NUR208 EAQ 1: Health and Maintenance

What is the nurse's first action when developing a teaching plan for self-administration of insulin to a school-aged child? 1 Assessing the child's developmental level 2 Determining the family's understanding of the procedure 3 Discussing community resources for the child in the future 4 Collaborating with the school nurse to ensure continuity of care in school

1

An increase in which factor causes urinary frequency in the first trimester of pregnancy? Incorrect1 Estrogen level 2 Extracellular fluid volume 3 Kidney glomerular filtration 4 Bladder pressure from the enlarged uterus

4.

Which average daily caloric intake is appropriate in preschoolers? 1 400 2 700 3 1000 4 1800

4.

Which point is included in the World Professional Association for Transgender Health (WPATH) document regarding core principles of care for transgender clients?

Seeking informed consent before providing treatment

Which behaviors would the nurse anticipate when conducting a developmental assessment for a newborn? Select all that apply. One, some, or all responses may be correct. 1 Sucking on a pacifier 2 Grasping a parent's finger 3 Discovering hands and feet 4 Swallowing while breast-feeding 5 Rooting when the cheek is stroked

1,2,4,5

What is the correct order of the different stages in Piaget's theory of cognitive development?

1.Sensorimotor 2.Preoperational 3.Concrete operations 4.Formal operations

Which age would the nurse teach the parents of a school-age client to expect mandibular second molars to erupt? 1 7 to 8 years 2 9 to 10 years 3 10 to 12 years 4 11 to 13 years

Mandibular second molars often erupt between 11 and 13 years of age. The maxillary central incisor is expected to erupt between 7 and 8 years of age. The mandibular cuspids are expected to erupt between 9 and 10 years of age. The mandibular second bicuspids are expected to erupt between 11 to 12 years of age.

Which is the range of heart rate for a healthy, alert neonate? 1 120 to 180 beats/min 2 130 to 170 beats/min 3 110 to 160 beats/min 4 100 to 130 beats/min

3. 110 to 160

Which relationship is the most important to the formation of personality? 1 Peer relationships 2 Sibling relationships 3 Spousal relationships 4 Parent-child relationships

Children base their own worth on the feedback they receive from their parents. This sense of worth sets the basic ego strengths and is vital to the formation of the personality. Peer groups and sibling relationships are important; however, the parent-child relationship is the most important. Spousal relationships come later in life, after the basic personality has been formed. STUDY TIP: A helpful method for decreasing test stress is to practice self-affirmation. After you have adequately studied and really know the material, start looking in the mirror each time you pass one and say to yourself—preferably out loud—"I know this material, and I will do well on the test." After several times of watching and hearing yourself reaffirm your knowledge, you will gain inner confidence and be able to perform much better during the test period. This technique really works for students who are adventurous enough to use it. It may feel silly at first, but if it works, who cares? It will work for performing skills in clinical as well, as long as you have practiced the skill sufficiently.

The nurse teaches a client with a diagnosis of emphysema about the importance of preventing infections. The nurse would include which information in the education? 1 Purpose of bronchodilators t2 Importance of meticulous oral hygiene 3 Technique used in pursed-lip breathing 4 Methods used to maintain a dust-free environment

Microorganisms in the mouth are transferred easily to the tracheobronchial tree and are a source of potential infection; meticulous oral hygiene is essential to reduce the risk of respiratory infection. Bronchodilators will not prevent infection; they dilate the bronchi. Pursed-lip breathing will not prevent infection; it promotes gas exchange in the alveoli and facilitates more effective exhalation. It is impossible to maintain a dust-free environment. Test-Taking Tip: Attempt to select the answer that is most complete and includes the other answers within it. For example, a stem might read, "A child's intelligence is influenced by what?" and three options might be genetic inheritance, environmental factors, and past experiences. The fourth option might be multiple factors, which is a more inclusive choice and therefore the correct answer.

How does exercise help relieve menstrual discomfort in adolescents? Select all that apply. One, some, or all responses may be correct. 1 By reducing ischemia 2 By decreasing vasodilation 3 By increasing prostaglandins 4 By reducing pelvic discomfort 5 By releasing endogenous opiates

1,4,5 Exercise helps relieve menstrual discomfort through increased vasodilation followed by a subsequent decrease in ischemia. Exercise reduces congestion in the pelvis and minimizes the discomfort in the pelvis. Exercise promotes the release of endogenous opiates and suppresses prostaglandin production.

The nurse is teaching a high school student about scoliosis treatment options. On which priority information would the nurse focus? 1 Effect on body image 2 Least invasive treatment 3 Continuation with schooling 4 Maintenance of contact with peers

1. Establishing an identity, the major developmental task of the adolescent, is related to the affirmation of self-image. To achieve this task there is a need to conform to group norms, one of which is appearance. The type of treatment is not an issue. Although it is important to continue schooling and to maintain contact with peers, the effect on body image is more important. Test-Taking Tip: Have confidence in your initial response to an item because it more than likely is the correct answer.

Which is the primary focus of nursing care in the "family as context" approach? 1 The relationship among family members 2 The health and development of an individual 3 The ability of the family to meet its basic needs 4 The family's process of caregiving for a sick member

2

The nurse is teaching a class about nutrition to a group of adolescents. Taking into consideration the prevalence of overweight teenagers, which is the best recommendation? 1 "Join a gym." 2 "Drink fewer diet sodas." 3 "Decrease fast-food intake." 4 "Take a multivitamin daily."

Decrease fast-food intake

Which factor is associated with the aging process? Correct1 Slowing of responses 2 Change of personality 3 Loss of intelligence 4 Loss of long-term memor

1 Neurological responses are slowed because of reduced sensory-receptor sensitivity. Excluding pathological processes, the personality will be consistent with that of earlier years. There is no loss of intellectual ability unless there is a pathological problem. Short-term, not long-term, memory is reduced because of a shortened attention span, delayed transmission of information to the brain, and perceptual deficits.

At which age does the anterior fontanel of the skull close? 1 12 to 18 months 2 20 to 24 months 3 26 to 30 months 4 32 to 36 months

12 to 18 months

The nurse is performing an assessment of fine motor skills on an infant. Which actions would the nurse observe? Select all that apply. One, some, or all responses may be correct. 1 Crawling 2 Creeping 3 Sitting erect 4 Holding a rattle 5 Picking up objects 6 Holding a baby bottle

4,5,6

Which activity can be performed by infants aged 6 to 8 months? 1 Holding a pencil 2 Showing hand preference 3 Placing objects into containers 4 Transferring objects from hand to hand

Infants aged 6 to 8 months may be able to transfer objects from hand to hand. Infants aged 10 to 12 months may be able to hold a pencil. Infants aged 8 to 10 months may show a hand preference. Infants aged 10 to 12 months may be able to place objects into a container. STUDY TIP: A word of warning: do not expect to achieve the maximum benefits of this review tool by cramming a few days before the examination. It doesn't work! Instead, organize planned study sessions in an environment that you find relaxing, free of stress, and supportive of the learning process.

Which physiological changes should be noticed in an adolescent during puberty? Select all that apply. One, some, or all responses may be correct. 1 Increase in the respiratory rate 2 Increase in the number of neurons 3 Increase in number of neural connections 4 Decrease in the basal body temperature gradually 5 Increase in serum iron, hemoglobin, and hematocrit

3,4,5 During puberty, as a part of normal physiological growth, there is proliferation of support cells that nourish the neurons along with increase in number of neural connections in the brain. The basal body temperature decreases gradually and reaches adult value by 12 years of age. The size and strength of heart, blood volume, systolic blood pressure, serum iron levels, hemoglobin, and hematocrit values increase whereas heart rate decreases and reaches adult value. The diameter and length of the lungs increase, but respiratory rate decreases gradually to reach the adult value by adolescence. The growth of neurons does not increase but slows to a more gradual rate by adolescence.

