N550 EBP EAQs
Which developmental milestone is characteristic of language development in preschoolers? a) They start questioning events. b) They realize that words have arbitrary meanings. c) They distinguish between phonetically similar sounds. d) They use 2000 to 8000 words to express their desires.
a) They start questioning events. Preschoolers start to look for the reasons behind events. Their questions expand to "Why?" and "How come?" School-aged children, not preschoolers, realize that words have arbitrary rather than absolute meanings. Phonetically similar words such as die and dye or wood and would cause confusion in preschool children. They use 8000 to 14,000 words to define familiar objects, identify colors, and express their desires and frustrations.
Which describes the similarity between grand theory and descriptive theory? a) Both theories explain Neuman's model. b) Both theories are nonspecific to a particular nursing intervention. c) Both theories are starting levels of theory development. d) Both theories explain an individual's maturation process.
b) Both theories are nonspecific to a particular nursing intervention. Both grand theory and descriptive theory provide a wide range of ideas about nursing. Hence, they are not specific to a particular nursing intervention. Neuman's model is a grand theory, not a descriptive theory. Descriptive theory is considered the first level of theory development. An individual's maturation process at different ages is described under descriptive theory.
Immediately after a subtotal gastrectomy, a client is admitted to the postanesthesia care unit (PACU). The nurse irrigates the nasogastric tube and observes small blood clots in the return. Which action would the nurse take? a) Clamp the nasogastric tube. b) Irrigate the tube with iced saline. c) Document this expected response. d) Notify the health care provider of this finding.
c) Document this expected response. As a result of the trauma of surgery, some bleeding is expected for several hours. Clamping the tube will cause increased pressure on the gastric sutures from a buildup of gas and fluid. Iced saline is used rarely because it causes vasoconstriction, local ischemia, and a reduction in body temperature. Notifying the health care provider of this finding is not necessary; bleeding during the immediate postoperative period is an expected occurrence.
Which descriptions of play are developmentally normal in preschoolers? Select all that apply. a) Preschoolers hinder the play of other children. b) Preschoolers follow set rules while playing. c) Preschoolers engage in pretend play. d) Preschoolers get engaged in associative play. e) Preschoolers need a temporary leader to play.
c) Preschoolers engage in pretend play. d) Preschoolers get engaged in associative play. e) Preschoolers need a temporary leader to play. Preschoolers enjoy pretend play, or imaginative, make-believe play that allows them to develop social, emotional, language, and thinking skills. Preschoolers shift from parallel play to associative play; playing helps them learn to understand others and become more creative. Also, they often select a temporary leader for each activity. Preschoolers play with other children in a cooperative manner, rather than hindering their play. However, there is no division of labor or set, rigid organization or rules.
To prevent hemorrhage of a client who underwent a liver biopsy, the nurse would place the client in which position? a) Prone b) High Fowler c) Right side-lying d) Trendelenburg
c) Right side-lying Placing a client on the right side after a liver biopsy compresses the liver against the abdominal wall, thus holding pressure on the biopsy site and allowing clot formation. There is no indication that the prone, high Fowler, and Trendelenburg positions are beneficial or appropriate for the client.
Which description of myelomeningocele is accurate? a) It is a fusion failure of the vertebral arches without herniation of cord or meninges. b) There is a defect in the base of the skull through which the brain and meninges have herniated. c) A membrane-covered sac of meninges, filled with spinal fluid, is protruding through a defect in the spine. d) A saclike cyst of meninges, containing a portion of spinal cord and fluid, is protruding through a defect in the spine.
d) A saclike cyst of meninges, containing a portion of spinal cord and fluid, is protruding through a defect in the spine. Myelomeningocele is a neural tube defect in which the meninges and spinal nerves protrude through the opening in the spinal column. Nerve damage may occur at or below the level of the defect. A fusion failure of the vertebral arches without herniation of cord or meninges is spina bifida occulta; there is no break in the skin or protrusion of any structure. A defect in the base of the skull through which the brain and meninges have herniated is an encephalocele; the spinal cord is not involved. A membrane-covered sac of meninges, filled with spinal fluid and protruding through a defect in the spine, is a meningocele; usually there is no nerve damage, although affected individuals may have minor disabilities.
Neuroleptic malignant syndrome develops in a client taking a conventional antipsychotic medication. Which signs and symptoms would the nurse expect? Select all that apply. a) Hyperpyrexia b) Blurred vision c) Increased muscle tone d) Respiratory depression e) Buccolingual lip-smacking
a) Hyperpyrexia d) Respiratory depression e) Buccolingual lip-smacking
Which are the current leading causes of death in the United States? Select all that apply. Stroke Cancers Dementia Accidents Infections
Stroke Cancers Dementia
Which position would the nurse place a client in during the immediate period after injury to the frontal lobe of the brain? a) Supine b) Side-lying c) Low-Fowler d) Trendelenburg
c) Low-Fowler Elevating the head of the bed increases drainage of cerebrospinal fluid and decreases intracranial pressure. Supine and side-lying positions will not promote cerebral drainage and may lead to increased intracranial pressure. Trendelenburg position will increase retention of cerebrospinal fluid and increase intracranial pressure.
