NUE 102 Exam 3
Which intervention has the highest priority when providing skin care to a bedridden client? A. Changing the bed linens frequently for an incontinent client B. Keeping the skin clean and dry without using harsh soaps C. Gently massaging the skin around the pressure areas D. Rubbing moisturizing lotion around the pressure areas
B. Keeping the skin clean and dry without using harsh soaps
A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require? A. strict B. contact C. respiratory D. enteric
B. contact
A home health nurse is evaluating a client's risk of contracting herpes zoster. Which client is most at risk for developing herpes zoster? A. a 42-year-old client with a previous myocardial infarction B. a 76-year-old client taking immunosuppressant medication C. a 5-year-old client recently diagnosed with strep throat D. a 21-year-old client with a heat rash and psoriasis
B. a 76-year-old client taking immunosuppressant medication
A nurse is caring for a client diagnosed with herpes zoster. What data does the nurse gather from this client? Select all that apply. A. nontender vesicular lesions B. a clustered rash following the sensory nerves C. lesions noted bilaterally on the inner aspect of the client's thighs D. severe, deep pain at the site of the rash E. pruritus
B. a clustered rash following the sensory nerves D. severe, deep pain at the site of the rash E. pruritus
A nurse is caring for a school age child with systemic lupus erythematosus (SLE). Which of the following prescribed medication should the nurse administer to combat inflammation? A. Corticosteroids B. Aspirin C. Antibiotics D. Diuretics
A. Corticosteroids
A child is sent to the school nurse because, according to the teacher, the child is constantly scratching their head. When the nurse evaluates the hair and scalp, there is evidence of lice. What strategies should the nurse recommend to the teacher and parents to minimize the spread of lice to other students? Select all that apply. A. Do not allow children to share combs, brushes, or towels. B. Avoid head-to-head (hair-to-hair) contact during play and other activities at home, school, and elsewhere. C. Fumigate the classroom and cafeteria areas used by the child infected with lice. D. Do not allow children to share clothing such as hats, scarves, coats, sports uniforms, hair ribbons, or barrettes. E. All household members and other close contacts should be checked; those persons with evidence of an active infestation should be treated.
A. Do not allow children to share combs, brushes, or towels. B. Avoid head-to-head (hair-to-hair) contact during play and other activities at home, school, and elsewhere. D. Do not allow children to share clothing such as hats, scarves, coats, sports uniforms, hair ribbons, or barrettes. E. All household members and other close contacts should be checked; those persons with evidence of an active infestation should be treated.
A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions can help prevent pressure ulcer formation in this client? Select all that apply. A. Reposition the client every 2 hours. B. Perform range-of-motion exercises. C. Use commercial soaps to keep the skin dry. D. Tuck bed covers tightly in the foot of the bed. E. Encourage the client to eat a well-balanced diet.
A. Reposition the client every 2 hours. B. Perform range-of-motion exercises. E. Encourage the client to eat a well-balanced diet.
A staffing agency is assigning a licensed practical/vocational nurse (LPN/VN) to cover a shift on a pediatric unit. Because the unit manager is unfamiliar with the nurse's skill level, what assignment is best for the LPN/VN? A. 8-year-old child admitted that morning with suspected meningitis B. 9-year-old child receiving subcutaneous insulin for diabetes mellitus C. 10-year-old child who had a tonsillectomy that morning D. 9-year-old child with Legg-Calve'-Perthes disease
B. 9-year-old child receiving subcutaneous insulin for diabetes mellitus
A parent reports that their 6-year-old daughter recently started wetting the bed and running a low-grade fever. A urinalysis is positive for bacteria and protein. A diagnosis of a urinary tract infection (UTI) is made, and the child is prescribed antibiotics. Which interventions are appropriate? Select all that apply. A. Limit fluids for the next few days to decrease the frequency of urination. B. Assess the parent's understanding of UTI and its causes. C. Instruct the parent to administer the antibiotic as prescribed—even if the symptoms diminish. D. Provide instructions solely to the parent, not the child. E. Discourage taking bubble baths. F. Advise wiping from the back to the front after voiding and defecation.
B. Assess the parent's understanding of UTI and its causes. C. Instruct the parent to administer the antibiotic as prescribed—even if the symptoms diminish. E. Discourage taking bubble baths.
A school-age child begins to have a seizure while walking to the bathroom after an appendectomy. The nearby staff do not have the child's medical history. What is the nurse's first action? A. Notify the health care provider. B. Position the child on the side. C. Administer diazepam. D. Call a rapid response team.
B. Position the child on the side.
A charge nurse on a pediatric unit is giving a report to a licensed practical nurse (LPN) about four clients that the LPN will be caring for this shift. Which client should the LPN see first? A. an 8-year-old client from the post-anesthesia care unit (PACU) who is reporting pain B. a 10-year-old client with asthma whose oxygen saturation levels are 89% C. a 7-year-old client who has a respiratory rate of 26 breaths per minute D. a 9-year-old client with a broken leg who is requesting help with toileting
B. a 10-year-old client with asthma whose oxygen saturation levels are 89%
A nurse is participating in a health class for preteen girls about puberty. The nurse recognizes the teaching has been successful when the students are able to correctly identify which sign as the first sign of sexual maturation in females? A. onset of menstruation B. breast bud development C. appearance of pubic hair D. appearance of axillary hair
B. breast bud development
A nurse is reinforcing education with the parents of a 5-year-old on how to respond in case of accidental poisoning. If poisoning occurs and the child is alert and in no distress, what should the parents' first response be? A. administer syrup of ipecac B. call the poison control center C. take the child to the health care provider's office D. monitor the child for adverse effects
B. call the poison control center
The nurse is gathering data from a child that has a rash on the face, trunk, and extremities, but not on the palms of the hand. Which disorder should the nurse suspect this child may have? A. coxsackievirus B. measles C. Rocky Mountain spotted fever D. syphilis
B. measles
The incidence of hospital-acquired pressure ulcers on the medical-surgical unit has increased. A nurse should inform the: A. physician. B. risk manager. C. other nursing staff members. D. case manager.
B. risk manager.
The nurse is preparing to perform wound care for a client. What action should the nurse prioritize before changing the dressing? A. put on gloves B. wash hands thoroughly C. slowly remove the soiled dressing D. observe the dressing for the amount, type, and odor of drainage
B. wash hands thoroughly
A parent of a 9-year-old-child scheduled to have surgery expresses concern about the potential for postoperative infection. A nurse provides the parent with information about the measures taken to maintain surgical asepsis. Typical surgical asepsis involves: A. using sterile surgical scrubs. B. preoperative cleansing of jewelry worn by the surgical team. C. applying bandages to cover any wounds surgical team members have. D. performing a preoperative surgical scrub for at least 3 to 5 minutes.
D. performing a preoperative surgical scrub for at least 3 to 5 minutes.
sodium
- Na - maintenance of osmotic pressure, this maintains body fluid balance - assists with normal functioning of neurons and muscle cells - essential buffer system for acid bas balance
What organs and invlolved in homeostatic mechanisms to maintain electrolyte balance?
- kidneys - adrenal gland - parathyroid gland - thyroid gland
What are examples of nonelectrolytes?
- proteins - glucose - carbon dioxide - oxygen - organic acids
What is the age span for late adolescence?
18-20 years of age
potassium
- K - maintenance of osmotic pressure (thus maintains body fluid balance - normal functioning of neurons and muscle cells including the heart - essential buffer system for acid bas balance
magnesium
- Mg2+ - assists with normal functioning of neurons and muscle cells including the heart - required for ATP use, enzyme production, and maintenance of formation of bones
respiratory alkalosis
(low blood PaCO2) can occur as a result of hyperventilation
What is an example of helpful positive feedback?
- Blood clotting following an injury. - When a woman is in labor, impulses are sent to cause the release of oxytocin, which stimulates uterine contractions
calcium
- Ca2+ - assists with normal functioning of neurons and muscle cells including the heaart - essential for neurotransmitter release - maintenance of bones and bone formation - essential for blood clotting
What are examples of disorders that can cause dehydration?
- Electrolyte dysfunction - Addision's disease - Diabetes (both mellitus and insipidus) - Hypercalcemia - Glycosuria
What is the age span for adolescence?
10 to 20 years of age
What is the age span for early adolescnce?
11-14 years of age
What is the age span for middle adolescence?
15-17 years of age
What is the age span for early adulthood/emerging adulthood?
20-early 40s
A physician orders phenytoin 150 mg by mouth twice per day for a child. The dosage strength of the oral suspension on hand is 30 mg/5 ml. How many milliliters of suspension should the nurse administer with each dose? Record your answer using a whole number.
25 mL
A 10-year-old client with asthma is prescribed 2 mg of albuterol syrup four times per day. The syrup comes in a dosage strength of 2 mg/5 ml. How many milliliters of syrup should the nurse administer? Record your answer using a whole number.
5 mL
What is the age span for late adulthood/older adulthood/young-old phase?
50-79 years of age
The nurse is discussing sleep hygiene with the parents of a 9-year-old child who plays video games regularly. Which teaching(s) will the nurse provide? Select all that apply. A. "Create a ritualistic approach to bed time." B. "Keep the room at 67°F (19.4°C) or cooler." C. "Have your child turn the video game off right before going to bed." D. "Encourage reading before bed as a healthy way to rest the mind." E. "Allow the child to keep a smart phone at the bedside in case of emergencies."
A. "Create a ritualistic approach to bed time." B. "Keep the room at 67°F (19.4°C) or cooler." D. "Encourage reading before bed as a healthy way to rest the mind."
The nurse hears a CNA talking with a client who is in the end stage of pancreatic cancer and depressed. Which statement made by the CNA does the nurse recognize as nontherapeutic? A. "Everything happens for a reason; it will be okay." B. "I will stay with you for a while." C. "What can I do for you?" D. "Is there anyone you would like me to call for you?"
A. "Everything happens for a reason; it will be okay."
A nurse is caring for an adolescent female with cystic fibrosis. Which statements about the course of cystic fibrosis are true? Select all that apply. A. Breast development is commonly delayed. B. The client is at risk for developing diabetes. C. Pregnancy and childbearing are not affected. D. Normal sexual relationships can be expected. E. Only males carry the gene for the disease. F. By age 20, the client is able to decrease the frequency of respiratory treatments.
A. Breast development is commonly delayed. B. The client is at risk for developing diabetes. D. Normal sexual relationships can be expected.
Parents of a 15-year-old child are concerned about the influences of peers on their child's behavior. What suggestion can the nurse make to help the parents encourage the child to overcome these pressures? Select all that apply. A. Model safe habits and practices. B. Listen without judgment. C. Limit the time allowed to spend with peers. D. Give positive reinforcement for good behaviors. E. Have the child make decisions without parental input.
A. Model safe habits and practices. B. Listen without judgment. D. Give positive reinforcement for good behaviors.
An emancipated adolescent is pregnant and plans to raise her child. She has no income or health insurance. Which recommendation should the nurse make to help the client with her health care expenses? A. Completing a Medicaid application B. Applying for Medicare C. Asking her parents for financial aid D. Providing her with the name of a lawyer to obtain child support from the baby's father
A. Completing a Medicaid application
A client is at risk for fluid volume excess related to heart failure. Which information would the nurse provide to the client to assist with prevention of this occurrence? A. Comply with diuretic therapy B. Maintain a high-sodium diet C. Increase level of potassium in the diet D. Drink 8 to 10, 8-oz glasses of fluid per day.
A. Comply with diuretic therapy
The nurse is gathering subjective data regarding pain from a client. Which information is important for the nurse to consider when gathering this information? A. Culture B. Physical symptoms C. Cause of pain D. Financial status
A. Culture
The nurse is talking with an oldest adult client and the client states, "I have done so many things in life and was able to achieve my goals." Which developmental stage has this client achieved? A. Ego integrity B. Despair C. Stagnation D. Generativity
A. Ego integrity
The nursing staff is developing a care plan for a client who's receiving palliative care for end-stage leukemia. The client is experiencing breakthrough pain, rated as a 5 on a pain scale of 1 to 10. Which action by the nurse should be included in the client's care plan? A. Meeting with the pain management team to devise a more effective pain control plan B. Explaining that pain relief may not be possible because she's receiving maximum doses of pain medications C. Assessing whether the client is abusing the pain medications D. Providing nonpharmacologic pain measures only, because maximum doses of pain
A. Meeting with the pain management team to devise a more effective pain control plan
The nurse is caring for a 14-year-old child in skeletal traction for treatment of a fractured femur. The child is expected to be hospitalized for several weeks. When assisting with the plan of care, which nursing actions take into account the need to achieve developmental milestones in adolescence? Select all that apply. A. Encourage visitation of friends during hospitalization. B. Allow parents to make all stressful decisions for the adolescent. C. Provide for privacy, especially during ADLs and toileting. D. Encourage the parents to stay with the adolescent at all times. E. Arrange for in-hospital schooling so the child does not fall behind while hospitalized.