The nurse recognizes which mental process is associated with deterioration that accompanies aging? 1 Judgment 2 Intelligence 3 Creative thinking 4 Short-term memory

4

Which stage of Piaget's theory of cognitive development would the nurse observe in a preschooler? 1 Sensorimotor 2 Preoperational 3 Formal operations 4 Concrete operations

The second stage of Piaget's theory of cognitive development is the preoperational stage. It is observed from 2 to 7 years. During this stage, the child may learn to think with the use of symbols and mental images. The first stage is the sensorimotor stage, observed from birth to 2 years. During this stage, the child learns about her- or himself and her or his environment through motor and reflex actions. The fourth stage is formal operations, characterized by a prevalence of egocentric thought. The concrete operations stage is stage 3, which signifies that the child is able to perform mental operations.

Which statement is accurate regarding erythropoietin? 1 Erythropoietin is released by the pancreas. 2 An erythropoietin deficiency causes diabetes. 3 An erythropoietin deficiency is associated with renal failure. 4 Erythropoietin is released only when there is adequate blood flow.

3 Erythropoietin is produced by the kidneys; its deficiency occurs in renal failure. Erythropoietin is released by the kidneys, not the pancreas. Erythropoietin deficiency causes anemia. Erythropoietin is secreted in response to hypoxia, which results in decreased oxygenated blood flow to the tissue

Which range of heart rate is acceptable for a preschooler? 1 60 to 100 2 80 to 110 3 75 to 100 4 90 to 140

80-110

Which clinical finding is associated with high-dose lead exposure? 1 Blindness 2 Hyperactivity 3 Hearing impairment 4 Mild intellectual deficit

Blindness could indicate that the client is suffering from encephalopathy as a result of high-dose exposure to lead. Hyperactivity, hearing impairment, and mild intellectual deficit are clinical signs of low-dose exposure to lead.

Which of these cultural groups adopts a combination of dietary, herbal, and other naturalistic therapies to prevent and treat illness? 1 East Asian 2 Hispanic 3 Asian Indian 4 Native American

Asian Indian

Which method would the nurse use to best elicit the Moro reflex in a full-term newborn? 1 Touching the infant's cheek 2 Striking the surface of the infant's crib suddenly 3 Allowing the infant's feet to touch the surface of the crib 4 Stroking the sole of the foot along the outer edge from the heel to the toe

Jarring the crib produces a startle response (Moro reflex); the legs and arms extend, and the fingers fan out, while the thumb and forefinger form a C. When the cheek is touched, the head turns toward the side that was touched; this is the rooting reflex. When the feet touch the crib surface the stepping reflex is elicited; one foot is placed before the other in a simulated walk with the weight on the toes. When the bottom of the foot is stroked along the outer edge of the sole from the heel to the toe, the toes flare out. This is the Babinski reflex, which is expected because of the newborn's immature nervous system. In an adult, this reflex is a sign of neurological damage.

According to Piaget's theory of cognitive development, which milestone would the nurse expect a 6-month-old infant to demonstrate? 1 Early traces of memory 2 Beginning sense of time 3 Repetitious reflex responses 4 Beginning of object permanence

The concept of object permanence begins to develop around 6 months of age. Early traces of memory and beginning sense of time occur at between 13 and 24 months. Repetitious reflex responses occur during the first several months of life. These diminish as the newborn grows.

Which theories are relevant only to development in adults? Select all that apply. One, some, or all responses may be correct. 1 Piaget's theory 2 Erikson's theory 3 Kohlberg's theory 4 Stage-Crisis theory 5 Life Span approach

4, 5

Which are examples of health promotion activities? Select all that apply. One, some, or all responses may be correct. 1 Good nutrition 2 Regular exercise 3 Physical awareness 4 Immunization against measles 5 Education about stress management

Health promotion activities enable clients to enhance or maintain their current health levels. Good nutrition and regular exercise are examples of such activities. Immunization against measles is an example of an illness prevention activity. Education about stress management and physical awareness are examples of a wellness education activity.

According to Erikson's psychosocial stages of development, which developmental conflict is a college student attempting to resolve as he struggles with indecision about an academic major? 1 Initiative versus guilt 2 Integrity versus despair 3 Industry versus inferiority 4 Identity versus role confusion

The client is demonstrating a search for self and has not resolved the developmental conflict of adolescence, identity versus role confusion. Initiative versus guilt is the developmental conflict of early childhood. Integrity versus despair is the developmental conflict of old age. Industry versus inferiority is the developmental conflict of middle childhood. Test-Taking Tip: Answer every question. A question without an answer is always a wrong answer, so go ahead and guess.

A parent is worried about the infant's excessive dependence on nonnutritive sucking. Which intervention will help decrease this dependence? 1 Prolonging the feeding time 2 Using infant formulas frequently 3 Offering pacifier as soon as the crying begins 4 Wrapping the infant snugly most of the time

1 An infant's dependence on nonnutritive sucking can be reduced by prolonging the feeding time, so that the sucking pleasure is increased. Using infant formulas will not help prevent nonnutritive sucking, because the child needs the pleasure of sucking. Using a pacifier as soon as the crying begins increases the child's dependence on nonnutritive sucking, because it reinforces a pattern of distress-relief. Wrapping the infant snugly most of the time may not be possible, because it may cause the infant to feel uncomfortable.

The nurse is differentiating between cephalhematoma and caput succedaneum. Which finding is unique to caput succedaneum? 1 Edema that crosses the suture line 2 Scalp tenderness over the affected area 3 Edema that increases during the first day 4 Scalp over the area becomes ecchymosed

1.

A 55-year-old client reports cessation of menstrual periods for a year. Which term describes the client's condition? 1 Menarche 2 Menopause 3 Dyspareunia 4 Menorrhagia

2. Cessation of menstruation is called menopause; this is an aging process and occurs due to functional decline of the ovaries. The first episode of menstrual bleeding is called menarche. Dyspareunia refers to painful sexual intercourse. Menorrhagia is excessive vaginal bleeding.

Which hormone aids in regulating intestinal calcium and phosphorous absorption? 1 Insulin 2 Thyroxine 3 Glucocorticoids 4 Parathyroid hormone

3 Adrenal glucocorticoids aid in regulating intestinal calcium and phosphorous absorption by increasing or decreasing protein metabolism. Insulin acts together with growth hormone to build and maintain healthy bone tissue. Thyroxine increases the rate of protein synthesis in all types of tissues. Parathyroid hormone secretion increases in response to decreased serum calcium concentration and stimulates the bones to promote osteoclastic activity.

Which stage of Kohlberg's theory of moral development defines "right" by the decision of the conscience? 1 Social contract orientation 2 Society-maintaining orientation 3 Instrumental relativist orientation 4 Universal ethical principle orientation

4

Which identified clinical manifestation is a sign of allergic rhinitis? 1 Presence of high-grade fever 2 Reduced breathing through the mouth 3 Presence of pinkish nasal discharge 4 Reduced transillumination on the skin over the sinuses

4 Reduced transillumination on the skin overlying the sinuses indicates allergic rhinitis. This effect is caused by the sinuses becoming inflamed and blocked with thick mucoid secretions. Generally, fever does not accompany allergic rhinitis unless the client develops a secondary infection. In allergic rhinitis, the client is unable to breathe through the nose because it gets stuffy and blocked. Instead, the client will resort to mouth breathing. Clients with allergic rhinitis will have clear or white nasal discharge.