The nurse develops a plan of care for a client with an ileostomy and would include which item? a) Teach the client to eat foods high in residue. b) Explain that drainage can be controlled with daily irrigations. c) Expect the stoma to start draining on the third postoperative day. d) Anticipate that any emotional stress can increase intestinal peristalsis.
d) Anticipate that any emotional stress can increase intestinal peristalsis. Emotional stress of any kind can stimulate peristalsis and thereby increase the volume of drainage. The client should be encouraged to eat a regular diet if possible. Ileostomy drainage is liquefied and continuous, so irrigations are not indicated. The stoma will start to drain within the first 24 hours after surgery.
The nurse is eliciting a health history from a client with ulcerative colitis. Which factor would the nurse consider to be most likely associated with the client's colitis? a) Food allergy b) Infectious agent c) Dietary components d) Genetic predisposition
d) Genetic predisposition Studies indicate that inflammatory bowel diseases, which include ulcerative colitis and Crohn disease, are familial, which suggests that they are hereditary. Although food allergy or an infectious agent may be causative factors, they are not the most common factors. No specific dietary component has been identified.
Which represents a significant shift in U.S. health policy in recent years? a) Palliative care is now being offered to children and adults. b) End-of-life care is no longer covered by insurance companies. c) Terminal clients now have standardized support for ending their lives. d) There is a focus on better managing clients with multiple chronic conditions.
d) There is a focus on better managing clients with multiple chronic conditions.
Which hormones are involved in building and maintaining healthy bone tissue? Select all that apply. a) Insulin b) Thyroxine c) Glucocorticoids d) Growth hormone e) Parathyroid hormone
a, c, d Insulin works together with growth hormone to increase bone length, which helps build and maintain healthy bone tissue. Glucocorticoids regulate protein metabolism to reduce or intensify the organic matrix of bone. Thyroxine increases the rate of protein synthesis in all types of tissues. Parathyroid hormone secretion stimulates bones to promote osteoclastic activity and release calcium into the blood when serum calcium levels are lowered.
Which is a similarity between the preoperational period and the formal operations period? a) Both periods reflect egocentrism in the individual. b) Both periods demonstrate animism in the individual. c) Both stages outline play as a means for fostering development. d) Both periods are characterized by an individual's capacity to reason with respect to all possibilities.
a) Both periods reflect egocentrism in the individual. Both the preoperational and the formal operations period show that there is a prevalence of egocentric thought in the individual. The preoperational period demonstrates animism in an individual. The preoperational period also demonstrates play as a means of fostering development in the child. During formal operation period, the individual has the capacity to reason with respect to possibilities.
Which medication therapy lowers a child's resistance to varicella? a) Anticonvulsant b) Systemic steroid c) Antihypertensive d) Topical antibiotic
b) Systemic steroid Individuals who are taking steroids have lowered resistance and may become fatally ill if exposed to the varicella virus. Anticonvulsants and antihypertensives do not lower body resistance; therefore, they do not increase susceptibility. Topical antibiotics do not affect body resistance because topical antibiotics do not have systemic effects.
A client had part of the ileum surgically removed. The nurse monitors the client closely for anemia based on which rationale? a) Folic acid is absorbed in the ileum. b) Cobalamin is absorbed in the ileum. c) Iron absorption is dependent on simultaneous bile salt absorption in the ileum. d) Copper, cobalt, and nickel are dependent on simultaneous bile salt absorption in the ileum.
b) Cobalamin is absorbed in the ileum. Vitamin B 12 (cobalamin) combines with intrinsic factor, a substance secreted by the parietal cells of the gastric mucosa, and is absorbed in the ileum. Cobalamin is needed to make red blood cells. Folic acid and iron are not absorbed. Copper, cobalt, and nickel are not absorbed in the ileum.
For which clinical indicators would the nurse monitor when caring for a client with cholelithiasis and obstructive jaundice? Select all that apply. a) Dark urine b) Yellow skin c) Pain on urination d) Clay-colored stool e) Coffee-ground vomitus
a) Dark urine b) Yellow skin d) Clay-colored stool
Which factor contributes to skeletal calcium loss by a client who has paraplegia? a) Decreased weight bearing b) Inadequate fluid intake c) Decreased calcium intake d) Inadequate kidney function
a) Decreased weight bearing The bones respond to the stress of weight-bearing exercise (walking, running, etc.) by laying down new bone substance along the lines of stress. Inactivity leads to reduced bone deposition and actual bone decalcification. Fluid intake has no effect on bone decalcification. Calcium intake does not alter bone demineralization in clients with paraplegia. Kidney function may be altered while bone decalcification occurs and stones are formed in the kidneys, but this is not the cause of demineralization.
Which goal would the nurse identify as the reason for snugly bandaging the client's residual limb after an amputation? a) Promoting tissue shrinkage b) Preventing injury to the area c) Preventing suture line infection d) Promoting drainage of secretions
a) Promoting tissue shrinkage Wrapping of the residual limb applies pressure that prevents swelling and shapes it for the fitting of a prosthesis in the future. A sock is used to protect the residual limb from irritation and injury. Infection is not prevented in this manner; surgical asepsis should be maintained. Secretion drainage is not promoted by wrapping the limb; portable drainage systems are used for this purpose.