A. Encourage visitation of friends during hospitalization. C. Provide for privacy, especially during ADLs and toileting. E. Arrange for in-hospital schooling so the child does not fall behind while hospitalized.
A 16-year-old client comes to the physician's office for a physical examination that's required to play sports. The mother reports that her son is unusually tired during the day. She explains that he works at a part-time job, is socially active, and gets about 7 hours of sleep each night. Physical examination reveals that the client grew 3" during the past year. Which intervention by the nurse is most appropriate? A. Explaining that his sleep requirements have increased related to the increased metabolic demands of growth B. Doing nothing because fatigue is normal during adolescence C. Informing the physician so he can order diagnostic tests to further investigate the fatigue D. Referring the client to a mental health specialist because he might be exhibiting signs of depression
A. Explaining that his sleep requirements have increased related to the increased metabolic demands of growth
A client reports no relief of pain after administration of an opioid analgesic. Which nonpharmacologic action would the nurse provide to assist with relieving the pain? A. Give the client a backrub. B. Give another dose of the medication even though it may be too early. C. Administer an antiemetic with the medication. D. Ambulate the client in the hall.
A. Give the client a backrub.
A middle-aged client informs the nurse of an increasing weight gain. Which screening should the nurse prepare the client for to assess for potential complications of the weight gain? A. Glucose level to screen for diabetes B. White blood count to screen for infection C. Hemoglobin and hematocrit to screen for anemia D. Urine specimen to screen for ketones
A. Glucose level to screen for diabetes
Which description accurately identifies metabolic alkalosis? A. HCO3->(+/-)26 mEq/L B. -CO2<35 C. -HCO3-,(+/-)22 mEq/L D. CO2>45
A. HCO3->(+/-)26 mEq/L
A client is hyperventilating and has a pH of 7.52 and a PCO2 of 68 mm Hg. Which intervention by the nurse will assist in correcting this acid-base imbalance? A. Have the client use a rebreather mask. B. Administer oxygen. C. Administer lactated Ringers IV. D. Elevate the head of the bed.
A. Have the client use a rebreather mask.
A young-old adult client informs the nurse, "I want to remain independent and not have to depend on my children." What key elements does the nurse recognize will allow this to occur? Select all that apply. A. Healthcare B. Financial stability C. Number of adult children D. Social resources E. Psychological integrity
A. Healthcare B. Financial stability D. Social resources
What physiologic process commonly occurs during dehydration? A. Increase in sodium and electrolyte disturbance. B. Increased capillary permeability. C. Loss of proteins in the plasma of the blood. D> Obstruction of venous blood or lymphatic return.
A. Increase in sodium and electrolyte disturbance.
A nurse is teaching newborn care to expectant parents. Which information about sleep should the nurse include in the teaching plan? A. Infants should not sleep in a bed with another person. B. Only use soft bedding in the crib. C. Infants should be put to sleep in their own room. D. Infants should be placed in the prone position for sleep.
A. Infants should not sleep in a bed with another person.
The client has an order for IV fluids. Normal saline, an isotonic solution, is ordered. What is the best description the nurse can provide to a student about isotonic solutions? A. Its osmotic pressure is similar to that of blood. B. Causes blood cells to swell. C. Causes blood cells to shrink. D. Its concentration of solutes is greater than that of blood.
A. Its osmotic pressure is similar to that of blood.
A client is experiencing chronic pain related to a back injury. Which suggestions would the nurse make to help control pain perception? Select all that apply. A. Limit the intake of caffeine. B. Avoid smoking. C. Perform regular exercise. D. Increase sodium intake. E. Increase alcohol intake.
A. Limit the intake of caffeine. B. Avoid smoking. C. Perform regular exercise.
A client had severe diarrhea for 3 days. When arterial blood gases (ABGs) are obtained, which acid-base disturbance does the nurse anticipate observing? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis
A. Metabolic acidosis
The mother of a school-age child reports that her child is having some problems in school. Which of the following would be the priority action? A. Obtain more information from the mother and the child. B. Refer the child to the school psychologist for testing. C. Talk to the child's health care provider to understand the child better. D. Talk to the child's teacher to gain a perspective on the situation.
A. Obtain more information from the mother and the child.
An older adult client is at risk for fluid volume deficit. Which action by the nurse could prevent this event? A. Offer fluids frequently. B. Withhold fluids after bedtime. C. Increase the amount of sodium in the diet. D. Insert an indwelling urinary catheter.
A. Offer fluids frequently.
The nurse is observing a client with a calcium level of 4.2 mEq/L. Which clinical manifestations may correlate with this level? Select all that apply. A. Paresthesia B. Hypotension C. Muscular weakness D. Depressed reflexes E. Tetany
A. Paresthesia B. Hypotension E. Tetany
A nurse is preparing to teach a group of school-age children about injury prevention. Which intervention is most appropriate? A. Play group games involving sports safety equipment. B. Teach the children to say "no" to their peers. C. Encourage children to be independent. D. Have the children try on safety equipment.
A. Play group games involving sports safety equipment.
A nurse is caring for a 17-year-old brought to the mental health facility by a family member who is concerned about the client's recent 20-lb (9 kg) weight loss, and weight loss total of 50 lb (22.7 kg) in the last year. What interventions are essential in the treatment of an adolescent diagnosed with an eating disorder? Select all that apply. A. Provide a highly structured environment. B. Monitor the clients' weight, vitals, intake and output, caloric intake, and exercise. C. Provide an isolation environment to monitor all activities. D. Instruct the client and family that treatment for eating disorders takes a few weeks and the family is not involved in the process. E. Assist the client in changing the negative perception to a positive one, and assist in setting realistic goals.
A. Provide a highly structured environment. B. Monitor the clients' weight, vitals, intake and output, caloric intake, and exercise. E. Assist the client in changing the negative perception to a positive one, and assist in setting realistic goals.
A nurse is caring for a school-age child who is at risk for harming himself or herself when left alone. What is the nurse's most appropriate intervention? A. Provide one-on-one observation. B. Use restraints to ensure the child's safety. C. Check on the child every 1-2 hours. D. Require that the parents must stay with the child while hospitalized.
A. Provide one-on-one observation.
A girl, age 15, is 7 months pregnant. When teaching parenting skills to an adolescent, the nurse knows that which teaching strategy is most effective? A. Providing a one-on-one demonstration and requesting a return demonstration, using a live infant model B. Initiating a parent support group with older first- and second-time mothers C. Providing age-appropriate reading material and time to ask questions D. Lecturing the adolescent about infant care
A. Providing a one-on-one demonstration and requesting a return demonstration, using a live infant model
What is considered a chronic condition?
Any ongoing illness lasting a year or more that requires continued medical attention.
The nurse is providing care for a client with presbycusis. Which nursing action should the nurse perform to accommodate the client's condition? A. Speak in a clear voice while facing the client. B. Provide educational brochures in large print. C. Speak very loudly so that the client can hear. D. Have the walkways to the client's bed clear from obstruction.
A. Speak in a clear voice while facing the client.
A nurse is caring for a 10-year-old child hospitalized for treatment of acute osteomyelitis. The child's left leg is immobilized in a splint. What is the nurse's most appropriate action? A. Support and handle the leg gently during turning and repositioning. B. Assist the client to bear weight on the affected limb. C. Assist the client to ambulate with crutches. D. Encourage the client to participate in age-appropriate activities.
A. Support and handle the leg gently during turning and repositioning.
The nurse is caring for an adolescent client who lost consciousness after being struck in the head during a soccer game and was subsequently diagnosed with a concussion. For which prescriptions from the health care provider will the nurse seek clarification? Select all that apply. A. Take acetaminophen 300mg with 30mg codeine for headache every 4 hours PRN. B. Perform a neurological assessment every hour for the next 12 hours. C. Avoid physical exertion for the next 48 hours. D. Take no food or fluids by mouth for the next 12 hours. E. Refrain from cognitive activities that exacerbate headache, such as reading.
A. Take acetaminophen 300mg with 30mg codeine for headache every 4 hours PRN. D. Take no food or fluids by mouth for the next 12 hours.
A school nurse suspects that a 13-year-old has structural scoliosis. Asking the adolescent to perform which maneuver would be the nurse's priority when gathering data for this condition? A. The child bends over and touches the toes while the nurse observes from behind. B. The child stands sideways while the nurse observes the profile. C. The child assumes a knee-chest position on the examination table. D. The child arches the back while the nurse observes from behind.
A. The child bends over and touches the toes while the nurse observes from behind.
Which behavior demonstrated by a 6-year-old would help the nurse recognize a learning disability as opposed to attention deficit hyperactivity disorder (ADHD)? A. The child reverses letters and words while reading. B. The child is easily distracted and reacts impulsively. C. The child is always getting into fights during recess. D. The child has a difficult time reading a chapter book.
A. The child reverses letters and words while reading.
A 10-year-old child is hospitalized for treatment of acute osteomyelitis. After assessing swelling and tenderness of the left tibia, the nurse initiates antibiotic therapy as prescribed. The child's left leg is immobilized in a splint. What is an appropriate goal at this time for this child? A. The child will change position every 2 hours while awake. B. The child will bear weight on the affected limb. C. The child will ambulate with crutches. D. The child will participate in age-appropriate activities.
A. The child will change position every 2 hours while awake.
A child who was hospitalized for sickle cell crisis is being discharged. Which client outcome demonstrates effective teaching regarding prevention of future crises? A. The client verbalizes the need to stay away from anyone with a known or suspected infection. B. The client verbalizes appropriate dietary restrictions. C. The client verbalizes the need to restrict fluid intake. D. The client participates in an aerobic exercise program.
A. The client verbalizes the need to stay away from anyone with a known or suspected infection.
A parent reports that their teenager is losing hair in small, round areas on the scalp. The nurse interprets this as suggesting which condition? A. alopecia B. amblyopia C. exotropia D. seborrhea dermatitis
A. alopecia
The nurse is teaching a group of adolescents about proper nutrition. The nurse should explain that it's necessary to increase intake of which nutrients? Select all that apply: A. calcium B. vitamin D C. iron D. protein E. grain
A. calcium B. vitamin D C. iron D. protein
An otherwise-healthy adolescent has meningitis and is receiving I.V. and oral fluids. The nurse should monitor this client's fluid intake because fluid overload may cause: A. cerebral edema. B. dehydration. C. heart failure. D. hypovolemic shock.
A. cerebral edema.
A child is admitted with a tentative diagnosis of clinical depression. Which data collection finding is most significant in confirming this diagnosis? A. Irritability B. Sadness C. Weight gain D. Fatigue
B. Sadness
The nurse is observing a 6-year-old child with a spiny projection from the skin suspended from a narrow stalk on the forehead. Which condition would the nurse suspect? A. filiform wart B. flat wart C. plantar wart D. venereal warts
A. filiform wart
An adolescent typically achieves formal operational thought, Piaget's final stage of cognitive development. Which cognitive abilities are achieved during this stage? Select all that apply. A. flexibility B. complex deductive reasoning C. transductive reasoning D. representational language E. abstract thinking
A. flexibility B. complex deductive reasoning E. abstract thinking
The school nurse is gathering data related to the diabetic status of a 15-year-old athlete. Which physiologic change should the nurse anticipate as a diabetic teenager becomes more physically active during the day? A. increased need for food B. decreased need for food C. decreased risk of insulin shock D. increased risk of hyperglycemia
A. increased need for food
The nurse is caring for an adolescent male diagnosed with Klinefelter syndrome. What will the nurse expect to see with the client with Klinefelter syndrome? A. less facial and body hair B. short stature C. cardiomegaly D. small testes E. infertility
A. less facial and body hair D. small testes E. infertility
A 14-year-old is seen in the pediatrician's office with a history of mild sore throat, low-grade fever, a diffuse maculopapular rash, and reports swelling of the wrists and redness in the eyes. The nurse interprets these findings as indications of which condition? A. rubella B. rubeola C. roseola D. varicella
A. rubella
When providing care for a school-age child with diabetes insipidus, the nurse recognizes that which behavior might be difficult related to this child's growth and development? A. taking the medication at school B. taking the medication before bedtime C. letting the mother administer his medication D. self-administering vasopressin injection before school starts
A. taking the medication at school
Which use of restraints in a school-age child should the nurse question? A. to substitute for observation B. to ensure the child's comfort or safety C. to facilitate examination D. to aid in carrying out procedures
A. to substitute for observation
An adolescent with diabetes is learning to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the teen, would indicate the need for further instruction? A. withdraws the NPH insulin first B. injects air into the NPH insulin bottle first C. after drawing up the first insulin, removes air bubbles from the syringe D. injects an amount of air equal to the desired dose of insulin
A. withdraws the NPH insulin first
During chemotherapy for lymphoma, a child, age 15, is at risk for stomatitis. Which statement by the child supports a nursing diagnosis of Deficient knowledge related to mouth care? A. "I use a soft toothbrush to clean my teeth." B. "I remove white patches on my tongue and cheeks with my toothbrush." C. "I rinse my mouth every 2 to 4 hours with a solution of baking soda and water." D. "I don't use bottled mouthwashes."
