ill ch 2

An older adult has cancer and is on several chemotherapy drugs. They are nauseous, and an antiemetic medication is prescribed. When is the best time to administer this medication?

30 minutes before chemotherapy2 Rationale:Antiemetic drugs are administered 30 to 60 minutes before chemotherapy and then at appropriate intervals throughout the expected duration of nausea and vomiting.

At what age does a child begin to discriminate between the mother's face and a stranger's face?

4 months4

The nurse is screening clients waiting to receive an influenza vaccine. Which client would the nurse question receiving the vaccination?

A 48-year-old woman with a fever of 102°F orally.2

A mother brings her 5-year-old child to the wellness clinic with a rash covering the child's body. The nurse recognizes the rash as chickenpox when noting what characteristic?

A maculopapular rash4

Which toy(s) would provide stimulation for a 3-month-old infant?

A mobile above the crib2

In the older adult client (over 60 years), what will the nurse identify as normal growth and development activities?

A restructure and reorganization of family and social activities Submit

A father brings his 4-year-old child to the community clinic immediately after the child ingested a small bottle of aspirin. What is the priority nursing action?

Administer activated charcoal.2

As the dying process progresses, a client with metastatic cancer experiences severe weakness. What is a therapeutic nursing intervention?

Administer pain medication more frequently.2

The nurse is screening a group of clients regarding the administration of the herpes zoster vaccination. Which statement is true about which clients should receive a herpes zoster vaccination?

All clients over 60 years old should receive the vaccination.2 Rationale:According to CDC 2014 adult immunization guidelines, all clients 60 years of age or older should receive the herpes zoster vaccination regardless of whether or not they report an episode of shingles or herpes zoster. Clients with a chronic condition should receive the vaccination unless there is a specific contraindication for the condition.

A father calls the clinic regarding his 6-year-old child who has been diagnosed with chickenpox and has extensive lesions. The child is uncomfortable, and the lesions are itching. What would be the best nursing response?

Apply calamine lotion and provide cool baths without soap. Rationale:Keep the child cool and provide calamine lotion. Increasing warmth may increase the number of vesicles, as well as increase irritation. Increasing fluids is appropriate, but the warm packs and warm bath will irritate the vesicles. Soap is not recommended. Aspirin should not be given to children with viral infections.

A 11-month-old child is in a private room for treatment of burns. Which intervention can best meet the developmental needs of the child?

Ask that a familiar adult be available to room with the child.3 Rationale:It is important for a familiar adult to be present all of the time, not only to provide emotional support but also to meet the child's safety and developmental needs. This particular age is when the toddler is most susceptible to separation anxiety. A toddler is likely to be apprehensive toward unfamiliar adults, so although the same nurse being assigned to the toddler may promote continuity of care, it is not the best answer. Determining favorite television cartoon shows is a poor substitute for human contact. A balloon is a safety hazard for a toddler.

In treating the cancer client, what would the nurse identify as the primary goal of the chemotherapeutic drugs?

Assist the client into remission. Rationale:The main goal is to get the client into remission. Medications may be discontinued after three years of remission.

Before a well-baby checkup in the pediatrician's office, an 8-month-old infant is sitting contentedly on the mother's lap, chewing a toy. When preparing to examine this infant, which step should the nurse do first?

Auscultate heart and lung sounds.4 Rationale:While the infant is quiet, it is important to auscultate the heart and lungs. Placing a tape measure on the infant's head, shining a light in the eyes, or undressing the infant before weighing may cause distress, which could make auscultating the heart and lungs, as well as the rest of the examination, more difficult.

What is important to teach a client regarding self-care during radiation therapy?

Avoid exposure to the sun and do not remove the skin dye markings.3 Rationale:The skin in the area of radiation is sensitive to sunlight; it is important to leave the markings on the skin so the radiologist will know the boundaries of the treatment area.

The nurse explains to a young adult female client that the most common site for cancer development in women is which anatomical structure?

Breast

What is the first sign of sexual maturation in females?

Breast development3

A client reports being lactose intolerant. The nurse would recommend which foods?

Broiled fish, fresh fruits, and vegetables2 Rationale:Lactose is contained in milk and milk products. "Broiled fish, fresh fruits, and vegetables" is the only answer that does not have a milk product (ice cream, yogurt, cheese, milk) included.