The goal of a particular nursing theory is to use communication to help a client reestablish positive adaptation to the environment, and the framework for the nursing practice is based on treating nursing as a dynamic interpersonal process among the nurse, the client, and the health care system. Which nursing theory are these points related to? a) King's theory b) Neuman's theory c) Nightingale's theory d) Benner and Wrubel's theory
a) King's theory King's theory focuses on using communication to help the client reestablish positive adaptation to the environment; its framework for practice is based on treating nursing as a dynamic interpersonal process among the nurse, the client, and the health care system. Neuman's theory focuses on helping individuals, families, and groups attain and maintain a maximum level of total wellness by purposeful interventions. Nightingale's theory is based on facilitating the reparative processes of the body by manipulating a client's environment. Benner and Wrubel's theory focuses on a client's need for caring as a means of coping with the stressors of an illness.
When discussing a scheduled liver biopsy with a client, the nurse explains that for several hours after the biopsy the client will have to remain in which position? a) The left side-lying position with the head of the bed elevated b) A high-Fowler position with both arms supported on several pillows c) The right side-lying position with pillows placed under the costal margin d) Any comfortable recumbent position as long as the client remains immobile
c) The right side-lying position with pillows placed under the costal margin In the right side-lying position with pillows placed under the costal margin, the liver capsule at the entry site is compressed against the chest wall, and escape of blood or bile is impeded. The left side-lying position with the head of the bed elevated, a high-Fowler position with both arms supported on several pillows, and any comfortable recumbent position as long as the client remains immobile are unsafe because pressure will not be applied to the puncture site and the client can bleed from the insertion site.
Which is the priority nursing intervention for a client admitted to the hospital with a brain attack (cerebrovascular accident)? a) Changing position every 2 hours b) Keeping a serial record of the pulse c) Performing range-of-motion exercises d) Monitoring for increased intracranial pressure
d) Monitoring for increased intracranial pressure Cerebral edema may occur with a brain attack, resulting in increased intracranial pressure. Although preventing pressure ulcers is important, it is not the priority. All vital signs are important, not just the pulse. Although maintaining joint mobility is important, it is not the priority; range-of-motion exercises may increase intracranial pressure and should be instituted in collaboration with the health care provider.
A client who had an open reduction and internal fixation of a femoral neck fracture has a prescription for ambulation with slight weight bearing on the affected extremity. The nurse identifies that the client has kyphosis and strong upper-arm strength. Which assistive device would the nurse expect the primary health care provider to prescribe? a) Crutches b) Quad cane c) Straight cane d) Walker
d) Walker A standard walker can be used by a client with partial weight bearing who has enough upper-body strength to lift and move the walker forward. A standard walker with rubber tips is designed for those who need more support than a cane. Kyphosis is an exaggerated angulation of the posterior curve of the thoracic spine; it alters the client's center of gravity, making the use of crutches unsafe. A quad cane requires weight bearing on both legs. Partial weight bearing means that the client may put minimal weight on the affected extremity. A straight cane requires weight bearing on both legs.
On reviewing the x-ray report of a client with rheumatoid arthritis, the nurse learns that three small joints are involved. Which score will the nurse assign the client for joint involvement? 1 2 3 5
2 According to the diagnostic criteria for rheumatoid arthritis, involvement of one to three small joints (with or without large-joint involvement) is given a score of 2. Involvement of two to 10 large joints is given a score of 1. Involvement of four to 10 small joints (with or without large-joint involvement) is given a score of 3. Involvement of more than 10 joints (and at least one small joint) is given a score of 5.
Arrange these health risks in decreasing order of the frequency at which they cause death among adolescents. 1) Homicide/violence 2) substance abuse 3) suicide 4) accidents
4, 1, 3, 2 Accidents remain the leading cause of death in adolescence. As of 2011, motor vehicle accidents, which are the most common cause of death, resulted in 74% of all unintentional deaths among adolescents aged 10 to 19 years. Homicide is the second leading cause of death in the 15- to 24-year-old age group. Suicide is the third leading cause of death in adolescents 13 to 19 years of age. Substance abuse is the fourth leading death risk among adolescents.
The nurse is assessing a client with severe liver disease. Which assessment finding will the nurse expect to observe? a) Icterus b) Urticaria d) Uremic frost e) Hemangioma
Icterus Bile deposits will impart a yellowish tinge (jaundice or icterus) to the skin, often first observed in the sclerae. Urticaria (or hives) generally is characteristic of an allergic response. Uremic frost is characteristic of kidney failure. Hemangioma is a benign lesion composed of blood vessels.
Which is true regarding the sleep pattern of toddlers? a) They sleep for roughly 12 hours a day. b) They sleep for about 7 hours per night. c) About 30% of sleep time is in rapid eye movement (REM) sleep. d) Approximately 20% of sleep time is REM sleep.
a) They sleep for roughly 12 hours a day. By the age of 2, children usually sleep through the night and take daily naps. Total sleep averages 12 hours a day. About 30% of an infant's sleep time is in the REM cycle. On average, teenagers get about 7 hours of sleep per night. Approximately 20% of the total sleep time in an adult is REM sleep.
After a client has a bone marrow aspiration performed, which action would the nurse take first? a) Position the client on the affected side. b) Administer prescribed analgesics for pain. c) Apply firm pressure over the aspiration site. d) Monitor the client's blood pressure and pulse.
c) Apply firm pressure over the aspiration site.