At which age is a toddler physiologically and psychologically prepared for toilet training? 1 13 months 2 16 months 3 19 months Correct 4 22 months

4 The 22-month-old toddler is both physiologically and psychologically prepared for toilet training. The 13-month-old, 16-month old, and 19-month old are not yet physiologically and psychologically prepared for toilet training.

Which preventive and primary care service provided by a community health center is most expensive? 1 Running errands 2 Health education 3 Disease management 4 Routine physical examinations

Disease management is the most expensive service provided by community health centers. Running errands is relatively inexpensive, because the cost is the merely the cost of transportation. Health education and routine physical examinations are inexpensive and can usually stop complications of diseases, which prevents from having to "manage" diseases, leading to costly and expensive treatment.

The school nurse would teach the students that the ovum is no longer viable at which time interval after ovulation? 1 12 hours 2 24 hours 3 48 hours 4 72 hours

The ovum is viable for about 24 hours after ovulation; if not fertilized before this time, it degenerates. For this reason, 12 hours, 48 hours, and 72 hours are all incorrect answers.

The nurse understands which vaccine may cause intussusception in children? 1 Rotavirus 2 Hepatitis 3 Measles, mumps, and rubella 4 Diphtheria, tetanus, and pertussis

Rotavirus vaccines very rarely cause intussusception, a form of bowel obstruction in which the bowel telescopes in on itself. Hepatitis vaccines can cause anaphylactic reactions. The measles, mumps, and rubella vaccine may cause thrombocytopenia. The diphtheria, tetanus, and pertussis vaccine carries a small risk of causing acute encephalopathy, convulsions, and a shock-like state.

Which domain of the nursing intervention phase includes electrolyte and acid-base management? 1 Domain 1 2 Domain 2 3 Domain 3 4 Domain 4

Domain 2 Domain 2 of the nursing intervention phase includes electrolyte and acid-base management. Domain 2, or the physiological complex, includes care that supports homeostatic regulation. Domain 1 includes care that supports physical functioning. Domain 3 incorporates care that supports psychosocial functioning and facilitates lifestyle changes. Domain 4 involves care that supports protection against harm.

Which domain of the Nursing Interventions Classification (NIC) taxonomy includes care that supports homeostatic regulation? 1 Domain 1 2 Domain 2 3 Domain 3 4 Domain 4

Domain 2 of the NIC taxonomy includes care that supports homeostatic regulation. Domain 1 includes care that supports physical functioning. Domain 3 includes care that supports psychosocial functioning and facilitates life style changes. Domain 4 includes care that supports protection against harm.

The nurse knows that jaundice first becomes visible in a newborn when serum bilirubin reaches which level? 1 1 to 3 mg/dL (17.1-51.3 µmol/L) 2 2 to 4 mg/dL (34.2-68.4 µmol/L) 3 5 to 7 mg/dL (85.5-119.7 µmol/L) 4 8 to 10 mg/dL (136.8-171 µmol/L)

Jaundice in a newborn first becomes visible when the serum bilirubin level reaches 5 to 7 mg/dL (85.5-119.7 µmol/L). Jaundice will not be visible at a serum bilirubin level of less than 5 mg/dL (85.5 µmol/L).

Which dietary modifications help improve the nutritional status of a client with acquired immunodeficiency syndrome (AIDS)? 1 Refraining from consuming fatty foods 2 Refraining from consuming frequent meals 3 Refraining from consuming high-calorie foods 4 Refraining from consuming high-protein foods

Many clients with AIDS become intolerant to fat due to the disease and the antiretroviral medications. The client should be instructed to refrain from consuming fatty foods. The client should be encouraged to eat small and frequent meals to improve nutritional status. High-calorie and high-protein foods are beneficial to clients with AIDS because they provide energy and build immunity.

Which is the most important nursing intervention when working with an older adult client? 1 Encouraging frequent naps 2 Strengthening the concept of ageism 3 Reinforcing the client's strengths and promoting reminiscing 4 Teaching the client to increase calories and focusing on a high-carbohydrate diet

Reinforcing strengths promotes self-esteem; reminiscing is a therapeutic tool that provides a life review that assists adaptation and helps achieve the task of integrity associated with older adulthood. Frequent naps may interfere with adequate sleep at night. Reinforcing ageism may enhance devaluation of the older adult. A well-balanced diet that includes protein and fiber should be encouraged; increasing calories may cause obesity.

Which is the average annual increase in the height of preschoolers? 1 2 inches (5 cm) 2 2 to 8 inches (5-20 cm) 3 4 to 8 inches (10-30 cm) 4 2.5 to 3 inches (6.2-7.5 cm)

The average increase in the height of preschoolers per year is 2.5 to 3 inches (6.2-7.5 cm). The average increase in the height of school-aged children per year is 2 inches (5 cm). The average increase in the height of adolescent girls is 2 to 8 inches (5-20 cm). The average increase in the height of adolescent boys is 4 to 8 inches (10-30 cm).

The nurse is educating parents about the changes to expect when their child enters toddlerhood. Which information would the nurse include? 1 The toddler's body appears slender. 2 The toddler has a protruded abdomen. 3 The toddler's feet are severely everted. 4 The toddler has inconspicuous cervical curves.

The nurse explains to the parents that at the start of toddlerhood, the abdomen of the child will be protruded. The bodies of toddlers start appearing slender by the age of 3 years, not in the beginning of toddlerhood. As the child walks, the legs and feet are usually far apart, and the feet are slightly everted, not severely everted. Toward the end of toddlerhood, curves in the cervical and lumbar vertebrae are accentuated. STUDY TIP: Remember that intelligence plays a vital role in your ability to learn. However, being smart involves more than just intelligence. Being practical and applying common sense are also part of the learning experience.

Which is the recommended protein intake for preschoolers? 1 1 g/day 2 13 g/day 3 300 mg/day 4 700 mg/day

The recommended protein intake for preschoolers is 13 to 19 g/day. The recommended protein intake for preschoolers is not 1 g/day. The recommended cholesterol consumption for children over the age of 2 years should be less than 300 mg/day, whereas the recommended daily allowance for calcium for children 1 to 3 years old is 700 mg.

Which stage of Kohlberg's theory can be seen in an individual seeking to modify a law if it is not fair to a particular group? 1 Social contract orientation 2 Society-maintaining orientation 3 Instrument relativist orientation 4 Universal ethical principle orientation

The universal ethical principle orientation stage is associated with a person who wants to modify a law if it does not seem just. According to the social contract orientation stage, a person tends to follow a law even if it is not fair. During the society-maintaining stage, an individual shows concerns for his or her society and makes decisions in accordance to his or her society. During the instrument relativist orientation stage, a child recognizes that there is more than 1 correct view. Test-Taking Tip: After you have eliminated 1 or more choices, you may discover that 2 of the options are very similar. This can be very helpful because it may mean that 1 of these look-alike answers is the best choice and the other is a very good distractor. Test both of these options against the stem. Ask yourself which one completes the incomplete statement grammatically and which one answers the question more fully and completely. The option that best completes or answers the stem is the one you should choose. Here, too, pause for a few seconds, give your brain time to reflect, and recall may occur.

