound weight gain from 2 weeks ago. What is the nurses initial action? a. Assess food intake. b. Weigh the patient again. c. Take the blood pressure. d. Notify the physician.

The pediatric nurse is caring for child that weighs 15 kilograms and calls the physician for an order for Acetaminophen for pain control. What is the maximum amount of medication per dose the nurse anticipates ordering? a. 100 mg b. 150 mg c. 225 mg d. 250 mg

The treatment provided to a patient with prostatitis is being evaluated. What information should the nurse use to determine that treatment has been successful? a. No evidence of erectile dysfunction b. Stabilized hemoglobin and hematocrit levels c. Clean catch urine specimen absent of bacteria d. Prostate specific antigen level within normal limits

What action does the nurse implement to protect newborns from infection while in the nursery? a. Keep the newborn dressed warmly. b. Adjust room temperature between 23.8 C (75 F) and 26.6 C (80 F). c. Wash hands before touching each infant. d. Wear a disposable gown when giving infant care

What assessment does the school nurse recognize as the cardinal sign of a hyphema? a. Opacity of the lens b. A yellow-white reflex on the pupil c. A dark-red spot in front of the iris d. Inflamed mucous membranes of the eyelids

What characteristic manifestation does the nurse caring for a child with Duchennes muscular dystrophy document? a. Ambulates by holding onto furniture b. Exhibits atrophy of the calf muscles c. Falls frequently and is clumsy d. Has delayed fine-motor development

What classic sign would the nurse, auscultating the breath sounds of a child hospitalized for an acute asthma attack, expect to find? a. Fine crackles b. Coarse rhonchi c. Expiratory wheezing d. Decreased breath sounds at lung bases

What does the nurse expect the appearance of the stools of a child with celiac disease to be? a. Ribbon like b. Hard, constipated c. Bulky, frothy d. Loose, foul-smelling

What drug will the nurse plan to have available for immediate IV administration whenever magnesium sulfate is administered to a maternity patient? a. Ergonovine maleate (Ergotrate) b. Oxytocin c. Calcium gluconate d. Hydralazine (Apresoline)

What factor does the nurse explain affects the infants physiological response to medications? a. Faster metabolism in the liver b. Slower intestinal transit c. Immature kidney function d. Increased secretion of hydrochloric acid

What important focus of nursing care for the dying child and the family should the nurse implement? a. Nursing care should be organized to minimize contact with the child. b. Adequate oral intake is crucial to the dying child. c. Families should be made aware that hearing is the last sense to stop functioning before death. d. It is best for the family if the nursing staff provides all of the childs care.

What instruction would the nurse provide to an adolescent who has been fitted with a Milwaukee brace? a. Wear the brace directly against the skin. b. Wear the brace over regular clothing. c. Wear the brace over a T-shirt 23 hours a day. d. Remove the brace before sleeping

What intervention should the nurse implement after topical administration of hydrocortisone cream to the buttocks and abdomen of an infant? a. Diaper the infant snugly with a disposable diaper. b. Cover the area with a transparent dressing. c. Apply a cloth diaper. d. Place the infant on a plastic pad, undiapered.

What is accurate about the characteristics of high-density lipoproteins (HDLs)? a. They have high amounts of triglycerides. b. They have only small amounts of protein. c. They have little cholesterol. d. They aid in steroid production.

What is the best suggestion by the nurse when parents ask, When is the best time to begin to prepare a 5-year-old for surgery and hospitalization? a. As soon as the surgery is scheduled b. About 2 weeks before surgery c. About 4 days before surgery d. On the night before admission to the hospital

What is the best way for the nurse to communicate with a 10-year-old child who has a hearing impairment? a. Use gestures and signs as much as possible. b. Let the childs parents communicate for her. c. Face the child and speak clearly in short sentences. d. Recognize that the childs ability to communicate will be on a 6-year-old childs level

What is the embryonic membrane that contains fingerlike projections on its surface, which attach to the uterine wall? a. Amnion b. Yolk sac c. Chorion d. Decidua basalis

What is the nurses best response to a mother who is voicing concern about the molding of her 2-day-old infant? a. Molding doesnt cause any problems. Dont worry about it. b. Did you deliver vaginally or by cesarean section? c. The babys head conformed to the shape of the birth canal. It will go away soon. d. A traumatic delivery can cause molding.

What is the rationale for placing a preterm infant born at 34 weeks of gestation in an incubator? a. The infant has a small body surface-to-weight ratio. b. Heat increases the flow of oxygen to the extremities. c. The infants temperature control mechanism is immature. d. Heat within the incubator facilitates drainage of mucus.

What nursing action will the nurse implement after feeding an infant with hydrocephalus? a. Position the infant sitting upright in an infant seat. b. Place the infant over the shoulder to burp. c. Leave the infant in a side-lying position. d. Stimulate the infant by rubbing its feet.

What nursing assessment should be reported immediately after an amniotomy? a. Fetal heart rate is regular at 154 beats/min. b. Amniotic fluid is clear with flecks of vernix. c. Amniotic fluid is watery and pale green. d. Maternal temperature is 37.8 C.

What part of the fetal body derives from the mesoderm? a. Nails b. Oil glands c. Muscles d. Lining of the bladder

What should the nurse keep in mind when providing care to the school-age child hospitalized with a burn injury? a. Hospitalization will be brief. b. Analgesics should be given immediately after dressing changes. c. Contact with peers should be maintained. d. Parents usually handle injury worse than the child.

What should the nurse, preparing to collect an admission history from parents who have recently emigrated from Russia, keep in mind? a. Eye-to-eye contact is considered disrespectful. b. Touching the childs head means the nurse is superior. c. Smiling is inappropriate in a serious situation. d. Staring is a sign of the nurses rudeness.

What should the nurses first action be when postpartum hemorrhage from uterine atony is suspected? a. Teach the patient how to massage the abdomen and then get help. b. Start IV fluids to prevent hypovolemia and then notify the registered nurse. c. Begin massaging the fundus while another person notifies the physician. d. Ask the patient to void and reassess fundal tone and location.

What statement indicates the parent understands the guidelines for bathing a newborn? a. Ill use a mild soap to clean all of the body parts. b. I am going to add bath oil to the water to keep the babys skin soft. c. I should shampoo the head after washing the rest of the body. d. Ill wash from the feet upward and change the washcloth for the face.

What symptom leads the nurse caring for a 5-month-old with viral influenza to suspect the development of Reyes syndrome? a. Respirations drop from 18 to 14 breaths/min b. Falling asleep after feeding c. Sudden vomiting without effort d. Development of a macular rash

What symptom presented by a pregnant women is indicative of abruptio placentae? a. Painless vaginal bleeding b. Uterine irritability with contractions c. Vaginal bleeding and back pain d. Premature rupture of membranes

What will the nurse begin with when asking a patient about drug use during a prenatal history? a. Do you smoke, drink alcohol, or use drugs? b. Do you ever use prescription or street drugs? c. What over-the-counter and prescription drugs have you taken in the past 3 months? d. We need to know if you take drugs so we can help your baby.

What will the nurse explain to a 12-year-old patient when describing what characterizes nocturnal emissions? a. A drop in testosterone level b. Sexual stimulation c. Absence of sperm in ejaculate d. Association with violent dreams

What will the nurse include when caring for a child in Bucks extension? a. Positioning the child with hips flexed 90 degrees at all times b. Keeping the weights in contact with the floor c. Checking for skin irritation from traction equipment d. Releasing the weights on a schedule

What will the nurse teach parents when giving instructions for acute conjunctivitis? a. Apply cool compresses to the affected eye several times a day. b. Instill topical steroid eye drops for 1 week. c. Clear drainage from the inner to the outer aspect of the eye. d. Keep the eye patched until the inflammation resolves.

What will the nurses instructions for a new mother to care for the infants umbilical cord include? a. Keeping the area covered with a sterile dressing b. Dressing the stump with antibiotic ointment at every diaper change c. Fastening the diaper low to allow for air circulation d. Giving the newborn a daily tub bath until the cord falls off

What would the nurse include in planning teaching to parents of a child with Legg-Calv-Perthes disease about the long-term effects of this disease? a. There are no long-term effects. b. The disease is self-limited and requires no long-term treatment. c. Degenerative arthritis may develop later in life. d. There is risk of osteogenic sarcoma in adulthood

What would the nurse include in teaching when preparing to teach parents about air travel instructions to prevent barotrauma in infants? a. Using ear plugs during takeoff b. Omitting the meal just before takeoff c. Letting the infant nurse during descent d. Applying ear drops before takeoff

What would the nurse include when creating a teaching plan that includes the long-term administration of phenytoin (Dilantin)? a. The medication should be given on an empty stomach. b. Insomnia can be a significant side effect. c. Gums should be massaged regularly to prevent hyperplasia. d. Blood pressure should be closely monitored.

What would the nurse include when planning postoperative teaching for a child who has had a tympanostomy with insertion of tubes? a. Keeping the infant flat after feeding b. Giving over-the-counter decongestants c. Avoiding getting water in the ears d. Cleaning the ear canal with cotton-tipped applicators

When assessing a neonate born at 38 weeks of gestation, the nurse records his weight as 8 pounds, 10 ounces. What will the nurse consider this newborn? a. Term b. Small for gestational age c. Large for gestational age d. Late preterm

When auscultating breath sounds of an infant with respiratory syncytial virus, which assessment would the nurse immediately report? a. Respiration rate decrease from 40 to 32 breaths/min b. Heart rate decrease from 110 to 100 beats/min c. Quiet chest from previous assessment of wheezing d. Oxygen saturation of 90%

Where are the secretions responsible for nourishing sperm excreted from? a. Vas deferens b. Epididymis c. Cowpers gland d. Scrotum

Which initial intervention will the nurse suggest to the parents of a child experiencing laryngeal spasm? a. Take the child outside in the cool air. b. Bring the child directly to the emergency department. c. Take the child to the bathroom and turn on a hot shower. d. Have the child drink plenty of fluids

Which intervention will the nurse implement when suctioning a tracheostomy? a. Suction for two to three breaths. b. Clear the catheter with water after suctioning for reuse. c. Apply suction for no more than 15 seconds. d. Establish a regular schedule for suctioning.

Which statement indicates that the childs parents understand how to perform respiratory therapy? a. We do her postural drainage before the aerosol therapy. b. We give her respiratory treatments when she is coughing a lot. c. We give the aerosol followed by postural drainage before meals. d. She needs respiratory therapy every day when she has an infection

Which statement made by a parent alerts the nurse to the need for additional education about poison prevention? a. I keep the poison control center phone number easily accessible. b. All medication is kept out of reach in a locked cabinet. c. I keep a bottle of syrup of ipecac handy. d. Our garden is free from marigolds.