B. "I remove white patches on my tongue and cheeks with my toothbrush."
The nurse is teaching a 10-year-old soccer player about hygiene after sporting events or practice. Which client statement reflects an understanding of this education? A. "I will wash my socks every other time I wear them." B. "I should wear shower shoes in the locker room." C. "Fungal infections thrive in cold locations." D. "A topical cream is the only thing that will kill athlete's foot."
B. "I should wear shower shoes in the locker room."
The nurse is caring for a wheelchair-bound client. Which piece of equipment impedes circulation to the area it is meant to protect? A. air-fluidized bed B. ring or donut C. gel flotation pad D. water bed
B. ring or donut
The nurse is caring for a 14-year-old with type 1 diabetes who has been admitted with ketoacidosis for the second time in 3 months. The parent states, "I don't know why this keeps happening." Which response by the nurse is the most appropriate? A. "Adolescents need strict rules to make sure they adhere to their treatment plans." B. "Adolescents sometimes become overwhelmed by having to adhere to dietary restrictions and taking medications." C. "You'll need to keep a closer eye on your daughter to make sure she adheres to the treatment plan." D. "You should notify the school nurse so she can monitor your daughter closely while she's at school."
B. "Adolescents sometimes become overwhelmed by having to adhere to dietary restrictions and taking medications."
The nurse is teaching a group of high school students about obesity. Which information will the nurse provide when discussing this topic? A. "Recognize that obesity is caused only by genetics." B. "Calculating body mass index is preferred to weighing yourself on a scale." C. "It is recommended to try intermittent fasting to lose weight quickly." D. "The terms 'overweight' and 'obese' are interchangeable."
B. "Calculating body mass index is preferred to weighing yourself on a scale."
A nurse is reinforcing education about type 1 diabetes with an adolescent. Which instruction by the nurse about how to prevent hypoglycemia would be most appropriate for the adolescent? A. "Limit participation in planned exercise activities that involve competition." B. "Carry crackers or fruit to eat before or during periods of increased activity." C. "Increase the insulin dosage before planned or unplanned strenuous exercise." D. "Check your blood glucose level before exercising, and eat a protein snack if the level is elevated."
B. "Carry crackers or fruit to eat before or during periods of increased activity."
A 15-year-old adolescent confides in the nurse that the adolescent has been contemplating suicide. The adolescent has developed a specific plan to carry it out and pleads with the nurse not to tell anyone. What is the nurse's best response? A. "We can keep this between you and me, but promise me you won't try anything." B. "I need to protect you. I will tell your physician, but we don't need to involve your parents. We want you to be safe." C. "For your protection, I can't keep this secret. After I notify the physician, we will need to involve your family. We want you to be safe." D. "I will need to notify the local authorities of your intentions."
B. "I need to protect you. I will tell your physician, but we don't need to involve your parents. We want you to be safe."
The nurse is planning care for a 10-year-old child in the acute phase of rheumatic fever. Which activity would be most appropriate for the nurse to schedule in the care plan? A. Playing cards in the playroom B. Reading books C. Climbing on play equipment in the playroom D. Unrestricted ambulation
B. Reading books
The nurse is triaging phone calls at a local pediatrician's office. Which statement by the parent of a child being treated for pinworms indicates that further teaching is needed? A. "I'll make my child wash his/her hands well before meals." B. "I'll warn my child to avoid sharing hairbrushes and hats to prevent spreading pinworms to others." C. "I'll give my child only one dose of medication." D. "I'll keep my child's nails short."
B. "I'll warn my child to avoid sharing hairbrushes and hats to prevent spreading pinworms to others."
The nurse is teaching a group of adolescent clients about personal hygiene. Which client statement indicates the need for further teaching? A. "It's good to bathe or shower each day." B. "It's unsafe to swim during your period." C. "I shouldn't share my razor with anyone." D. "I need to use only my personal lip care products."
B. "It's unsafe to swim during your period."
A client in chronic pain states that the pain medication does not work. Which response by the nurse is best? A. "You probably need a stronger narcotic." B. "Take your medications regularly, not waiting until pain occurs." C. "Do you think maybe the pain felt is exaggerated?" D. "The primary care provider has given you all you can have."
B. "Take your medications regularly, not waiting until pain occurs."
The parent of an adolescent diagnosed with Legg-Calvé-Perthes disease (LCPD) asks the nurse, "What caused this condition?" Which nursing response is appropriate? A. "The health care provider can give you more information." B. "The hip joint has been damaged due to lack of blood supply." C. "Exposure to toxins in the womb can result in this condition." D. "Taking antibiotics causes this disorder."
B. "The hip joint has been damaged due to lack of blood supply."
The nurse is performing a health assessment for an adolescent client when the client reports the recreational use of cannabis. Recreational use is legal in this jurisdiction for ages 21 years and older. How should the nurse respond initially? Select all that apply. A. "You are under the legal age for recreational cannabis use. I have a duty to report this to authorities." B. "What form of cannabis do you use? There are some health risks I want to be sure you are aware of." C. "Who is buying the cannabis for you? Did you know it is illegal to supply a minor with cannabis?" D. "Thank you for letting me know. Are there any other substances that you use on a recreational basis?" E. "If you have a qualifying medical condition you may be able to get a prescription so you can use it legally."
B. "What form of cannabis do you use? There are some health risks I want to be sure you are aware of." D. "Thank you for letting me know. Are there any other substances that you use on a recreational basis?"
A 15-year-old boy wants to try out for the football team. His parents are concerned that, because he's small for his age, he might be subjecting himself to ridicule. Which response by the parents best supports the adolescent's decision-making process? A. "We're concerned for your safety because the other players are so much bigger than you are." B. "Whether or not you play football is your decision; tell us why you want to play." C. "Why don't we look into another sport in which body size isn't an issue." D. "Why do you want to play football?"
B. "Whether or not you play football is your decision; tell us why you want to play."
The nurse is obtaining data from a client with fluid volume excess. When the nurse presses against the lower left leg, a slight indent remains for a second. How should this be documented? A. Anasarca B. +1 pitting edema C. +3 pitting edema D. +4 pitting edema
B. +1 pitting edema
A nurse is preparing to reinforce education with a 13-year-old child with asthma on how to administer breathing treatments. Which principle should the nurse keep in mind when planning the education session? A. Adolescents are unable to follow detailed instructions. B. Adolescents are worried about appearing different from their peers. C. Adolescents' fine motor coordination is not sufficiently developed to administer treatments. D. Adolescents have a well-developed sense of self-identity.
B. Adolescents are worried about appearing different from their peers.
A teenager is brought to the facility by friends after accidentally ingesting gasoline while siphoning it from a car. Based on the nurse's knowledge of petroleum distillates, which system would be most affected? A. GI system B. Respiratory system C. Neurologic system D. Cardiovascular system
B. Respiratory system
The nurse is working with adolescents. Which developmental rationale explains risk-taking behavior? A. Adolescents are concrete thinkers and concentrate only on what is happening at that time. B. Belief in their own invulnerability persuades adolescents that they can take risks safely. C. Risk of parents' anger and disappointment usually deters adolescents from risky behavior. D. Peer pressure usually does not play an important part in an adolescent's decision to become sexually active.
B. Belief in their own invulnerability persuades adolescents that they can take risks safely.
Parents inform the nurse that they found laxatives in their daughter's room and have heard her vomiting in the bathroom with the door locked after eating. What should the nurse provide information to the parents regarding? A. Pregnancy B. Bulimia C. Gastric ulcers D. Diabetes
B. Bulimia
A nurse is caring for a 14-year-old client who was admitted with cellulitis and has been ordered warm compresses. The nurse delegates the treatment to the unlicensed assistive personnel (UAP). The compress causes a first-degree burn to the area. Which actions should the nurse initiate? A. Initiate a disciplinary action toward the UAP B. Complete an incident report regarding the event C. Notify the healthcare provider of the injury D. Place ice compresses on the injured area E. Document the injury describing the UAPs actions
B. Complete an incident report regarding the event C. Notify the healthcare provider of the injury
A young-old adult nurse wishes to mentor the younger new nurse and asks the supervisor for permission to be a mentor. According to Erikson, which developmental stage is the young-old adult nurse experiencing? A. Stagnation B. Generativity C. Integrity D. Despair
B. Generativity
An adolescent female arrives in the emergency department after a physical assault. How could the male nurse best protect the client's rights during the physical examination? A. Leave the door open. B. Have a female health care worker present. C. Keep the suspected attacker away from the examination room. D. Keep the client's friends (who are waiting in the lounge area) informed of her medical condition.
B. Have a female health care worker present.
A 13-year-old visits the school nurse experiencing back pain, fatigue, and dyspnea. The nurse suspects that the child may have scoliosis. What is the nurse's first action? A. Send the child home to recover. B. Inspect the child for uneven shoulder height or uneven hip height. C. Arrange for the child to have spinal X-rays as soon as possible. D. Ask the child's parent to take him to a primary care provider immediately.
B. Inspect the child for uneven shoulder height or uneven hip height.
When planning a program to educate adolescents about acquired immunodeficiency syndrome (AIDS), which action might lead to better acceptance of the program? A. Survey the community to evaluate the level of education. B. Obtain peer educators to provide information about AIDS. C. Set up clinics in community centers and supply condoms readily. D. Invite health care providers to host workshops in community centers.
B. Obtain peer educators to provide information about AIDS.
The nurse prepares a young adolescent client for the operating room for an appendectomy. Which is the primary approach used by the nurse for this age group? A. Use a doll to demonstrate what will occur during and after surgery. B. Provide simple, straightforward explanations about the procedure. C. Leave a written explanation with pictures and ask the client to view before surgery. D. Put a video on for the client to watch regarding post-surgical care.
B. Provide simple, straightforward explanations about the procedure.
A child, age 14, is hospitalized for nutritional management and drug therapy after experiencing an acute episode of ulcerative colitis. Which nursing intervention would be appropriate? A. Administering digestive enzymes before meals as prescribed B. Providing small, frequent meals C. Administering antibiotics with meals as prescribed D. Providing high-fiber snacks
B. Providing small, frequent meals
An adolescent presents to a community clinic for treatment of vulvar lesions associated with Type 2 herpes simplex. Which action does the nurse take? A. Call the adolescent's parents for permission to assess and treat. B. Show the adolescent to a private examination room for further assessment. C. Inform the adolescent that parents will be informed by the insurance company. D. Ask the adolescent if the parents know that their child is seeking treatment for a condition.
B. Show the adolescent to a private examination room for further assessment.
A nurse is caring for a 16-year-old male client who needs an appendectomy. His parents are not present at the hospital. Prior to the surgery, the nurse needs to ensure that informed consent is obtained. Which situations allows the healthcare provider to obtain an informed consent from an adolescent? A. The adolescent is the appropriate age to sign an informed consent. B. The adolescent has declared himself emancipated. C. The adolescent has a power-of-attorney document. D. The adolescent is under the protection of a court guardian.