Which instruction should be included in the teaching plan of a client who does not like dairy products and rarely eats vegetables?

Calcium supplements may be necessary.2

A mother arrives at the office with her 9-month-old infant for a well-baby check. What observation would cause the most concern?

Cannot sit alone without support2

The mother of a newborn asks when she can begin to give her infant some fruits. What is the best response?

Cereals are started at 5 to 6 months, followed by fruit. Rationale:The American Academy of Pediatrics recommends that infants at age 5 months should receive iron-fortified formula if breastfeeding is discontinued. Solid foods (iron fortified cereals) may be introduced from 5 to 6 months. Strained meats and citrus fruit are not started until after the infant is eating cereals, generally around 6 months.

A client's breast cancer is being treated with external radiation therapy. What will be important for the nurse to understand regarding skin care of the area?

Check with the health care provider about skin care to the radiated area. Rationale:The skin of the treated area is fragile and easily damaged. It is important to check with the health care provider to determine how to provide skin care to the radiated area. Often, a mild soap and thorough rinsing with warm water is sufficient cleansing, but can be contraindicated in some situations. A hydrophilic moisture lotion can be used for drying, the area should not be exposed to sun, and clothing should be loose and nonbinding.

A nurse is discussing with a client the need to eat a high-protein diet. The nurse knows the client understands the diet when the client selects which foods from the hospital menu?

Chicken breast sandwich, sliced cheese, and milk

A client arrives to the clinic with a penetrating wound received while clearing lumber. What is the priority nursing action?

Cleanse the wound with an antiseptic solution.2

An adult is placed on a 500-mg sodium diet. Which of the following foods should the nurse suggest when assisting this client to select a daily menu? (Select all that apply.)

Cooked rice and baked fish Chicken and fresh fruit Spinach and carrot salad

A healthy 40-year-old adult is at the office for a routine yearly examination. The client shares with the nurse that, "My mother had cancer of the colon and I'm concerned about my risk factors for cancer". What would be important for the nurse to discuss with this client?

Current screening procedures recommends for clients with a family history of cancer.3

What advice should the nurse give a mother who reports, during a routine well-child exam, that her 5-month-old (weight of 15 lb) who was sleeping all night at 3 months of age is now waking up in the middle of the night hungry? The nurse obtains a diet history that reveals that the infant is taking six 6-oz bottles of formula in a 24-hour period and has 2 tablespoons of rice cereal in the morning.

Decrease the amount of formula to 32 oz in 24 hours and add fruits, cereals, and juices.4

Which clinical findings would indicate a deviation from the normal age-related changes in the neurological system and may indicate a need for further follow-up of the older client?

Decreased ability to maintain balance Rationale:A decreased ability to maintain balance is a major safety issue and not a part of normal aging. The first three findings are normal age-related changes to the neurological system.

The nurse is assessing the nutritional status of an 85-year-old client. What would the nurse identify as common physiological changes associated with aging?

Decreased absorption of iron3 Rationale:Decreased production of hydrochloric acid, which occurs with aging, leads to decreased absorption of iron and vitamin B12. Fat absorption would decrease, as would peristalsis and drug metabolism.

As the nurse plans care for the older adult female client, considerations related to incontinence include which physiological characteristic?

Decreased bladder capacity Submit

The nurse is assessing a 6-month-old infant in an immunization clinic. The nurse knows that by 6 months, the infant should have had which immunizations?

Diphtheria, acellular pertussis, tetanus, hepatitis B, polio Rationale:DTaP, polio, pneumococcal, hepatitis B, and the influenza vaccination are required immunizations by age 6 months. Varicella and MMR are not given until the infant is 1 year old.

The nurse is caring for a client who is being treated with a temporary radioactive cervical implant. What will be an important nursing action?

Do not spend an excessive amount of time at the client's bedside. Rationale:Clients with temporary implants emit radioactivity while the implants are in place, so the nurse should limit the amount of time spent close to the client. No special laundry container is needed, and the toilet does not have to be flushed twice. The radiation is not systemic, so body fluids are not contaminated. The client's skin has no radiation markings.

The nurse is serving a food tray to a client who has glomerulonephritis and azotemia. Which food selection would the nurse question?

