health and illness II practice questions exam 1

A nurse is teaching parents about the developmental milestones of an infant. Place the following developmental activities for an infant in order of occurrence by age from earliest to latest. All options must be used:

1. turning self from prone to supine (tummy to back) 2. turning self from supine to prone (back to tummy) 3. sitting alone 4. crawling on hands and knees 5. effectively using pincer grasp

You are working in the neonatal ICU and you are taking care of a 27-week-old infant that is going through withdrawal symptoms, ventilated, and is being tube fed. The mother states she did not know she was pregnant when she was doing drugs. The mother appears concerned for the infant and spends much of the day in the unit with the infant. What is the best way you can support her need?

Ensure explanations and patient conditions are given in understandable terms.

A client with heart failure is admitted to the hospital. What should the nurse assess in the client to determine a risk for impaired skin integrity secondary to fluid volume excess? Select all that apply. a. weight gain of one pound over the past month b. crackling breath sounds auscultated over lung fields c. increase in blood pressure from 122/76 to 144/90 d. pulse amplitude graded at 2+ in bilateral radial pulses e. neck vein distention with head of bed at 90 degrees

a, c, e

The nurse has administered 3% saline to a patient with hyponatremia. Which of these assessment data will require the most rapid response by the nurse? a. Audible bilateral crackles in lungs. b. Sediment and blood noted in the patient's urine. c. Radial pulse is 105 beats/minute. d. Blood pressure increased from 120/80 to 142/92.

a. Audible bilateral crackles in lungs.

Which comment by a 17 y/o male during a history and physical would indicate a development crisis according to Erikson's theory? a. My mom helps me make most decisions. b. I am gay and I am okay with that c. I have no idea what type of career I want to pursue, but I know I am going to college d. I enjoy spending a lot of time with my friends

a. my mom helps me make most decisions

A 3-month-old has moderate dehydration. The nurse should assess the client for which sign of moderate dehydration? a. oliguria b. bulging eyes c. sunken posterior fontanel d. pale skin color

a. oliguria

A nurse is caring for a 5-year old child who had a hernia repair 1-day ago. The child is experiencing diarrhea and has a NG tube set to low-intermittent suction. Which of the following laboratory tests would be the priority for the nurse to assess? a. Potassium level b. Magnesium level c. Calcium level d. Phosphate level

a. potassium level

An adolescent typically achieves formal operational thought. Piaget's final stage of cognitive development. Which cognitive abilities are achieved during this? (select all that apply) a. abstract thinking b. complex deductive reasoning c. representational language d. flexibility d. transductive reasoning

abstract thinking complex deductive reasoning flexibility

You are working in the ER and a 50-year-old male comes in with his wife complaining of SOB. Upon triaging you learn the patient has a history of CHF. He denies chest pain but states he cannot catch his breath. He states he has not been taking his maintenance medications for three months due to having lapsed in insurance coverage. You assessment yields = adventitious lung sounds, 2+ pitting, edema in lower extremities, tachycardia, bounding pulse, and orthopnea. What is the most appropriate nursing interventions now?

administer oxygen via face mask at 8L/min

which action should the nurse take when teaching a 5-year-old patient about a scheduled surgery?

allow the child to touch and hold medical equipment such as thermometers

an 18-month-old patient is brought into the clinic for evaluation because the patient is concerned. The 18-month-old hits siblings and says "no" when communicating verbally. Which recommendation by the nurse will be best for this situation?

assure the mother that the child is developmentally within specified norms

A 13-month-old client is admitted to the pediatric unit with gastroenteritis. The toddler has experienced vomiting and diarrhea for the past 3 days, and laboratory tests reveal dehydration. Which nursing interventions are correct to prevent further dehydration? Select all that apply. a. Encourage the child to eat a balanced diet. b. Give clear liquids in small amounts. c. Give milk in small amounts. d. Encourage the child to eat non-salty soups and broth. e. Monitor the intravenous (IV) solution per the physician's order. f. Withhold all solid food and liquids until the symptoms pass.

b, d, e

You are caring for a 24-year old male with Crohn's disease. He is here with severe malnutrition, abdominal pain and cramping. His serum potassium level is 3.1mEq/L and his serum magnesium level is 1 mg/dL. The doctor said he is going to order electrolyte replacements, but first puts an order in to "Implement seizure precautions." Which of the following will not be implemented? a. Bed locked and in the lowest position. b. All bedrails up and padded. c. Suction set up at bedside. d. Oxygen and tubing at bedside.

b. All bedrails up and padded.