B. The adolescent has declared himself emancipated.
One day after an appendectomy, a 9-year-old client rates his pain at 4 out of 5 on the pain scale but is playing video games and laughing with his friend. Which of the following would the nurse document on the child's chart? A. The child is in no apparent distress, and no pain medication is needed at this time. B. The child rates pain at 4 out of 5. Pain medication administered as prescribed. C. The child doesn't understand the pain scale. Performed teaching to help child match his pain rating to how he appears to be feeling. D. The child rates his pain at 4 out of 5; however, he appears to be in no distress. Reassess when he's visibly showing signs of pain.
B. The child rates pain at 4 out of 5. Pain medication administered as prescribed.
The nurse is assessing a school-age child for whom sexual abuse is suspected. Which evidence will the nurse apply as warning sign(s) of possible sexual abuse? Select all that apply. A. The child is naive and underinformed for the developmental age related to sexual topics. B. The child reacts negatively when needing to undress for bathing or changing clothing. C. The child seems to have developed a new fear of certain people or social situations. D. The caregivers note a change in how the child communicates in social situations. E. The child is spending more time engaging in schoolwork and participating in sports.
B. The child reacts negatively when needing to undress for bathing or changing clothing. C. The child seems to have developed a new fear of certain people or social situations. D. The caregivers note a change in how the child communicates in social situations.
An adolescent client is hospitalized with anorexia nervosa. What data support a nursing diagnosis of disturbed body image? A. The client sets the goal of gaining 0.5 pounds (0.23 kg) this week. B. The client expresses a fear of overeating at meals. C. The client uses the full-length mirror each morning. D. The client is wearing jeans and a shirt that fit well.
B. The client expresses a fear of overeating at meals.
The nurse is working with a group of adolescents reviewing information regarding the human immunodeficiency virus (HIV). What fact is important for the nurse to include in the review? A. The incidence of HIV in the adolescent population has declined since 1995. B. The virus can be spread through many routes, including sexual contact. C. Knowledge about HIV spread and transmission has led to a decrease in the spread of the virus among adolescents. D. About 50% of all new HIV infections in the United States occur in people younger than age 22.
B. The virus can be spread through many routes, including sexual contact.
An overweight girl, age 15, has lost 12 lb (5.4 kg) in 8 weeks by dieting. Now, after reaching a weight plateau, she has become discouraged. She and the nurse decide she should keep a food diary. What is the primary purpose of keeping such a diary? A. To help the client stay busy and more focused on losing weight B. To help the nurse and client analyze the amount of food the client is eating and determine when food intake occurs C. To help the nurse and client determine whether the client has been cheating on her diet D. To provide a written record for the client's next visit
B. To help the nurse and client analyze the amount of food the client is eating and determine when food intake occurs
The nurse is reinforcing education with an adolescent about gonorrhea. Which information should be included? A. It is caused by Treponema pallidum. B. Treatment of sexual partners is an essential part of treatment. C. It is usually treated by multidose administration of penicillin. D. It may be contracted through contact with a contaminated toilet seat.
B. Treatment of sexual partners is an essential part of treatment.
To treat a client with acne vulgaris, the physician is most likely to prescribe which topical agent for nightly application? A. Minoxidil B. Tretinoin (retinoic acid) C. Zinc oxide gelatin D. Fluorouracil (5-fluorouracil)
B. Tretinoin (retinoic acid)
Which adolescent client would the school nurse consider at greatest risk for developing acquired immunodeficiency syndrome (AIDS)? A. a client living with a parent who uses intravenous drugs B. a client who states they have multiple sexual partners C. a client whose sibling died from AIDS last year D. a client in a committed relationship with one partner
B. a client who states they have multiple sexual partners
A pediatric nurse is providing discharge instructions for the family of a school-age child with idiopathic thrombocytopenia. Which activity should be restricted until further notice? A. swimming B. bicycle riding C. computer games D. exposure to large crowds
B. bicycle riding
A child with asthma is receiving theophylline. The nurse knows that theophylline is administered primarily to: A. decrease coughing induced by postnasal drip. B. dilate the bronchioles. C. reduce airway inflammation. D. eradicate the infection.
B. dilate the bronchioles.
A child is receiving total parenteral nutrition (TPN). During TPN therapy, the most important nursing action is: A. assessing vital signs every 30 minutes. B. monitoring the blood glucose level closely. C. elevating the head of the bed 60 degrees. D. providing a daily bath.
B. monitoring the blood glucose level closely.
The nurse is helping the adolescent deal with diabetes. What characteristic of adolescence should be considered? A. desire to be an individual B. need to be like peers C. preoccupation with future plans D. ability to educate peers about the seriousness of the disease
B. need to be like peers
The nurse obtains the blood gas results for a client experiencing respiratory difficulty. Which blood gas result would require immediate intervention by the nurse? A. pH 7.35, paCO2 37, HCO3 23 B. pH 7.28, paCO2 58, HCO3 26 C. pH 7.42, paCO2 44, HCO3 22 D. pH 7.45, paCO2 39, HCO3 25
B. pH 7.28, paCO2 58, HCO3 26
The nurse is working with an adolescent female diagnosed with scoliosis. What problem is commonly encountered by this group? A. respiratory distress B. poor self-esteem C. poor appetite D. renal difficulty
B. poor self-esteem
An 11-year-old child with a head injury has been in the hospital 2 weeks while receiving therapy. The child sometimes makes inappropriate statements, and occasionally has combative and violent outbursts. When questioned about this behavior, what is the best response by the nurse? A. "Your child probably didn't receive enough discipline growing up and is throwing tantrums." B. "Your child needs to be restrained during these episodes." C. "This is a stage of healing for your child." D. "Your child will need to be on life-long medication to control his temper."
C. "This is a stage of healing for your child."
A middle-aged client informs the nurse of a 15-lb weight gain without changing any eating habits or level of activity. Which response by the nurse is the best? A. "You are going to have to go on a diet." B. "That's what happens when you don't exercise and eat junk food." C. "This occurs from excessive calorie intake and decreased metabolism." D. "I wouldn't worry about 15 lb. That isn't so bad."
C. "This occurs from excessive calorie intake and decreased metabolism."
A pediatric client with iron deficiency anemia is prescribed ferrous sulfate, an oral iron supplement. When teaching the child and parent how to administer this preparation, the nurse should provide which instruction? A. "Administer ferrous sulfate with meals to prevent stomach upset." B. "Administer ferrous sulfate with milk to promote absorption." C. "Administer ferrous sulfate with fruit juice to promote absorption." D. "Administer ferrous sulfate with antacids to prevent stomach upset."
C. "Administer ferrous sulfate with fruit juice to promote absorption."
A nurse is teaching the proper use of crutches to a school-age child with a femur fracture with no weight bearing. What will the nurse include with teaching about walking with crutches? A. "After advancing both crutches the length of one step, move your 'good' leg forward." B. "After advancing both crutches the length of one step, move your 'bad' leg forward." C. "Advance one crutch forward on the affected side, then advance your 'good' leg." D. "Advance the one crutch forward on your good side, then advance your 'bad' leg."
C. "Advance one crutch forward on the affected side, then advance your 'good' leg."
The nurse is talking to a 15-year-old client with diabetes type 1. What statement made by the client demonstrates further instruction regarding risky behaviors is required? A. "I need to check my blood sugar before and after I play football." B. "If I begin to feel like my blood sugar is low, I will eat a fast-acting carbohydrate." C. "I am going to eat what I want. It won't hurt me." D. "I will let my parents know if I have an injury."
C. "I am going to eat what I want. It won't hurt me."
Which statement by a female adolescent reveals an early indicator of anorexia nervosa? A. "I have my menstrual period every 28 days." B. "I go out to eat with my friends at least three times per week." C. "I jog three times per day for a total of 5 hours per day." D. "I try to maintain my weight around 115 lb, which is good for my height of 5'."
C. "I jog three times per day for a total of 5 hours per day."
A 16-year-old states to the nurse, "Don't worry about me, nothing bad will happen. It's just sex and doesn't mean anything." What is the best response by the nurse? A. "I wouldn't be so cavalier about sex if I were you." B. "Do you want to get a sexually transmitted infection?" C. "I would like to talk with you about the consequences of sexual activity." D. "I am going to have to tell your parents about your behaviors."
C. "I would like to talk with you about the consequences of sexual activity."
A 13-year-old client tells the nurse, "I have not yet started my period, but all my friends have." Which nursing response is appropriate? A. "Let's talk with your health care provider about this." B. "I am concerned that you have not started to menstruate yet." C. "Some individuals do not start menstruating until age 15 or 16." D. "You should not be worried about having a period at this age."
C. "Some individuals do not start menstruating until age 15 or 16."
The nurse is providing nutritional guidance to an adolescent client with ulcerative colitis. Which responses from the client indicate to the nurse that teaching was effective? Select all that apply. A. "Adding nuts to my diet will increase my protein intake during exacerbations." B. "I will tolerate three regular meals a day better than six small meals." C. "When eating fruit, I need to make sure I peel the skin off." D. "Adding whole grains to my meals will aid in me digesting food better." E. "Eating cream soups and milkshakes will help me increase the number of calories I eat."
C. "When eating fruit, I need to make sure I peel the skin off." E. "Eating cream soups and milkshakes will help me increase the number of calories I eat."
A client asks the nurse why so many wrinkles have developed on the client's face. Which response by the nurse is the best? A. "This is related to problems with your liver." B. "The wrinkles are caused by stress." C. "Wrinkles are the result of a loss of elasticity." D. "The wrinkles are caused by an increase in pigmentation."
C. "Wrinkles are the result of a loss of elasticity."
An intradermal skin test to detect tuberculosis infection is administered to a high-risk adolescent client. How long after the test is administered should the nurse wait to evaluate the results? A. 12 to 24 hours B. 24 to 36 hours C. 48 to 72 hours D. 72 to 96 hours
C. 48 to 72 hours
Which client should the nurse monitor more closely for signs of developing depression? A. A 58-year-old Hispanic female raising a grandchild B. A 70-year-old married African American male C. A 68-year-old Caucasian male who lives alone D. A 46-year-old married mother of three
C. A 68-year-old Caucasian male who lives alone
A client is admitted with vomiting and diarrhea and the nurse observes a potassium level of 2.9 mEq/L. Which nursing action is appropriate? A. Administer lactated Ringers IV at 150 mL/hr. B. No intervention is required because the level is within normal limits. C. Administer potassium supplementation IV as ordered. D. Administer sodium polystyrene (Kayexalate) to promote potassium excretion.
C. Administer potassium supplementation IV as ordered.
The nurse is discussing safe sexual practices with an adolescent. What is the best way for the nurse to engage the adolescent? A. Make sure the parent or legal guardian is present for the conversation. B. Make sure the conversation remains within the confines of the adolescent's religious beliefs. C. Assess the adolescent's level of knowledge and concerns. D. Obtain an informed consent from the parent before initiating the discussion.
C. Assess the adolescent's level of knowledge and concerns.
The nurse is teaching a group of adolescents about safety. Which safety topic takes priority in this age-group? A. Poisoning prevention B. Stranger awareness C. Automobile safety D. Bicycle safety
C. Automobile safety
The nurse is interviewing an adolescent client at a drop-in clinic. The client reports that the client's caregivers do not believe in vaccines, but the client now wishes to receive the measles, mumps, and rubella vaccine (MMR) against the caregivers' wishes. What is the nurse's priority action? A. Interview the client about knowledge related to the risks and benefits of the vaccine. B. Respect the client's right to autonomy and administer the vaccine confidentially. C. Consult local legislation related to the age of consent for immunizations. D. Encourage the client to return to the clinic with the caregivers to discuss vaccination.
C. Consult local legislation related to the age of consent for immunizations.
The nurse is teaching a group of adolescents about automobile safety. Which is the most effective teaching method for this age-group? A. Lecturing about the effects of drugs and alcohol use on driving B. Providing written materials on the hazards of driving C. Coordinating a panel of peers who were involved in motor vehicle accidents D. Showing an animated video about the responsibilities of driving
C. Coordinating a panel of peers who were involved in motor vehicle accidents
A middle-aged client is experiencing some age-related skin changes. Which action is a priority by the nurse related to these changes? A. Tell the client to be checked every 3 months for skin changes. B. Inform the client that there are no problems related to these changes. C. Discuss with the client normal versus abnormal changes. D. Inform the client that the age spots on the hands can be cancerous.