Dried peaches and apricots Rationale:The increased potassium found in dried fruits (peaches and apricots) is contraindicated in client with increased potassium and blood urea nitrogen levels. These clients may also be on a decreased protein intake as well; however, in this question the potassium is the most important nutrient to exclude.

A child with a severe immunodeficiency is admitted to the hospital with a diagnosis of rubella. What types of precautions are important for the nurse to implement?

Droplet and contact precaution SRationale:Rubella is a virus that is spread via respiratory droplets and direct contact. Droplet and contact precautions include all of the standard precautions plus precautions specific to respiratory communicability. Rubella is not transmitted via airborne, being around the person will not create an increased risk; the respiratory droplets from the infected client must be inhaled.

During a very hot summer day, a mother of a 4-month-old breast-fed infant calls the clinic to ask about giving her baby water because of the very warm weather. What would be an appropriate response?

During a very hot summer day, a mother of a 4-month-old breast-fed infant calls the clinic to ask about giving her baby water because of the very warm weather. What would be an appropriate response?

What foods chosen by the client would indicate an understanding of nutritional teaching for wound healing?

Fish, tomatoes, rice Rationale:Protein and complex carbohydrates are necessary for wound healing. Foods containing empty calories, such as chocolate pudding and gelatin, would not be correct. The other options do not provide as much protein as fish. Chicken provides protein, but it is combined with chocolate pudding. The cheese sandwich selection provides more carbohydrates than protein. Remember, if one portion of an answer is incorrect, the entire answer is incorrect.

The nurse understands that which procedure is an example of palliative surgery for cancer?

Gastrostomy2

The nurse is assessing an 8-month-old infant in an immunization clinic. The nurse knows that by 8 months the child should have had which immunizations?

Hepatitis B first and second doses, all of the DTaP (diphtheria, tetanus, acellular pertussis) series, two doses of IPV, pneumococcal conjugate vaccine (PCV), and rotavirus (RV)2

Which assessment is a normal physiological change of the respiratory system that occurs with aging?

Hyperresonance3

A parent comes to the clinic with their 4-month-old for routine immunizations. What immunizations will be administered at this time? (Select all that apply.)

IPV (poliovirus) Rotavirus (RV) DTaP (diphtheria, tetanus, acellular pertussis) Hib (Haemophilus influenzae, type b) PCV (pneumococcal conjugate vaccine)

The nurse is planning the care for a chronically ill pediatric client. What is important to understand about pediatric rehabilitation?

Identify strengths and needs of the child.2

What psychosocial data would indicate that a 19-month-old child is demonstrating a nonadaptive reaction to hospitalization?

Ignores mother when she arrives to visit.3

The nurse understands that which immunization leads to long-lasting immunity?

Inactivated poliomyelitis (IPV)3

A client is 85 years old. Which dietary modification should the nurse consider due to the client's age?

Increase dietary intake of calcium and vitamins C and A3

The nurse is monitoring a client with cancer who has been receiving chemotherapy. What observations are associated with bone marrow depression? (Select all that apply.)

Increased bruising2 Hematuria3 Nosebleeds Nausea

The nurse would advise a young mother of a 5-month-old to include which foods in her infant's diet after the child is no longer breastfeeding?

Iron-rich formula3

Immunization for infants should start at what age?

1 month

The mother of a 3-month-old infant is concerned because her baby seems to sleep most of the time. The nurse's response is based on the knowledge that a 3-month-old infant usually spends

10 hours sleeping in a 24-hour period.2 Rationale:Normally, 3-month-old infants sleep 9-11 hours in a 24-hour period. Most infants do not begin sleeping through the night (six to eight hours periods) without waking until about three months of age, or until they weigh 12 to 13 lb. One reason for this is the small stomach capacity of newborns and infants that causes them to wake every few hours to eat.

A client who has had a myocardial infarction is discharged on a low-sodium, low-cholesterol diet. Which comment by the client would indicate to the nurse that he needs further diet teaching?

"I will have three servings of bread daily."4 Rationale:Bread and bakery products are most often a source of significant sodium and clients are generally encouraged to avoid them.

Planning anticipatory guidance is an important nursing function. Considering the teaching for the family of an 18-month-old child, which comment by the mother indicates she understands safety concerns?

