NURS 405

The nurse is caring for an infant who is at risk for increased intracranial pressure. What statement by the parent would alert the nurse to further assess the child's neurological status? a. "She is a pretty happy baby, unless her diaper is wet, then she cries until we change her diaper." b. "She typically breastfeeds, but lately we have had to supplement with some oat cereal." c. "She always cries when the person holding her has on glasses...I guess glasses scare her." d. "She has been irritable for the last hour....seems like she is just upset for some reason." Ricci Chapter 38

"She has been irritable for the last hour....seems like she is just upset for some reason." Rationale: Irritability in an infant can be a sign of declining neurological function. Because infants are not able to answer questions pertaining to person, place and time, their neurological assessment must be catered to their level of development. The other responses would be typical and normal for an infant.

The blood cell becomes an erythrocyte. Rank the following steps in the proper order of occurrence. Erythropoietin helps the cell turn into a red blood cell. The myeloid cell becomes a megakaryocyte. Thrombopoietin acts on the cell. The bone marrow releases a stem cell. Ricci Chapter 46

1. The bone marrow releases a stem cell. 2. Thrombopoietin acts on the cell. 3. The myeloid cell becomes a megakaryocyte. 4. Erythropoietin helps the cell turn into a red blood cell.

A client is receiving intravenous (IV) mannitol to prevent increased intracranial pressure. The order is for mannitol 1.5 grams per kg of body weight IV now. The client weighs 143 lbs (65 kg). How many grams will the nurse administer to the client? Enter the correct number in tenths. Hinkle Chapter 61

97.5

The nurse is reviewing the medical record of a child diagnosed with Hodgkin lymphoma at the asymptomatic stage. Which would the nurse identify as typically the first sign reported by the child? A. anorexia B. weight loss C. night sweats D. painless, enlarged lymph node Ricci Chapter 46

D. painless, enlarged lymph node

The nurse identifies which type of jaundice in an adult experiencing a transfusion reaction? a. Hemolytic b. Obstructive c. Nonobstructive d. Hepatocellular Hinkle Chapter 43

Hemolytic Hemolytic jaundice occurs because, although the liver is functioning normally, it cannot excrete the bilirubin as quickly as it is formed. This type of jaundice is encountered in patients with hemolytic transfusion reactions and other hemolytic disorders. Obstructive jaundice is the result of liver disease. Nonobstructive jaundice occurs with hepatitis. Hepatocellular jaundice is the result of liver disease.

A nurse is preparing a presentation for a local community group about hepatitis. Which of the following would the nurse include? a. Hepatitis B is transmitted primarily by the oral-fecal route. b. Hepatitis A is frequently spread by sexual contact. c. Infection with hepatitis G is similar to hepatitis A. d. Hepatitis C increases a person's risk for liver cancer. Hinkle Chapter 43

Hepatitis C increases a person's risk for liver cancer. Rationale: Infection with hepatitis C increases the risk of a person developing hepatic (liver) cancer. Hepatitis A is transmitted primarily by the oral-fecal route; hepatitis B is frequently spread by sexual contact and infected blood. Hepatitis E is similar to hepatitis A whereas hepatitis G is similar to hepatitis C.

The nurse is collecting data from a child who may have a seizure disorder. Which nursing observations suggest an absence seizure? a. Muscle tone maintained and child frozen in position b. Brief, sudden contracture of a muscle or muscle group c. Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention d. Sudden, momentary loss of muscle tone, with a brief loss of consciousness Ricci Chapter 38

Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention Rationale: Absence seizures are characterized by a brief loss of responsiveness with minimal or no alteration in muscle tone. They may go unrecognized because the child's behavior changes very little. A sudden loss of muscle tone describes atonic seizures. A frozen position describes the appearance of someone having akinetic seizures. A brief, sudden contraction of muscles describes a myoclonic seizure.

A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? a. Hyperoxygenation before and after tracheal suctioning b. Maintaining adequate hydration c. Restricting fluid intake and hydration d. Administering prescribed antipyretics Hinkle Chapter 61

Restricting fluid intake and hydration Rationale: Fluid restriction may be necessary if the client develops cerebral edema and hypervolemia from SIADH. Antipyretics are administered to clients who develop hyperthermia. In addition, it is important to maintain adequate hydration in such clients. A client with neurological infection should be given tracheal suctioning and hyperoxygenation only when respiratory distress develops.