C. Discuss with the client normal versus abnormal changes.
The parents of an adolescent girl have recently learned that their daughter has a terminal illness. At first, as they try to cope, they display avoidance behaviors. Then they demonstrate behaviors that indicate possible acceptance of the diagnosis. Which of the following behaviors would indicate acceptance? A. Failure to recognize the seriousness of the child's condition despite physical evidence B. Intellectualization about the illness in areas unrelated to the child's condition C. Expression of feelings, such as sorrow and anger, about the child's condition D. Avoidance of staff, family members, or the child
C. Expression of feelings, such as sorrow and anger, about the child's condition
An 8-year-old client has tested positive for West Nile virus infection. The nurse suspects the client has the severe form of the disease when she recognizes which signs and symptoms? A. Fever, rash, and malaise B. Anorexia, nausea, and vomiting C. Fever, muscle weakness, and change in mental status D. Fever, lymphadenopathy, and rash
C. Fever, muscle weakness, and change in mental status
An adolescent is diagnosed with iron deficiency anemia. After emphasizing the importance of consuming dietary iron, the nurse asks the child to select iron-rich breakfast items from a sample menu. Which selection demonstrates knowledge of dietary iron sources? A. Grapefruit and white toast B. Pancakes and a banana C. Ham and eggs D. Bagel and cream cheese
C. Ham and eggs
A terminally ill dying client begins to have visual hallucinations. Which nursing action is appropriate at this time? A. Orient the client to reality. B. Tell the client "You are hallucinating." C. Identify self and others in the room. D. Administer a sedative.
C. Identify self and others in the room.
The parent of an adolescent who is going to camp during the summer expresses concern about a recent outbreak of methicillin resistant staphylococcus aureus (MRSA) at the camp. What education can the nurse reinforce in order to help with prevention of this infection? Select all that apply. A. Request a prescription for an antibiotic prior to going. B. Use an antibiotic ointment prophylactically on skin. C. Keep cuts and scrapes clean and covered. D. Wash hands with soap and water regularly. E. Avoid sharing towels and razors with others.
C. Keep cuts and scrapes clean and covered. D. Wash hands with soap and water regularly. E. Avoid sharing towels and razors with others.
An 8-year-old child is suspected of having meningitis. Signs of meningitis include: A. Cullen's sign. B. Koplik spots. C. Kernig's sign. D. Chvostek's sign.
C. Kernig's sign
After collecting data on an adolescent with sickle cell anemia, the nurse assists with formulating a nursing diagnosis of Impaired skin integrity. Which finding best supports this nursing diagnosis? A. Swelling of the hands and feet B. Petechiae C. Leg ulcers D. Hemangiomas
C. Leg ulcers
An adolescent, age 17, with acute lymphoblastic leukemia is discharged with written information about chemotherapy administration and the outpatient appointment schedule. The child now is in the maintenance phase of chemotherapy but has missed clinic appointments for blood work and admits to omitting some chemotherapy doses. To improve the client's compliance, the nurse should include which intervention in the plan of care? A. Emphasizing the long-term consequences of noncompliance B. Reprimanding the client for failing to comply C. Letting the client participate in the planning and scheduling of treatments D. Threatening to discontinue care if the client doesn't comply
C. Letting the client participate in the planning and scheduling of treatments
An adolescent client is admitted for a sickle cell crisis. Which intervention is most important for the nurse to implement? A. Gather information about the child's ability to cope. B. Monitor the child's temperature every 4 hours. C. Manage pain aggressively and continually. D. Involve the family in every step of the child's care.
C. Manage pain aggressively and continually.
The nurse cares for an older adolescent client. The nurse observes a visitor wearing a gun and gun holster. Which action does the nurse take? A. Ask the visitor to take the weapon out of the building. B. Evacuate the unit for the safety of the clients and staff. C. Notify security personnel of the observation and location. D. Watch the visitor for signs of threatening behavior or aggression.
C. Notify security personnel of the observation and location.
A diabetic client is admitted to a healthcare facility for diarrhea, nausea, vomiting, and altered mental status. The arterial blood gas (ABG) report of the client shows decreased pH and decreased HCO3-. What immediate action should the nurse take? A. Give a bicarbonate infusion. B. Give Ringer solution. C. Notify the physician. D. Apply a rebreathing mask.
C. Notify the physician.
A 16-year-old client is admitted to the emergency department following an accident. The client sustained a head injury, is unconscious, and has compound fractures of the right tibia and fibula. No family members accompanied the client and none can be reached by phone. The surgeon instructs the nurse to take the client to the operating room immediately. Which of the following actions should the nurse take regarding informed consent? A. Call the nursing supervisor and ask that the hospital lawyer be contacted. B. Keep the client in the emergency department until the family is contacted. C. Take the client to the operating room for surgery without informed consent. D. Contact the hospital chaplain to sign the consent on the client's behalf.
C. Take the client to the operating room for surgery without informed consent.
A 10-year-old child must undergo a surgical procedure. What is the child's involvement in the consent process? A. The child does not need to know about the procedure because the child is a minor. B. The child must sign the form giving written informed consent. C. The child must be informed of the procedure and concur with his parent, who is giving written consent. D. The child only needs to know if the procedure is part of a research protocol.
C. The child must be informed of the procedure and concur with his parent, who is giving written consent.
The nurse is caring for a client with dehydration. Which observation made by the nurse should be reported immediately? A. The client is drinking water frequently. B. Urine output of 30 mL/hr. C. The client has become confused. D. The client's mucous membranes are dry.
C. The client has become confused.
A nurse is preparing a presentation to a group of female adolescents about pelvic inflammatory disease (PID). Which statement best reflects the focus of preventive education needs for this age group? A. Poor hygiene practices increase the risk of PID. B. The use of hormonal contraceptives decreases the risk of PID. C. There are long-term complications related to reproductive tract infections. D. There are risks of defects in future infants born to adolescents with PID.
C. There are long-term complications related to reproductive tract infections.
Parents of a 6-year-old child tell a physician that the child has been having periods of unawareness with short periods of staring. Based on his history, the child is probably having which type of seizure? A. Complex partial B. Myoclonic C. Typical absence D. Tonic
C. Typical absence
The nurse enters the room of a client who was just informed of having an inoperable brain tumor by the physician. The client is throwing items off of the bedside table and yelling. Which action is the priority by the nurse? A. Inform the client that this behavior is not making the situation better. B. Inform the client that it would be best to get a second opinion. C. Understand that the client is reacting in the anger stage of grief. D. Call security and have the client restrained.
C. Understand that the client is reacting in the anger stage of grief.
A female client with genital herpes simplex is being treated in the outpatient department. The nurse teaches her about measures that may prevent herpes recurrences and emphasizes the need for prompt treatment if complications arise. Genital herpes simplex increases the risk of: A. cancer of the ovaries. B. cancer of the uterus. C. cancer of the cervix. D. cancer of the vagina.
C. cancer of the cervix.
The nurse is caring for a teenage client involved in a motor vehicle accident. The client has a chest tube in place. If the chest tube is accidentally removed, the nurse should immediately: A. reintroduce the tube and attach it to water seal drainage. B. call the physician and obtain a chest tray. C. cover the opening with sterile petroleum gauze. D. clean the wound with povidone-iodine and apply a gauze dressing.
C. cover the opening with sterile petroleum gauze.
When collecting data on a child with cellulitis, which symptoms would the nurse expect to find? A. pale, irritated, and cold to touch B. vesicular blisters at the site of the injury C. fever, edema, tenderness, and warmth at the site D. swelling and redness with well-defined borders
C. fever, edema, tenderness, and warmth at the site
While caring for a 2-day-old neonate, a nurse notices the left side of the neonate reddens for 2 to 3 minutes. What does this finding suggest? A. contact dermatitis B. environmental conditions C. harlequin color change D. hypercyanotic event
C. harlequin color change
Which interview strategy contributes to a poor nurse-adolescent relationship? A. maintaining objectivity by avoiding assumptions, judgments, and lectures B. beginning with less-sensitive issues and proceeding to more-sensitive ones C. interviewing adolescents with their parents present D. asking open-ended questions and moving to more directive questions when possible
C. interviewing adolescents with their parents present
A nurse is caring for a school-age child with cerebral palsy. The child has difficulty eating using regular utensils and requires a lot of assistance. Which referral is most appropriate? A. registered dietitian B. physical therapist C. occupational therapist D. nursing assistant
C. occupational therapist
An adolescent is admitted to the adolescent unit with pain caused by sickle cell crisis. Who should be consulted first about this adolescent's care? A. nutritionist B. physical therapist C. pediatric pain specialist D. case manager
C. pediatric pain specialist
Which finding best indicates to the nurse that an adolescent client with a chronic condition should be assessed further for pain? A. insomnia B. tachycardia C. restlessness D. hypertension
C. restlessness
An adolescent reports feet that itch, sweat a lot, and have a foul odor. The nurse suspects which condition? A. candidiasis B. tinea corporis C. tinea pedis D. molluscum contagiosum
C. tinea pedis
osmosis
Diffusion of water through a selectively permeable membrane; equalizes concentrations of nondiffusible solutes within the body
The parents of a 9-year-old child in the terminal phase of a fatal illness ask the nurse for guidance in discussing death with their child. Which response is appropriate? A. "Children of that age view death as temporary and reversible, which makes it hard to explain." B. "Children of that age typically fantasize about what dying will be like, which is much better than knowing the truth." C. "At this developmental stage, children are afraid of death, so it's best not to discuss it with them." D. "At this developmental stage, most children have an adult concept of death and should be encouraged to discuss it."
D. "At this developmental stage, most children have an adult concept of death and should be encouraged to discuss it."
A 15-year-old girl visits the neighborhood clinic seeking information on "how to keep from getting pregnant." What should the nurse say in response to her request? A. "What would you like to know?" B. "Let's discuss what your friends are doing to keep from getting pregnant." C. "Can you tell me if you've told your parents you're having sex?" D. "Can you tell me about the precautions you're taking now?"
D. "Can you tell me about the precautions you're taking now?"
A school nurse is planning a program on skin cancer prevention for a group of teenagers. Which instruction should the nurse emphasize during the program? A. "Stay out of the sun between 1 p.m. and 3 p.m." B. "Tanning booths are a safe alternative for those who wish to tan." C. "Sun exposure is safe, provided you wear protective clothing." D. "Examine your skin once per month, looking for suspicious lesions or changes in moles."
D. "Examine your skin once per month, looking for suspicious lesions or changes in moles."
The nurse is teaching a 16-year old client who has menstruated for more than a year. Which client statement will the nurse respond to as the priority? A. "Sometimes I have pain when I have a period." B. "Two weeks before my period, I get one-sided abdominal cramping." C. "I feel so moody and anxious around the time of my cycle." D. "I was having regular periods before but haven't had one for a couple of months."
D. "I was having regular periods before but haven't had one for a couple of months."
A nurse determines that an adolescent with a fractured left femur understands the instructions to perform only touch-down weight bearing when making what statement? A. "I will place full weight on my left leg." B. "I will place about 30% to 50% of my weight on my left leg." C. "I will keep my left leg off the floor." D. "I will allow my left leg to touch the floor without placing weight on it."
D. "I will allow my left leg to touch the floor without placing weight on it."
The nurse is reinforcing education for a breast-feeding mother. Which statement made by the client demonstrates an understanding of adequate fluid intake? A. "If my mouth is dry, I will drink more fluids." B. "As long as I am eating food, I don't need to increase fluids." C. "I won't lose fluid when my baby is breast feeding." D. "I will drink more fluid than I did when I was not breast-feeding to replace lost fluids."
D. "I will drink more fluid than I did when I was not breast-feeding to replace lost fluids."
The parent of a 16-year-old child calls the emergency department, suspecting their child's abdominal pain may be appendicitis. In addition to pain, the child has a fever of 100° F (37.8° C) and has vomited twice. What would be appropriate advice for the nurse to give the parent? A. "Give your child a laxative to rule out the possibility that constipation is causing the pain." B. "Gently press on the lower left quadrant of your child's abdomen to test for rebound tenderness." C. "It's most likely the flu because your child is too young to have appendicitis." D. "Immediately bring your child into the emergency department."