"I will need to be sure that the locks on the medicine cabinet are secure."4 Rationale:Having medications and other dangerous cleaning materials and chemicals locked away in secure areas is an important safety issue for toddlers. It is not advisable to induce vomiting without calling the local poison control center first to be sure that it is okay to have the toddler vomit. Often, ingested materials may be corrosive, and induction of vomiting would not be an appropriate nursing action.

A preschool-age child is admitted to the hospital for treatment of pneumonia. The mother is embarrassed because the child has wet the bed, which he has not done since he was toilet-trained. Which response by the nurse would be most appropriate?

"This happens quite often with children when they are admitted to the hospital. When he feels better, his toileting skills will return to normal."2 Rationale:Children often regress during hospitalization. Regression may coincide with a stressful family situation. Behavior such as toilet-training may temporarily be lost but will return when the child feels better and returns home to a normal routine. Antibiotics do not typically cause incontinence. The other responses do not involve therapeutic communication.

What is an important aspect of client teaching regarding external radiation therapy?

Leave skin markings between treatments. Rationale:Skin markings are used by the radiotherapist to delineate the exact area of the body to be irradiated. Treatments are completed in a series and do not require fasting or any form of isolation.

What are the current American Cancer Society dietary recommendations for cancer prevention?

Maintain a desirable body weight and eat a variety of foods, including fruits and vegetables and foods that are high in fiber.2

The nurse is teaching the family about the treatment plan for an adolescent diagnosed with infectious mononucleosis. What would be important for the nurse to teach the client and her parents regarding the acute phase of infectious mononucleosis?

Maintain adequate bed rest. Submit

What nursing action should be included in the care plan of all clients with cancer?

Monitor and protect the client against infection.2

A client is receiving chemotherapy for lung cancer. The nurse understands that the medication may be nephrotoxic. What is an important nursing action?

Monitor daily weight and intake and output.3 Rationale:The fluid balance needs to be carefully monitored in order to determine renal changes that may impact intake and output as well as fluid retention. Baseline fluid balance should be determined when the client is started on the chemotherapy.

The nurse is planning the care for an older adult client being admitted to a long-term care facility. What is most important for the nurse to include in the plan?

Obtain information regarding how the client is cared for at home.2

A mother expresses concern that her 1-year-old son refuses solid food and that his diet consists mostly of milk and simple carbohydrates. What would be important for the nurse to discuss with the mother regarding the child's nutrition?

Offer him small amounts of meat and vegetables before offering him milk.3

The nurse at the women's, infant's, and children's center recommends which strategies to provide a 12-month-old infant with nutrients for growth?

Offer the infant small amounts of meat and vegetables before offering milk.3 Rationale:Children at this age are prone to anemia, especially when milk is offered frequently. Therefore, holding milk and other liquids until after solid food is offered prevents the child from "filling up" on the liquid.

A preschool child is diagnosed with chickenpox. The mother is concerned about how long the child will be contagious. On what principle will the nursing response be based?

One day before appearance of the lesions until all lesions have crusted is considered the most contagious period. Rationale:The most contagious period is the day before the child is breaking out to the time when all the lesions have crusted. The incubation period usually ranges from 2 to 3 weeks, or around 13 to 17 days.

The nurse is serving a bland diet to a client. Which foods would the nurse question?

Orange juice3 A bland diet is very nonirritating and usually consists of white foods. There are very few brightly colored foods on a bland diet. A milkshake, baked potato, and cream of wheat are bland in color and in taste; therefore, orange juice is different and makes it the correct answer.

An appropriate treatment for overweight children younger than 8 years would include which actions?

Plan a program of activity and exercise.4

The nurse explains a bone marrow aspiration procedure to a 5-year-old child. Which behavior of the child reflects effective teaching?

Points at her doll, saying that they have to put a needle here to look at my blood Submit

A nurse is planning a teaching program for an older adult. Which of these strategies would take into consideration the learning needs of the older adult?

Provide opportunities and information that relate to client's actual experience and situations from other older adults with similar experiences. Rationale:Adult learner characteristics provide the basis for guiding education for both adults and older adults. Older adults learn best when experience can be called upon and when the topic is of immediate value and can be discussed and shared with others. Although adults may forget some recently presented information, their thinking does not slow. Repetition is a good strategy for older adults with cognitive problems, such as dementia. Teaching should be provided when there is readiness to learn, not when the client can practice independently, because this may not be a realistic goal.