The nurse is talking with a woman in her second trimester of pregnancy who has been diagnosed with polyhydramnios. The physician has ordered an ultrasound be performed to check for the presence of esophageal atresia. Which statement by the woman indicates an understanding of the relationship between these conditions? a. "Babies with esophageal atresia have an inability to swallow amniotic fluid causing the excess buildup." b. "Reductions in amniotic fluid are associated with the development of esophageal atresia." c. "Babies with esophageal atresia produce an excessive amount of amniotic fluid." d. "Enzymes in amniotic fluid can cause the development of esophageal atresia." RIcci Chapter 42

a. "Babies with esophageal atresia have an inability to swallow amniotic fluid causing the excess buildup."

The nurse helps position a child for a lumbar puncture. Which statement describes the correct positioning for this procedure? a. "For a lumbar puncture, the child will be placed in a side-lying position with knees bent and neck flexed to assist with arching the back." b. "The child will be held by the mother on her lap with his back toward the health care provider." c. "When positioning the child, the nurse needs to assist the child to a side-lying position and keep his back as flat as much as possible." d. "The child will be placed in the prone position with the nurse holding the child still." Ricci Chapter 38

a. "For a lumbar puncture, the child will be placed in a side-lying position with knees bent and neck flexed to assist with arching the back."

An otherwise healthy 18-month-old child with a history of febrile seizures is in the well-child clinic. Which statement by the parent indicates to the nurse that additional teaching is needed? a. "I always keep phenobarbital with me in case of a fever." b. "The most likely time for a seizure is when the fever is rising." c. "I have ibuprofen available in case it is needed." d. "My child will likely outgrow these seizures by age 5." Ricci Chapter 38

a. "I always keep phenobarbital with me in case of a fever." Rationale: Anticonvulsants, such as phenobarbital, are administered to children with prolonged seizures or neurologic abnormalities. Ibuprofen, not phenobarbital, is given for fever. Febrile seizures usually occur after age 6 months and are unusual after age 5. Treatment is to decrease the temperature because seizures occur as the temperature rises.

The health care provider has just informed the parents of a 3-year-old that their child has leukemia. The mother begins crying and tells the nurse she does not want her baby to die. What is the nurse's best response? a. "I know this is scary, but leukemia has a high cure rate in children these days." b. "Don't worry, the health care provider is very good at treating leukemia." c. "I don't blame you for being upset; any parent would be scared too." d. "You are very lucky to have caught it so early; that makes the treatments easier." Ricci Chapter 46

a. "I know this is scary, but leukemia has a high cure rate in children these days."

A nurse caring for an infant born with a cleft palate notices that the parents rarely interact with their child. The nurse overhears the mother telling her spouse that she "feels like crying" every time she looks at their infant. What would be the best response from the nurse? a. "I sense you could use more information on caring for a cleft palate. Would you be interested in meeting with other parents who have dealt with this?" b. "Your infant needs you right now. You should put your negative feelings about the condition aside for your infant's sake." c. "Keep in mind that your infant's condition is not life-threatening and can be corrected eventually." d. "Many infants are born with this condition. Your infant's palate is not nearly as bad as some cases." Ricci Chapter 42

a. "I sense you could use more information on caring for a cleft palate. Would you be interested in meeting with other parents who have dealt with this?" Rationale: For many parents, having their infant born with a cleft lip or palate is overwhelming and to some even appalling. The nurse can support the parents by acknowledging their normal feelings of guilt, anger, and sadness. The nurse should support the family's adjustment to an infant's condition by demonstrating an accepting, caring attitude toward the child and family and providing the parents with opportunities and support for normal infant-parent interactions. Many parents need additional support outside the hospital or during surgical repairs. Parent-to-parent support groups are available and parents should be given information about to how to contact a local group. It may be difficult for a parent to bond with an infant who the parent feels is not perfect and those feeling cannot be easily dismissed. It does not matter if the defect is not life-threatening; it is still important to the parents and requires much skill to repair and heal. Stating this is being judgmental.

The parents of a 17-year-old adolescent diagnosed with bacterial meningitis tell the nurse, "We just do not understand how this could have happened. Our adolescent has always been healthy and just received a booster vaccine last year." How should the nurse respond? a. "I understand your frustration. Unfortunately, immunizations are not 100% effective in preventing the infection." b. "Your child may have been exposed to the type of meningitis that is not covered by the vaccine received." c. "Maybe your child's immune system is not strong enough to fight off the infection, even with having received the vaccine." d. "Meningococcal conjugate vaccine covers only two types of bacterial meningitis." Ricci Chapter 38

a. "I understand your frustration. Unfortunately, immunizations are not 100% effective in preventing the infection."