Which two factors would the nurse state influence the effectiveness of a leader? Select all that apply. a) Ability b) Attitude c) Readiness d) Willingness e) Assessment
c) Readiness e) Assessment Readiness and assessment are two factors that influence the effectiveness of the leader. Ability and willingness are the two factors that need to be assessed to determine the level of the leader's readiness. Attitude is related to the individual's willingness.
Which medication strengthens the urinary sphincters? a) Midodrine b) Duloxetine c) Oxybutynin d) Mirabegron
b) Duloxetine Duloxetine is a serotonin-norepinephrine reuptake inhibitor (SNRI) that strengthens urinary sphincters and has anticholinergic action. Midodrine is an alpha-adrenergic agonist, which increases the contractile force of the urethral sphincter. Oxybutynin is an antispasmodic that causes bladder muscle relaxation. Mirabegron is a beta-3 blocker that relaxes the detrusor smooth muscle, which increases bladder capacity and urinary storage.
A nurse is supportive of a child receiving long-term rehabilitation in the home rather than in a health care facility. Why is living with the family so important to a child's emotional development? a) It provides rewards and punishment. b) The child's development is supported. c) It reflects the norms of a larger society. d) It is where child's identity and roles are learned.
d) It is where child's identity and roles are learned. Socialization, values, and role definition are learned within the family and help develop a sense of self. Once established in the family, the child can move more easily into society. Although important, providing rewards and punishments, supporting the child's development, and reflecting the norms of society are just one aspect of the family's influence and are not as important as identity and roles in relation to emotional development.
The nurse is assessing a client with a cast to the extremity. Which assessment finding would the nurse document in the electronic health record without any follow-up intervention required? a) Warmth b) Numbness c) Skin desquamation d) Generalized discomfort
a) Warmth is a sign of adequate circulation; after documentation that finding requires no intervention. Numbness is a neurological sign that indicates pressure on the nerves and blood vessels and should be reported immediately. Skin desquamation results from inadequate skin care and can be managed with hygiene support. Some degree of discomfort is expected after cast application and may require comfort measures.
Which family history would the nurse recognize as a risk factor for an infant developing hypertrophic pyloric stenosis (HPS)? a) A first cousin underwent surgery for HPS. b) The birth was preterm, and the birth weight was 4 lb (1814 g). c) An older brother had idiopathic vomiting during infancy. d) The older sister experienced an intestinal obstruction during early infancy.
a) A first cousin underwent surgery for HPS. The higher incidence of hypertrophic pyloric stenosis among first-degree relatives seems to indicate a hereditary cause. Full-term infants are more likely to be affected than preterm infants. HPS is not related to other gastrointestinal disorders, even among close relatives.
Which critical thinking skill is being taught when the nurse explains to a student the importance of examining client information with an open mind? a) Analysis b) Inference c) Evaluation d) Interpretation
a) Analysis Analysis is a critical thinking skill that involves examining information about a client carefully and with an open mind. Inference involves looking at client findings and assigning meaning and significance to them. Evaluation involves looking at situations objectively and measuring them. Interpretation involves being orderly in the collection of client data.
Which medication increases the risk of hematuria? a) Warfarin b) Cimetidine c) Phenazopyridine d) Nitrofurantoin
a) Warfarin Warfarin is an anticoagulant. Anticoagulants may cause hematuria, which is the presence of blood in the urine. Cimetidine is an antihistamine. Antihistamines affect the normal contraction and relaxation of the urinary bladder. Phenazopyridine and nitrofurantoin cause urine discoloration.
The parents tell the nurse that their preschooler often awakes from sleep screaming in the middle of the night. The preschooler is not easily comforted and screams if the parents try to restrain the child. Which would the nurse instruct the parents? a) "Always read a story to the child before bedtime." b) "Intervene only if necessary to protect the child from injury." c) "Discuss counseling options with the primary health care provider." d) "Try to wake the child and ask the child to describe the dream."
b) "Intervene only if necessary to protect the child from injury." Waking up screaming from sleep at night indicates sleep terrors. The nurse would advise the parents to observe the child and intervene only if there is a risk for injury. Reading a story before bedtime helps calm the child before sleeping, but it does not ensure that the child will not have a sleep terror. There is no need for professional counseling, because sleep terrors are a common phenomenon in preschool-age children. The child is not aware of anybody's presence during a sleep terror, so it is not appropriate to wake up the child; this may cause the child to scream and thrash more.
Which component of delegation is defined as "the ability to perform duties in a specific role"? a) Authority b) Supervision c) Responsibility d) Accountability
a) Authority Authority is the ability to perform duties in a specific role. Supervision is the provision of guidance and oversight of a delegated task. Responsibility refers to reliability, dependability, and obligation to accomplish work. Accountability involves determining whether the actions are appropriate and providing a detailed explanation of what has occurred.
Which position would help the client who has an above-the-knee amputation prevent a contracture? a) Prone position b) Sitting position c) Supine position with a pillow under the residual limb d) Side-lying position with a pillow between the thighs
a) Prone position The prone position maintains the hips in extension, which helps prevent flexion contractures of the hips. The sitting position flexes the hips and knees, which promotes hip and knee flexion contractures. The supine position with a pillow under the residual limb will flex the hip, promoting a hip flexion contracture. In the side-lying position the left hip will be flexed, which will promote the development of a hip flexion contracture.