What are the nursing interventions regarding the care of a client with a vaginal radium implant?

Raise the head of the bed no more than 20 degrees. Rationale:Once the implant is in place, keeping it in the exact measured position without disruption is important. Strict bed rest is maintained. The head of the bed should be raised only slightly to accomplish this. A urinary retention catheter is placed to facilitate gravity drainage. The client should be in a private room. Constipation should be avoided, but a high-residue diet will increase the bulk of the stool and possibly dislodge the implant.

The nurse understands that the rash of roseola differs from that of rubella. Which statement is correct?

Rash of roseola starts on the trunk.4

A client is continuing his recovery from extensive surgery at home. The nurse instructs the client to increase his intake of which foods to promote healing?

Red meat, oranges, green beans4 Rationale:The client needs an increased intake of protein and vitamin C to promote healing. Red meat, citrus fruits, and green vegetables will give the highest amounts of these elements from the selections offered.

An 8-year-old boy is hospitalized for continued intravenous treatments for his leukemia. He is on a regular diet, but he eats very little. He tells the nurse he wants a hamburger, French fries, and a milk shake. What is the best nursing action?

Request these foods from the dietary department.3

A client comes to the emergency department with a deep penetrating wound he received in the garden. What is the best nursing action?

Rinse the wound with antibiotic solution. Rationale:Deep penetrating wounds that are contaminated by soil, dust, or excreta containing Clostridium tetani are the cause of tetanus, or lockjaw. First, the wound should be thoroughly cleansed, then the nurse should determine when the client received his last tetanus immunization. As a rule, clients will receive a tetanus booster as a safeguard.

A child diagnosed with hemophilia is admitted to the pediatric unit for treatment. The nurse encourages fantasy play, role-playing with dolls and puppets, and participation in his own care. The nurse understands that this developmental approach is most appropriate for which age group?

School-age child4

Which of these best describes guidelines for syrup of ipecac administration?

Should not be used routinely.3

The clinic nurse is discussing nutrition with the parents of a 10-month-old infant. The nurse determines that the infant is in the 97th percentile for weight and age. The parents want to begin giving the infant skimmed or low-fat milk. What is the best nursing response?

Skimmed or decreased-fat milk should not be given to children until 2 years of age.4

The nurse is assessing a client who has recently begun external radiation. What is a nursing observation that confirms the presence of early side effects of the radiation?___

Skin erythema followed by dry desquamation3

In doing an assessment on a 3-week-old infant, what would the nurse expect the infant to be able to do?

Smile indiscriminately.2 Rationale:At 3 weeks, infants may smile indiscriminately. Turning from side to side occurs around 2 to 3 months of age. Grasping for objects occurs around 6 months. Holding the head in alignment with no support occurs around 4 to 5 months of age.

What are appropriate toys for an 18-month-old infant to have for play while in a croup tent?

Stacking rings3

A client on a low-sodium diet is brought a meal tray. Which food should be removed?

Stuffed olives3

A school-age child has a history of an appendectomy and is now scheduled for an open reduction and internal fixation of the femur. What would be appropriate for preoperative teaching?

Suggest role-playing and provide appropriate materials.4

A child has a diagnosis of rubeola. What is important information that the parents should understand? (Select all that apply.)

Symptoms will continue to increase for 3 to 4 days after the rash has occurred. Encourage bed rest and quiet activities. Child is contagious for approximately 5 days after rash appears.

Which of these signs indicates the onset of puberty in male adolescents?

Testicular enlargement3

The client who has a chronic hematological disorder with anemia is recovering from a stroke. How will this client's rehabilitation activities differ from those of other clients after a stroke?

The client will require more frequent rest periods.2

The nurse understands that if excessive amounts of water-soluble vitamins are ingested, which of the following happens?

The excess will be excreted in the urine.

The measles, mumps, and rubella (MMR) vaccine is not administered to infants younger than 12 months. Why is this vaccination not recommended for this group of children?

The immune system of the child will not respond effectively to the vaccination. Submit

A client is 5 days postoperative for a mastectomy. The client has expressed an intense dislike for hospital food, and her appetite is unusually poor. What is important for the nurse to explain to the client?