Which statement made by a parent of a child with nephrotic syndrome indicates an understanding of discharge teaching? a. I will make sure he gets his measles vaccine as soon as he gets home. b. He can stop taking his medication next week. c. I should check his urine for protein when he goes to the bathroom. d. He should eat a low-protein diet for the next few weeks.

While assisting a health care provider (HCP) conduct a pelvic examination, the patient complains of severe pain during the bimanual examination. For which health problem should the nurse suspect this patient is going to need care? a. Syphilis b. Gonorrhea c. Pelvic inflammatory disease d. Human papillomavirus infection

While inspecting a newborns head, the nurse identifies a swelling of the scalp that does not cross the suture line. How would the nurse refer to this finding when documenting? a. Molding b. Caput succedaneum c. Cephalohematoma d. Enlarged fontanelle

While reviewing a medical record the nurse notes that patient has a strawberry cervix. For which sexually transmitted infection (STI) would the nurse plan care? a. Gonorrhea b. Herpes simplex c. Trichomoniasis d. Human papillomavirus infection

Why are infants more vulnerable to fluid and electrolyte imbalances than adults? a. They have a smaller surface area than adults in proportion to body weight. b. Water needs and losses per kilogram are lower than those for adults. c. A greater percentage of body water in infants is extracellular. d. Infants have a lower metabolic turnover of water.

Why are rapid respirations a possible cause of dehydration? a. They prevent the child from drinking. b. They increase circulation, thus increasing urine production. c. They cause evaporation of fluid on the mucous membranes. d. They often lead to vomiting.

Why is a tympanic thermometer considered more accurate than other types of thermometers? a. The thermometer probe is blunt and wide. b. It takes a brief time to register. c. The tympanic membrane shares circulation with the hypothalamus. d. The tympanic membrane and the brain have the same temperature

a patient returns to the observation area after outpatient submucous resection for a deviated septum. which of the following observations is most concerning? a. blood pressure of 136/88 b. patient complains of tenderness in nasal area c. patient swallows frequently d. patients mustace dressing has a 2 cm area of blood on it

nurse answers a call light and finds patient gasping for breath and looking very anxious. nurse believes the patient ay be experiencing a pulmonary embolism. which action should be done first? a. place patient in left lateral position b. page physician c. yell for help and start oxygen d. check the patients vitals

nurse teaches a patient with tuberculosis about drug therapy. which of the following statements indicates patient teaching has been effective? a. i will have to take antibiotics for 10 days b. i will get a prescription for 2 weeks of antibiotics c. i will probably need to be on antibiotic therapy for 6 months to 2 years d. i will have to take antibiotics for the rest of my life

which action by the nurse is most important after laryngectomy surgery? a. keep head of bed elevated b. assess patients acceptance of the laryngectomy c. maintain a patent airway d. control postoperative pain

which is the most important chemical regulator of respiration? a. blood level of oxygen b. amount of hemoglobin in red blood cells c. blood level of carbon dioxide d. blood level of nitrogen

What occurrence results from obstruction within the ventricles of the brain or inadequate reabsorption of cerebrospinal fluid? a. Meningitis b. Meningocele c. Spina bifida occulta d. Hydrocephalus

A patient at the obstetric office has just learned she is pregnant with dizygotic twins. What facts will the nurse include when educating this patient? (Select all that apply.) a. Dizygotic twins are the same sex. b. Dizygotic twins share a placenta. c. Dizygotic pregnancies tend to repeat in families. d. Dizygotic twins have separate chorions. e. Dizygotic twin incidence decreases with maternal age.

c, d

A patient diagnosed with syphilis reminds the HCP of having an allergy to penicillin. Which medications should the nurse expect to be prescribed for this patient? (Select all that apply.) a. Gentamicin b. Amoxicillin c. Tetracycline d. Doxycycline e. Erythromycin

c, d

A patient is planning to have an allogeneic bone marrow transplant. What will the patient most likely have completed before this transplant occurs? (Select all that apply.) a. Electrophoresis b. Peritoneal dialysis c. Total body irradiation d. High-dose chemotherapy e. Massive blood transfusions

c, d

A patient with type O+ blood is to receive 4 units of packed red blood cells. Which type of blood should the nurse expect to see prepared for this patient? (Select all that apply.) a. Type A+ b. Type AB- c. Type O+ d. Type O- e. Type B- f. Type A-

c, d

A school-aged child is living with a chronic disease process. How would the nurse anticipate chronic illness will effect growth and development? (Select all that apply.) a. Delayed bonding with parents b. Delayed toilet training c. Impaired sense of belonging d. Decreased feelings of independence e. Impaired speech development

c, d

The nurse is contributes to the plan of care for an older patient. What should the nurse recognize as normal signs of aging within the renal system? (Select all that apply.) a. Bladder size increases b. Urethral changes position c. Number of nephrons decreases d. Detrusor muscle tone decreases e. Glomerular filtration rate increases

c, d

The nurse performing a neurovascular check on a limb in traction would report and document which finding(s) as indicative of altered circulation? (Select all that apply.) a. Pulse is equal to uncasted limb. b. Patient is aware of touch and warm and cold application. c. Limb is cool to the touch. d. Capillary refill is 5 seconds. e. Distal limb can flex and extend.

c, d

A woman who is 36 weeks pregnant tells the nurse she plans to take a 12-hour flight to Hawaii. What would the nurse recommend that the patient do during the flight? (Select all that apply.) a. Wear tight-fitting clothing to promote venous return. b. Eat a large meal before boarding the flight. c. Request a seat with greater leg room. d. Drink at least 4 ounces of water every hour. e. Get up and walk around the plane frequently.

c, d, e

While participating in the creation of a teaching plan, the nurse suggests that a patient ingest cranberry juice every day to reduce the risk of developing a UTI. What information did the nurse use to make this suggestion? (Select all that apply.) a. The fiber in cranberries reduces the amount of sediment in the urine. b. Cranberries facilitate the removal of fluid from the interstitial spaces. c. Compounds in cranberries inhibit the adherence of E. coli to the urogenital mucosa. d. Cranberries reduce the incidence of UTIs in patients after renal transplants. e. Cranberries contain a substance that prevents bacteria from sticking on the walls of the bladder.

c, d, e

A female patient approaching menopause asks about the use of hormone replacement therapy. Which findings from a study on hormone replacement therapy should the nurse explain to the patient? (Select all that apply.) a. A decrease in strokes b. A decrease in breast cancer c. An increase in heart attacks d. A reduction in total fractures e. A decrease in colorectal cancer f. An increase in thromboembolism

c, d, e, f

The nurse is providing care for a woman with trichomoniasis who is being treated with metronidazole (Flagyl). Which patient statements indicate that teaching has been effective? (Select all that apply.) a. I might notice a metallic taste with this medication. b. This medication should be taken on an empty stomach. c. I should take this medication until the symptoms are gone. d. I may have some vaginal dryness while taking this medication. e. My partner should see a physician for treatment as well. f. Drinking alcohol while taking this medication will cause nausea and vomiting.

c, d, e, f

Parents are preparing their child for admission to the pediatric unit for minor surgery. What should they expect to see when visiting the pediatric unit? (Select all that apply.) a. Nurses wearing all white b. Formal atmosphere c. Availability of a playroom d. Dim lighting e. Colored bedding

c, e

A patient is recovering from a renal arteriogram. What actions should the nurse take when caring for this patient? (Select all that apply.) a. Check vital signs twice daily. b. Raise the head of the bed to 90 degrees. c. Check distal pulses in leg every 30 to 60 minutes. d. Encourage the patient to ambulate as soon as possible. e. A pressure dressing and sandbag used to apply pressure. f. Implement bedrest for 12 hours, and instruct the patient not to bend leg.

c, e, f

The nurse is reviewing data for a patient with acute kidney injury. Which diagnostic test results should the nurse recognize that indicate kidney injury? (Select all that apply.) a. Hematocrit 20% b. Uric acid 8 ng/dL c. Serum creatinine 4.2 mg/dL d. Blood urea nitrogen 40 mg/100 mL e. Urine output of 100 mL in 24 hours f. Fixed urine specific gravity of 1.010

c, e, f

A patient with chronic kidney disease has a serum potassium level of 6 mEq/L. Which action should the nurse take? (Select all that apply.) a. Obtain consent for hemodialysis. b. Administer the patient an antacid. c. Place the patient on a cardiac monitor. d. Give the patient a glass of orange juice. e. Repeat laboratory test of electrolyte levels. f. Inform RN to notify physician.

c, f

The nurse is reviewing the results of a patients urinalysis. Which components should the nurse identify as being abnormal in urine? (Select all that apply.) a. Urea b. Water c. Protein d. Ammonia e. Hormones f. Red blood cells

c, f

16. The nurse enters the room of a patient who is 1 day postoperative left-sided mastectomy and notes a phlebotomist taking blood from her left antecubital space. What should the nurse do first? a. Nothing; the nurse is not the phlebotomists's supervisor. b. Nothing; blood pressures should be avoided in the affected arm, but blood draws are safe. c. Stop the phlebotomist and point out that needlesticks must be avoided in the affected arm. d. Notify the physician.

c. Because of compromised circulation in the affected arm, needlesticks and blood pressure measurements should be avoided

21. A patient with benign prostatic hyperplasia expresses concern that he has cancer. Which response by the nurse is best? a. "Don't worry; prostatic hyperplasia is not the same thing as cancer." b. Since it is called benign, you don't have to worry about it. No treatment should be necessary; you will just need to have it watched." c. "Hyperplasia means your prostate is growing too many cells. They are not cancerous, but they could interfere with your ability to urinate, so it is important to have it treated. d. "You are correct, it is a form of cancer, but it is very slow growing and very treatable. Your doctor will recommend treatments for you."

c. Benign prostatic hyperplasia is not cancer, but it must be treated. Telling a patient not to worry is inappropriate

45. Which response by the nurse is most appropriate when a 60-year-old woman who has been menopausal for several years relates that she has begun having vaginal bleeding again? a. "Don't be concerned--it's perfectly normal." b. "Try taking some ibuprofen. That may reduce the bleeding." c. "You should see a physician to have that checked as soon as possible." d. "Give it time--bleeding after menopause usually goes away within a month."

c. Bleeding again after menopause is always cause for concern

22. A young woman is seen at a walk-in clinic and is diagnosed with an STD. She says, "How could I have an STD? I only have sex with my boyfriend. I don't sleep around!" Which of the following responses by the nurse is best? a. "You are right, that should have kept you safe. There just are no guarantees." b. "If your boyfriend is not infected, then it is apparent that you have had sex with someone else." c. "You or your boyfriend could be infected from past sexual encounters. He should also be tested at this time for STDs." d. "Even lifelong monogamy cannot prevent many STDs."

c. Having a sexual relationship with someone is the epidemiological equivalent of engaging in sexual activity with all of that person's previous partners

2. An older man is admitted to the hospital with mental status changes. As the nurse begins the shift assessment, the patient begins to cry and says his doctor thinks his problems stem from an untreated syphilis infection when he was in the military as a young man. Which response by the nurse is the best? a. "Why didn't you have it treated when it occurred?" b. "What's done is done; it's unfortunate that treatment is too late now." c. "That must be upsetting for you. Do you want to talk about it?" d. "Don't cry; I am sure there is treatment that can help now."

c. The man's statement indicates that he would like to talk. Selection c is a therapeutic response that gives the man permission to talk further

A newborn is born with hypothyroidism. A complication of this disorder if it is not recognized and treated is a) cognitive impairment. b) blindness. c) dehydration. d) muscle spasticity.

cognitive impairment. Correct Explanation: Congenital hypothyroidism can lead to extreme cognitive challenge impairment if not treated.