The student nurse is caring for a child with the nursing diagnosis "Risk for fluid volume deficit related to inadequate oral intake." Which statement by the student would indicate a need for further education by the nursing instructor? a. "I will make sure there is plenty of orange juice available. It's her favorite juice." b. "I will monitor her IV line to help maintain her fluid volume." c. "I will weigh her every morning at the same time." d. "I will teach her mother to give her small drinks frequently." Ricci Chapter 42

a. "I will make sure there is plenty of orange juice available. It's her favorite juice." Rationale: Proper interventions for children at risk for fluid volume deficit include maintaining IV line and administer IV fluid as ordered to maintain fluid volume. Offer small amounts of oral rehydration solution frequently to maintain fluid volume. Small amounts are usually well tolerated by children with diarrhea and vomiting. Avoid high-carbohydrate fluids such as Kool-Aid and fruit juice, as they are low in electrolytes, and increased simple carbohydrate consumption can decrease stool transit time. Daily weights are one of the best indicators of fluid volume status in children.

The parents of a 6-year-old child with idiopathic thrombocytopenic purpura (ITP) ask the nurse, "What causes this disease?" Which response by the nurse would be most appropriate? a. "ITP is primarily an autoimmune disease in that the immune system attacks and destroys the body's own platelets, for an unknown reason." b. "ITP is characterized by the loss of surface area on the red blood cell membrane." c. "ITP is a serious bleeding disorder characterized by a decreased, absent, or dysfunctional coagulation." d. "ITP occurs when the body's iron stores are depleted due to rapid physical growth, inadequate iron intake, inadequate iron absorption, or loss of blood." Ricci Chapter 46

a. "ITP is primarily an autoimmune disease in that the immune system attacks and destroys the body's own platelets, for an unknown reason."

The nurse is teaching a group of caregivers of children diagnosed with diabetes. The nurse is explaining insulin shock and the caregivers make the following statements. Which statement indicates the best understanding of a reason an insulin reaction might occur? a. "My child measures their own medication but sometimes doesn't administer the correct amount." b. "If my child eats as much as their older brother eats they could have an insulin reaction." c. "On the weekends we encourage our child to participate in lots of sports activities and stay busy so they don't have an insulin reaction." d. "My child monitors their glucose levels to keep them from going too high." Ricci Chapter 48

a. "My child measures their own medication but sometimes doesn't administer the correct amount."

A 10-year-old child has been diagnosed with type 1 diabetes. The child is curious about the cause of the disease and asks the nurse to explain it. Which explanation will the nurse provide? a. "Special cells in a part of your body called the pancreas cannot make a chemical called insulin, which helps control the sugar level in your blood." b. "The pancreas inside your belly makes enough chemical called insulin, but your body does not want to use it to keep your blood sugar level normal." c. "The part of your body called the pancreas is broken and produces too much chemical called glucagon, which makes you really thirsty and have to go to the bathroom a lot." d. "The alpha and beta cells in your pancreas are fighting against each other; that is why your blood sugar stays high and you need insulin injection." Ricci Chapter 48

a. "Special cells in a part of your body called the pancreas cannot make a chemical called insulin, which helps control the sugar level in your blood." When providing instruction to a child, the nurse must consider the developmental age. Type 1 diabetes is a disorder that involves an absolute or relative deficiency of insulin, thus the blood glucose level remains high if an appropriate amount of insulin is not administered to the client.

The nurse is educating parents of a male infant with Chiari type II malformation. Which statement about their child's condition is most accurate? a. "Take your time feeding your baby." b. "Lay him down after feeding." c. "You won't need to change diapers often." d. "You'll see a big difference after the surgery." Ricci Chapter 38

a. "Take your time feeding your baby." Rationale: One of the problems associated with Chiari type II malformation is poor gag and swallowing reflexes, so the infant must be fed slowly. There is a great risk of aspiration, requiring that the child be placed in an upright position after feeding. The goal of surgery is to prevent further symptoms, rather than to relieve existing ones. Infrequent urination is a problem associated with type I malformations.

The nurse is collecting data on a 2-year-old child admitted with a diagnosis of gastroenteritis. When interviewing the caregivers, which question is most important for the nurse to ask? a. "Tell me about the types of stools your child has been having." b. "How long has your child been toilet trained?" c. "How many times a day does your child urinate?" d. "What foods has your child eaten during the last few days?" Ricci Chapter 42

a. "Tell me about the types of stools your child has been having."

The parents of a child diagnosed with rhabdomyosarcoma ask the nurse to explain what this means. What is the nurse's best response? a. "The tumor is in the muscle." b. "There is a tumor in the eye." c. "There is a tumor in the bone." d. "This is a tumor of the kidney." Ricci Chapter 46

a. "The tumor is in the muscle."