A client who has received tap water enemas until clear is at risk for developing which complication? a) Hypercalcemia b) Hypocalcemia c) Hyperkalemia d) Hypokalemia
d) Hypokalemia Repeated tap water enemas deplete cells and extracellular fluid of potassium and sodium, resulting in hypokalemia, hyponatremia, and the potential for water intoxication. Repeated tap water enemas do not have a direct effect on hyper- or hypocalcemia. Potassium is depleted from cells and extracellular fluid and does not result in hyperkalemia.
Which child is at the highest risk for blunt trauma and indirect entry (hematogenous stage) of microorganisms? a) 8-year-old boy b) 10-year-old girl c) 13-year-old girl d) 14-year-old boy
a) 8-year-old boy The indirect entry of microorganisms, which is the hematogenous stage of osteomyelitis, most frequently affects the growing bones of boys younger than 12 years of age. An 8-year-old boy would be at the highest risk for blunt trauma.
How do adolescents establish health identity during psychosocial development? a) By evaluating their own health with feelings of well-being b) By fostering their independence with a balanced family structure c) By building close peer relationships to achieve societal acceptance d) By achieving marked physical changes with masculine and feminine behaviors
a) By evaluating their own health with feelings of well-being Adolescents establish health identity by evaluating their own health with feelings of well-being. An individual establishes family identity by fostering their independence with a balanced family structure. By building close peer relationships, adolescents establish a group identity. The healthy growth of an adolescent, with marked physical and behavioral changes, helps build sexual identity.
Which movements would the nurse assess to determine a client's range of motion in the ankle? Select all that apply. a) Eversion b) Inversion c) Abduction d) Dorsiflexion e) Plantar flexion
a) Eversion b) Inversion d) Dorsiflexion e) Plantar flexion
When preparing a client for a liver biopsy, the nurse explains that during the test the client will be placed in which position? a) In the supine position, with the right arm raised behind the head b) On the right side, with the left arm stretched up and over the head c) On the left side, with the right arm extended out in front across the bed d) In the prone position, with both elbows flexed and the hands resting on the pillow
a) In the supine position, with the right arm raised behind the head
Which nutritional interventions would the nurse include when planning care for a client with acquired immunodeficiency syndrome (AIDS)? Select all that apply. a) Some correct answers were not selected b) Offer ice chips throughout the day. c) Instruct on the use of oral antifungal medication. d) Collaborate with the dietitian for small, frequent meals. e) Emphasize an eating plan incorporating high-fat food items. f) Schedule routine mouth care, avoiding alcohol-based mouthwashes. g) Increase the intake of vitamin D micronutrients.
a) Some correct answers were not selected b) Offer ice chips throughout the day. c) Instruct on the use of oral antifungal medication. e) Emphasize an eating plan incorporating high-fat food items.
According to Erikson's theory, which behavior would the nurse expect a preschooler to exhibit? a) The child develops the superego. b) The child plays beside other children. c) The child concentrates on work and play. e) The child becomes casual about body appearance.
a) The child develops the superego. According to Erikson's theory, a preschooler develops superego or conscience during the initiative versus guilt stage. During the autonomy versus shame and doubt stage, the toddler engages in parallel play and starts to play beside other children. A school-aged child learns to work and play with his or her peers during the industry versus inferiority stage. During the identity versus role confusion stage, an adolescent can have a marked preoccupation with appearance and body image.
Which education would the nurse provide to the parents of a preschooler? a) They need around 1800 calories in a day. b) Their caloric needs are half of what adults need c) They become choosy about food around 5 years of age. d) Their physical growth is faster than their cognitive development
a) They need around 1800 calories in a day. Preschoolers need approximately 1800 calories on a daily basis. Preschooler caloric needs far exceed half of adult caloric needs, which average 2000 calories per day. Preschoolers are overly particular about their food at 4 years of age. At the age of 5 years, they typically become more interested in eating different foods. The physical growth of preschoolers is slower than their cognitive and psychosocial development.
Which statements correctly states how toddlers are different from infants? a) Toddlers grow at a slower rate. b) Toddlers are more prone to lead poisoning. c) Toddlers lack the anteroposterior curves of the spine. d) Toddlers face difficulties in recovering from upper respiratory tract infections (URTIs).
a) Toddlers grow at a slower rate. The growth rate of toddlers is slower than that of infants. The incidence of lead poisoning is highest in both late infancy and toddlerhood. Toddlers have accentuated cervical and lumbar vertebral curves, whereas infants lack them. URTIs are usually not dangerous, and infants and toddlers both recover from them with little difficulty.
Which care activities, if performed correctly, would be in the delegation process? Select all that apply. a) A licensed practical nurse (LPN) cleans the client's body b) An unlicensed assistive personnel (UAP) provides medication to the client c) An unlicensed assistive personnel (UAP) assists the client with oral feedings d) A licensed practical nurse (LPN) evaluates the client's temperature condition e) A registered nurse (RN) guides the unlicensed assistive personnel (UAP) while recording client's temperature
a, c, e Activities such as cleaning the client's body and assisting the client with oral feeding can be performed by the LPN and UAP. It is always the responsibility of the RN to guide the UAP while performing any activity. The UAP is not allowed to perform activities such as providing medication. The LPN should not evaluate the client condition; it is the responsibility of the RN.