A 12-year-old female pediatric patient experienced menarche 3 months ago. Her mother voices concern to the pediatric office nurse regarding the irregularity of her daughters menstrual cycle. What is the nurses best response? a. Worrying is not the answer. b. I will talk to the pediatrician about a gynecological referral. c. I can only discuss this with your daughter. d. Early cycles are often irregular.

A 16-year-old girl is admitted to the hospital with toxic shock syndrome (TSS). Which action by the nurse should take priority? a. Teach the girl risk factors for TSS. b. Teach the girls mother risk factors for TSS. c. Educate the girl on signs and symptoms of TSS. d. Determine what the girl understands about risk factors for TSS.

A 19-year-old patient reports flank pain and scanty urination. The nurse notices periorbital edema, and the urinalysis reveals white blood cells, red blood cells, albumin, and casts. What question would be most important for the nurse to include in data collection? a. Is your vision blurred? b. Are you sexually active? c. Have you had any gastrointestinal problems lately? d. Have you had a strep infection of the throat or skin recently?

A 30-year-old male patient has just received a diagnosis of testicular cancer. He appears sad and states, I always wanted to have children. Now it will be impossible. What nursing intervention would be most helpful? a. Contact pastoral care to counsel the patient. b. Provide the patient with literature about adoption. c. Inform the patient that children will be out of the question. d. Tell the patient that it may be possible to deposit sperm in a sperm bank before treatment is begun.

A 4-week postpartum patient with mastitis asks the nurse if she can continue to breastfeed. What is the nurses most helpful response? a. Stop breastfeeding until the infection clears. b. Pump the breasts to continue milk production, but do not give breast milk to the infant. c. Begin all feedings with the affected breast until the mastitis is resolved. d. Breastfeeding can continue unless there is abscess formation.

A 4-year-old begins to cry when his mother tells him it is time for his operation. The nurse understands this is an expected reaction. On which particular fear of the preschooler does the nurse base this understanding? a. Loss of control b. Restricted mobility c. Unfamiliar routines d. Invasive procedures

A 5-year-old boy is admitted to the hospital with acute glomerulonephritis. In taking the childs history, what does the nurse recognize as the probable cause? a. Recovery from German measles 2 months ago b. Dysuria since the previous night c. A history of allergy d. A sore throat 2 weeks ago

A 50-year-old woman states, It is such a relief not to need birth control any more. I havent had a period in 3 months. How should the nurse respond? a. Birth control is usually unnecessary after age 50, even if you are still having periods. b. It is still possible for you to get pregnant. You should consider having a tubal ligation. c. You should continue to use birth control for at least 6 months after cessation of your periods. d. You may still be fertile for several months after your last period. You should consult with your physician to know when to stop using birth control.

An adolescent girl with acne is being treated with an antibiotic in addition to topical applications. What side effect does the nurse caution the girl to expect? a. Lessened effectiveness of oral contraceptives b. Urinary burning and frequency c. Breast engorgement d. Vaginitis

A 9-year-old child is preparing for a lumbar puncture. What position will the nurse explain the child will assume for this procedure? a. On your stomach with your head turned to the side. b. On your side, keeping the legs bent and the head arched back. c. On your back with your legs extended straight out. d. On your side with the knees bent and the head close to the knees.

A child has just been diagnosed with acute lymphoblastic leukemia. What is the result of an overproduction of immature white blood cells in the bone marrow? a. Decreased T-cell production b. Decreased hemoglobin c. Increased blood clotting d. Increased susceptibility to infection

A child with thalassemia major receives blood transfusions frequently. What is a complication of repeated blood transfusions? a. Hemarthrosis b. Hematuria c. Hemoptysis d. Hemosiderosis

A female patient has just learned that she is infertile. She says, All I ever wanted in life was to have a baby. My life is over. What is the best response by the nurse? a. You are overreacting because you are upset. Your life really is not over. b. You have a wonderful husband. Maybe you should think about adoption. c. There is an infertility clinic I just heard about in Mexico. Do you want the address? d. A baby must have been very important to you. When you feel ready, we can talk about other alternatives.

A male patient has a curved penis. What term should the nurse use to document this observation? a. Priapism b. Phimosis c. Paraphimosis d. Peyronies disease

A male patient is experiencing erectile dysfunction. For which medication classification should the nurse assess if the patient is prescribed? a. NSAIDs b. Antibiotics c. Antidiabetics d. Antihypertensives

A mother asks the nurse, When will I know my child has entered puberty? What will the nurse state based on an understanding of changes associated with puberty? a. Your daughter will have her first period. b. Youll recognize puberty by the mood swings. c. The child becomes interested in the opposite sex. d. Secondary sex characteristics, such as pubic hair, appear.

A mother is concerned about what might have caused a heat rash on her infant. The nurse observes tiny pinhead-sized reddened papules on the infants neck and axilla. What does the nurse explain as the most likely cause of this rash? a. Sun exposure b. Allergic reaction c. Infection d. Heat and moisture

A new mother is distressed and tearful about the elevated dome over her infants posterior fontanelle. The nurse responds, This condition will resolve itself in a few days. What is the cause? a. Prolonged pressure against the partially dilated cervix b. Small leak of fluid through the posterior fontanelle c. Pressure of the forceps during delivery d. The effect of the vacuum extractor

A parent comments that her infant has had several ear infections in the past few months. Why are infants more susceptible to otitis media? a. Infants are in a supine or prone position most of the time. b. Sucking on a nipple creates middle ear pressure. c. They have increased susceptibility to upper respiratory tract infections. d. The eustachian tube is short, straight, and wide.

A patient asks why the physician has recommended systemic interferon treatment for genital warts. Which explanation should the nurse provide to the patient? a. Interferon can improve liver function. b. Interferons can increase your red blood cell count. c. Interferon treatment does not have any side effects. d. Interferon therapy can attack warts all over the body at the same time.

A patient asks, What is the main purpose of these medications I take for my HIV? Which response should the nurse make? a. They encapsulate the virus-infected cells. b. They mark the virus for natural killer cells to destroy. c. They attract macrophages to the cells making the virus. d. They inhibit enzymes to interfere with viral production.

A patient at a walk-in clinic requests oral contraceptives (OCs) because she heard they can prevent sexually transmitted infections (STI). What information should the nurse use to base a response to this patient? a. OCs provide excellent protection against most STIs. b. There is no connection between OC use and risk of STIs. c. Only OCs with estrogen and progestin can prevent STIs. d. Not enough research has been done to prove that OCs can prevent STIs.

A patient comes into the emergency department with a fear of developing poison ivy after falling while walking through a wooded area earlier in the day. What should the nurse instruct the patient to do if exposure to poison ivy occurs again? a. Flood the area with cold water. b. Wrap the area with a thick towel. c. Cover the area with cotton gauze. d. Wash the area with brown soap or any soap.

A patient has a glomerular filtration rate of 55%. What should this value indicate to the nurse? a. This is a normal value. b. The patient is in renal failure. c. The patient needs to be on a fluid restriction. d. The patients other tests will be in the normal range.

A patient has a platelet count of 20,000/mm3. What action should the nurse take? a. Assist out of bed to a chair b. Draw another blood sample c. Measure a rectal temperature d. Place on bleeding precautions

A patient is being prepared to receive a prescribed blood transfusion. What is the best way that the LPN can assist the health team to prevent a transfusion reaction? a. Monitor vital signs every 15 minutes. b. Warm blood to 98.6F (37C) before infusion. c. Administer diphenhydramine (Benadryl) before the infusion. d. Assist the registered nurse (RN) to identify correctly the patient and the blood product

A patient is diagnosed with end-stage kidney disease. The nurse realizes that what percentage of functioning nephrons have been lost in this patient? a. 25% b. 50% c. 75% d. 90%

A patient is undergoing treatment that involves the burning of lesions with heat or chemical agents. The nurse recognizes that this patient most likely has which condition? a. Syphilis b. Chlamydia c. Hepatitis B d. Genital warts

A patient receiving blood complains of dyspnea. The nurse auscultates the patients lungs and finds crackles that were not present before the start of the transfusion. Which type of reaction should the nurse suspect? a. Urticarial b. Hemolytic c. Anaphylactic d. Circulatory overload

A patient who has HIV asks the nurse why blood work has to be done so frequently. Which response should the nurse make to the patient? a. B-lymphocyte levels increase if you have an acute infection. b. Phagocytes are decreased when the disease is in an active phase. c. Neutrophil counts help the doctor titrate medication levels to keep you healthy. d. CD4+ lymphocyte counts are monitored to determine the progression of the disease.

A patient who has diabetic nephropathy asks the nurse, Why am I using smaller doses of insulin than I used to? What would be the best explanation by the nurse? a. Insulin is now more potent than it used to be. b. It would be best if you spoke with your physician about this. c. You have probably decreased the amount of food you are eating. d. Your kidneys are no longer breaking down the insulin as much as before.

A patient who is on hemodialysis for chronic kidney disease is prescribed sevelamer hydrochloride (Renagel) with meals. What explanation should be provided to the patient as the primary reason the medication is being given? a. To prevent metabolic acidosis b. To prevent gastrointestinal ulcer formation c. To relieve gastric irritation from excess acid production d. To prevent damage to bones from high phosphorus levels

A patient who is taking warfarin (Coumadin) 5 mg daily has an international normalized ratio (INR) of 2.5. It is time to administer the next dose of Coumadin. What should the nurse do? a. Notify the physician STAT. b. Hold the dose of Coumadin. c. Prepare to administer vitamin K. d. Administer the daily Coumadin as ordered.