The nurse is preparing a client for surgery and the client asks, "What does it mean when they say they are going to reduce my abdominal hernia?" Which response by the nurse is most appropriate? a. "This means the hernia contents will be manipulated back into your peritoneal cavity during surgery." b. "If you do not understand this, I need to cancel your surgery and have the health care provider come back." c. "The health care provider will remove about half of the herniated contents during the procedure." d. "All this means is that the herniated intestines are twisted and edematous, which is why you need surgery." Ricci Chapter 42

a. "This means the hernia contents will be manipulated back into your peritoneal cavity during surgery." Rationale: A hernia in the abdominal region is considered reducible when its contents are easily manipulated back through the inguinal ring into the peritoneal cavity. The nurse would reinforce this education, already provided by the primary health care provider when the surgery was explained, to the client. It is not necessary to cancel surgery when the nurse can provide education to the client. Reducing does not mean the intestines are twisted and edematous. Nor does it mean half of the contents will be removed.

The emergency room nurse is taking a history of a 1-year-old child whose parent said that she had a "fit" at home. Which inquiry would be best to start with? a. "What happened just before the seizures?" b. "Were there any jerky movements?" c. "How did you treat the child afterwards?" d. "Was the child unconscious?" Ricci Chapter 38

a. "What happened just before the seizures?" Rationale: Asking what happened just before the seizure will suggest whether the episode was a seizure or a breath-holding event, which is frequently precipitated by an expression of anger or frustration.

The nurse is speaking with the parents of a child recently diagnosed with hypothyroidism. Which statement by a parent indicates an understanding of symptoms of this disorder? a. "When they get my son's thyroid levels normal, he won't be so tired." b. "Most people with hypothyroidism have smooth, velvety skin." c. "Heat intolerance is a caused by low thyroid levels." d. "My son's nervousness may be a symptom of his hypothyroidism." Ricci Chapter 48

a. "When they get my son's thyroid levels normal, he won't be so tired."

When collecting data on a child diagnosed with diabetes mellitus, the nurse notes that the child has had weight loss and other symptoms of the disease. The nurse would anticipate which finding in the child's fasting glucose levels? a. 220 mg/dl b. 60 mg/dl c. 100 mg/dl d. 140 mg/dl Ricci Chapter 48

a. 220 mg/dl A fasting glucose greater than or equal to 126 mg/dL or higher on two separate occassions diagnostic for diabetes when other signs such as polyuria and weight loss, despite polyphagia, are present.

A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? a. 3 b. 12 c. 9 d. 6 Hinkle Chapter 61

a. 3

Which patient assessed by the nurse is most likely to develop myelodysplastic syndrome (MDS)? a. A 72-year-old patient with a history of cancer b. A 40-year-old patient with a history of hypertension c. A 52-year-old patient with acute kidney injury d. A 24-year-old female taking oral contraceptives Hinkle Chapter 30

a. A 72-year-old patient with a history of cancer

A client is suspected of having cirrhosis of the liver. What diagnostic procedure will the nurse prepare the client for in order to obtain a confirmed diagnosis? a. A liver biopsy b. A prothrombin time c. Platelet count d. A CT scan Hinkle Chapter 43

a. A liver biopsy

In a child with diabetes insipidus, which characteristic would most likely be present in the child's health history? a. abrupt onset of polyuria, nocturia, and polydipsia b. vomiting early in the morning, headache, and decreased thirst c. delayed closure of the fontanels (fontanelles), coarse hair, and hypoglycemia in the morning d. gradual onset of personality changes, lethargy, and blurred vision Ricci Chapter 48

a. Abrupt onset of polyuria, nocturia, and polydipsia Diabetes insipidus is characterized by deficient secretion of antidiuretic hormone leading to diuresis. Most children with this disorder experience an abrupt onset of symptoms, including polyuria, nocturia, and polydipsia. The other choices reflect symptoms of pituitary hyperfunction

An important message for any nurse to communicate is that drug-induced hepatitis is a major cause of acute liver failure. The medication that is the leading cause is: a. Acetaminophen b. Ibuprofen c. Dextromethorphan d. Benadryl Hinkle Chapter 43

a. Acetaminophen Although any medication can affect liver function, use of acetaminophen (found in many over-the-counter medications used to treat fever and pain) has been identified as the leading cause of acute liver failure. Other medications commonly associated with liver injury include anesthetic agents, medications used to treat rheumatic and musculoskeletal disease, antidepressants, psychotropic medications, anticonvulsants, and antituberculosis agents.

The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the priority nursing intervention? a. Administer corticosteroids as ordered. b. Document signs and symptoms of inflammation. c. Assess for weight loss. d. Give acetaminophen per orders. Hinkle Chapter 61

a. Administer corticosteroids as ordered.