D. "Immediately bring your child into the emergency department."
During chemotherapy, a boy, age 10, loses his appetite. When teaching the parents about his food intake, the nurse should include which instruction? A. "Offer dry toast and crackers." B. "Withhold all food and fluids." C. "Ignore your child's lack of food intake." D. "Let your child eat any food he wants."
D. "Let your child eat any food he wants."
An adolescent client comes to the clinic for treatment of an upper respiratory infection. The nurse notes bruising that appears to be in the shape of fingers on the client's upper arm. The client becomes tearful. Which response by the nurse is correct? A. "Abuse should not be kept secret." B. "Do you feel safe to leave your relationship?" C. "I need to know whom I can call for you." D. "Let's devise a safety plan for possible situations."
D. "Let's devise a safety plan for possible situations."
After a nurse reinforces education with an adolescent about syphilis, which statement by the adolescent indicates the need for further education? A. "The disease is divided into four stages: primary, secondary, latent, and tertiary." B. "Affected persons are most infectious during the first year." C. "Syphilis is easily treated with penicillin or doxycycline." D. "Syphilis is rarely transmitted sexually."
D. "Syphilis is rarely transmitted sexually."
An adolescent female client at the health clinic is considering having sexual intercourse. The client tells the nurse that she wants to begin taking oral contraception because "Birth control pills would mean I don't have to worry about pregnancy or HIV." What is the most appropriate initial response from the nurse? A. "Let's talk about where you found this information, and then we can look for better resources about intercourse." B. "Nothing prevents HIV, but we also need to discuss the potential side effects of oral contraceptives." C. "Oral contraceptives do protect against any chance of pregnancy, but we should talk about HIV and other infections." D. "The pill will not protect you from getting sexually transmitted infections, and it isn't 100% effective for preventing pregnancy."
D. "The pill will not protect you from getting sexually transmitted infections, and it isn't 100% effective for preventing pregnancy."
A 15-year-old girl visits the neighborhood clinic seeking information on how to prevent pregnancy. How should the nurse respond to her request? A. "What would you like to know?" B. "Let's discuss what your friends are doing to keep from getting pregnant." C. "Have you've told your parents you're sexually active?" D. "What precautions are you taking now when you have sex?"
D. "What precautions are you taking now when you have sex?"
An adolescent client was offered a babysitting job after school. The nurse coaches the parents to make which response to the client? A. "Do not make a choice that would detract from your schoolwork." B. "Your job is to get good grades in school so you can get into a good college." C. "We'll take you to the bank so you can set up a savings account for your earnings." D. "What thought have you given as to how you'll manage your responsibilities?"
D. "What thought have you given as to how you'll manage your responsibilities?"
A client diagnosed with terminal lung cancer states to the nurse, "I am okay with this. I have had a wonderful life and my family will be with me." Which stage of grief does the nurse recognize the client is experiencing? A. Denial B. Anger C. Bargaining D. Acceptance
D. Acceptance
The nurse is caring for a school-age child whom she suspects has been physically abused. What legal responsibility does the nurse have toward this client? A. Interpreting the client's behavior B. Interpreting the parent's behavior C. Documenting her suspicions about abuse D. Describing the client's and parent's behavior
D. Describing the client's and parent's behavior
The nurse is discussing safe sex practices with an adolescent client who reports interest in becoming sexually active. How does the nurse teach this information? A. Use standard medical terminology to teach the client. B. Ask the client to describe their current understanding of sex. C. Only answer questions that are asked, being specific. D. Discuss sexual information using a straightforward manner.
D. Discuss sexual information using a straightforward manner.
A dying client is not eating and only drinks small sips of fluid occasionally. Which action by the nurse is appropriate? A. Use a syringe to feed the client. B. Obtain an order for a nasogastric tube. C. Inform the client that life cannot be sustained without food and fluids. D. Do not force food or fluids.
D. Do not force food or fluids.
The nurse is caring for an adolescent with cancer who is well informed about the medical condition and treatment. The adolescent refused the morning medications and states intentions of refusing all future medications. What is the best action by the nurse? A. Persuade the adolescent to take the medication as ordered. B. Ensure that the adolescent understands the rationale for taking the medication. C. Ask the adolescent's parents to encourage the adolescent to take the medication. D. Document the adolescent's choice and offer to discuss feelings about the medication.
D. Document the adolescent's choice and offer to discuss feelings about the medication.
An adolescent with diabetes tells the community nurse they recently started drinking alcohol on the weekends. Which action would be most appropriate for the nurse to take? A. Recommend referral to counseling. B. Make the adolescent promise to stop drinking. C. Discuss with the adolescent why he or she started drinking. D. Educate the adolescent about the effects of alcohol on diabetes.
D. Educate the adolescent about the effects of alcohol on diabetes.
The nurse overhears an oldest adult client saying to another client, "I feel depressed because I have so many regrets about my life." Which activity can the nurse provide to help this client gain a positive perspective? A. Provide a craft project B. Encourage ambulation C. Provide a game such as Bingo D. Encourage reminiscence
D. Encourage reminiscence
A nurse is caring for a client whose cast has just been taken off after treatment of his fractured hand. Which instruction should the nurse provide the client when performing exercises after the cast has been taken off? A. Maintain the same level of activity daily. B. Exercise past the point of pain for 10 minutes. C. Alter exercises as you see might be necessary to increase your activity. D. Monitor your body for cues of discomfort during exercise.
D. Monitor your body for cues of discomfort during exercise.
The nurse is planning sex and contraceptive education for adolescents. Which factor should the nurse consider? A. Neither sexual activity nor contraception requires planning. B. Most teenagers today are knowledgeable about reproduction. C. Most teenagers use pregnancy as a way to rebel against their parents. D. Most teenagers are open about contraception, but inconsistently use birth control.
D. Most teenagers are open about contraception, but inconsistently use birth control.
A school-age child is admitted to the facility with a diagnosis of acute lymphoblastic leukemia (ALL). The nurse recognizes a nursing diagnosis of Risk for infection. What is the most effective way for the nurse to reduce the child's risk of infection? A. Implementing reverse isolation B. Maintaining standard precautions C. Requiring staff and visitors to wear masks D. Practicing thorough hand washing
D. Practicing thorough hand washing
The nurse obtains a 24-hour food recall from a 14-year-old child and determines that the majority of the food consumed is "junk food" or empty calories. What education should be provided to the adolescent? A. Teach the client how to shop for food. B. Inform the client that junk food should be eliminated and replaced with only healthy food. C. Tell the client there is nothing to worry about at this time but the child will need to be careful when older. D. Provide information and suggestions for improvements in diet choices and portions.
D. Provide information and suggestions for improvements in diet choices and portions.
The nurse is gathering data regarding a 2-year-old child's pain level. Which scale would be most effective for obtaining this information? A. Pain Distress Scale B. Wong-Baker Faces Pain Scale C. McGill-Melzack Pain Questionnaire D. The FLACC scale
D. The FLACC scale
A 10-year-old child has been experiencing insatiable thirst and urinating excessively and the serum glucose is normal. Which condition is the child most likely experiencing? A. type 2 diabetes B. type 1 diabetes C. hyperthyroidism D. diabetes insipidus
D. diabetes insipidus
According to Erikson, the psychosocial task of adolescence is the development of a sense of identity. The nurse can best promote the development of a hospitalized adolescent by: A. emphasizing the need to follow the facility regimen. B. allowing parents and siblings to visit frequently. C. arranging for tutoring in school work. D. encouraging peer visitation.
D. encouraging peer visitation.
The nurse is caring for an adolescent with syphilis. What factor must the nurse determine before the client can be treated? A. portal of entry B. size of the chancre C. names of sexual contacts D. existence of medication allergies
D. existence of medication allergies
An 11-year-old child contracted severe acute respiratory syndrome (SARS) when traveling abroad with the parents. The nurse knows to put on personal protective equipment to protect herself while providing care. Based on the mode of SARS transmission, which personal protective equipment should the nurse wear? A. gloves B. gown and gloves C. gown, gloves, and mask D. gown, gloves, mask, and eye goggles or eye shield
D. gown, gloves, mask, and eye goggles or eye shield
The nurse is caring for a 14-year-old child in skeletal traction for treatment of a fractured femur. The child is expected to be hospitalized for several weeks. When planning care, the nurse should take into account the client's need to achieve what developmental milestone? A. autonomy B. initiative C. industry D. identity
D. identity
The nurse is collecting data from an adolescent with pelvic inflammatory disease (PID). What symptoms are anticipated when reviewing data? A. a hard, painless, red defined lesion B. small vesicles on the genital area with itching C. cervical discharge with redness and edema D. lower abdominal pain and urinary tract symptoms
D. lower abdominal pain and urinary tract symptoms
A nurse is caring for 10-year-old child with sickle cell anemia admitted for vaso-occlusive crisis. Which would be the most appropriate activity for the nurse to provide for the child? A. exercising in the physical therapy department B. finger painting C. walking in the hallways D. reading
D. reading
A female adolescent client refuses to allow male nurses to care for her while she's hospitalized. Which of these health care rights is this adolescent exerting? A. right to competent care B. right to have an advance directive on file C. right to confidentiality of her medical record D. right to privacy
D. right to privacy
The nurse is assessing an 11-year-old female client. Which assessment finding must be reported to the health care provider? A. weight 81 lb (37 kg) B. blood pressure 112/70 mm Hg C. report of being nervous to give school presentations D. visible decay of the two front teeth
D. visible decay of the two front teeth
A school-age child is admitted to the medical facility with a diagnosis of acute lymphocytic leukemia (ALL). Which nursing interventions are most appropriate? A. implementing reverse isolation precautions B. limiting the number of visitors C. having client wear a mask in his/her room D. washing hands before/upon entering room
D. washing hands before/upon entering room
What fluid is most important in regulation of fluid balance?
Extracellular fluid
What is the leading cause of hospital admissions for both young-old adults and oldest adults?
Falls
What is aging associated with?
Having one or more chronic medical conditions that interfere with lifestyle but do not necessarily prohibit activities needed for work or recreation.
What are two major causes of death in the US?
Heart attack and stroke
What population is most at risk for fluid volume deficit?
Infants, as they have a higher percentage of ECF, making them at an increased risk for fluid volume deficit because ECF is lost more easily than ICF. Additionally their kidney function is immature, which also puts them at a greater risk.
What are the major systems involved in feedback?
Nervous and endocrine systems
What are examples of excess fluid accumilation in interstitial spaces?
Pleural effusion and pericardial effusion
What does the nervous system do in feedback?
Regulates homeostasis by sensing system deviations and sending nerve impulses to appropriate organs.
What does the endocrine system do in feedback?
Uses the release and action of hormones to restore and maintain homeostasis.
What is an example of dangerous positive feedback?
Very high fever, as it can lead to greater instability and even death
ion
an atom that has gained or lost an electron
What is the age span for oldest adults?
anyone over age 80
ABG
arterial blood gas; is measure to determine the extent of compensation by the buffer system. the pH level and amounts of specific gases ub the blood indicate if there is more acid or base
What is the most important extracellular anion?
chlorine
What is the leading cause of death for adults aged 65 and older?
chronic conditions
What is the age span for middle adulthood?
early 40s-49 years of age
alkaline
having a pH greater than 7
hypertonic
increased tension, more concentrated; solution draws the water out of the cell, causing it to shrink
What are IADLs?
instrumental activities of daily living; being able to manage money, prepare meals, take medications, and physically care for oneself
metabolic acidosis
normal metabolism is impaired, causing a decrease in bicarbonates and buildup of lactic acid
metabolic alkalosis
occurs when bicarbonate ion concentration increases causing an elevation in blood pH
respiratory acidosis
occurs when breathing is inadequate and PaCO2 (respiratory acid) builds up. the extra CO2 combines with water for form carbonic acid, causing acidosis
What age group has the highest rate of suicides?
older adults, particularly older Caucasian men who live alone
What are two of the earliest and most common chronic age-related problems?
osteoarthritis and hypertension
acidic
pH less than 7
What is the most dominant anion intracellularly?
phosphate
What is the most dominant cation intracellularly?
potassium
diffusion
random movement of molecules from a region of higher concentration toward one of lower concentration
hypotonic
reduced tension, less concentrated; dilution causes the cell to swell and eventually burst because a large amount of water moving into the cell
What is the most important extracellular cation?
sodium
What is the best example of active transport?
sodium potassium pump
Presbycusis is...
the gradual loess of hearing in both ears that occurs gradually starting in the middle age and becoming very noticeable by mid-60s
Presbyopia is...
the loss of flexibility of the lenses in both eyes, making it difficult to see close object
filtration
the transport of water and dissolved materials through a membrane from an area of higher pressure to an area of lower pressure
What is another name for excess accumulation of fluid in the interstitial fluid spaces other than edmea?
third-space fluid
The parents of a child with cystic fibrosis ask the nurse why their child must receive supplemental pancreatic enzymes. Which response by the nurse would be most appropriate? A. "Pancreatic enzymes promote absorption of nutrients and fat." B. "Pancreatic enzymes promote adequate rest." C. "Pancreatic enzymes prevent intestinal mucus accumulation." D. "Pancreatic enzymes help prevent meconium ileus."