Which parent education would the nurse provide the parents of a 6-month-old about how to introduce their infant to pureed foods? 1 "Introduce 1 food at a time every 4 to 7 days." 2 "Mix the pureed food with the formula 2 or 3 times a day." 3 "Try to maintain the formula intake regardless of solid food intake." 4 "Offer pureed foods by spoon after the bottle of formula is finished.

1

An 80-year-old client is admitted to the hospital with severe dehydration. The client's daughter asks the nurse how her mother could have become dehydrated. Which response by the nurse is correct? 1 "The body's fluid needs decrease with age because of tissue changes." 2 "Access to fluid may be insufficient to meet the daily needs of the older adult." 3 "Memory declines with age, and the older adult may forget to ingest adequate amounts of fluid." 4 "The thirst reflex diminishes with age, and the recognition of the need for fluid is decreased."

"The thirst reflex diminishes with age, and the recognition of the need for fluid is decreased." For reasons that are still unclear, the thirst reflex diminishes with age, and this may lead to a concomitant decline in fluid intake. There are no data to support the statement "The body's fluid needs decrease with age because of tissue changes." The statement "Access to fluid may be insufficient to meet the daily needs of the older adult" is not true for an alert person who is able to perform the activities of daily living. Research does not support progressive memory loss in normal aging as a contributor to decreased fluid intake. STUDY TIP: Begin studying by setting goals. Make sure they are realistic. A goal of scoring 100% on all exams is not realistic, but scoring an 85% may be a better goal.

According to Erikson's psychosocial stages of development, mastery of which task increases a child's ability to cope with separation or pending separation from significant others? 1 Trust 2 Identity 3 Initiative 4 Autonomy

1 Trust

Which education would the nurse provide the parents of a 6-week-old immunocompromised infant about why their baby is still so healthy? 1 Exposure to pathogens during this time can be limited. 2 Some antibodies are produced by the infant's colonic bacteria. 3 Bottle feeding with soy formula has boosted the immune system. 4 Antibodies are passively received from the mother through the placenta and breast milk

4

Which type of joint is present in the client's shoulders? 1 Pivotal 2 Saddle 3 Condyloid 4 Spheroidal

4

The nurse is instructing a group of clients in the community about food preparation. Which statement indicates that a client is at an increased risk for contracting botulism? 1 "I do not usually brush my teeth after I finish eating a meal." 2 "Sometimes I eat grapes before I have a chance to wash them." 3 "Utensils that I use to cut up chicken are put into the dishwasher." 4 "I save money when I buy the slightly damaged cans of vegetables."

4.

An auditory screening reveals that a child has mild hearing loss. Which statement would the nurse use to explain this degree of hearing loss? 1 "A severe hearing deficit may develop." 2 "It will not interfere with progress in school." 3 "An immediate follow-up visit is not necessary." 4 "Speech therapy and hearing aids may be required."

4. A mild degree of hearing loss causes the child to miss 25% to 40% of conversations; it may result in speech deficits and interfere with the child's educational progress if it is not corrected. Hearing aids usually help improve function. There is no evidence that this child's hearing loss is progressive. The significance of the hearing loss requires further analysis and intervention.

In which settings would the nurse prepare to administer developmental assessment for pediatric clients? Select all that apply. One, some, or all responses may be correct. 1 Home 2 School 3 Hospital 4 Daycare center 5 Assisted living center

ALL EXCEPT ASSISTED LIVING CENTER

According to Kohlberg's theory, which stage comes before the society-maintaining orientation stage? 1 Social contract orientation 2 Good boy-nice girl orientation 3 Instrumental relativist orientation 4 Punishment and obedience orientation

According to Kohlberg's theory, the good boy-nice girl orientation phase (stage 3) occurs before the society-maintaining orientation phase (stage 4). Social contract orientation is the fifth stage. Instrumental relativist orientation is the second stage.

Which cognitive developmental stage would the nurse expect for a 3-year-old child? 1 Intuitive 2 Abstract 3 Concrete 4 Preconceptual

According to Piaget, at approximately 2 years of age the toddler enters the preconceptual phase of cognitive thought, which lasts, at most, until about 4 years of age; the preconceptual phase is a subdivision of the preoperational stage, which lasts from 2 years to 7 years of age. Four-year-old children are in the stage of intuitive thought, which gives rise to imaginative play. Abstract thought is developed during the adolescent ages of 15 to 20 years. Concrete operational thought occurs in school-age children when they perform actions mentally rather than through behavior, as in the earlier years.

Which information about nausea and vomiting in the first trimester would the nurse provide to the pregnant client? 1 It is always present during early pregnancy. 2 It will disappear when lightening occurs. 3 It is a common response to an unwanted pregnancy. 4 It may be related to an increased human chorionic gonadotropin level.

An increased level of human chorionic gonadotropin, or hCG, may cause nausea and vomiting, but the exact reason is unknown. Some pregnant women do not experience nausea and vomiting. Lightening occurs at the end of the third trimester; nausea and vomiting usually cease at the end of the first trimester. Nausea and vomiting are unrelated to whether a pregnancy is desired or unwanted.

The nurse is conducting a client interview. Which response by the nurse is an example of back channeling? 1 "All right, go on... " 2 "What else is bothering you?" 3 "Tell me what brought you here." 4 "How would you rate your pain on a scale of 0 to 10?"

Back channeling involves the use of active listening prompts such as "Go on... ," "all right," and "uh-huh." Such prompts encourage the client to complete the full story. The nurse uses probing by asking the client, "What else is bothering you?" Such open-ended questions help obtain more information until the client has nothing more to say. The statement, "Tell me what brought you here" is an open-ended statement that allows the client to explain his or her health concerns in his or her own words. Closed-ended questions such as, "How would you rate your pain on a scale of 0 to 10?" are used to obtain a definite answer. The client answers by stating a number to describe the severity of pain.

Which nursing action is most accurate when assessing the chest circumference of a newborn? 1 Measuring during expiration only 2 Taking 3 measurements and recording the average 3 Measuring during inspiration and plotting this data on the growth chart 4 Placing the measuring tape around the rib cage at the nipple line

Placing the measuring tape around the rib cage at the nipple line

Which hormone is crucial in maintaining the implanted ovum at its site? 1 Inhibin 2 Estrogen 3 Progesterone 4 Testosterone

Progesterone is necessary to maintain an implanted egg. Inhibin regulates the release of follicle-stimulating hormone and gonadotropin-releasing hormone. Estrogen plays a vital role in the development and maintenance of secondary sexual characteristics. Testosterone is important for bone strength and development of muscle mass.

Which education would the nurse provide parents about the side effects of the Haemophilus influenzae (Hib) vaccine? 1 Lethargy 2 Urticaria Incorrect3 Generalized rash Correct4 Low-grade fever TheHib vaccine may cause a low-grade fever. Lethargy is not expected. Urticaria is more likely to occur with the tetanus and pertussis vaccines. There may be a mild reaction at the injection site, but a generalized rash is not expected.

The Hib vaccine may cause a low-grade fever. Lethargy is not expected. Urticaria is more likely to occur with the tetanus and pertussis vaccines. There may be a mild reaction at the injection site, but a generalized rash is not expected.