A patient who underwent lymphangiography the day before asks the licensed practical nurse (LPN), Why does my urine look blue? What should the LPN respond to this patients concern? a. It is nothing to be concerned about. b. I will notify the RN and physician immediately. c. This indicates that the procedure found abnormal results. d. The dye used in the procedure may cause bluish skin and urine for 2 days.

A patient with AIDS-related wasting syndrome is very weak, lies listlessly in bed, has an intravenous (IV) drip, and receives antiretroviral medications via injection. What should be the priority nursing diagnosis for this patient? a. Pain related to immobility b. Ineffective Individual Coping due to terminal stage of HIV c. Risk for Injury due to impaired mobility, weakness, and weight loss d. Risk for Infection due to weak immune system and parenteral therapy

A patient with hepatitis B virus (HBV) delivers a 6-pound 2-ounce baby boy. Which action should the nurse anticipate will be needed for the infant? a. Intravenous antibiotics for 12 hours b. Antiviral eye medication less than 2 hours after birth c. There is no treatment that is safe and effective for infants. d. HBV-immune globulin less than 12 hours after birth and then HBV vaccine series

A patient with thrombocytopenia is having pain. If each of the following medications is ordered, which should the nurse choose to administer? a. Morphine SQ b. Meperidine (Demerol) IM c. Oxycodone with aspirin (Percodan) PO d. Acetaminophen with codeine (Tylenol No. 3) PO

A pediatric patient is scheduled for a noninvasive procedure to determine if his heart is structurally normal and to localize a murmur. What diagnostic test does the nurse anticipate? a. Barium swallow b. Chest x-ray c. Electrocardiogram d. Echocardiogram

A pregnant woman states, My husband hopes I will give him a boy because we have three girls. What will the nurse explain to this woman? a. The sex chromosome of the fertilized ovum determines the gender of the child. b. When the sperm and ovum are united, there is a 75% chance the child will be a girl. c. When the pH of the female reproductive tract is acidic, the child will be a girl. d. If a sperm carrying a Y chromosome fertilizes an ovum, then a boy is produced.

A woman is having a difficult labor because the fetus is presenting in the right occipital position (ROP). What position will the nurse promote to encourage fetal rotation and pain relief? a. Prone with legs supported and give her a back massage b. Supine with legs bent at the knee c. Standing with support d. Sitting up and leaning forward on the over-bed table

A woman is prescribed Coumadin (warfarin) to treat deep vein thrombosis. What will the nurse instruct this woman is the antidote for warfarin overdose? a. Vitamin A b. Vitamin B c. Vitamin E d. Vitamin K

A woman required a cesarean section for safe delivery of her newborn. She is planning to breastfeed and verbalized concern about pain. What is the best suggestion by the nurse? a. Consider formula feeding for the first few days. b. Pumping breast milk would be best for now. c. Take pain medication 30 to 40 minutes prior to nursing. d. Use the football hold when breastfeeding.

A woman seeking prenatal care relates a history of macrosomic infants, two stillbirths, and polyhydramnios with each pregnancy. What does the nurse recognize these factors highly suggest? a. Toxoplasmosis b. Abruptio placentae c. Hydatidiform mole d. Diabetes mellitus

A woman tells the nurse that she is quite sure she is pregnant. The nurse recognizes which as a positive sign of pregnancy? a. Amenorrhea b. Uterine enlargement c. HCG detected in the urine d. Fetal heartbeat

A woman who is 8 weeks pregnant becomes concerned when she has light vaginal bleeding accompanied by abdominal pain. An ectopic pregnancy is confirmed by ultrasound. Which statement indicates that the woman understands the explanation of an ectopic pregnancy? a. The chorionic villi develop vesicles within the uterus. b. The placenta develops in the lower part of the uterus. c. The fetus dies in the uterus during the first half of the pregnancy. d. The embryo is implanted in the fallopian tube.

After the examination is completed, the patient asks the nurse why Chadwicks sign occurs during pregnancy. What would the nurse explain as the cause of Chadwicks sign? a. Enlargement of the uterus b. Progesterone action on the breasts c. Increasing activity of the fetus d. Vascular congestion in the pelvic area

An HIV-infected patient reports being a cat lover and says, I always get my pets from a known sanitary source. What should the nurse instruct the patient about cats and the risk of infection? a. Keep cats outdoors most of the time. b. Obtain only cats that are less than 1 year old. c. Remove all pets from your home. Avoid all contact with cats. d. Be sure all the cats have up-to-date immunizations, and avoid their feces.

An infant with congestive heart failure is receiving digoxin (Lanoxin). What does the nurse recognize as a sign of digoxin toxicity? a. Restlessness b. Decreased respiratory rate c. Increased urinary output d. Vomiting

An ultrasound on a woman who is 32 weeks pregnant reveals the placenta implanted over the entire cervical os. What does the nurse understand best describes this condition? a. Low-lying placenta b. Marginal placenta previa c. Partial placenta previa d. Total placenta previa

At what age is a woman who becomes pregnant for the first time described as an elderly primip? a. After 25 years old b. After 28 years old c. After 30 years old d. After 35 years old

Below what blood glucose level is the newborn considered hypoglycemic? a. Below 70 mg/dL b. Below 60 mg/dL c. Below 50 mg/dL d. Below 40 mg/dL

Diuresis has not occurred on a child with nephrotic syndrome after a month on corticosteroids. What protocol can the nurse encourage to bring about diuresis? a. Ibuprofen, an anti-inflammatory agent b. Furosemide (Lasix), a diuretic c. Ciprofloxacin (Cipro), an antibiotic d. Cyclophosphamide (Cytoxan), an antisuppressant

Following surgery for pyloric stenosis, an infant awoke from anesthesia hungry and crying. What is the most appropriate nursing action? a. Delay feeding the child for 6 hours. b. Offer regular formula thinned with water. c. Give small amounts of regular formula thickened with cereal. d. Allow 1 ounce of glucose water at frequent intervals.

For what is the decrease in estrogen and progesterone during the menstrual cycle responsible? a. Degeneration of the corpus luteum b. Ovulation c. Follicle maturation d. Shedding of the endometrium

How does Russell traction provide adequate skin traction? a. Subluxates the tibia b. Does not interfere with range of motion c. Prevents the knee from flexing d. Supplies continuous pull in two directions

In a routine prenatal visit, the nurse examining a patient who is 37 weeks pregnant notices that the fetal heart rate (FHR) has dropped to 120 beats/min from a rate of 160 beats/min earlier in the pregnancy. What is the nurses first action? a. Ask if the patient has taken a sedative. b. Notify the physician. c. Turn the patient to her right side. d. Record the rate as a normal finding.

On what knowledge would the nurse base a response to a mother who questions, Do you think my baby recognizes my voice? a. Voice recognition is delayed because the ears are not well developed at birth. b. Infants respond to voice by increasing movements and sucking. c. Infants initially respond to low-pitched voices. d. Neonates can distinguish a mothers voice from other sounds in the first days of life.

Parents ask the nursery staff what the light does for their jaundiced infant. What is the nurses best response? a. The light increases the infants metabolism. b. The light stimulates liver function. c. The light dilates blood vessels. d. The light breaks down bilirubin.

Parents express concern about the milia on the face and nose of their infant. What is the nurses most helpful response when instructing the parents? a. Contact a pediatric dermatologist for topical medication. b. Squeeze out the white material after cleansing the face. c. Wash the infants face with a mild astringent several times a day. d. Leave the milia alone; it will disappear spontaneously. No treatment is needed.

Parents of a newborn are worried about dark areas over the sacrum of the newborn. What does the nurse explain this transitory skin discoloration is called? a. Epsteins pearls b. Milia c. Stork bites d. Mongolian spots

Several hours after delivery the nurse finds a woman crying. The woman says repeatedly, My baby is beautiful, but I was planning on a vaginal delivery. Instead I needed an emergency C-section. What is the most appropriate nursing diagnosis? a. Anxiety related to the development of postpartum complications b. Ineffective individual coping related to unfamiliarity with procedures c. Risk for ineffective parenting related to emergency cesarean section d. Grieving related to loss of expected birth experience

The asthmatic child who has been taking theophylline complains of stomachache and tachycardia and is sweating profusely. What does the nurse recognize as the cause of these symptoms? a. Severe asthma attack b. Allergic response to theophylline c. Onset of bronchitis d. Drug toxicity

The child receiving a transfusion complains of back pain and itching. What is the best initial action by the nurse? a. Notify the charge nurse. b. Disconnect intravenous lines immediately. c. Give diphenhydramine (Benadryl). d. Clamp off blood and keep line open with normal saline.

The mother of a 2-week-old infant tells the nurse, I think the baby is constipated. Ive noticed she strains when she has a bowel movement. What is nurses most helpful response? a. Give the baby one serving of fruit per day. b. Increase the amount and frequency of her feedings. c. It sounds like the baby is uncomfortable because she is constipated. d. Newborns might strain with bowel movements because their muscles arent fully developed

The mother of a 4-day-old calls the pediatricians office because she is concerned about her infants skin. Which finding needs to be reported promptly to the childs pediatrician? a. The hands and feet feel cooler than the rest of the body. b. Skin is peeling on several parts of the infants body. c. There is a small pink patch on the left eyelid and one on the neck. d. Today, the infants skin has a yellowish tinge.

The mother of a 4-month-old infant, born prematurely, asks the nurse if her daughter will always be small for her age. What is the most appropriate nursing response? a. Preterm infants usually remain smaller than term infants throughout childhood. b. Your daughter will be the same size as other children by the time she is 1 year old. c. Prematurity is associated with short stature but does not affect weight gain. d. It takes about two years for the preterm infant to catch up to a full-term infant.

The mother of a 5-year-old child taking prednisone for nephrotic syndrome tells the nurse he needs to get immunizations to enter kindergarten. What does the nurse clarify about receiving immunizations while on prednisone? a. Can interfere with the treatment for nephrosis b. Require that the child have antibiotic coverage c. Can be given in smaller, divided doses d. Should be delayed

The mother of an infant diagnosed with hypogammaglobulinemia asks the nurse how the disease process occurred. What should the nurse explain to the mother? a. It rarely occurs in males. b. It occurs after exposure to pesticides. c. It is because the infant was premature. d. There are no known causes for this disorder.

The new mother who had a vaginal delivery yesterday has a white blood cell count of 30,000 cells/dL. What action should the nurse implement? a. Notify the charge nurse of a possible infection. b. Prepare to put the patient in isolation. c. Have the infant removed from the room and returned to the nursery. d. Assess the patient further.