The nurse is caring for a 14-year-old boy with hyperpituitarism. What would be the priority treatment? a. Administering octreotide acetate as ordered b. Treating the child according to his chronological age c. Teaching the child and family about proper treatment d. Assessing the child's self-image due to the disorder Ricci Chapter 48

a. Administering octreotide acetate as ordered

The nurse enters the client's room and finds the client with an altered level of consciousness (LOC). Which is the nurse's priority concern? a. Airway clearance b. Risk for impaired skin integrity c. Deficient fluid volume d. Risk of injury Hinkle Chapter 61

a. Airway clearance

A client reporting shortness of breath is admitted with a diagnosis of cirrhosis. A nursing assessment reveals an enlarged abdomen with striae, an umbilical hernia, and 4+ pitting edema of the feet and legs. What is the most important data for the nurse to monitor? a. Albumin b. Bilirubin c. Temperature d. Hemoglobin Hinkle Chapter 43

a. Albumin

Which is a late sign of increased intracranial pressure (ICP)? a. Altered respiratory patterns b. Slow speech c. Headache d. Irritability Hinkle Chapter 61

a. Altered respiratory patterns

While administering a blood transfusion to a child with a hematologic disorder, the nurse notes the child develops urticaria and wheezing. Which collaborative interventions will the nurse begin? Select all that apply. a. Apply oxygen as needed. b. Administer a diuretic. c. Discontinue the transfusion. d. Obtain a blood culture. e. Give an antihistamine. Ricci Chapter 46

a. Apply oxygen as needed. c. Discontinue the transfusion. e. Give an antihistamine.

What information is most correct regarding the nervous system of the child? a. As the child grows, the gross and fine motor skills increase. b. The child's nervous system is fully developed at birth. c. The child has underdeveloped fine motor skills and well-developed gross motor skills. d. The child has underdeveloped gross motor skills and well-developed fine motor skills. Ricci Chapter 38

a. As the child grows, the gross and fine motor skills increase.

A client with AML has pale mucous membranes and bruises on the legs. What is the primary nursing intervention? a. Assess the client's hemoglobin and platelets. b. Assess the client's skin. c. Assess the client's pulse and blood pressure. d. Check the client's history. Hinkle Chapter 30

a. Assess the client's hemoglobin and platelets. Rationale: Clients with AML may develop pallor from anemia and a tendency to bleed because of a low platelet count. Assessing the client's hemoglobin and platelets will help to determine whether this is the cause of the symptoms. This would be the priority above assessing pulses, blood pressure, history, or skin.

A 9-year-old client who suffered a head injury has strabismus. The nurse assesses the client for intracranial pressure (ICP). Which additional intervention is most important for the nurse to perform? a. Assess the level of consciousness (LOC). b. Place the child on fall precaution. c. Place a patch over the client's affected eye. d. Notify the primary health care provider. Ricci Chapter 38

a. Assess the level of consciousness (LOC).

The nurse is taking a health history of a 2-year-old girl presenting with a sudden onset of severe vomiting. Which description would suggest an obstruction? a. Bilious vomiting b. Bloody vomiting c. Effortless vomiting d. Projectile vomiting Ricci Chapter 42

a. Bilious vomiting

Which signs are manifestations of the Cushing triad? Select all that apply. a. Bradycardia b. Hypertension c. Bradypnea d. Tachycardia Hinkle Chapter 61

a. Bradycardia b. Hypertension c. Bradypnea

The nurse is preparing a discharge teaching plan for the parents of an 8-year-old girl with leukemia. Which instruction would be the priority? a. Calling the doctor if the child gets a sore throat b. Writing down phone numbers and appointments c. Keeping a written copy of the treatment plan d. Using acetaminophen if the child needs an analgesic Ricci Chapter 46

a. Calling the doctor if the child gets a sore throat Rationale: Calling the doctor if the child gets a sore throat is the priority. Because of the child's impaired immune system, any sign of potential infection, such as sore throat, must be evaluated by a physician. Using acetaminophen if the child needs an analgesic, writing down phone numbers and appointments, and keeping a written copy of the treatment plan are important teaching points but secondary to guarding against infection.

The nurse is caring for a client who has been admitted with a head injury and continually assesses for signs of increasing intracranial pressure (ICP). The earliest sign of increasing ICP is a. Change in level of consciousness b. Widening pulse pressure c. Slowing of heart rate d. Elevation of systolic blood pressure Hinkle Chapter 61

a. Change in level of consciousness

Which insult or abnormality can cause an ischemic stroke? a. Cocaine use b. Intracerebral aneurysm rupture c. Trauma d. Arteriovenous malformation Hinkle Chapter 62

a. Cocaine use

Antibiotic therapy to treat meningitis should be instituted immediately after which event? a. Collection of cerebrospinal fluid (CSF) and blood for culture b. Admission to the nursing unit c. Initiation of IV therapy d. Identification of the causative organism Ricci Chapter 38

a. Collection of cerebrospinal fluid (CSF) and blood for culture Rationale: Antibiotic therapy should always begin immediately after the collection of CSF and blood cultures. After the specific organism is identified, bacteria-specific antibiotics can be administered if the initial choice of antibiotic therapy isn't appropriate. Admission and initiation of I.V. therapy aren't, by themselves, appropriate times to begin antibiotic therapy.