Which is the best way for a school nurse to determine a young child's readiness to learn? 1 By assessing the child's vision and hearing 2 By making a referral for psychological and intelligence testing 3 By ensuring that the teacher has an understanding of the child's needs 4 By confirming that the parents understand the importance of homework

Vision and hearing are vital to the child's ability to learn because they provide pathways for stimuli to reach and be interpreted by the brain. Neither psychological nor intelligence testing is necessary for all children. Although important in the learning process, ensuring that the teacher understands the child's needs and confirming that the parents understand the importance of homework are not related to a child's readiness to learn. STUDY TIP: Establish your study priorities and the goals by which to achieve these priorities. Write them out and review the goals during each of your study periods to ensure focused preparation efforts.

The parents of an adolescent treated for allergies privately tell the nurse that they suspect that their child is a hypochondriac. Which therapeutic response would the nurse provide? 1 Discussing developmental behaviors of adolescents 2 Explaining potentially serious complications of allergies 3 Discussing some of the underlying causes of hypochondriasis 4 Explaining that the parents may be transferring their fears to their adolescent

1 Discussing developmental behaviors of adolescents

The nurse is helping a client maintain and regain health, manage his or her disease and symptoms, and attain a maximal level of function and independence through the healing process. Which role is the nurse playing? 1 Manager 2 Advocate 3 Caregiver 4 Communicator

As a caregiver, the nurse helps clients maintain and regain health, manage diseases and symptoms, and attain a maximal level of function and independence through the healing process. As a manager, the nurse coordinates the activities of members of the nursing staff in delivering nursing care and has personnel, policy, and budgetary responsibility for a specific nursing unit or agency. As a client's advocate, the nurse protects the client's human and legal rights and provides assistance in asserting these rights if the need arises. As a communicator, the nurse learns about a client's strengths and weaknesses and his or her needs through effective communication.

Which is the purpose of block and parish nursing? 1 To provide services to older clients 2 To promote health throughout a school curriculum 3 To provide nursing services with a focus on health promotion and education 4 To deliver primary care to a client population living in a community

In block and parish nursing, nurses living within a neighborhood provide services to older clients or those unable to leave their homes. Health promotion throughout a school curriculum is provided by school health. Nurse-managed clinics provide nursing services with a focus on health promotion and education, chronic disease assessment management, and support for self-care and caregivers. Community health centers are outpatient clinics that provide primary care to a client population living in a community.

A 26-year-old G1 P0 client at 29 weeks' gestation has gained 8 lb (3.6 kg) in 2 weeks; her blood pressure has increased from 128/74 Hg to 150/90 mm Hg; and she has developed 1+ proteinuria on urine dipstick. Which condition do these signs suggest? 1 Mild preeclampsia 2 Severe preeclampsia 3 Chronic hypertension 4 Gestational hypertension

Mild preeclampsia "Preeclampsia is hypertension that develops after 20 weeks' gestation in a previously normotensive woman. With mild preeclampsia the systolic blood pressure is below 160 mm Hg and diastolic BP is below 110 mm Hg. Proteinuria is present, but there is no evidence of organ dysfunction. Severe preeclampsia is a systolic blood pressure of greater than 160 mm Hg or diastolic blood pressure of at least 110 mm Hg and proteinuria of 5 g or more per 24-hour specimen. Chronic hypertension is hypertension that is present before the pregnancy or diagnosed before 20 weeks' gestation. Gestational hypertension is the onset of hypertension during pregnancy without other signs or symptoms of preeclampsia and without preexisting hypertension. Test-Taking Tip: Read carefully and answer the question asked; pay attention to specific details in the question."

Which substance is released in response to low serum levels of calcium? 1 Renin 2 Erythropoietin 3 Parathyroid hormone 4 Atrial natriuretic peptide

3 Parathyroid Hormone

Which of these statements about pregnancy in the adolescent population are true? Select all that apply. One, some, or all responses may be correct. 1 Pregnant adolescents often seek out less prenatal care. 2 Infants of teen mothers are at risk of delivering babies late. 3 Adolescent mothers need competent daycare for their infants. 4 Infants of adolescent mothers are at increased risk for prematurity. 5 Fetuses of adolescent mothers are at higher risk for chromosomal defects

1 Pregnant adolescents often seek out less prenatal care. 3 Adolescent mothers need competent daycare for their infants. 4 Infants of adolescent mothers are at increased risk for prematurity.

According to Erikson's psychosocial stages of development, which outcome will occur if an individual fails to master the maturational crisis of adolescence? 1 Role confusion 2 Feelings of inferiority 3 Interpersonal isolation 4 Difficulties with intimacy

1. According to Erikson, adolescents are struggling to find out who they are; this is identity versus role confusion. If an adolescent is unsuccessful in this task, role confusion may result. Industry versus inferiority is the developmental struggle of the school-aged child. This reflects part of the struggle for autonomy. Adolescents tend to be group oriented, not isolated. Developing intimacy is the developmental task for the young adult. STUDY TIP: Becoming a nursing student automatically increases stress levels because of the complexity of the information to be learned and applied and because of new constraints on time. One way to decrease stress associated with school is to become very organized so that assignment deadlines or tests do not come as sudden surprises. By following a consistent plan for studying and completing assignments, you can stay on top of requirements and thereby prevent added stress.

Which synovial joint movement is described as turning the sole away from the midline of the body? 1 Pronation 2 Eversion 3 Adduction 4 Supination

2

Which activity by the community nurse is an illness prevention strategy? 1 Encouraging the client to exercise daily 2 Arranging an immunization program for chickenpox 3 Teaching the community about stress management 4 Teaching the client about maintaining a nutritious diet

2 An illness prevention program protects people from actual or potential threats to health. A chickenpox immunization program is an illness prevention program. It motivates the community to prevent a decline in health or functional levels. A health promotion program encourages the client to maintain his or her present levels of health. The nurse promotes the health of the client by encouraging the client to exercise daily. Wellness education teaches people how to care for themselves in a healthy manner. The nurse provides wellness education by teaching about stress management. The nurse promotes the health of the client by teaching the client to maintain a nutritious diet.

According to Erikson's theory of psychosocial development, which task does the nurse recognize as the chief psychosocial task of preschoolers? 1 Control over bodily functions 2 Development of a sense of initiative 3 Toleration of separation from parents 4 Ability to interact with others in a less egocentric manner

2 Development of a sense of initiative

Which term is used for the tip of a pyramid in the kidney? 1 Calyx 2 Papilla 3 Renal pelvis 4 Renal column

2 Pyramids are components of renal medulla, and the tip of each pyramid is called a papilla. A calyx is a structure that collects the urine at the end of each pyramid. The renal calices join together to form the renal pelvis. A renal column is a cortical tissue that separates the pyramids.

A chronically ill, older client lives with their daughter. The client reports the daughter, who has three small children, seems run-down, coughs a lot, and sleeps all the time. Which statement supports the need for the nurse to pursue the daughter's condition as a potential case finding? 1 Tuberculosis has been rising dramatically in the general population. 2 Older adults with chronic illness are more susceptible to tuberculosis. 3 There is a high incidence of tuberculosis in children less than 12 years of age. 4 Death from tuberculosis has been decreasing in the United States and Canada.

2 The client's chronic illness and older age increase vulnerability; the daughter's condition should be explored in greater detail. Tuberculosis is only one of many potential causes of the daughter's clinical condition. Children who have not yet reached puberty and adolescence have the lowest incidence of tuberculosis. Morbidity and mortality resulting from tuberculosis are increasing, not decreasing.