The nurse assesses a positive Homans sign when the patients leg is flexed and foot sharply dorsiflexed. Where does the patient report that the pain is felt? a. Groin b. Achilles tendon c. Top of the foot d. Calf of the leg

The nurse caring for a patient with severe frostbite observes a purple flush on the hands and feet. What is the most appropriate nursing action? a. Report this sign immediately. b. Place a warm towel over the extremities. c. Gently sponge with cool water. d. Medicate for pain.

The nurse finds an adolescent with Hodgkins disease crying. The adolescent says, I am so scared. What is the most appropriate nursing response to this comment? a. I understand how you must feel. b. You shouldnt feel that way. c. Is this the strongest feeling youve had today? d. Tell me whats got you scared.

The nurse has just removed an indwelling catheter from a patient following transurethral resection of the prostate. What action by the nurse is most important? a. Monitor vital signs. b. Watch for bladder spasms. c. Offer the urinal every 15 minutes. d. Collect serial samples of urine to monitor for color.

The nurse has reviewed dietary restrictions for celiac disease with concerned parents. Which grain will the nurse explain can be eaten with celiac disease? a. Wheat b. Oats c. Barley d. Rice

The nurse instructs the mother of a 2-year-old who is taking iron supplements for anemia that some foods reduce the absorption of iron. What would be the best example provided by the nurse? a. Red meat b. Green, leafy vegetables c. Acidic fruit juices d. Egg yolks

The nurse is advising parents about feeding their infant with phenylketonuria. What formula and/or diet should the nurse suggest? a. Lifelong high-protein diet b. A formula that is low in the amino acid leucine c. A soy-based formula d. Substitute Lofenalac for some protein foods

The nurse is assessing a newborn. What sign of hypoglycemia does the nurse record? a. Increased nasal mucus b. Increased temperature c. Active muscle movements d. High-pitched cry

The nurse is assessing a patient with stage III Hodgkins disease. Where should the nurse expect to find enlarged lymph nodes? a. In the neck only b. Above the diaphragm only c. Below the diaphragm only d. Generalized throughout the body

The nurse is assessing a preterm infant. To what does the infants level of maturation refer? a. Actual time the fetus remained in the uterus b. Age on the Dubowitz scoring system c. Infants weight as compared to the gestational age d. Ability of the organs to function outside of the uterus

The nurse is assisting a 28-year-old man who is undergoing testing for infertility. He says, I cant believe I have to stop wearing tight jeans. What on earth could that have to do with anything? Which response by the nurse is best? a. Tight jeans do not cause infertility. That is an old wives tale. b. The pressure on your scrotum from tight jeans can damage your testes. c. Its not the tight jeans, but the way they make you sit that causes the problem. d. Tight jeans hold your scrotum too close to your body, where the heat can inhibit sperm production.

The nurse is assisting a new mother who returns to a clinic for a 6-week visit. What instructions about birth control should the nurse provide? a. Breastfeeding has no effect on your ability to conceive. b. As long as you are breastfeeding, you will not get pregnant. c. You should avoid having intercourse until you are finished breastfeeding. d. You should plan to use birth control; breastfeeding is not a reliable form of contraception.

The nurse is assisting in the preparation of a teaching seminar for adolescents to prevent the development of a sexually transmitted infection (STI). Which nonsexual activity should the nurse teach that may transmit a sexually transmitted infection (STI)? a. Sharing a cigarette b. Borrowing a hairbrush c. Coughing and sneezing d. Sharing intravenous drug equipment

The nurse is assisting with teaching a patient who will be discharged with a catheter after a prostatectomy. Which patient statement indicates the need for further teaching? a. I should call you if the bleeding increases. b. I need to wash around the meatus with soap and water each day. c. I should keep the drainage bag below the level of my bladder at all times. d. Applying antibiotic ointment to the meatus twice a day will prevent skin breakdown.

The nurse is assisting with teaching a woman who is having difficulty conceiving. What instruction should the nurse provide about keeping a basal body temperature chart? a. Record your temperature in the late afternoon each day for 3 months. b. Record your temperature every 4 hours, starting the first day of each month. c. Record your temperature three times each day of your period, then once a day thereafter. d. Starting with the first day of your period, record your temperature first thing each morning.

The nurse is assisting with the collection of data from a patient with a hematologic disorder. On which body system should the nurse expect to focus when collecting this data? a. Respiratory b. Genitourinary c. Cardiovascular d. All body systems

The nurse is careful to apply only the prescribed amount of ointment to the skin of a 2-month-old. How is infant skin different from adult skin? a. Less perfusion b. Greater moisture c. More perspiration d. Greater absorption

The nurse is caring for a 3-year-old who suffered a smoke inhalation injury. How long is this patient at the highest risk for pulmonary edema after exposure? a. 2 hours b. 4 hours c. 18 hours d. 72 hours

What risk is increased with children who have been diagnosed with infantile eczema? a. Pneumonia b. Acne c. Sun sensitivity d. Asthma

The nurse is caring for a child who has had a ventriculoperitoneal shunt (VP) for hydrocephalus and observes an increasing abdominal girth. What is the most appropriate response? a. Elevate the childs head. b. Check bowel sounds. c. Record retention of feeding. d. Notify the charge nurse of possible malabsorption

The nurse is caring for a patient diagnosed with hypotonic labor dysfunction. What will the nurse expect when caring for this patient? a. Elevated uterine resting tone b. Painful and poorly coordinated contractions c. Implementation of fluid restriction d. Use of frequent position changes

The nurse is caring for a patient in sickle cell crisis. What is the rationale for providing warm compresses and blankets for this patient? a. Sickle cell crisis causes shivering and discomfort. b. Heat helps prevent the cells from becoming sickled. c. Heat speeds production of new healthy RBCs. d. Heat prevents vasoconstriction and impaired circulation.

The nurse is caring for a patient in the emergency department in a hypertensive crisis. He states he stopped taking his blood pressure medicine because it made him impotent. What should be the nurses first response? a. No, it is a myth that blood pressure medications cause erectile dysfunction. You should see a urologist to look for other causes. b. You are right; blood pressure medications can cause erectile dysfunction. You should consider seeing a urologist for treatment. c. No, blood pressure medications do not usually cause erectile dysfunction; it is the high blood pressure that can cause the problem. You need to be careful to take your medications to keep it under control. d. Yes, blood pressure medications can cause erectile dysfunction, but there are many different classes of drugs for high blood pressure. Lets ask your physician what might work better for you.

The nurse is caring for a patient who had a kidney transplant 5 days ago. The patient had been very outgoing and jovial, but this morning the patient is very quiet and refusing breakfast, and ambulation. What would be the most appropriate nursing action at this time? a. Notify the physician for laboratory orders. b. Notify the social worker for discharge follow-up care. c. Inform the patient that kidney rejection signs are appearing. d. Spend extra time with the patient, allowing verbalization of feelings.

The nurse is caring for a patient who has AIDS. For which opportunistic lung infection caused by a fungus should the nurse monitor in this patient? a. Tuberculosis b. Cytomegalovirus c. Candida albicans d. Pneumocystis jiroveci pneumonia

The nurse is caring for a patient who has a white blood cell (WBC) count of 8000/mm3. What concern should the nurse have about this finding? a. The patient has an infection. b. The patient is at risk for infection. c. The patient has a hematological disorder. d. There is no concern; this is a normal finding.

The nurse is caring for a patient with an acidbase imbalance from kidney disease. How should the nurse explain the role of the kidneys to maintain acidbase balance in the body to the patient? a. Promoting retention of proteins b. Promoting excretion of carbon dioxide c. Conserving or excreting potassium ions d. Conserving or excreting bicarbonate ions

The nurse is caring for a woman who had a cesarean birth yesterday. Varicose veins are visible on both legs. What nursing action is the most appropriate to prevent thrombus formation? a. Have the woman sit in a chair for meals. b. Monitor vital signs every 4 hours and report any changes. c. Tell the woman to remain in bed with her legs elevated. d. Assist the woman with ambulation for short periods of time

The nurse is caring for an 18-pound child who has had one stool of diarrhea. The nurse knows that the child needs to consume how many milliliters of oral fluid to make up for the fluid loss? a. 18 b. 36 c. 64 d. 81

The nurse is caring for an infant born at 35 weeks of gestation. What physical characteristic might the nurse expect this infant to exhibit? a. Thin, long extremities b. Large genitals for its size c. Minimal vernix caseosa d. Loose, transparent skin

The nurse is caring for an unstable patient with acute kidney injury. What therapy should the nurse expect to be ordered? a. Hemodialysis b. Urinary catheter c. Peritoneal dialysis d. Continuous renal replacement therapy (CRRT)

The nurse is caring for the newborn of a mother who is HIV positive. What treatment should the nurse expect to be prescribed for the infant? a. Bacitracin b. Erythromycin c. Protease inhibitor d. Zidovudine (AZT)

The nurse is collecting data from a patient with stress incontinence. Which finding should the nurse document? a. The patient is unable to tell when there is the need to urinate. b. The patient is unable to hold urine when under emotional stress. c. The patient is unable to reach the bathroom and urinates in underwear. d. The patient loses small amounts of urine when he or she coughs or sneezes.

The nurse is collecting data on a patient with Chlamydia. Which assessment finding should be reported immediately to the RN or physician? a. Painful urination b. Red conjunctivae c. Vaginal discharge d. Sharp pain at the base of the ribs

The nurse is contributing to a teaching plan. What should the nurse emphasize as being the most effective method known to control the spread of HIV infection? a. Premarital serological screening b. Prophylactic exposure treatment c. HIV screening for pregnant women d. Education about preventive behaviors

The nurse is determining the effectiveness of treatment prescribed for a patient with anemia. Which question should the nurse use to make this evaluation? a. Is your appetite improving? b. Are you sleeping all night? c. Are you requiring many analgesics? d. Are you keeping up with your work schedule?

The nurse is documenting a description of a skin assessment. What term can be used for an elevated, fluid-filled blister? a. Pustule b. Papule c. Wheal d. Vesicle

The nurse is documenting findings after completing data collection with a patient. What term should the nurse use to document a large area of discoloration from hemorrhage under the skin? a. Pallor b. Rubor c. Petechiae d. Ecchymosis

The nurse is educating a pregnant patient who expects to breastfeed. The nurse knows that when a patient breastfeeds, which portions of the breast secrete milk? a. Lactiferous sinuses b. Lobes c. Montgomerys glands d. Alveoli

The nurse is identifying approaches to reduce the risk of infection in a patient with leukemia. Why is it important for the nurse to institute infection control measures for this patient? a. Infection can precipitate hemorrhage in the patient with leukemia. b. The drugs needed to fight infection have life-threatening side effects. c. Infection in the patient with leukemia can lead to permanent neurological damage. d. Leukemia seriously impairs the leukocytes and the bodys ability to fight infection.