According to Piaget's theory, which are the cognitive or moral developmental changes in children aged 6 to 12 years? Select all that apply. a) The child develops logical thinking. b) The child is in the sensorimotor period. c) The child is in the preoperational period. d) The child is in the concrete operations period e) There is a progress from reflex activity to simple activity.
a, d According to Piaget's theory, a child is in the concrete operations period between the ages of 6 and 12 years and he or she develops logical thinking. According to Piaget's theory, a child from the age of 18 months is in the sensorimotor period. A child from the age of 18 months to 3 years is in the preoperational period. A child between 18 months and 3 years old progresses from reflex activity to simple repetitive actions.
According to Erikson's theory, which behaviors will the nurse notice in 13-year-old students? Select all that apply. a) Such students want to know "Who am I?" b) Such students exhibit the sense of care for others. c) Such students show eagerness to learn social skills. d) Such students like to pretend and try out different new roles. e) Such students show a marked preoccupation with body appearance.
a, d The nurse is likely to notice that during puberty, students want an answer to " Who am I?" This stage is called identity versus role confusion in Erikson's theory. At this stage, adolescents are concerned about their own body appearance. Young adults exhibit the sense of care for others at the stage of intimacy versus isolation. Children from 6 to 11 years of age show eagerness to learn social skills. This stage is identified as industry versus inferiority. Children like to pretend and try out new roles at the stage of initiative versus guilt. This is seen at the age of 3 to 6 years.
The nurse is caring for a client 4 hours after the client's hip replacement surgery. Which action would the nurse take when assisting the client out of bed? a) Tell the client that both legs must bear equal weight. b) Advise the client that the legs must be kept wide apart. c) Sit the client in a straight-back chair so that the hips are kept flexed. d) Transfer the client using a mechanical lift to avoid weight bearing on either leg.
b) Advise the client that the legs must be kept wide apart. Abduction keeps the prosthesis firmly in place; adduction of the extremity may cause the prosthesis to dislocate. Only partial weight bearing on the affected leg is indicated initially. Sitting flexes the hips to 90 degrees; this is contraindicated initially because it can cause the prosthesis to dislocate. Full weight bearing on the unaffected leg and partial weight bearing on the affected leg generally are permitted on the second or third postoperative day.
Which nursing action would be included in the plan of care after herniorrhaphy in a client with a history of lower extremity thrombophlebitis and varicose veins? a) Remind the client to keep the head of the bed elevated. b) Assist the client to ambulate multiple times during the day. c) Teach the client to self-monitor for coolness or pallor of the feet. d) Maintain the client in alignment with firm support of the extremities.
b) Assist the client to ambulate multiple times during the day. Because of the client's history and the site of the surgery, venous thromboembolism is a possible complication and ambulation will prevent blood stasis. Elevating the head of the bed will not improve venous blood flow or decrease thromboembolism risk, although the client may elevate the head for comfort. Coolness or pallor of the feet might be seen in arterial disease; the nurse would teach this client to self-monitor for unusual warmth or redness of the feet. Although body alignment is important for all clients, it will not discourage thrombus formation.
Which health care team member is responsible for establishing systems to monitor and verify the competency requirements related to delegation in an organization? a) Primary health care team b) Chief nursing officers (CNOs) c) American Nursing Association d) National Council of State Boards of Nursing (NCSBN)
b) Chief nursing officers (CNOs) The CNOs are accountable and responsible for establishing systems to assess, monitor, verify, and communicate competency requirements related to delegation. The primary health care team may not establish the principles of delegation. The American Nursing Association and NCSBN mainly helped in outlining the principles of delegation to the registered nurse (RN).
Which factor that contributes to the incidence of hip fractures is a higher risk for older adults? a) Carelessness b) Fragility of bone c) Sedentary existence d) Rheumatoid diseases
b) Fragility of bone Bones become more fragile because of loss of bone density associated with the aging process; this often is associated with lower circulating levels of estrogens or testosterone. Carelessness is a characteristic applicable to certain individuals rather than to people within a developmental level. Although prolonged lack of weight-bearing activity is associated with bone demineralization, hip fractures also occur in active older adults. Rheumatoid diseases can affect the skeletal system but do not increase the incidence of hip fractures.
An older adult fell at home and fractured the left hip. Which clinical indicator would the emergency department nurse identify as typical with a fractured left hip? a) Left hip is ecchymotic b) Left leg is noticeably shorter than the right c) Left leg is internally rotated d) Left hip is tender when touched
b) Left leg is noticeably shorter than the right There is overriding of bones in the fractured hip, and the leg on the affected side appears noticeably shorter than the unaffected leg. Ecchymosis is evidence of soft tissue and blood vessel damage; this may or may not be associated with a fractured hip. The affected leg is externally, not internally, rotated with a fractured hip. Pain associated with a fractured hip is not mild; it causes extreme pain.