The nurse observes that an 18-month-old toddler is crawling up stairs but needs assistance when climbing the stairs upright. Which would this indicate to the nurse? 1 Presence of talipes equinovarus 2 Presence of neurological damage 3 Expected behavior in a toddler of this age 4 Existence of developmental dysplasia of the hip

3 It is not until 2 years of age that toddlers are able to use their feet to walk up stairs instead of crawling. Talipes equinovarus is identified with the use of other criteria. At 18 months of age the inability of the toddler to use the feet to go up stairs is not a problem; it is expected and does not indicate neurological damage. Developmental dysplasia of the hip is identified with the use of other criteria.

Which client statement indicates understanding of teaching about a nonstress test? 1 "I'll need to have an intravenous (IV) line so the medication can be injected before the test." 2 "My baby may get very restless after I have this test." 3 "I hope this test doesn't cause my labor to start too early." 4 "If the heart reacts well, my baby should do OK when I give birth.

4 The nonstress test is used to evaluate the response of the fetus to movement and activity. A reactive test indicates that the fetus is healthy. No injections of any kind are used during a nonstress test; it involves only the use of a fetal monitor to record the fetal heart rate during periods of activity. The nonstress test will not influence the activity of the fetus because no exogenous stimulus is used. Early labor is unlikely because the nonstress test is noninvasive. Test-Taking Tip: Never leave a question unanswered. Even if answering is no more than an educated guess on your part, go ahead and mark an answer. You might be right, but if you leave it blank, you will certainly be wrong and lose precious points.

Which statement is true for collaborative problems in a client? 1 They are the identification of a disease condition. 2 They include problems treated primarily by nurses. 3 They are identified by the primary health care provider. 4 They are identified by the nurse during the nursing diagnosis stage.

4 They are identified by the nurse during the nursing diagnosis stage. The nurse assesses the client to gather information for reaching diagnostic conclusions. Collaborative problems are identified by the nurse during this process. If the client's health problem requires treatment by other disciplines, such as medical or physical therapy, the client has a collaborative problem. A medical diagnosis is the identification of a disease condition. Problems that require treatment by the nurse are referred to as nursing diagnoses. A medical diagnosis is identified by the primary health care provider based on the results of diagnostic tests.

According to current statistics, what percent of adolescents try marijuana by the end of high school? Record your answer using a whole number. ________

49

Which intervention would the nurse do before formulating a teaching plan for a child who is to undergo ostomy surgery? 1 Assess the child's developmental level. 2 Determine the family's comprehension of the procedure. 3 Provide a list of available community resources to the family. 4 Collaborate with the school in ensuring the child's smooth return

Assess the child's developmental level Teaching methods in each age group vary with the child's cognitive ability; individual differences depend on a variety of factors, including both intelligence and emotional status. Also, the child's readiness to learn must be assessed before a teaching plan that will support success can be developed. Although determining the comprehension of the treatment by family members is important, it does not focus on the learning needs of the child, which is the priority. Providing a list of community resources will be important later, but not initially. Working with the school's staff will be important later, but not initially.

Which is a characteristic of the glands that secrete a thick substance in response to emotional stimulation and become odoriferous because of bacterial action? 1 Highly active in childhood 2 Absent around the umbilicus 3 Widely distributed throughout the body 4 Grow in conjunction with axillary hair follicles

Grow in conjunction with axillary hair follicles The apocrine sweat glands secrete a thick substance in response to emotional stimulation and become odoriferous because of bacterial action. These glands grow in conjunction with hair follicles around the axillae. The apocrine glands are inactive during childhood and reach their secretory potential at the time of puberty. The apocrine glands are situated around the umbilicus. They have limited distribution and are found only around the axillae, areolae, external auditory canal, and anal and genital regions. Eccrine sweat glands, not the apocrine glands, have wide distribution throughout the body.

Which information would the nurse include in the discharge teaching of a postpartum client? Correct1 The prenatal Kegel tightening exercises should be continued. 2 A bowel movement may not occur for up to a week after the birth. 3 The episiotomy sutures will be removed at the first postpartum visit. 4 A postpartum checkup should be scheduled as soon as menses returns.

Kegel exercises may be resumed immediately and should be done for the rest of the client's life because they help strengthen muscles needed for urinary continence and may enhance sexual intercourse. Episiotomy sutures do not have to be removed. Bowel movements should spontaneously return in 2 to 3 days after the client gives birth; a delay of bowel movements promotes constipation, perineal discomfort, and trauma. The usual postpartum examination is 6 weeks after birth; the menses may return earlier or later than this and should not be a factor when the client is scheduling a postpartum examination. Test-Taking Tip: Pace yourself when taking practice quizzes. Because most nursing exams have specified time limits, you should pace yourself during the practice testing period accordingly. It is helpful to estimate the time that can be spent on each item and still complete the examination in the allotted time. You can obtain this figure by dividing the testing time by the number of items on the test. For example, a 1-hour (60-minute) testing period with 50 items averages 1.2 minutes per question. The NCLEX exam is not a timed test. Both the number of questions and the time to complete the test vary according to each candidate's performance. However, if the test-taker uses the maximum of 5 hours to answer the maximum of 265 questions, each question equals 1.3 minutes.

On a routine prenatal visit, which is the sign or symptom that a healthy primigravida at 20 weeks' gestation will most likely report for the first time? 1 Quickening 2 Palpitations 3 Pedal edema 4 Vaginal spotting

The recognition of fetal movement or quickening commonly occurs in primigravidas at 18 to 20 weeks' gestation; it is felt about 2 weeks earlier in multigravidas. Palpitations should not occur in the healthy primigravidas. Pedal edema may occur at the end of the pregnancy as the gravid uterus presses on the femoral arteries, impeding circulation. Immediate follow-up care is required when it occurs this early in the pregnancy. Vaginal spotting is abnormal and requires immediate follow-up care.

After a prolonged period in a regional hospital far from home to which the parents were unable to travel, an 18-month-old toddler becomes depressed, withdrawn, and apathetic. Eventually the toddler begins playing with toys and relating to others, even strangers. When the parents visit, the child ignores them. The parents tell the nurse that their child has forgotten them. How would the nurse explain the child's behavior? 1 The nurse suggests that they may be right and that their child will have to get to know them again. 2 This indicates approval of the staff and the child's understanding that they will not inflict bodily harm. 3 It reflects acceptance of the hospitalization and the experience will enhance their child's maturation. Correct4 This is typical behavior in toddlers who are separated from their parents for prolonged periods, and indicates that their child will need special attention from them.

The child has progressed to the third phase of separation anxiety, detachment or denial, in which there is a resignation to the loss of the parents and a superficial appearance of adjustment to the environment. Eighteen-month-old children do not forget their parents. The child's behavior indicates resignation, not acceptance or understanding of the situation. Toddlers who have parental support usually view staff members as unfamiliar, frightening, and often threatening. Acceptance of the hospitalization is often the mistaken interpretation of such behavior.

During the assessment of a client in labor, the cervix is determined to be dilated 4 cm. Which stage of labor would the nurse record? 1 First 2 Second 3 Prodromal 4 Transitional

The first stage of labor is from zero cervical dilation to full cervical dilation (10 cm). The second stage is from full cervical dilation to delivery. The prodromal stage is before cervical dilation begins. The transitional phase is the first stage of labor, from 8 cm of dilation to 10 cm of dilation.The first stage of labor is from zero cervical dilation to full cervical dilation (10 cm). The second stage is from full cervical dilation to delivery. The prodromal stage is before cervical dilation begins. The transitional phase is the first stage of labor, from 8 cm of dilation to 10 cm of dilation.