The nurse is instructing a mother how to administer oral nystatin suspension prescribed to treat thrush. What will the nurse include? a. Pour the prescribed amount into a nipple and have the infant suck the medication. b. Squirt the prescribed dose into the back of the mouth and have the infant swallow. c. Give the medication mixed with a small amount of juice in a bottle. d. Use a sterile applicator to swab the medication on the oral mucosa.

The nurse is monitoring a patient receiving a blood product and is concerned that the blood is going to deteriorate before it is complete infused. What is the maximum time that blood can hang during infusion before it begins to deteriorate? a. 1 hour b. 2 hours c. 3 hours d. 4 hours

The nurse is planning discharge teaching for a patient with polycythemia. Which nursing intervention should the nurse consider to help prevent complications in this patient? a. Monitor intake and output. b. Avoid use of injections for pain. c. Maintain bedrest during treatment. d. Encourage 3 L of water intake daily.

The nurse is planning to teach parents about preventing sudden infant death syndrome (SIDS). What significant information would the nurse include? a. Wrapping the infant snugly for rest periods b. Positioning the infant prone for sleep c. Sitting the infant up in an infant seat d. Placing infants on their backs or sides for sleep

The nurse is preparing to give an injection of iron (Imferon) to a patient with anemia. What is the rationale for using the Z-track method for injection? a. Prevent pain at the site b. Prevent tissue damage at the site c. Promote absorption of the medication d. Prevent discoloration of tissue at the site

The nurse is preparing to read the Mantoux tuberculin skin test placed on the forearm of a patient with HIV. Which finding should the nurse report as a positive test for this patient? a. 2 mm b. 3 mm c. 4 mm d. 5 mm

The nurse is providing pre-operative care for an 80-year-old patient who is scheduled to have prostate surgery. The patient says, I know a man who was impotent after this surgery. Will that happen to me? Which response by the nurse is most appropriate? a. There are many treatments available if it does occur. b. Most men your age learn to deal with erectile dysfunction if it does occur. c. Impotence should not be a problem; sperm production is not affected by this surgery. d. Some prostate surgery can cause erectile dysfunction. Ill ask your surgeon to explain the risks to you

The nurse is reinforcing teaching on transmission of HIV for a family of a patient diagnosed with HIV. Which explanation by the nurse would be correct? a. HIV can be spread by casual contact. b. HIV lives for long periods outside the body. c. HIV is most commonly transmitted via tears and saliva. d. HIV enters the body through breaks in the skin or mucous membranes.

The nurse is reinforcing teaching provided to a patient about risk factors for prerenal injury. Which risk factor should the patient state that indicates understanding of this teaching? a. Kidney stones. b. Enlarged prostate. c. Exposure to nephrotoxins agents. d. Use of nonsteroidal anti-inflammatory drugs.

The nurse is reviewing laboratory results for a patient with a blood disorder. Reduced fibrinogen and platelet levels, increased thrombin time, and reduced factor assays are laboratory results associated with which hematological disorders? a. Aplastic anemia b. Sickle cell anemia c. PV d. Disseminated intravascular coagulation

The nurse is reviewing the anatomy of the kidney with a patient scheduled for renal surgery. What should the nurse explain as being the structural and functional unit of the kidney? a. Cortex b. Medulla c. Pyramid d. Nephron

The nurse is reviewing the health histories of several patients scheduled for appointments in the health clinic. Which patient should the nurse recognize as being predisposed to developing a vaginal yeast infection? a. A 23-year-old who eats a high-protein diet b. A 31-year-old woman who runs 2 miles every day c. A 38-year-old woman who frequently uses NSAIDs d. A 28-year-old woman who sits at a desk 5 days a week

The nurse is reviewing the history and physical of a patient who has an infection. What term should the nurse realize describes an infection of the kidneys? a. Cystitis b. Hepatitis c. Urethritis d. Pyelonephritis

The nurse is reviewing the male reproductive system with a couple being evaluated for infertility. What concentration of sperm should the nurse instruct this couple as being needed for normal conception to occur? a. 5 million sperm per mL of semen b. 10 million sperm per mL of semen c. 15 million sperm per mL of semen d. 20 million sperm per mL of semen

The nurse is reviewing the parts of the complete blood count and differential with a patient. Where should the nurse state that neutrophils, eosinophils, and basophils are produced? a. Spleen b. Thymus c. Lymph nodes d. Red bone marrow

The nurse is reviewing the use of a condom to prevent the transmission of HIV with a young adult patient seeking testing for HIV. Which patient statement indicates an understanding of how to use a condom? a. Use a non-latex condom. b. Apply adequate oil-based lubricant. c. Apply condom before penile erection occurs. d. Withdraw from partner while the penis is erect.

The nurse is speaking with a couple trying to conceive a child. What will the nurse remind the couple is a factor that can decrease sperm production? a. Infrequent sexual intercourse b. The man not being circumcised c. The penis and testes being small d. The testes being too warm

The nurse notes that a patient has an elevated lactate dehydrogenase, fragmented RBCs seen on microscopic examination, and low RBC count, hematocrit (Hct), and hemoglobin (Hgb) levels. For which health problem should the nurse consider planning care for this patient? a. Serum sickness b. Pernicious anemia c. Hemolytic transfusion reaction d. Idiopathic autoimmune hemolytic anemia

The nurse notes that a patient with AIDS is prescribed trimethoprim-sulfamethoxazole (Bactrim). For which opportunistic infection should the nurse realize that is this medication indicated? a. Tuberculosis b. Cytomegalovirus retinitis c. Mycobacterium avium complex d. Pneumocystis jiroveci pneumonia

The nurse notes that the urine from a patient with an ileal conduit has mucus strands. What action should the nurse take? a. Notify the physician. b. Send a urine sample to the laboratory for culture. c. Ask the patient about a history of UTIs. d. Nothing, as the nurse understands that this is a normal finding.

The nurse notices that the mother of a child with cerebral palsy corrects and redoes many of the things the nurse does for her child. What is the nurses most appropriate response to this mother? a. Would you like to do all of your childs care? b. Im doing the very best job that I can with your child. c. Why dont you go have a cup of coffee? You are going to be exhausted if you dont take a break. d. Id love for you to share with me some of the special things you do for your child.

The nurse observes that the infants anterior fontanelle is bulging after placement of a ventriculoperitoneal shunt. How should the nurse position this infant? a. Prone, with the head of the bed elevated b. Supine, with the head flat c. Side-lying on the operative side d. In a semi-Fowlers position

The nurse suspects a patient has polycythemia. Which hematocrit value is causing the nurse to have this concern? a. 38% b. 45% c. 47% d. 55%

The parent of a 1-year-old child with tetralogy of Fallot asks the nurse, Why do my childs fingertips look like that? On what understanding does the nurse base a response? a. Clubbing occurs as a result of untreated congestive heart failure. b. Clubbing occurs as a result of a left-to-right shunting of blood. c. Clubbing occurs as a result of decreased cardiac output. d. Clubbing occurs as a result of chronic hypoxia.

The parents of a hospitalized 9-month-old infant ask if their preschool child may visit his younger sibling. What understanding would assist the nurse most in formulating a response? a. Preschool children can be disruptive in the hospital environment. b. Seeing his younger sibling would probably frighten the preschooler and thus should be avoided. c. The sibling could view the infant from the doorway but not enter the room to prevent the spread of microorganisms. d. The preschooler needs to visit his infant sister to reassure himself that she is all right.

The pediatric clinic nurse receives lab results on several newborn patients. Which of the following should be brought to the physicians attention first? a. White blood cell count of 18,000 b. Hemoglobin of 18.5 c. Hematocrit of 56 d. Bilirubin of 15

The teaching plan for the use of a dry powder inhaler for the treatment of asthma should include the warning to rinse the mouth after inhaling the powder. What does this prevent? a. Discoloration of tooth enamel b. Halitosis c. Irritation of oral membranes d. Candidiasis

The young prenatal patient with gestational diabetes mellitus (GDM) says, I am frightened that I will have to deal with insulin injections for the rest of my life. What is the best response by the nurse? a. After delivery your doctor will prescribe oral hypoglycemic medication to control your disease. Pills are so much simpler than insulin injections. b. Have you considered an insulin pump? c. After a while those insulin injections wont seem so bad. d. It will most likely resolve 6 weeks or so after the baby is born

Three weeks after delivering her first child, a woman tells the nurse, I waited so long for this baby and now that she is here, I cant believe how different my life is from what I expected. What is the best nursing response to the womans statement? a. How is your partner adjusting to the change? b. I hear this from a lot of first-time mothers. c. Have you told anyone else about your feelings? d. Tell me how things are different

Through what does the infant born with hypoplastic left heart syndrome acquire oxygenated blood? a. The patent ductus arteriosus b. A ventricular septal defect c. The closure of the foramen ovale d. An atrial septal defect

What complication can result from untreated respiratory distress in the newborn? a. Esophageal atresia b. Gastric dilation c. Cold stress d. Reopening of the foramen ovale

What deficiency causes a preterm infant respiratory distress syndrome? a. Protein b. Estrogen c. Hyaline d. Surfactant

What does the nurse explains to parents of a child with febrile seizures? a. They occur when the body temperature exceeds 38.3 C (101 F). b. They can be prevented by anticonvulsant medication. c. They usually lead to the development of epilepsy. d. They occur when the temperature rises quickly.

What finding would the nurse assessing the neurovascular status of a child in Russell traction report immediately? a. Skin thats warm to the touch b. Capillary refill less than 3 seconds c. Ability to wiggle toes d. Bluish coloration of skin

What finding would the nurse expect when measuring blood pressure on all four extremities of a child with coarctation of the aorta? a. Blood pressure higher on the right side b. Blood pressure higher on the left side c. Blood pressure lower in the arms than in the legs d. Blood pressure lower in the legs than in the arms

What foods does the nurse recommend the child with acute glomerulonephritis avoid to prevent hyperkalemia? a. Dairy products b. Whole-grain cereals c. Organ meats d. Bananas

What is the best intervention for the nurse caring for a child experiencing an acute asthma attack? a. Offer plenty of fluids, particularly carbonated beverages. b. Place the child in a humidified cool mist tent with oxygen. c. Administer sedatives as ordered to decrease anxiety. d. Position the child with arms resting on the overbed table.

What is the best response to a postpartum woman who tells the nurse she feels tired and sick all of the time since I had the baby 3 months ago? a. This is a normal response for the body after pregnancy. Try to get more rest. b. Ill bet you will snap out of this funk real soon. c. Why dont you arrange for a babysitter so you and your husband can have a night out? d. Lets talk about this further. I am concerned about how you are feeling.