You are caring for an 18-year-old female who was involved in a motor vehicle collision and suffered a mild traumatic brain injury, facial fractures, fractured collar bone, and multiple bruises. She has been inpatient for three days. Her recent CT and MRI scan was negative for hemorrhagic bleeding and absence of structural damage. Last night she was alert and oriented. This morning you asked her where she was and she responded, "I need to get dressed, I am late for the party... I feel sick, I think I need to vomit." Her vitals are 110 HR, BP 90/48, 20 respirations, and has a temperature of 97.9F. She is also complaining of her head hurting. Lab is calling you on the phone to report a critical value regarding this patient. Which lab are they most likely reporting? a. Serum Magnesium 1.0mg/dL b. Serum Sodium 118mmol/L c. Serum Potassium 3.0mEq/L d. Serum Calcium 9.0mg/dL

b. Serum Sodium 118mmol/L

A family is in the midst of a divorce. Their 3 year-old son states, "I got in trouble with my dad and I wished he would go away. It's my fault he doesn't live here anymore. This statement exhibits which of the following characteristics according to Piaget? a. egocentrism b. magical thinking c. transductive reasoning d. animism

b. magical thinking

According to Erikson, the nurse is alert to stressors that have an influence on school-aged child (6-11 yrs). One example of a common stressor for this age group is: a. puberty b. poor achievement in school c. privacy d. health-related concerns

b. poor achievement in school

A client is admitted with full-thickness burns to 30% of the body, including both legs. After establishing a patent airway, which intervention is a priority? a. covering the wounds with antibacterial dressings b. replacing fluid and electrolytes c. supporting the lower extremities in normal anatomic position d. evaluating the presence and quality of pulses distal to the burn injury

b. replacing fluid and electrolytes

The rate at which IV fluids are infused is based on the burn patient's: a. lean muscle mass and body surface area (BSA) burned. b. total body weight and BSA (body surface area) burned. c. serum sodium level and BSA (body surface area) burned. d. height and weight and BSA (body surface area) burned.

b. total body weight and BSA burned

Which assessment would be the most important for the nurse to include in the plan of care for an infant experiencing severe diarrhea? a. monitoring the total 8-hour formula intake b. weighing the infant each day c. checking the anterior fontanel every shift d. monitoring abdominal skin turgor every shift

b. weighing the infant each day

A newborn admitted with pyloric stenosis is lethargic and has poor skin turgor. The primary care provider has ordered I.V. fluids of dextrose water with sodium and potassium. The baby's admission potassium level is 3.4Meq/ L. What should the nurse do FIRST? a) Notify the primary care provider. b) Administer the ordered fluids. c) Verify that the infant has urinated. d) Have the potassium level redrawn.

c) Verify that the infant has urinated

A patient has Cushing's disease which causes the body to retain calcium. Which of the following signs and symptoms would be associated with a high serum sodium level? a. Anorexia. b. Low back pain. c. Altered level of consciousness d. Nausea, vomiting and diarrhea

c. Altered level of consciousness

You are caring for a patient with chronic renal failure. The laboratory results indicate hypocalcemia and hyperphosphatemia. When assessing the patient, what characteristic would you expect to see? a. Drowsiness and lethargy. b. Constipation. c. Prolonged QT Intervals and arrhythmias. d. decreased deep tendon reflexes

c. Prolonged QT Intervals and arrhythmias.

You are working in labor and delivery and started a magnesium drip on a 32-year-old female with severe preeclampsia last night. Her current continuous magnesium titration is at 2g/hour. What symptoms would indicate potential magnesium toxicity? a. Increased urine output. b. Respiration rate of 32 bpm. c. Significantly decreased deep tendon reflexes. d. Increased serum calcium level.

c. Significantly decreased deep tendon reflexes.

You are caring for a diabetic patient with bowel obstruction and have orders to ensure that the volume of intake matches the output. In the past 4 hours, the patient received dextrose 5% with 0.9% sodium chloride through a 22-gauge catheter infusing at 150 ml/hr and has eaten 200 mL of ice chips. The patient also has an NG suction tube set to low continuous suction that had 300-mL output. The patient has voided 400 mL of urine. After reporting these values to the healthcare provider, which order would you anticipate? a. discontinue NG and suction b. decrease IV to 100 ml/hour c. add potassium supplements to IV d. encourage more ice chips orally

c. add potassium supplement to IV

An older adult client diagnosed with end-stage renal disease (ESRD) presents with fluid volume excess. Which nursing intervention is the priority? a. Weigh the client. b. Assess the client's heart rate and blood pressure. c. Assess the client's lung sounds. d. Place the client on intake and output measurement.