The lack of food, especially protein, will interfere with her wound healing.3

Which is not a consideration when providing care to a client receiving internal radiotherapy?

The organ that is being irradiated3

Parents of a child ask the nurse how their child could catch chickenpox. The nurse's response would be based on what principle of disease transmission?

The organism is spread by droplets when a child sneezes or coughs.2

A parent calls the outpatient clinic and states that his 2-year-old just took an unknown amount of various medications. The child is sleepy, and the parent is having a difficult time arousing the child. What would be the best instructions to the parent?

Transport the child immediately to the closest ED.4

What is characteristic of the developmental socialization in an adolescent?

Uses peer group as a standard against which to compare self.

The nurse finds the client's radiation implant in the bed. What is the best nursing action?

Using tongs, replace it in the lead container in the room.2 Rationale:Whenever a client is treated with a radiation implant, there should always be a lead container and tongs in the room in which to place the radiation source if it should become dislodged. Getting the client away from the radiation source is most important to prevent skin irradiation. The room does not need to be evacuated. If gloves are ever used, they must be lead-lined.

The nurse is caring for a child who may have ingested excessive amounts of lead. What test will confirm a diagnosis of lead poisoning?

Venous blood sample for determination of lead level2

At the head start center, the nurse assesses a toddler, 12 to 24 months old. The nurse will choose this activity to provide a distraction.

Wagon

What is a common growth and development nursing assessment finding for a 3-year-old?

Walks upstairs with alternating feet.4

The nurse is serving a dietary tray to a client who has a bland diet ordered. What item on the tray would the nurse question?

White bread4

The nurse understands that appropriate treatment for a child with roseola infantum includes

antipyretic medications, rest, and hydration.3

The nurse understands that the food guide (MyPlate) is a

basic message is about healthy eating and portion control.3

The father of a 12-year-old boy tells the nurse that he is concerned about his son's weight—"he is getting fat." The child is at the 50th percentile for height and the 75th percentile for weight on the growth chart. The most appropriate nursing response would be to

explain that this is typical of the growth pattern of boys at this age. Rationale:It is normal for boys at this age to appear heavier before they get their "growth spurt." Reassuring the father, although appropriate, is not the best response. Because the findings are within normal limits, it would not be necessary to assess the family for the presence of obesity. Low-calorie, low-fat diets are contraindicated for the growing child.

The nurse understands what major difference between benign tumors and malignant tumors? Malignant tumors

invade adjacent tissue and metastasize.4 Rationale:The primary difference between benign and malignant tumors is the ability of the malignant tumor to invade adjacent tissues and metastasize. Benign tumors tend to be encapsulated and both types of tumors can lead to death. The benign tumors can expand into normal organ function which may lead to death.

In caring for a client with cancer, the nurse is aware that one of the primary toxic effects of chemotherapy is

neutropenia

The nurse in a long-term care facility would expect the elderly client to be most confused and disoriented

on awakening during the night.

Combined therapy of radiation and chemotherapy can have a significant therapeutic impact on the survival of an individual with cancer. The nursing priority for these clients includes measures to

prevent infection.4

The nurse is assisting a client with Parkinson's disease and the family with discharge planning. A priority home care goal for this client would be to

promote daily activity and independence.3

The parents of a 10-month-old who weighs 19 lb are asking about the positioning of their current car seat and whether they should change to a convertible car seat. The nurse should explain that the safest position for the car seat is

rear facing in back seat.2 Rationale:Infants should ride facing rear of car until 1 year old, weight 9 to 10 kg (20 to 22 lb, depending on the model of the car seat), which provides the best protection for the infant's heavy head and weak neck. Infants are safest if the car seat is placed in the middle of the back seat. There should be a three- and five-point harness, so clips are not at neck or throat level but adjusted to be at mid-chest level. Infants should not be placed in the front seat, because severe injuries and deaths have occurred from air bags deploying on impact in the front passenger seat. To use a convertible car seat, the toddler must be at least 1 year old and weigh at least 9 kg (20 lb). Toddlers can use a convertible seat up to 18 kg (40 lb) or booster seat and can ride facing forward. Harness straps should be at or above toddler's shoulders.