What should the nurse implement for security purposes when bringing the infant from the nursery to the mother? a. Ask, Is this your band number? b. Confirm room number of mother. c. Ask the mother to identify herself verbally. d. Check the band number of the infant with that of the mother.

What should the nurse stress to the mother of a child with impetigo? a. The condition is caused by the herpes simplex virus type I. b. The crusts on the lesions should be left in place. c. The lesions may spread, but the disease is not contagious. d. Small cuts and bites should be treated promptly.

What should the school nurse recommend when encouraging a heart-healthy diet for a child with high cholesterol? a. A fat intake reduction of 5-10% of total calories b. A fat intake reduction of 10-15% of total calories c. A fat intake reduction of 15-20% of total calories d. A fat intake reduction of 25-35% of total calories

What signifies the end of puberty for a male? a. Facial hair is evident. b. Erections can be sustained. c. Ejaculate is greater than 5 mL. d. Mature sperm are formed.

What statement by a patients mother leads the nurse to determine she understands instructions about administering an oral antibiotic for otitis media? a. I will continue using the medication until symptoms are relieved. b. I will share the medicine with siblings if their symptoms are the same. c. I will give the medication with a glass of milk. d. I will administer prescribed doses until all the medication is used

What statement made by a new mother indicates she needs additional information about breastfeeding? a. I let the baby nurse 10 to 15 minutes on the first breast and then switch to the other breast. b. The baby needs to nurse at least 5 minutes on the breast to get the hindmilk. c. The baby has been nursing every 2 to 3 hours. d. If the baby gets fussy between feedings, I give her a bottle of water.

What symptoms of cold stress might the nurse recognize in a preterm infant? a. Tremors and weak cry b. Plasma glucose level below 40 mg/dL c. Warm skin with low core temperature d. Increased respiratory rate and periods of apnea

What would the nurse include when instructing parents about positioning their toddler who has just had a body spica cast applied? a. Prop the child upright with pillows for meals. b. Use the bar between the legs to turn the child. c. Put the child on her abdomen to sleep. d. Change the childs position frequently

When obtaining a prenatal history on a pregnant patient the nurse notes a family history of sickle cell disease. Given this information, what lab test can the nurse anticipate the physician will order? a. Endovaginal ultrasound b. Pap test c. Complete blood count d. Hemoglobin electrophoresis

Where is the best site for giving an IM injection to a 15-month-old child? a. Ventrogluteal muscle b. Dorsogluteal muscle c. Deltoid muscle d. Vastus lateralis muscle

Which allergy would contraindicate the use of silver sulfadiazine (Silvadene) as a topical agent for burns? a. Penicillin b. Iodine c. Tetanus immunizations d. Sulfa

Which assessment performed by a nursing student performing a neurovascular check alerts the instructor that further education is necessary? a. Pulses b. Capillary refill c. Movement d. Pupils

Which hormone is responsible for converting the endometrium into decidual cells for implantation? a. Estrogen b. Human chorionic gonadotropin c. Human placental lactogen d. Progesterone

Which intervention is correct when a nurse is administering a gastrostomy feeding by gravity? a. Discard the residual and increase the volume of feeding by the amount of residual. b. Flush the gastrostomy tube with 2 to 4 ounces of water before the feeding. c. Refill the syringe with formula after it has completely emptied. d. Position the child on the right side after a feeding.

Which is the most appropriate nursing action when planning care for a child with cystic fibrosis? a. Provide chest physiotherapy before meals every day. b. Assess weight monthly. c. Administer pancrease with protein food at mealtime. d. Ensure high-protein, high-calorie diet

Which nursing interventions will be implemented for the mother of a 10-month-old infant with nonorganic failure to thrive? a. Pointing out errors that the nurse observes when the mother is caring for the infant b. Discussing negative characteristics of the infant with the mother c. Having the nurse provide as much of the infants care as possible d. Teaching the mother about the developmental milestones to expect in the next few months

Which situation would cause the nurse to suspect a hearing impairment? a. 3-month-old infant with a positive Moro reflex b. 15-month-old toddler who is babbling c. 18-month-old toddler who is speaking one-syllable words d. 24-month-old toddler who communicates by pointing

Which statement indicates the parents understand when to contact the pediatrician or nurse practitioner? a. Infant refuses a feeding b. Infant has an axillary temperature of 97 F c. Infant has three pasty, yellow-brown stools in 24 hours d. Infants diaper is not wet after 8 hours

Which strategy might the nurse use when administering oral medications to a young child who is reluctant? a. Mix the medication with chocolate milk. b. Tell the child that the medication is candy. c. Give the medication quickly if the child is crying. d. Offer the child fruit juice after the medication is swallowed

Why does a childs fracture heal more rapidly than the adults? a. A childs bones are less porous than adult bone. b. A childs bones are covered by a thicker periosteum. c. A childs bones are not affected by bone overgrowth. d. A childs bones have faster callus formation.

Why is the postterm neonate at risk for cold stress? a. Inadequate vernix caseosa b. Hypoxia from a deteriorated placenta c. Polycythemia d. Fat stores have been used in utero for nourishment

a nurse is providing routine follow up care for a young adult with asthma who has been on a 3 month course of maintenance therapy. which activity would best help the nurse determine if the patient's treatment plan was effective? a. obtain an ABG analysis b. determine patients pulse oximeter reading c. evaluate patients use of incentive spirometer d. examine daily tracking records of the peak expiratory flow rate

a summer camp worker reports to camp nurse with complaints of shortness of breath and audible wheezing. which of the following inhaled medications would the nurse provide? a. cromolyn sodium (Intal) b. triamcinolone (azmacort) c. nedocromil sodium (tilade) d. albuterol (proventil)

nurse is examining a chest drainage system on a patient with a pneumothorax and notes the water level in the water seal chamber fluctuating with each respiration. how should the nurse respond? a. examine entire sytem and tubing for leaks b. clamp tubing and call for help. c. have patient take a deep breath d. no action is necessary; this is an expected final

nurse prepares to admit a patient who is being evaluated for suspected cancer of the larynx. which of the following assessment findings does the nurse anticipate? a. wheezing b. coarse crackles c. noticeable lumps in the neck d. hoarse voice

which drugs are commonly prescribed to treat tuberculosis a. alupent and theophyline b. aspirin and guaifenesin c. claforan an penicillin d. isoniazid and rifampin

A 32-year-old female patient is diagnosed with uncomplicated cystitis. Which medications should the nurse expect to be prescribed for this patient? (Select all that apply.) a. Ciprofloxacin (Cipro) b. Aztreonam (Azactam) c. Decadron (Solu-Medrol) d. Nitrofurantoin (Macrodantin) e. Sulfamethoxazole and trimethoprim (Bactrim, Septra)

d, e

A patient who has AIDS has been instructed on foods to eat to reduce the risk of infection. Which foods should the patient select that indicates correct understanding of this teaching? (Select all that apply.) a. Rare meat b. Raw seafood c. Soft egg yolks d. Pasteurized milk e. Well-cooked meat

d, e

The nurse is providing care for a patient recently diagnosed with Chlamydia. Which information should the nurse recommend be included in patient teaching? (Select all that apply.) a. Women with Chlamydia may complain of a sore throat. b. Chlamydia is characterized by the development of chancres. c. Ophthalmia neonatorum is seen in infants born to women with Chlamydia. d. Chlamydia can be transmitted sexually and by blood and body fluid contact. e. The risk of ectopic pregnancy is increased in women with a history of Chlamydia. f. The Chlamydia virus can lie dormant in the nervous system tissues and reactivate when an individual is under stress or has a compromised immune system.

d, e

What are the rationales for labor induction? (Select all that apply.) a. Placenta previa b. Prolapse of cord c. High station of fetus d. Maternal diabetes e. Placental insufficiency

d, e

The nurse is contributing to a teaching plan. What information should the nurse include that identifies the methods in which HIV can be transmitted? (Select all that apply.) a. Urine b. Sweat c. Saliva d. Semen e. Breast milk f. Vaginal secretions

d, e, f

The nurse reviews the process to obtain a midstream urine specimen for culture and sensitivity with a female patient. Which patient statements indicate understanding of this process? (Select all that apply.) a. A 24-hour urine specimen is needed. b. A second-voided specimen is preferred. c. I should wash from the back to the front. d. The labia should be kept separated while voiding. e. When urine starts to flow, collect it in the clean container provided. f. The genitalia should be thoroughly cleaned with the towelettes provided.

d, f

19. A home care nurse is preparing to change a dressing on a patient who had genital warts removed the previous day. Which intervention should be completed first? a. Clean the wounds b. Remove the old dressing c. Assess for drainage d. Administer an analgesic

d. An analgesic is necessary. Wart removal is very painful.

8. Which procedure is most helpful in distinguishing a fluid-filled mass form a solid mass of the breast? a. BSE b. Mammogram c. Clinical breast examination d. Ultrasound

d. An ultrasound can identify fluid-filled cysts.

A gene that is expressed when paired with another gene for the same trait is called a) recessive. b) dominant. c) heterozygous. d) homozygous.

dominant. Correct Explanation: A dominant gene is one that will be expressed when paired with a like gene.

You teach a child with type 1 diabetes mellitus to administer her own insulin. She is receiving a combination of short-acting and long-acting insulin. You know that she has appropriately learned the technique when she a) wipes off the needle with an alcohol swab. b) administers the insulin intramuscularly into rotating sites. c) administers the insulin into a doll at a 30-degree angle. d) draws up the short-acting insulin into the syringe first.

draws up the short-acting insulin into the syringe first. Correct Explanation: Drawing up the short-acting insulin first prevents mixing a long-acting form into the vial of short-acting insulin. This maintains the short-acting insulin for an emergency. Insulin is given subcutaneously.

RDS type 1

hyaline membrane disease; result of lung immaturity which leads to decreased gas exchange due to deficient synthesis or release of surfactant

A 7-year-old is diagnosed as having type 1 diabetes. One of the first symptoms usually noticed by parents when this illness develops is a) craving for sweets. b) loss of weight. c) severe itching. d) swelling of soft tissue.

loss of weight. Correct Explanation: Lack of insulin reduces the ability of body cells to use glucose; this leads to starvation of cells and loss of weight as an early symptom.