An older adult who was in a motor vehicle collision exhibits a decreased level of consciousness and serosanguineous drainage from the left ear. Which action would the nurse take? a) Irrigate the ear with normal saline. b) Place a sterile pad over the external ear. c) Gently insert a cotton-tipped swab in the ear canal. d) Pack a cotton ball in the external meatus of the ear.
b) Place a sterile pad over the external ear. A lowered level of consciousness indicates a potential head injury, and drainage from an ear may be cerebrospinal fluid; a sterile pad gently affixed over the ear will absorb drainage and prevent infection and can help detect the halo sign. Irrigating the ear with normal saline is contraindicated if a cerebrospinal fluid leak is suspected. Packing a cotton ball in the external meatus of the ear or inserting a cotton-tipped swab may be traumatic and may injure the ear further; also, it will obstruct free flow of drainage.
Which nursing intervention would be provided to a hospitalized client during the identity versus role confusion stage? a) Choosing creative ways to promote social participation b) Providing information to the client about the treatment plan c) Encouraging the client to participate actively in treatment procedures d) Involving the client's partners or family members in the caring process
b) Providing information to the client about the treatment plan During the identity versus role confusion or puberty stage, the nurse would help hospitalized adolescents deal with their illness by giving them enough information to allow them to make decisions about their treatment plan. During the generativity versus self-absorption and stagnation stage, the nurse would help clients choose ways to promote social participation. This action helps clients find a sense of fulfillment. If an individual in the intimacy versus isolation stage is admitted to the hospital, the nurse would try involving the client's partners or family members in the caring process so that the client can have a strong support structure. During the industry versus inferiority stage, a nurse would ensure the active participation of a hospitalized client.
A client has cholelithiasis with possible obstruction of the common bile duct. The nurse performs a nutritional assessment. Which is the primary goal for this assessment? a) To determine if the client follows a high fatty diet b) To determine if the client is deficient in vitamins A, D, and K c) To determine if the client eats adequate amounts of dietary fiber d) To determine if the client consumes excessive amounts of protein
b) To determine if the client is deficient in vitamins A, D, and K Bile promotes the absorption of the fat-soluble vitamins. An obstruction of the common bile duct limits the flow of bile to the duodenum and thus the absorption of these fat-soluble vitamins. Most clients have pain after eating a fatty meal and do not follow this diet, but this is expected in cholelithiasis and is not the primary goal. Dietary fiber is not relevant to the situation. Although adequate dietary protein is desirable for wound healing, it is unrelated to cholelithiasis.
Which psychosocial attribute plays an important role in the development of a healthy personality from birth to 1 year of age? a) Initiative versus guilt b) Trust versus mistrust c) Autonomy versus shame d) Industry versus inferiority
b) Trust versus mistrust
Which age group would the nurse observe engaging in parallel play? a) Infants b) Toddlers c) Adolescents d) Preschoolers
b) toddlers Parallel play is common among toddlers. In this form of play, each child engages in an independent activity that is similar to, but not influenced by or shared with, others. Infants do not perform parallel play. Adolescents spend time with multiple friends at once. Preschoolers are able to play with one other child in a cooperative manner in which they make something or play designated roles.
Which characteristics would the nurse expect infants with failure to thrive to exhibit? Select all that apply. a) Hyperactivity b) Language deficit c) Being overweight d) Tendency to illness e) Responsiveness to stimuli
b, d Infants with undernutrition and failure to thrive often have developmental delays, including language, motor, social, and adaptive deficits. Infants with failure to thrive are usually frail and are at risk for physical and emotional illnesses. Infants with failure to thrive are usually quiet and lethargic, not hyperactive. Being overweight is not characteristic of infants with failure to thrive; infants are usually underweight (below the fifth percentile). Responsiveness to stimuli is limited or nonexistent with failure to thrive.
The nurse is reviewing the clinical record of a client with a diagnosis of benign prostatic hyperplasia (BPH). Which test result would confirm the diagnosis? a) Digital rectal examination b) Serum phosphatase level c) Biopsy of prostatic tissue d) Massage of prostatic fluid
c) Biopsy of prostatic tissue A definitive diagnosis of the cellular changes associated with BPH is made by biopsy, with subsequent microscopic evaluation. Palpation of the prostate gland through rectal examination is not a definitive diagnosis; this only reveals size and configuration of the prostate. The serum phosphatase level will provide information for prostatic cancer; a definitive diagnosis cannot be made with this test for BPH. A sample of prostatic fluid helps diagnosis prostatitis.
Which factor would the nurse explain as the likely cause of pain to a client who is diagnosed as having a herniated nucleus pulposus? a) Inflammation of the lamina of the involved vertebra b) Shifting of two adjacent vertebral bodies out of alignment c) Compression of the spinal cord by the extruded nucleus pulposus d) Increased pressure of cerebrospinal fluid within the vertebral column
c) Compression of the spinal cord by the extruded nucleus pulposus Pain results because herniation of the nucleus pulposus into the spinal column irritates the spinal cord or the roots of spinal nerves. Inflammation of the lamina of the involved vertebra is not involved; the lamina is that portion of the vertebra removed during surgery to gain access to the site. The vertebral bodies themselves are not shifting. Circulation of cerebrospinal fluid is not affected.
A young adult client sustains a spinal injury at the level of T5. Which developmental task will be most difficult for this client to achieve? a) Mastering his environment b) Identifying with the male role c) Developing meaningful relationships d) Differentiating himself from the environment
c) Developing meaningful relationships Developing meaningful relationships is the young adult's developmental task associated with intimacy versus isolation. Mastering his environment is a school-age child's developmental task associated with initiative versus guilt. Identifying with the male role is a toddler's developmental task associated with autonomy versus shame and doubt. Differentiating himself from the environment is a toddler's developmental task associated with autonomy versus shame and doubt.