The nurse is preparing to teach a community health program for senior citizens. Which physical findings would the nurse include that are typical in older adults? 1 Increased skin elasticity and an increase in testosterone production 2 Impaired fat digestion and an increase in pepsin production 3 Increased blood pressure and decreased cardiac output 4 An increase in body warmth and some swallowing difficulties

With aging, narrowing of the arteries causes some increase in the systolic and diastolic blood pressures. Decreases occur in diastolic pressure, diastolic filling, and beta-adrenergic stimulation; increases occur in arterial pressure, systolic pressure, wave velocity, and left ventricular end diastolic pressure. Decreased cardiac output and cardiac reserve decrease the older adult's response to stress. Changes in libido may occur. Testosterone appears to influence the frequency of nocturnal erections; however, low testosterone levels do not affect erections produced by erotic stimuli. There is a loss of skin elasticity. By the age of 60, gastric secretions decrease 70% to 80% of those of the average adult. A decrease in pepsin may hinder protein digestion. There may be a decrease in subcutaneous fat and decreasing body warmth. Some swallowing difficulties occur because older people are susceptible to fluid loss and electrolyte imbalance. This results from decreased thirst sensation, difficulty swallowing, chronic disease, reduced kidney function, diminished cognition, or adverse medication reactions.

During testing of the neurological reflexes of an infant, which reflex would the nurse expect to appear at 3 months and persist until 24 to 36 months of age? 1 Neck righting 2 Body righting 3 Otolith righting 4 Labyrinth righting

1. While the infant is supine, if the head is turned to one side, the shoulder, trunk, and finally the pelvis will turn toward that side. This reflex appears at 3 months, and persists until 24 to 36 months of age. Body righting is a modification of the neck-righting reflex in which turning hips and shoulders to one side causes all other body parts to follow; it appears at 6 months and persists until 24 to 36 months of age. When the body of an erect infant is tilted, the head is returned to an upright, erect position; this is known as otolith righting, which appears at 7 to 12 months of age, and persists indefinitely. When an infant in prone or supine position is able to raise his or her head, it is known as labyrinth righting. It appears at 2 months and is strongest at 10 months of age.

According to Erikson's psychosocial stages of development, which developmental conflict affects a 4-year-old child? 1 Initiative versus guilt 2 Industry versus inferiority 3 Trust versus mistrust 4 Autonomy versus shame

1. Initiative versus guilt is the developmental conflict that faces the preschool child; the child will feel guilty if initiative is stifled by others. Industry versus inferiority is the conflict of the school-aged child. Trust versus mistrust is the conflict of infants aged 0 to 18 months. Autonomy versus shame is the conflict for children aged 18 months to 3 years. STUDY TIP: Determine whether you are a "lark" or an "owl." Larks, day people, do best getting up early and studying during daylight hours. Owls, night people, are more alert after dark and can remain up late at night studying, catching up on needed sleep during daylight hours. It is better to work with natural biorhythms than to try to conform to an arbitrary schedule. You will absorb material more quickly and retain it better if you use your most alert periods of each day for study. Of course, it is necessary to work around class and clinical schedules. Owls should attempt to register in afternoon or evening lectures and clinical sections; larks do better with morning lectures and day clinical sections.

Which stage is a part of postconventional reasoning? 1 Social contract orientation 2 Society-maintaining orientation 3 Instrumental relativist orientation 4 Punishment and obedience orientation

1. The social contract orientation stage is a part of postconventional reasoning. Society-maintaining orientation is part of the conventional/role conformity reasoning level. The instrumental relativist orientation stage and the punishment and obedience orientation stage are parts of the preconventional reasoning level. Test-Taking Tip: Have confidence in your initial response to an item because it more than likely is the correct answer.

Which safeguards would the school nurse teach parents to assess for before allowing school-age clients to participate in athletic programs? Select all that apply. One, some, or all responses may be correct. 1 A life-long enjoyment of fitness 2 The use of appropriate equipment 3 The development of basic motor skills 4 A physical examination every year 5 Participation in warm-up exercises before physical activity

2,4,5 Safeguards before participation in athletic programs include a physical examination every year, the use of appropriate equipment, and participating in warm-up exercise before physical activity. A life-long enjoyment of fitness and the development of basic motor skills are goals related to the participation in athletic programs, not safeguards.

Under which type of health care services would the student nurse include sports medicine? 1 Primary care 2 Tertiary care 3 Preventive care 4 Restorative care

4 Restorative care

Which fine motor developmental milestone emerges in 4-year-olds? 1 Uses scissors well 2 Builds a tower of 9 to 10 cubes 3 Can lace shoes but may not be able to tie the bow 4 Cannot draw a stick figure but may make a circle with facial features

A 4 year old can lace shoes but may not be able to tie the bow. A 5 year old uses scissors well. A 3 year old can build a tower of 9 to 10 cubes. Four year olds are usually unable to draw a stick figure, but they may make a circle with facial features.

Which is a primary focus of teaching for a pregnant adolescent at her first prenatal clinic visit? 1 Instructing her about the care of an infant 2 Informing her of the benefits of breast-feeding 3 Advising her to watch for danger signs of preeclampsia 4 Encouraging her to continue regularly scheduled prenatal care

It is not uncommon for adolescents to avoid prenatal care; many do not recognize the deleterious effect that lack of prenatal care can have on them and their infants. Instruction in the care of an infant can be done in the later part of pregnancy and reinforced during the postpartum period. Informing the client of the benefits of breast-feeding should come later in pregnancy but not before the client's feelings about breast-feeding have been ascertained. Advising the client to watch for danger signs of preeclampsia is necessary, but it is not the priority intervention at this time.

Which information would the nurse base a response on to a mother who asks for guidance regarding who to tell of the diagnosis of diabetes of her child, who plays on the soccer team? 1 Children with diabetes who participate in active sports can have episodes of hypoglycemia. 2 Children may have to leave athletic teams if school authorities learn that they have diabetes. 3 The school nurse will treat the child if clinical findings of hypoglycemia are recognized early. 4 The coach might violate confidentiality by discussing the child's condition with other faculty members.

1 The people associated with the school who are interacting with the child should be told about the child's condition. Knowledgeable people can be alert for early signs of hypoglycemia and have snacks available for the child to help prevent a hypoglycemic episode. Forcing the child to leave the team is a form of discrimination; children with diabetes are allowed to engage in activities as long as their diabetes remains under control. The adult who is with the child when the signs of hypoglycemia first appear should be prepared to treat the child; this person may or may not be the nurse. Information about the child's health status is on a "need to know" basis; professionals are expected to honor confidentiality.

Ingestion of which chemicals may cause chemical pneumonia? 1 Bleach 2 Lighter fluid 3 Toilet cleaner 4 Mildew remover

2. Lighter Fluid Certain hydrocarbons, like lighter fluid, can cause severe pneumonia on ingestion. Bleach, toilet cleaner, and mildew remover are corrosives that are not associated with chemical pneumonia.

Which activities can a child perform at 3 years of age? Select all that apply. One, some, or all responses may be correct. 1 Jumping rope 2 Drawing triangles 3 Turning doorknobs 4 Holding crayons with fingers 5 Eating with a spoon without rotating it 6 Classifying objects based on size and color

3,4,5 At the age of 3 years, a child can turn the pages of a book one at a time and can easily turn doorknobs. The child can now hold crayons with the fingers. A 3-year-old child can manage to eat with a spoon without rotating it. A preschooler by the age of 5 years is able to jump rope and can easily draw triangles and diamond shapes. By the age of 3 years, a child is able to drink from a cup without spilling it. A preschooler, not a toddler, is able to classify objects according to their size or color. Test-Taking Tip: On a test day, eat a normal meal before going to school. If the test is late in the morning, take a high-powered snack with you to eat 20 minutes before the examination. The brain works best when it has the glucose necessary for cellular function.