c. assess the client's lung sounds

a nurse takes the history of a middle-aged patient in a health clinic. Which information indicates the patient has achieved generativity? a. married for 30 years b. has no regrets with life choices c. teaches preschoolers d. cares for aging patients after work

c. teaches preschoolers

The nurse is teaching a young-adult couple about promoting the health and psychosocial development of their 8-year-old child. Which information the parent indicates a correct understanding of the teaching according to developmental stage? a. We will provide consistent, devoted relationships to meet needs b. We will limit choices and provide punishment for mistakes c. we will provide proper support for learning new skills d. we will instill a strong identity of who our child is

c. we will provide proper support for learning new skills

For which reason is it more difficult to diagnose psychiatric disorders in children than in adults?

children usually lack the abstract cognitive abilities and verbal skills to describe what is happening behaviors that are appropriate for a child of one development level may be inappropriate for a child of a different developmental level because they are constantly changing and developing, children are unable to discriminate unusual or unwanted symptoms from normal feelings and sensations

You are caring for a family who has suffered from the effects of a massive hurricane. The family lost their home, clothes, and belongings. The family is now staying at a local shelter through the community church. Which nursing diagnosis would most accurately describe this family?

compromised family coping

A home health nurse is seeing a patient with congestive heart failure. The patient is taking furosemide (Lasix). The nurse reviews the patient's most recent serum potassium which was 3.4 mEq/L. Which food would the nurse encourage this patient to add to their diet? a. Hardboiled eggs b. Avacados c. Salmon d. Cantaloupe

d. Cantaloupe

A 68-year-old male patient came into the family practice clinic complaining of lethargy, muscle weakness, severe constipation and abdominal cramps. His labs are Na 142 mEq/L; K 4.6 mEq/L; Calcium 11.3 mg/dL; and Magnesium 2.1 mg/dL. Which item on the patient's history could predispose him to this electrolyte imbalance? a. Daily exercise, walking 2 miles per day. b. History of hypoparathyroidism. c. History of pancreatitis 2-years ago. d. Currently on lithium for bipolar disorder.

d. Currently on lithium for bipolar disorder.

A nurse is planning care for a client who has heart failure. Which goal is appropriate for a client with excess fluid volume? a. A weight reduction of 10% will occur. b. Pain will be controlled effectively. c. Arterial blood gas values will be within normal limits. d. Serum osmolality will be within normal limits.

d. serum osmolarity will be within normal limits

Which of the following laboratory findings would the nurse expect in a child with an excess of water?

decreased serum osmolarity

The nurse is teaching the parents of a 3-year-old child who is at risk for development delays. Which instruction will the nurse include in the teaching plan?

encourage play as your child is exploring the surroundings

Which statement is accurate for 2nd degree burn?

entire epidermis and varying areas of the dermis are involved in injury

Which statement most accurately reflects the Structural-Functional theory?

family is viewed as a social system and each member has specific roles

You are taking care of a patient in the ER and are preparing to administer an IV solution of 3% NaCl. In which direction will the fluid shift?

from intracellular to extracellular

You are working in the pediatric floor and are taking care of a child age 3 years who was admitted for dehydration s/t vomiting three days. The patient was positive for influenza and is diagnosed with acute kidney renal failure resulting from dehydration. What clinical findings would be most associated with the child's injury?

hyperkalemia lab findings most associated with acute renal failure are hyperkalemia, hyponatremia, hypocalcemia, elevated BUN/Cr levels and metabolic acidosis

You are taking care of an elderly patient that was brought in form a nursing home for increased confusion. The patient is reported to have mild neurocognitive disorder. She was released three weeks ago following a placement of a PEG tube, which is now being used for her hypertonic enteral feedings only. The facility states the patient can take her pills and drink water orally if you remind her, but she often forgets to drinks. She also has three watery bowel movements daily for three days. What lab findings would you expect to see?

hypernatremia

You are caring for a person with end stage liver disease and are concerned that the patient may be experience third-space fluid shift. Which of the following would be evidence of third-space fluid shift?

increased HR and decreased BP

the nurse is caring for a 14-year-old patient in the hospital. Based on Erickson, which goal will be priority?

maintain identity

You are working in a post-surgical recovery unit. One of your patients is a 55-year-old female status post total thyroidectomy. The patient is alert and oriented and is complaining of sore throat and dull pain. She denied feeling nauseous. As you are assessing her pulses, you can feel mild twitching in her hands and feet. You ask here if this behavior was normal. She responds, "oh well... no. I am not worried it's probably from the anesthesia or pain medicine. I don't tolerate pain medication very well usually. Usually I get itchy." What is the most appropriate action to do next?