Which pathophysiological process would the nurse recognize as leading to the clinical manifestations commonly seen in cystic fibrosis? a) Airway irritability causes spasms. b) Lung parenchyma becomes inflamed. c) Excessively thick mucus obstructs airways. d) Endocrine glands secrete surplus hormones.
c) Excessively thick mucus obstructs airways. Dysfunction of the exocrine glands leads to the secretion of mucus that is thicker and more tenacious than normal. The characteristics of this mucus cause it to pool in the lungs and make expectoration difficult. In addition to airway obstruction, children with cystic fibrosis are more likely to have respiratory infections. Airway irritability is associated with hyperactive airway disease. Inflamed lung parenchyma is associated with pneumonia; this a secondary complication related to the stasis of secretions. The endocrine glands are not directly affected in cystic fibrosis.
After a subtotal gastrectomy (Billroth I), the client begins eating a variety of food textures and forms. After meals, the client reports cramping discomfort, rapid pulse, and waves of weakness, often followed by nausea and vomiting. Which physiological response does the nurse suspect occurs after the client eats? a) Slow movement of food from the stomach into the small intestine b) Rapid routing of diluted food mixture into the small intestine c) Quick passage of hyperosmolar food solution into the small intestine d) Entry of less concentrated food than the surrounding fluid into the small intestine
c) Quick passage of hyperosmolar food solution into the small intestine Without an adequate stomach reservoir, the hypertonic, concentrated food mass moves into the small intestine, drawing fluid from surrounding blood and tissue and causing hypovolemia and symptoms of shock (dumping syndrome). The food passes too quickly, not too slowly, into the small intestine. The food mass is more concentrated than the surrounding fluid (hypertonic).
Which parental statement would the nurse recognize as the proper approach to administering oral medication to the parent's 4-year-old child? a) "I should administer the medication with a cup or spoon." b) "I should mix the medicine in a large amount of food." c) "I should avoid giving a straw to my child to take pills." d) "I should use a disposable oral syringe to give liquid medicine."
d) "I should use a disposable oral syringe to give liquid medicine." The parent should use a plastic, disposable oral syringe to prepare accurate liquid doses, especially those less than 10 mL. The parent should not give medicine through a cup, spoon, or dropper because of the risk of inaccurate measurements. The parent should refrain from mixing the medicine in a large amount of the child's food because the child may refuse to eat such a large quantity. The parent can use straws for the child to swallow pills.
Which would the nurse need to do when collecting a urine sample from the toddler who is not toilet trained? Select all that apply. a) Squeeze urine from the diaper. b) Place a hat under the toilet seat. c) Convince the child to void in the unfamiliar receptacle. d) Attach single-use bags over the child's urethral meatus. e) Use terms for urination that the child can understand.
d) Attach single-use bags over the child's urethral meatus. e) Use terms for urination that the child can understand. The nurse would use special collection devices for infants or toddlers who are not toilet trained. A single-use bag with self-adhering material over the child's urethral meatus can be used in toddlers to collect urine. The nurse needs to use terms for urination such as "pee pee" that the child is able to understand. Urine should not be collected by squeezing urine from the diaper because the results may be inaccurate. A young child is often reluctant to void in unfamiliar receptacles and should not be forced to do so. A potty chair or specimen hat placed under the toilet seat is usually more effective for young children than toddlers.
Which client response during the insertion of a nasogastric tube indicates to the nurse that the client is experiencing serious difficulty with the insertion? a) Choking b) Redness c) Gagging d) Cyanosis
d) Cyanosis If the nasogastric tube is passed accidentally into the trachea rather than the esophagus, it will occlude the airway, causing cyanosis; this is a serious problem that must be corrected immediately. Choking may occur as the tube passes through the back of the throat; this commonly occurs with insertion of a nasogastric tube and is a temporary problem. Facial flushing (floridity) may result if the client attempts to fight the passage of the tube; this commonly occurs with insertion of a nasogastric tube and is a temporary problem. Gagging may occur as the tube passes from the nasal passage through the pharynx; this commonly occurs with insertion of a nasogastric tube and is a temporary problem.
Which outcome results from the development of sexual identity in an adolescent? Select all that apply. a) Creates a sense of admiration and acceptance b) Facilitates decision-making and budgeting skills c) Generates the ability to evaluate their own health d) Lessens the feeling that they are different from peers e) Aids in the development of masculine and feminine behaviors
d) Lessens the feeling that they are different from peers e) Aids in the development of masculine and feminine behaviors Physical evidence of maturity encourages the development of masculine and feminine behaviors and enhances sexual identity in the adolescent. Sexual identity assuages the adolescent's fear of being different from his or her peers. Adolescents depend on sexual clues because they want assurance of maleness or femaleness and do not wish to be different from their peers. Health identity helps the adolescent evaluate his or her own health. A group identity helps the adolescent develop a sense of being admired and accepted. A peer group provides the adolescent with a sense of belonging and approval and the opportunity to learn acceptable behavior. A family identity helps the adolescent develop decision-making and budgeting skills.