The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop? a. Damage to the optic nerve b. Damage to the olfactory nerve c. Damage to the vagal nerve d. Damage to the facial nerve Hinkle Chapter 61

a. Damage to the optic nerve

A preschool-age child has just been admitted to the pediatric unit with a diagnosis of bacterial meningitis. The nurse would include which recommendation in the nursing plan? a. Decrease environmental stimulation b. Take vital signs every 4 hours c. Monitor temperature every 4 hours d. Encourage the parents to hold the child Ricci Chapter 38

a. Decrease environmental stimulation

A child has been prescribed desmopressin acetate for the treatment of diabetes insipidus. The client and the parents ask the nurse how this drug works. What is the correct response by the nurse? a. Desmopressin acetate is a synthetic antidiuretic hormone that will slow down your urine output. b. Desmopressin acetate is a synthetic form of insulin used to lower your blood sugar. c. Desmopressin acetate works to help your kidneys work more efficiently. d. Desmopressin acetate works on your pancreas to stimulate insulin production. Ricci Chapter 48

a. Desmopressin acetate is a synthetic antidiuretic hormone that will slow down your urine output

A nurse is caring for a patient with cancer of the liver whose condition has required the insertion of a percutaneous biliary drainage system. The nurse's most recent assessment reveals the presence of dark green fluid in the collection container. What is the nurse's best response to this assessment finding? a. Document the presence of normal bile output. b. Irrigate the drainage system with normal saline as prescribed. c. Aspirate a sample of the drainage for culture. d. Promptly report this assessment finding to the primary provider. Hinkle Chapter 43

a. Document the presence of normal bile output.

The nurse is interacting with a family that has been caring for a client with cancer for several months. What are the best interventions to assist in relieving caregiver stress in this family? Select all that apply. a. Educate the family about medications and side effects. b. Suggest support for household maintenance. c. Suggest the prescription of antianxiety medications. d. Allow family members to express feelings. e. Suggest the family go to church more often. Hinkle Chapter 30

a. Educate the family about medications and side effects. b. Suggest support for household maintenance. d. Allow family members to express feelings.

A client is receiving vasopressin for the urgent management of active bleeding due to esophageal varices. What most serious complication should the nurse assess the client for after the administration? a. Electrocardiogram changes b. Liver enzyme changes c. Urinary output changes d. Electrolytes level changes Hinkle Chapter 43

a. Electrocardiogram changes Vasopressin (Pitressin) is administered during the management of an urgent situation with an acute esophageal bleed because of its vasoconstrictive properties in the splanchnic, portal, and intrahepatic vessels. This medication also causes coronary artery constriction that may dispose clients with coronary artery disease to cardiac ischemia; therefore, the nurse observes the client for evidence of chest pain, ECG changes, and vital sign changes. Vasopressin will does not infer with urinary output, electrolytes, or liver enzymes.

The nurse is caring for a client suspected of having stones that have collected in the common bile duct. What test should the nurse prepare the client for that will locate these stones? a. Endoscopic retrograde cholangiopancreatography (ERCP) b. Colonoscopy c. Cholecystectomy d. Abdominal x-ray Hinkle Chapter 43

a. Endoscopic retrograde cholangiopancreatography (ERCP) ERCP locates stones that have collected in the common bile duct. A colonoscopy will not locate gallstones but only allows visualization of the large intestine. Abdominal x-ray is not a reliable locator of gallstones. A cholecystectomy is the surgical removal of the gallbladder. (less)

The labor and delivery nurse is caring for a mother who has demonstrated polyhydramnios upon delivery. The newborn displays copious, frothy bubbles of mucus in the mouth and nose, as well as drooling. The nurse is concerned that the infant has what disorder? a. esophageal atresia b. omphalocele c. hiatal hernia d. gastroschisis Ricci Chapter 42

a. Esophageal atresia Rationale: Esophageal atresia refers to a congenitally interrupted esophagus where the proximal and distal ends do not communicate; the upper esophageal segment ends in a blind pouch and the lower segment ends a variable distance above the diaphragm. Polyhydramnios is often the first sign of esophageal atresia because the fetus cannot swallow and absorb amniotic fluid in utero, leading to accumulation. Omphalocele and gastroschisis are congenital anomalies of the anterior abdominal wall. Hiatal hernia involves a weakened diaphragm.