notify the surgeon immediately

A 59-year-old mother is in the medical ICU. SHe has coded twice in the last two days. Today her three daughters decided to make her DNAR (do not attempt resuscitation). The daughters however begin to argue loudly over who will inherit their mother's car, house, and furniture. They then start shouting over who is responsible for the bill as their mother had no medical insurance. As the patient's nurse, what would be the most appropriate approach in this situation to assist planning care?

suggest the family step outside the room and recommend a consult with the social worker

A psychiatric mental health nurse is applying Erikson's theory of psychosocial development in the care of a young adult client. What outcome should the nurse identify to best address the developmental conflict that this client is experiencing at this age?

the client demonstrates new interpersonal skills to promote the development of intimate relationships

In a dysfunctional family, a nurse notes that two people in the family are having a stressful relationship. One of these individuals has talked to another individual outside of the family unit about this stressful relationship to try to get this person to approach the family member about the stress they are causing. This type of behavior is called:

triangulation

You are working in a pediatric unit and are assessing a 5-year-old female weighing 25 kg. You are preparing to hang an IV solution of 0.9% NaCl with 20KCl additive. Before hanging the IV solution, which assessment finding would warrant holding administration and contracting to the provider?

urine output 10mL/hr

Which of the following statements best describes the purpose of designing a genogram?

used as a graphic presentation to represent the relationships within the family over three generations

As a nurse, there will be times when you may need to develop interventions to promote positive change in family functioning. Which nursing action below promotes positive change?

validating or normalizing emotional responses

A client begins to take stock of life and look into the future. The nurse assesses that this client is in which of Erikson's development stages?

Integrity versus despair

Based on Duvall's developmental stages of the family, what stage most accurately describe a married couple's pursuit in re-identifying their relationships and discovering their own individual interest?

Stage VII

The parent of a 15-year-old tells the nurse that the child is becoming more assertive in conflict situation and wants to get a job. The parent asks if it is healthy for a 15-year-old to be so independent. Which is valid information for the nurse to offer the parent?

The behavior reflect normal growth and development

You are leading a family therapy session to promote and identify strengths of the family, in order to build on these qualities and make the family unit stronger. What qualities would be identified with a strong family?

a sense of purpose that permeates the reasons and basis for "going on" in both good and bad times

A nurse works in the student health clinic at a local college where most of the students are young adults. Using Havighurst's developmental theory, the nurse includes which of the following questions in each intake interview because it is a major concern for this age group?

"Are you currently married or in serious relationship"

You are working in a family clinic and are educating a patient with CHF about a heart healthy diet and edema. What statement below would indicate understanding?

"I need to read the labels on store bought foods and bottled water for salt content"

a nurse that is teaching caregivers how to select appropriate toys for their 10-month-old infant. Which statements by the caregivers indicate effective teaching?

"We'll get the baby a push toy" "We'll get the baby some shape sorters"

A nurse is providing education to a group of parents who have children with ADHD. Which statement would be accurate and should be included in the education?

ADHD is not the fault of the parents or the child and techniques and school programs are available to help It is important for parents of children with ADHD to learn how to rebuild their child's self-esteem Because raising a child with ADHD can be frustrating and exhausting, it often helps parents to attend support groups that can provide information and encouragement from other parents with the same problems

In the pediatric Emergency Department, the nurse assesses a 6-month-old infant who is lethargic and suspected to be severely dehydrated. Which additional information is a priority for the nurse to determine? a. the infant's current weight b. number of feedings in the last 24 hours c. blood pressure and capillary refill time d. number of wet diapers in the last 24 hours

c. blood pressure and capillary refill time

You are working in the ER and a 25-year-old male is brought in by two of his co-workers who is stated to have suffered from a scalding accident at work when in a pipe in the boiler busted thirty minutes ago. He is groaning, has wet blankets on him, and is minimally response. Vitals are 130 HR, 98/57, RR 10, 89% O2. Based on bum protocol and following the ABA fluid resuscitation formula, the patient will be receiving IV fluid resuscitation. He is calculated to have a 50% TBSA 2nd degree burn on his upper body and arms. Which statement is true regarding fluid resuscitation?

Half of calculated fluid volume is given over first 8 hours post burn

Facial muscle twitching noted when you tap lightly over the facial nerve (located 2cm anterior to the ear lobe) is a positive result of which test? a. Homan's sign b. Romberg's sign. c. Chvostek's sign. d. Trousseau's sign.

c. Chvostek's sign.

It is evident that a client has entered Piaget's stage of formal operations when the client...

speaks about a recent ballad as being reflective of the client's life story

The nurse is observing a child in the pediatric unit at the hospital. Which behavior would alert the nurse that the child is in Piaget's preoperational stage of intellectual development?

the child is naming stuffed animals in the toy collection