A. "Pancreatic enzymes promote absorption of nutrients and fat."
Which statement would the nurse include when reinforcing education for a parent about salmon patches (stork bites)? A. "They're benign and usually fade in adult life." B. "They're usually associated with syndromes of the neonate." C. "They can cause mild hypertrophy of the muscle associated with the lesion." D. "They're treatable with laser pulse surgery in late adolescence and adulthood.
A. "They're benign and usually fade in adult life."
The nurse is caring for a resident in a long-term care facility who has venous stasis ulcers and is being treated with an Unna boot. Which of the nursing activities is best for the nurse to delegate to a unlicensed assistive personnel (UAP)? A. Assist the client in cleaning around the Unna boot. B. Evaluate foot sensation and movement every shift. C. Monitor capillary perfusion every shift. D. Teach the family members the signs of infection.
A. Assist the client in cleaning around the Unna boot.
An 8-year-old child is brought to the clinic with watery eyes and clear nasal drainage that has lasted more than 10 days, without fever. The nurse observes that the child has dark circles under the eyes and a crease above the tip of the nose. Which intervention should be the nurse's priority? A. Collect data about potential environmental allergy triggers. B. Prepare to administer amoxicillin 25 mg/kg. P.O. every 12 hours. C. Prepare to administer trivalent inactivated influenza vaccine 0.5 mL P.O. D. Prepare the child for sinus x-rays.
A. Collect data about potential environmental allergy triggers.
A client comes to the physician's office for treatment of severe sunburn. The nurse takes this opportunity to discuss the importance of protecting the skin from the sun's damaging rays. Which instruction would best prevent skin damage? A. "Minimize sun exposure from 1 to 4 p.m. when the sun is strongest." B. "Use a sunscreen with a sun protection factor of 6 or higher." C. "Apply sunscreen even on overcast days." D. "When at the beach, sit in the shade to prevent sunburn."
B. "Use a sunscreen with a sun protection factor of 6 or higher."
Which finding should the nurse anticipate when evaluating the skin of an older adult client? A. tenting when pinched B. inelastic skin turgor C. moist, supple texture D. an edematous appearance
B. inelastic skin turgor
A 10-year-old child monitors and adjusts insulin dosage independently. Which response reflects an understanding of appropriate adjustment of insulin dosage when the child has the flu? A. "I won't take my insulin because I'm too sick to eat right now." B. "I'll take my usual dose of regular and NPH insulin." C. "I'll do a fingerstick test first, then figure out how much insulin to take." D. "I'll do a fingerstick test and record the results."
C. "I'll do a fingerstick test first, then figure out how much insulin to take."
A school-age child needs an I.V. catheter inserted for administration of I.V. fluids. Which explanation by the nurse empowers the client to deal effectively with the procedure? A. "Inserting an I.V. catheter won't hurt you and will take only a few minutes if you cooperate." B. "You must lie perfectly still; if you don't we'll wrap you tightly in a restraint." C. "You can help by keeping your arm as still as a tree." D. "If you remain still, your parent can stay with you during the procedure."
C. "You can help by keeping your arm as still as a tree."
The nurse is collecting data from several clients at the clinic. Which client does the nurse determine is most likely receive the Zostavax vaccine for the prevention of shingles? A. 24-year old client that will be traveling out of the country B. 6-month-old infant having surgery to repair a cleft lip C. 62-year-old client that had a mild case of shingles 4 years previously D. 38-year-old pregnant client that has gestational diabetes
C. 62-year-old client that had a mild case of shingles 4 years previously
A 10-year-old child falls, injures the left shoulder, and is taken to the emergency department. While the child waits to be seen by the primary health care provider, what is the priority nursing action? A. Apply a warm compress to the injured shoulder. B. Ask the child to demonstrate full range of motion of the left arm. C. Apply ice to the injured shoulder. D. Give the child a nonopioid analgesic for pain.
C. Apply ice to the injured shoulder.
The nurse is developing the plan of care for a 9-year-old client with Down syndrome. How can the nurse best apply age-appropriate interventions? A. Plan interventions at a 9-year-old level. B. Plan interventions at a 7-year-old level. C. Assess the client's current developmental level. D. Assess the client's neurological functioning level.
C. Assess the client's current developmental level.
The nurse is caring for a terminally ill school-age child. Which resource might be most helpful in caring for this child? A. Child protective services B. Centers for Disease Control and Prevention (CDC) C. Child life specialist D. Legal nurse consultant
C. Child life specialist
When administering morphine (the drug of choice for moderate to severe pain in pediatric patients), to a school-age child, which symptom should cause the nurse to be concerned? A. Constipation B. Nausea and vomiting C. Pruritus D. Anemia
D. Anemia
Which advice should a nurse give over the phone to the parent of a 7-year-old child with right lower abdominal pain, fever, and vomiting? A. "Give prune juice to relieve constipation." B. "Test for rebound tenderness in the left lower abdominal quadrant." C. "Encourage fluids to prevent dehydration." D. "Seek immediate emergency medical care."
D. "Seek immediate emergency medical care."
A nurse in a well-child clinic is collecting data on children for scoliosis screening. Which child is at greatest risk for scoliosis? A. 8-year-old boy B. 14-year-old boy C. 6-year-old girl D. 10-year-old girl
D. 10-year-old girl
A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what percentage of the total body surface area has been burned? A. 9% B. 18% C. 34% D. 36%
D. 36%
A school-age client reports pain. After rating the pain on an age-appropriate pain scale, the nurse determines that the client's pain is minor. Which of the following drugs should the nurse administer? A. Morphine B. Fentanyl C. Ibuprofen D. Acetaminophen
D. Acetaminophen
A client has been admitted with burns on both legs. Which nursing intervention is most important to help prevent contractures? A. applying knee splints B. elevating the foot of the bed C. hyperextending the client's palms D. performing shoulder range-of-motion (ROM) exercises
A. applying knee splints
When collecting data on a girl, age 10, the nurse keeps in mind that the first sign of sexual maturity in girls is: A. breast bud development. B. pubic hair. C. axillary hair. D. menarche.
A. breast bud development.
After a series of tests, a 6-year-old client weighing 50 lb (22.7 kg) is diagnosed with complex partial seizures. The physician prescribes phenytoin, 125 mg by mouth twice per day. After the nurse administers phenytoin, where is the drug metabolized? A. Pancreas B. Kidneys C. Stomach D. Liver
D. Liver
Four clients are assigned to a nurse. Which client should the nurse identify who would benefit the most from hyperbaric oxygen therapy? A. client with a compromised skin graft B. client with chronic obstructive pulmonary disease C. client with Legionella-related pneumonia D. client with an open fracture of the femur
A. client with a compromised skin graft
A 1-year-old child is brought by a parent to the clinic with a rash on the abdomen and is diagnosed with scabies. What first line medication for the treatment of scabies does the nurse anticipate reinforcing education about? A. permethrin cream 5% B. crotamiton lotion 10% C. lindane lotion 1% D. ivermectin orally
A. permethrin cream 5%
A client is examined and found to have pinpoint, pink-to-purple, nonblanching macular lesions 1 to 3 mm in diameter. How should the nurse document the findings? A. ecchymosis B. hematoma C. petechiae D. purpura
C. petechiae
Which nursing diagnosis is the priority for a client with burns to 35% of the body surface area? A. fluid volume overload B. altered cardiac output C. risk for infection D. altered tissue perfusion
C. risk for infection
A nurse is caring for a client with a pressure ulcer on the sacrum. When educating the client about dietary intake, which foods should the nurse plan to emphasize? A. legumes and cheese B. whole-grain products C. fruits and vegetables D. lean meats and low-fat milk
D. lean meats and low-fat milk
A client is admitted to the emergency department with a deep, partial-thickness burn on the arm after a fire in the workplace. Which signs and symptoms should the nurse expect to see? A. pain and redness B. minimal damage to the epidermis C. necrotic tissue through all layers of skin D. necrotic tissue through most of the dermis
D. necrotic tissue through most of the dermis
The nurse is caring for a client who has been admitted to the hospital with a leg ulcer that is infected with vancomycin-resistant s. aureus (VRSA). Which nursing actions can be delegated to a licensed practical/vocational nurse (LPN/VN)? A. teaching the client about the care of the leg ulcer B. planning the client's diet to improve protein intake C. assessing the risk of further skin breakdown D. obtaining a wound culture during a dressing change
D. obtaining a wound culture during a dressing change
The nurse is obtaining data from a child who is suspected of having a scabies infestation. What finding by the nurse would correlate with this diagnosis? A. diffuse, pruritic wheals B. oval white dots stuck to the hair shafts C. pain, erythema, and edema with an embedded stinger D. pruritic papules, pustules, and linear burrows of the finger and toe webs
D. pruritic papules, pustules, and linear burrows of the finger and toe webs
During a routine examination of a client's fingernails, the nurse notes a horizontal depression in each nail plate. When documenting this finding, the nurse should use which term? A. Splinter hemorrhage B. Beau's line C. Paronychia D. Clubbing
B. Beau's line
A child with sickle cell anemia is being discharged after treatment for a crisis. Which instructions for avoiding future crises should the nurse provide to the child and family? Select all that apply. A. Avoid foods high in folic acid. B. Drink plenty of fluids. C. Use cold packs to relieve joint pain. D. Report a sore throat to an adult immediately. E. Restrict activity to quiet board games. F. Wash hands before meals and after playing.
B. Drink plenty of fluids. D. Report a sore throat to an adult immediately. F. Wash hands before meals and after playing.
Topical treatment with 2.5% hydrocortisone is prescribed for a 6-month-old infant with eczema. The nurse advises the parent to use the cream for no more than 1 week based on which rationale? A. The drug loses its efficacy after prolonged use. B. Excessive use can have adverse effects, such as skin atrophy and fragility. C. If no improvement is seen, a stronger concentration will be prescribed. D. If no improvement is seen after 1 week, an antibiotic will be prescribed.
B. Excessive use can have adverse effects, such as skin atrophy and fragility.
A newer nurse is assigned to care for several children with advanced cancer. The nurse finds the assignment extremely challenging due to a lack of experience and is considering requesting a different assignment. What is the best course of action by the nurse to resolve the situation? A. Notify the nurse manager that the assignment will be refused. B. Bring reference materials to the room when providing care. C. Pretend to be ill and leave the unit as soon as possible. D. Suggest a shared assignment with a senior staff nurse.
D. Suggest a shared assignment with a senior staff nurse.
The nurse completes a wet-to-dry dressing change on a client's lower extremity wound. When should the nurse document the dressing change? A. the next time they access the client's record to update vital signs B. just before the end of the shift, prior to giving a report C. as soon as they finish performing the dressing change D. immediately prior to the next dressing change
D. immediately prior to the next dressing change
When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority? A. Ineffective airway clearance related to edema of the respiratory passages B. Impaired physical mobility related to the disease process C. Impaired skin integrity related to disease process D. Risk for infection related to breaks in the skin
A. Ineffective airway clearance related to edema of the respiratory passages
A school-age child is experiencing graft versus host disease (GVHD) after bone marrow transplant for acute lymphocytic leukemia. After being informed that the child's prognosis is poor, the parents ask the nurse for advice on discussing the topic of resuscitation with their child. How should the nurse respond? Select all that apply. A. "Can you tell me what your child already knows about the prognosis?" B. "Does your family and child observe any religious or spiritual beliefs?" C. "Be honest about what takes place during resuscitation and its limitations." D. "Would you rather I discuss the topic of resuscitation with your child?" E. "It is advised you keep the topic more abstract given your child's age."
A. "Can you tell me what your child already knows about the prognosis?" B. "Does your family and child observe any religious or spiritual beliefs?" C. "Be honest about what takes place during resuscitation and its limitations."