The pediatric nurse reviews the radiographs of a child and observes that there are lesions on the bone. The nurse interprets this finding as suggesting which condition? a. Ewing sarcoma b. non-Hodgkin lymphoma c. Hodgkin disease d. neuroblastoma Ricci Chapter 46

a. Ewing sarcoma Explanation:Radiographs that show lesions on the bone may indicate tumors (e.g. Ewing sarcoma, osteosarcoma) or metastases of tumors warranting further investigation by bone scan, CT or MRI. Positron emission tomography is the most effective test to diagnose neuroblastoma, Hodgkin disease, Non-Hodgkin lymphoma, bone tumors, lung and colon cancers and brain tumors.

A client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. While assessing the client, the nurse expects which of the following findings? a. Excessive urine output and decreased urine osmolality b. Oliguria and serum hyperosmolarity c. Oliguria and decreased urine osmolality d. Excessive urine output and serum hypo-osmolarity Hinkle Chapter 61

a. Excessive urine output and decreased urine osmolality

The nurse is caring for a client with chronic myeloid leukemia (CML). The nurse knows that which symptoms indicate the client is in the accelerated phase of the condition? Select all that apply. a. Fatigue b. Confusion c. Splenomegaly d. Bone pain e. Dyspnea Hinkle Chapter 30

a. Fatigue c. Splenomegaly d. Bone pain e. Dyspnea

From which direction should a nurse approach a client who is blind in the right eye? a. From the left side of the client b. From the right side of the client c. From directly behind the client d. From directly in front of the client Hinkle Chapter 62

a. From the left side of the client

A nurse is making a home visit to a 12-year-old child with type 1 diabetes and is reviewing insulin administration. The nurse determines that the teaching was successful when the child performs which actions? Select all that apply. a. Gives the injection at a 45-degree angle. b. Stores the insulin vial at room temperature. c. Shakes the bottle of intermediate-acting insulin to make sure is it uniform. d. Aspirates for a blood return before injecting the medication. e. Draws up the short-acting insulin before the intermediate-acting insulin. Ricci Chapter 48

a. Gives the injection at a 45-degree angle. b. Stores the insulin vial at room temperature. e. Draws up the short-acting insulin before the intermediate-acting insulin.

A child with hemophilia A is scheduled for surgery. Which precautions would the nurse institute with this client? a. Handle the child gently when transferring to a stretcher. b. Mark the client's chart to receive no analgesia. c. Caution the child not to brush the teeth before surgery. d. Do not allow a dressing to be applied postoperatively. Ricci Chapter 46

a. Handle the child gently when transferring to a stretcher.

The nurse is caring for a child diagnosed with thalassemia. What laboratory value(s) would the nurse expect to monitor for this child? Select all that apply. a. Hemoglobin b. Iron level c. Vitamin B12 level d. Urine glucose e. Serum sodium Ricci Chapter 46

a. Hemoglobin b. Iron level

A neonatal nurse teaches students how to recognize gastrointestinal disorders in infants. The nurse tells the students that failure of the newborn to pass meconium in the first 24 hours after birth may indicate what disease? a. Hirschsprung disease b. Ulcerative colitis (UC) c. Gastroenteritis d. Short bowel syndrome (SBS) Ricci Chapter 42

a. Hirschsprung disease

The nurse is caring for a client at high risk for thrombocythemia. Which treatments will the nurse anticipate being prescribed for this client? Select all that apply. a. Hydroxyurea b. Aspirin c. Diphenhydramine d. Interferon-alfa e. Anagrelide Hinkle Chapter 30

a. Hydroxyurea b. Aspirin d. Interferon-alfa e. Anagrelide

The mother of an infant reports that her child is frequently choking when breastfeeding or taking a bottle. The nurse plans on assessing which cranial nerve when addressing the mother's concerns? a. IX b. VII c. VIII d. VI Ricci Chapter 38

a. IX

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the health care provider in the emergency department. Which is the origin of the client's symptoms? a. impaired cerebral circulation b. hypertension c. diabetes insipidus d. cardiac disease Hinkle Chapter 62

a. Impaired cerebral circulation Rationale: TIAs result from impaired blood circulation in the brain, which can be caused by atherosclerosis and arteriosclerosis, cardiac disease, or diabetes. The symptoms of a TIA are the result of impaired blood circulation in the brain, which may have been caused by cardiac disease. The symptoms of a TIA are the result of impaired blood circulation in the brain, which may have been caused by diabetes. The symptoms of a TIA are the result of impaired blood circulation in the brain, which may have been caused by hypertension.