Nursing Care of Posterm Newborns

observe for: respiratory distress due to aspiration of meconium-stained amniotic fluid; hypoglycemia, caused by depleted glycogen stores; hyperbilirubinemia, as result of polycythemia; cold stress, because fat stores have been used in utero for nourishment

causes of hypoglycemia

preterm doesn't remain in utero long enough to build up stores of glycogen and fat; any condition that increases metabolism increases glucose needs; preterm may be too weak to suck and swallow, may require gavage feedings

The nursing diagnosis most applicable to a child with growth hormone deficiency would be a) risk for self-directed violence related to oversecretion of epinephrine. b) risk for situational low self-esteem related to short stature. c) ineffective tissue perfusion related to infantile blood vessels. d) impaired skin integrity related to overproduction of melanin.

risk for situational low self-esteem related to short stature. Correct Explanation: Children who are short in stature can develop low self-esteem from their altered appearance.

Girls with Turner Syndrome will usually exhibit a) short stature b) progressive dementia c) chorealike movements d) painful joints

short stature Correct Explanation: Girls with Turner syndrome usually have a single X chromosome, causing them to have short stature and infertility. Persons with sickle cell anemia have painful joints. Color blindness occurs in persons diagnosed with Huntington disease and they may exhibit chorealike movements. Progressive dementia occurs in early-onset familial Alzheimer's disease.

s/s of RDS

tachypnea, gruntlike sounds, nasal flaring, cyanosis, retractions

The child has been diagnosed with a mental health disorder and the child's parents are beginning to incorporate behavior management techniques. Which of the following statements by the child's parent indicates the need for further education? Select all that apply. a) "We're trying to make her accountable and responsible for her own behavior." b) "We tell her when she is doing something well." c) "I am quick to point out the things that she does that make me crazy." d) "I use a higher pitched voice when I communicate with her." e) "We have set some boundaries that are nonnegotiable."

• "I am quick to point out the things that she does that make me crazy." • "I use a higher pitched voice when I communicate with her." Correct Explanation: The parents should use a calm, low-pitched voice when communicating with her. They should ignore inappropriate behaviors. The parents should not argue or bargain with the child about set limits. They should praise the child for accomplishments and help the child see the importance of accountability for her own behavior.

A nurse is assessing a child with cancer and suspects that the child has developed sepsis based on which of the following? Select all that apply. a) Increased blood urea nitrogen (BUN) b) Hyperkalemia c) Absolute neutrophil count (ANC) less than 500 d) Respiratory alkalosis e) Thrombocytosis

• Absolute neutrophil count (ANC) less than 500 • Increased blood urea nitrogen (BUN) • Hyperkalemia Explanation: Findings associated with sepsis include ANC less than 500, increased BUN, increased potassium, decreased platelets, and metabolic acidosis.

The nurse caring for a patient with leukemia documents the following signs that are clinical or diagnostic features of the disease (select all answers that apply): a) Lymphadenopathy b) Bruising c) Sore throat d) Increased hemoglobin e) Anorexia f) Increased platelet count

• Bruising • Anorexia • Sore throat • Lymphadenopathy Explanation: Clinical and diagnostic features of leukemia include fatigue, weakness, pallor, fever, bruising, bleeding (e.g., petechiae or purpura), weight loss, anorexia, swollen gums, sore throat, recurrent infections, flu-like symptoms, abdominal pain, nausea, vomiting, bone pain, lymphadenopathy, splenomegaly, hepatosplenomegaly, elevated leukocyte count (mm3), decreased hemoglobin (g/dL), and decreased platelets.

A child is suspected of having bipolar disorder. Which of the following would the nurse identify if the child was experiencing a manic episode? Select all that apply. a) Decreased sleep b) Pressured speech c) Loss of interest in activity d) Flamboyant behavior e) Decreased energy

• Decreased sleep • Pressured speech • Flamboyant behavior Correct Explanation: Manifestations associated with a manic episode include rapid, pressured speech; increased energy; decreased sleep; flamboyant behavior; and irritability. The child also may demonstrate an increase in risk-taking behaviors, resulting in accidents and sexual promiscuity.

The nurse is obtaining the history of an adolescent female who is suspected of having anorexia nervosa. Which of the following would the nurse expect to find? Select all that apply. a) Diarrhea b) Desire for perfectionism c) Warm hands and feet d) Syncope e) Secondary amenorrhea

• Desire for perfectionism • Syncope • Secondary amenorrhea Correct Explanation: The adolescent with anorexia may have a history of constipation, syncope, secondary amenorrhea, abdominal pain, and periodic episodes of cold hands and feet. In addition, the child's self-concept reveals multiple fears, high need for acceptance, disordered body image, and perfectionism.

The nurse identifies the nursing diagnosis of risk for infection related to chemotherapy-induced immunosuppression. Which of the following would the nurse include in the teaching plan for the child and parents about reducing the child's risk? Select all that apply. a) Encouraging frequent, thorough handwashing b) Cheering up the environment with fresh flowers and plants c) Encouraging frequent close contact with numerous visitors d) Having the child sleep in a single bed and room e) Providing a low-carbohydrate, low-protein diet

• Encouraging frequent, thorough handwashing • Having the child sleep in a single bed and room Correct Explanation: To reduce the risk of infection, the nurse should teach the child and parents about minimizing the child's exposure to potentially infectious situations. The nurse should encourage the parents to arrange for the child to sleep in a single bed and room and, if possible, avoid close contact with other family members who may be developing upper respiratory tract infections. Thorough and frequent handwashing, especially after using the bathroom and before eating, is essential. A high-calorie, high-protein diet helps to rebuild white blood cells and should be encouraged. If possible, the child's exposure to large crowds and visitors should be limited because of the increased risk of infection from these individuals. Fresh flowers and plants should be avoided because they could harbor mold spores.

A child is receiving chemotherapy and develops stomatitis. The nurse identifies a nursing diagnosis of impaired oral mucous membranes related to the effects of chemotherapy. Which of the following would the nurse include in the child's plan of care? Select all that apply. a) Provide various soft and bland foods to minimize further irritation. b) Have the child rinse the mouth with lukewarm water three times a day. c) Give the child acidic foods (eg, orange juice) to cleanse the mouth. d) Vigorously rub the child's gums with gauze to clean them. e) Apply a lip balm or petroleum jelly to prevent cracking.

• Provide various soft and bland foods to minimize further irritation. • Have the child rinse the mouth with lukewarm water three times a day. • Apply a lip balm or petroleum jelly to prevent cracking. Correct Explanation: For the child with stomatitis, the nurse should provide soft foods to prevent further abrasions, have the child rinse the mouth three times a day with lukewarm water to promote comfort and healing, avoid giving the child acidic foods that would further irritate the tissue, and apply a lip balm or petroleum jelly to prevent cracking of the lips. The nurse should offer a soft toothbrush to minimize discomfort.

The nurse is teaching a group of 13-year-old boys and girls about screening and prevention of reproductive cancers. Which of the following subjects would not be included in the nurse's teaching plan? (Select all that apply) a) Self examination is an effective screening method for testicular cancer b) Sexually transmitted disease is a risk factor for cervical cancer c) Testicular cancer is one of the most difficult cancers to cure d) Provide information regarding the benefits of receiving the HPV vaccine e) A papanicolaou (PAP) smear does not require parent consent in most states

• Self examination is an effective screening method for testicular cancer • A papanicolaou (PAP) smear does not require parent consent in most states • Sexually transmitted disease is a risk factor for cervical cancer • Provide information regarding the benefits of receiving the HPV vaccine Explanation: Answer b would not be part of the teaching plan. It would be more accurate and appropriate for the nurse to stress that testicular cancer is one of the most curable cancers if diagnosed early. Self-examination is an excellent way to screen for the disease. Girls should know that they can take responsibility for their own sexual health by getting a PAP smear. All the children should understand that early intercourse, sexually transmitted infections (STIs), and multiple sex partners are risk factors for reproductive cancer. Information should be provided so the teen girls can discuss the benefits of receiving the human papilloma virus vaccine since many cervical cancers are attributed to human papillomavirus.

The nurse is performing the physical examination of a child with bulimia. Which of the following would the nurse identify as supporting this disorder? Select all that apply. a) Pink moist gums b) Eroded dental enamel c) Dry sallow skin d) Bradycardia e) Split fingernails

• Split fingernails • Eroded dental enamel Explanation: The adolescent with bulimia will be of normal weight or slightly overweight. The hands will show calluses on the backs of the knuckles and split fingernails. The mouth and oropharynx will exhibit eroded dental enamel, red gums, and an inflamed throat from self-induced vomiting. Bradycardia and dry sallow skin suggest anorexia.

The child has been diagnosed with attention deficit hyperactivity disorder (ADHD) and has been prescribed methylphenidate (Ritalin). Which of the following findings are most likely adverse effects related to this type of medication? Select all that apply. a) The child complains that his head hurts at times b) The child has been more irritable since beginning methylphenidate (Ritalin) c) The child has gained weight since beginning methylphenidate (Ritalin) d) The child complains that he has developed abdominal pain e) The child's parents state that he sleeps much longer than he used to

• The child complains that his head hurts at times • The child has been more irritable since beginning methylphenidate (Ritalin) • The child complains that he has developed abdominal pain Explanation: Common side effects related to the use of psychostimulants are: headaches, irritability, and abdominal pain. Children typically exhibit a decreased appetite and may have difficulty with insomnia.

The 18-month-old toddler has been brought into the pediatrician's office by his parents. Which of the following findings are warning signs that the toddler may be autistic based on what he should be able to do according to his age? Select all that apply. a) The child does not use any words b) The child cannot jump rope c) The child does not speak in short sentences d) The toddler does not exhibit attempts to communicate by pointing to objects e) The parents stated that the toddler has never "babbled"

• The child does not use any words • The toddler does not exhibit attempts to communicate by pointing to objects • The parents stated that the toddler has never "babbled" Correct Explanation: An 18-month-old toddler should have babbled by 12 months. He should be using gestures and using single words to communicate. The use of sentences to communicate and the ability to jump rope would be expected later.

A child with a history of diabetes insipidus has been taking vasopressin. The parents bring the child to the clinic for an evaluation. During the visit, the parents mention that it seems like their son is hardly urinating. The nurse suspects syndrome of inappropriate antidiuretic hormone. Which of the following would the nurse expect to find to help confirm this condition? Select all that apply. a) Decreased urine osmolality b) Decreased serum sodium level c) Hypotension d) Weight loss e) Serum osmolality 300 mOsm/kg f) Urine specific gravity 1.033

• Urine specific gravity 1.033 • Decreased serum sodium level • Serum osmolality 300 mOsm/kg Explanation: Syndrome of inappropriate antidiuretic hormone (SIADH) is characterized by decreased urination, hyponatremia, serum osmolality greater than 280 mOsm/kg, urine specific gravity greater than 1.030, increased urine osmolality, fluid retention, weight gain, and hypertension.

Final Review @ Jean Erney

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