The school nurse learns a school-age student's teacher has used "the strap" on the child in response to misbehavior. Which action(s) should the nurse take in response to learning this information? Select all that apply. A. Determine the jurisdictional legislation related to corporal punishment in schools. B. Arrange to meet with the child to assess for any physical or emotional effects. C. Determine if the misbehavior was serious enough to warrant physical punishment. D. Speak to the teacher to provide information about alternative approaches to discipline. E. Report the incident to the school's administration to ensure proper documentation.
A. Determine the jurisdictional legislation related to corporal punishment in schools. B. Arrange to meet with the child to assess for any physical or emotional effects. D. Speak to the teacher to provide information about alternative approaches to discipline. E. Report the incident to the school's administration to ensure proper documentation.
A nurse is caring for a disabled school-age child whose parents are overprotective. What is the most appropriate action of the nurse? A. Encourage the parents to arrange a play date for their child with other children. B. Advise the parents to limit exposure to children who are not impaired. C. Focus exclusively on the child's disability. D. Teach parents to avoid social expectations and demands.
A. Encourage the parents to arrange a play date for their child with other children.
The nurse is caring for an older adult client who experienced burns to the hands and forearms from a grease fire. The plan is to discharge the client home with outpatient rehabilitation services. Which action(s) should the nurse include in preparing the client for discharge? Select all that apply. A. Recommend an occupational therapy referral for a kitchen assessment. B. Assess the client's knowledge of fire safety precautions for the home. C. Recommend the client have a home safety assessment completed. D. Advise the client to refrain from cooking with grease or oil once home. E. Advise the client to wear compression sleeves to protect skin when cooking.
A. Recommend an occupational therapy referral for a kitchen assessment. B. Assess the client's knowledge of fire safety precautions for the home. C. Recommend the client have a home safety assessment completed.
The nurse is caring for a client at risk for skin impairment. Which intervention is best to decrease this client's risk? A. using a specialty mattress B. positioning the client in alignment C. repositioning the client every 4 hours D. massaging bony prominences every shift
A. using a specialty mattress
A school-age child experiences symptoms of excessive polyphagia, polyuria, and weight loss. The physician diagnoses type I diabetes mellitus and admits the child to the facility for insulin regulation. The physician prescribes an insulin regimen of insulin (Humulin R) and isophane insulin (Humulin N) administered subcutaneously. How soon after administration can the nurse expect the regular insulin to begin to act? A. ½ to 1 hour B. 1 to 2 hours C. 4 to 8 hours D. 8 to 10 hours
A. ½ to 1 hour
The nurse is reinforcing teaching about the human papillomavirus vaccination. Which should be included? Select all that apply. A. It is administered only to girls, not boys. B. It consists of a series of injections at timed intervals. C. The second dose is given 6-12 months after the first. D. The vaccination helps prevent cervical cancer. E. The first dose should be given after the child is 16 years old.
B. It consists of a series of injections at timed intervals. C. The second dose is given 6-12 months after the first. D. The vaccination helps prevent cervical cancer.
A client with a severe staphylococcal infection is receiving the aminoglycoside gentamicin sulfate by the I.V. route. The nurse should monitor the client for which adverse reaction to this drug? A. Aplastic anemia B. Ototoxicity C. Hypokalemia D. Seizures
B. Ototoxicity
A client is diagnosed with primary herpes genitalis. Which instruction should the nurse provide? A. "Apply one applicator of terconazole intravaginally at bedtime for 7 days." B. "Apply one applicator of tioconazole intravaginally at bedtime for 7 days." C. "Apply acyclovir ointment to the lesions every 3 hours, six times per day for 7 days." D. "Apply sulconazole nitrate twice daily by massaging it gently into the lesions."
C. "Apply acyclovir ointment to the lesions every 3 hours, six times per day for 7 days."
The nurse is giving instructions to parents of a school-age child diagnosed with sickle cell disease. The instructions should include which of the following? A. Apply cold to affected areas to reduce the child's discomfort. B. Restrict the child's fluids during crisis situations. C. Avoid areas of low oxygen concentration such as high altitudes. D. Encourage the child to exercise to reduce the likelihood of crisis.
C. Avoid areas of low oxygen concentration such as high altitudes.
A client is brought to the emergency department with partial-thickness and full-thickness burns over 15% of the body. Admission vital signs are as follows: blood pressure, 100/50 mm Hg; heart rate, 130 beats/minute; respiratory rate, 26 breaths/minute. Which nursing interventions are appropriate for this client? Select all that apply: A. Clean the burns with hydrogen peroxide. B. Cover the burns with saline-soaked towels. C. Begin an intravenous (IV) infusion of lactated Ringer's solution. D. Place ice directly on the burn areas. E. Administer 6 mg of IV morphine. F. Administer tetanus prophylaxis, as ordered.
C. Begin an intravenous (IV) infusion of lactated Ringer's solution. E. Administer 6 mg of IV morphine. F. Administer tetanus prophylaxis, as ordered.
A child has been brought to the ED with a bite to the arm from a dog. What action by the nurse will assist in the prevention of infection? A. Give the rabies vaccine. B. Give antibiotics immediately. C. Clean and irrigate the wounds. D. No action is necessary since bites from a dog has a low incidence of infection.
C. Clean and irrigate the wounds.
A 9-year-old child presents to a school nurse and reports arm and leg pain. Upon assessment, the nurse identifies numerous purple to yellow ecchymotic areas. When asked, the child says that the bruises are the result of "being in trouble at home." Which action by the nurse is most appropriate? A. Arrange for the child to speak with the school psychologist as soon as possible. B. Arrange for a meeting with the nurse, psychologist, school administrators, and the child's parents. C. Contact the authorities immediately. D. Contact an ambulance to transport the child to the emergency department.
C. Contact the authorities immediately.
At the beginning of the school day, a student has come to see the school nurse. Upon observing tearing, redness of the eye, and a light crust at the canthus, which action will the nurse take? A. Apply ice to the canthus. B. Administer acetaminophen. C. Contact the parent to retrieve the student. D. Reassure the student that this is an allergic issue that will resolve without intervention.
C. Contact the parent to retrieve the student.
When assessing an elderly client, a nurse on the day shift notes redness in the sacral region. Close assessment reveals small breaks in the skin surface. The client says the area is tender and must have lost skin when a nursing assistant on the previous shift moved the client. The client tells the nurse, "The nursing assistant on the last shift was rough. I asked the nursing assistant to look at my backside, but the nursing assistant said they were too busy." What should the nurse do first? A. Prepare an incident report. B. Prepare a disciplinary warning for the nursing assistant. C. Document the findings. D. Contact the shift supervisor.
C. Document the findings.
A child, age 8, reports leg pain shortly after being admitted with a fractured tibia sustained in a fall. The nurse uses which approach to best assess the severity of the pain? A. Ask the child what makes the leg feel better. B. Ask the child what the pain feels like. C. Ask the child what makes the leg hurt more. D. Ask the child to rate the pain using a pain scale.
D. Ask the child to rate the pain using a pain scale.
The school nurse is examining a student at an elementary school who presents with vesicular lesions that ooze, forming crusts on the face and extremities. What is the nurse's most appropriate action? A. Gently washed the lesions with a warm, soapy washcloth. B. Take the child's temperature. C. Apply a topical over-the-counter antibiotic cream and cover with a Band-Aid. D. Contact the parents; the child requires medical treatment and cannot attend school.
D. Contact the parents; the child requires medical treatment and cannot attend school.
A school-age child with fever and joint pain has just received a diagnosis of rheumatic fever. The child's parents ask the nurse whether anything could have prevented this disorder. Which intervention is most effective in preventing rheumatic fever? A. Immunization with the hepatitis B vaccine B. Isolation of individuals with rheumatic fever C. Use of prophylactic antibiotics for invasive procedures D. Early detection and treatment of streptococcal infections
D. Early detection and treatment of streptococcal infections
An 8-year-old is admitted to a health care facility. During data collection, the nurse discovers that the child is experiencing the anxiety of separation from the caregivers. Which nursing intervention is most likely to help the child cope with the fear of separation? A. Ask the caregivers what approaches are used to calm the child at home. B. Calmly explain to the child why staying in the health care facility is necessary. C. Explain to the child that it is normal to have fear when in a health care facility. D. Let the caregivers stay with the child and participate in the child's care.
D. Let the caregivers stay with the child and participate in the child's care.
When reinforcing education for the parents of a child with Kawasaki disease, which information should the nurse be sure to include? A. It is highly contagious. B. It is an afebrile condition with cardiac involvement. C. It usually occurs in children older than age 5. D. Prolonged fever, with peeling of the fingers and toes, are the initial symptoms.
D. Prolonged fever, with peeling of the fingers and toes, are the initial symptoms.
In providing psychosocial care to a 6-year-old child who has had abdominal surgery for Wilms tumor, which activity initiated by the nurse would be most appropriate? A. Allow the child to watch a 2-hour movie without interruptions. B. Give the child a puzzle with five pieces to encourage the child to move while in bed. C. Tell the child that medication can be given so that there is no pain. D. Provide the child with supplies and ask the child to draw how he or she feels.
D. Provide the child with supplies and ask the child to draw how he or she feels.
A parent brings a child to the health care provider's office because the child reports pain, redness, and tenderness of the left index finger. The child is diagnosed with paronychia. Which organism is the most likely cause of this superficial abscess of the cuticle? A. Borrelia burgdorferi B. Escherichia coli C. Pseudomonas species D. Staphylococcus species
D. Staphylococcus species
The nurse is collecting data on a client admitted with second- and third-degree burns on the face, arms, and chest. Which finding indicates a potential problem? A. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg B. Urine output of 20 ml/hour C. White pulmonary secretions D. Rectal temperature of 100.6° F (38° C)
B. Urine output of 20 ml/hour
The nurse is gathering data from several children in the clinic with reports of diarrhea. Which child would be at greatest risk for giardiasis? A. child that rides a school bus B. child that plays on a playground close to home C. child that attended a sporting event at a large arena D. child that attends group day care
D. child that attends group day care
While in a skilled nursing facility, a client contracted scabies, which is diagnosed the day after discharge. The client is living at her daughter's home, where six other family members are living. During her visit to the clinic, she asks a staff nurse, "What should my family do?" The most accurate response from the nurse is: A. "All family members will need to be treated." B. "If someone develops symptoms, tell him to see a physician right away." C. "Just be careful not to share linens and towels with family members." D. "After you're treated, family members won't be at risk for contracting scabies."
A. "All family members will need to be treated."
The nurse is reinforcing education for a client taking tetracycline for severe inflammatory acne. Which instructions are important to reinforce? A. Take the drug with or without meals. B. Take the drug with milk and milk products. C. Take the drug on an empty stomach with small amounts of water. D. Take the drug 1 hour before or 2 hours after meals with large amounts of water.
D. Take the drug 1 hour before or 2 hours after meals with large amounts of water.
When attempting to facilitate spiritual support for a school-age child with a life-threatening disease and the child's family, which action would hinder the nurse-client relationship? A. becoming familiar with the family's spiritual beliefs and practices B. seeking assistance or referrals to the facility chaplain or other resources C. being open to the family's and the child's expressions of spiritual concerns D. promoting the nurse's personal values and beliefs if the nurse considers the family's to be inappropriate
D. promoting the nurse's personal values and beliefs if the nurse considers the family's to be inappropriate
The nurse is teaching caregivers about how to involve their 8-year-old child in home fire safety. Which information should the nurse include? Select all that apply. A. Allow the child to track the date smoke detectors should be tested. B. Teach the child how to use the fire extinguisher in the home. C. Teach the child how to distinguish between electrical and grease fires. D. Teach the child how to safely start a fire in a fireplace or wood stove. E. Allow the child to help plan and direct fire safety drills for the family.
A. Allow the child to track the date smoke detectors should be tested. B. Teach the child how to use the fire extinguisher in the home. E. Allow the child to help plan and direct fire safety drills for the family.
Which of the following would be an effective relaxation strategy for a school- age child to use during a painful procedure? A. Having the child keep his eyes shut at all times B. Having the child hold his breath and not yell C. Having the child take a deep breath and blow it out until told to stop D. Being honest with the child and telling him the procedure will hurt a lot
C. Having the child take a deep breath and blow it out until told to stop