How would the nurse prevent footdrop in a client with a leg cast? 1 Encourage complete bed rest to promote healing of the foot. 2 Place the foot in traction. 3 Support the foot with 90 degrees of flexion. 4 Place an elastic stocking on the foot to provide support.

3. To prevent footdrop (plantar flexion of the foot because of weakness or paralysis of the anterior muscles of the lower leg) in a client with a cast, the foot should be supported with 90 degrees of flexion. Bed rest can cause footdrop, and 45 degrees is not enough flexion to prevent footdrop. Application of an elastic stocking for support also will not prevent footdrop; a firmer support is required.

Which instruction would the nurse include when teaching episiotomy care? 1 Rest with legs elevated at least 2 times a day. 2 Avoid stair climbing for several days after discharge. 3 Perform perineal care after toileting until healing occurs. 4 Continue sitz baths 3 times a day if they provide comfort.

3. Performing perineal care after toileting until the episiotomy is healed is critical to the prevention of infection, which is at the core of episiotomy care. Resting is encouraged to promote involution and general recovery from childbirth. Stair climbing may cause some discomfort but is not detrimental to healing. There is no limit to the number of sitz baths per day that the client may take if they provide comfort. Test-Taking Tip: Calm yourself by closing your eyes, putting down your pencil (or computer mouse), and relaxing. Deep-breathe for a few minutes (or as needed, if you feel especially tense) to relax your body and to relieve tension.

In which stage of Erikson's theory does the child initiate self-care activities? 1 Initiative versus guilt 2 Integrity versus despair 3 Autonomy versus sense of shame and doubt 4 Generativity versus self-absorption and stagnation

3. The development of self-care activities in a toddler occurs at the stage of autonomy versus a sense of shame and doubt; this is the second stage of Erikson's theory. The initiative versus guilt stage is the third stage of Erikson's theory. During this stage, children like to pretend and try out new roles. Integrity versus despair is the eighth stage of Erikson's theory. At this stage, many older adults view their lives with a sense of satisfaction. Middle-age adults achieve success at the stage of generativity versus self-absorption and stagnation. Individuals contribute to future generations through parenthood, teaching, and community involvement. Test-Taking Tip: Sometimes the reading of a question in the middle or toward the end of an exam may trigger your mind with the answer or provide an important clue to an earlier question.

Which is a common attribute that the nurse assesses in an "easy" child? 1 Passive resistance 2 Predictable habits 3 Intense mood expressions 4 Slow adaptation to change

2 The nurse anticipates that the "easy" child will have predictable habits. Passive resistance is a trait assessed in the "slow to warm up" child. Intense mood expressions and slow adaptation to change are characteristics of the "difficult" child.

A client who is at 20 weeks' gestation visits the prenatal clinic for the first time. Assessment reveals temperature of 98.8°F (37.1°C), pulse of 80 beats per minute, blood pressure of 128/80 mm Hg, weight of 142 lb (64.4 kg) (prepregnancy weight was 132 lb [59.9 kg]), fetal heart rate (FHR) of 140 beats per minute, urine that is negative for protein, and fasting blood glucose level of 92 mg/dL (5.2 mmol/L). Which would the nurse do after making these assessments? 1 Report the findings because the client needs immediate intervention. 2 Document the results because they are expected at 20 weeks' gestation. 3 Record the findings in the medical record because they are not within the norm but are not critical. 4 Prepare the client for an emergency admission because these findings may represent jeopardy to the client and fetus.

2. Document the results because they are expected at 20 weeks' gestation. All data presented are expected for a client at 20 weeks' gestation and should be documented. There is no need for immediate intervention or an emergency admission because all findings are expected.

Which statement describes the latency stage of Freud's psychoanalytic model of personality development? 1 During this stage, genital organs are the focus of pleasure. 2 During this stage, sexual urges are repressed and channeled into productive activities. 3 During this stage, an infant begins to think that his or her parent is separate from the self. 4 During this stage, sexual urges reawaken and are directed to an individual outside the family circle.

2. During the latency stage, Freud believed that sexual urges from the earlier Oedipal stage are repressed and channeled into productive activities that are socially acceptable. During the phallic stage, the genital organs are the focus of pleasure. During the oral stage, infants begin to think that the parent is something separate from the self. During the genital stage, sexual urges reawaken and are directed to an individual outside the family circle. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

A neonate weighing 5 lb 6 oz (2438 g) is born in a cesarean birth and admitted to the newborn nursery. Which range of resting respiratory rate would the nurse anticipate? 1 20 to 40 breaths/min 2 30 to 60 breaths/min 3 60 to 80 breaths/min 4 70 to 90 breaths/min

30-60 After respiration is established, the normal neonate respiratory rate ranges from 30 to 60 breaths/min with short periods of apnea. Twenty breaths per minute is bradypnea. A respiratory rate faster than 60 breaths/min is tachypnea.

Which gross motor skill is found in children between 2 to 4 months of age? 1 The child can creep on its hands and knees. 2 The child has predominant inborn reflexes. 3 The child can sit alone without any kind of support. 4 The child can bear weight on forearms when prone.

A child between 2 and 4 months of age is able to bear his or her weight on the forearms when in the prone position. A child between 8 and 10 months of age can creep on his or her hands and knees. A child between birth and 1 month has predominant inborn reflexes. A child between 6 and 8 months of age can sit alone without support.

The nurse teaches a pregnant client regarding the necessity for a folic acid supplement. Folic acid taken in the first trimester of pregnancy helps reduce the risk for which neonatal disorder? 1 Phenylketonuria 2 Down syndrome 3 Neural tube defects 4 Erythroblastosis fetalis

A folic acid supplement (0.4 mg/day) greatly reduces the incidence of fetal neural tube defects. Phenylketonuria is a genetic disorder that cannot be prevented by the action of folic acid. Down syndrome is a genetic disorder that also cannot be prevented by the action of folic acid. Erythroblastosis fetalis is related to the Rh factor and is not prevented by the action of folic acid.

A child watches an older sibling playing with a ball but makes no effort to participate in the play. Which social character is the child exhibiting? 1 Parallel play 2 Pretend play 3 Onlooker play 4 Associative play

In onlooker play a child actively observes other children playing and does not attempt to enter into the activity; the child is interested only in observation and not in participation. In parallel play children play independently among other children. In pretend play children act out any event of daily life and practice the roles and identities as established in their surroundings. In associative play children play together and are engaged in a similar or identical activity.

After treatment for a bladder infection, a client asks whether there is anything she can do to prevent cystitis in the future. Which response would the nurse give? 1 "Avoid regular use of tampons." 2 "Decrease your intake of prune juice." 3 "Increase your daily fluid consumption." 4 "Cleanse the perineum from back to front."

Increasing fluid intake flushes the urinary tract of microorganisms. Use of tampons does not increase the risk of cystitis. Fluid consumption should be increased, not decreased. The preferred method of cleansing is from front to back (urethra to vagina); however, studies have shown that this method of cleansing is not a significant factor in the prevention of cystitis. Test-Taking Tip: Key words or phrases in the stem of the question such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. As in life, no real absolutes exist in nursing; however, every rule has its exceptions, so answer with care.