The nurse is teaching an in-service program to a group of nurses on the topic of gastrointestinal disorders. The nurses in the group make the following statements. Which statement is most accurate related to the diagnosis of gastroesophageal reflux? a. In this disorder the sphincter that leads into the stomach is relaxed. b. A thickened, elongated muscle causes an obstruction at the end of the stomach. c. A partial or complete intestinal obstruction occurs. d. There are recurrent paroxysmal bouts of abdominal pain. Ricci Chapter 42

a. In this disorder the sphincter that leads into the stomach is relaxed.

The nurse is caring for a client with a ventriculostomy. Which assessment finding demonstrates effectiveness of the ventriculostomy? a. Increased ICP is 12 mm Hg. b. The mean arterial pressure (MAP) is equal to the intracranial pressure (ICP). c. The pupils are dilated and fixed. d. Cerebral perfusion pressure (CPP) is 21 mm Hg. Hinkle Chapter 61

a. Increased ICP is 12 mm Hg. Rationale: A ventriculostomy is used to continuously measure ICP and allows cerebral spinal fluid (CSF) to drain, especially during a period of increased ICP. The normal ICP is 0 to 15 mm Hg, so an ICP measured at 12 mm Hg would demonstrate the effectiveness of the ventriculostomy. Dilated and fixed pupils are not a normal assessment finding and would not indicate an improvement in the neurologic system. Cerebral circulation ceases if the ICP is equal to the MAP. Normal CPP is 70 to 100. A CPP reading of less than 50 is consistent with irreversible neurologic damage.

The nurse is administering packed red blood cell (RBC) transfusions for a patient with myelodysplastic syndrome (MDS). The patient has had several transfusions and is likely to receive several more. What is a priority for the nurse to monitor related to the transfusions? a. Iron levels b. Magnesium levels c. Potassium levels d. Creatinine and blood urea nitrogen (BUN) levels Hinkle Chapter 30

a. Iron levels

The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has? a. Ischemic b. Hemorrhagic c. Right-sided d. Left-sided Hinkle Chapter 62

a. Ischemic

A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment? a. Lack of deep tendon reflexes b. Visual agnosia c. Limited attention span and forgetfulness d. Auditory agnosia Hinkle Chapter 62

a. Lack of deep tendon reflexes

A client is being prepared to undergo laboratory and diagnostic testing to confirm the diagnosis of cirrhosis. Which test would the nurse expect to be used to provide definitive confirmation of the disorder? a. Liver biopsy b. Magnetic resonance imaging c. Coagulation studies d. Radioisotope liver scan Hinkle Chapter 43

a. Liver biopsy A liver biopsy which reveals hepatic fibrosis is the most conclusive diagnostic procedure. Coagulation studies provide information about liver function but do not definitively confirm the diagnosis of cirrhosis. Magnetic resonance imaging and radioisotope liver scan help to support the diagnosis but do not confirm it. These tests provide information about the liver's enlarged size, nodular configuration, and distorted blood flow.

Absence seizures are marked by what clinical manifestation? a. Loss of motor activity accompanied by a blank stare b. Sudden, brief jerks of a muscle group c. Brief, sudden onset of increased tone of the extensor muscle d. Loss of muscle tone and loss of consciousness Ricci Chapter 38

a. Loss of motor activity accompanied by a blank stare

A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following actions would be the first priority? a. Maintenance of a patent airway b. Determination of the cause c. Assessment of pupillary light reflexes d. Positioning to prevent complications Hinkle Chapter 61

a. Maintenance of a patent airway Rationale: The most important consideration in managing the patient with altered LOC is to establish an adequate airway and ensure ventilation.

The nurse is caring for a 6-year-old boy with non-Hodgkin lymphoma who is being treated with monoclonal antibodies. What recommendation would the nurse include in the child's plan of care? a. Monitoring for allergic reactions or anaphylaxis. b. Assessing the child's hydration status secondary to vomiting. c. Monitoring for complaints of bone pain. d. Assessing for signs of capillary leak syndrome. Ricci Chapter 46

a. Monitoring for allergic reactions or anaphylaxis Explanation:The nurse would monitor for infusion-related reactions and anaphylaxis if monoclonal antibodies were administered and would have epinephrine, antihistamines, and steroids available at the bedside for treatment if a reaction occurred. Assessing the level of hydration due to vomiting would be necessary if tumor necrosis factor was administered. The flu-like symptoms produced by interferons require hydration maintenance also. Monitoring for complaints of bone pain is appropriate when administering colony-stimulating factors such as filgrastim or sargramostim. Assessing for signs of capillary leak syndrome within 2 to 12 hours of the start of treatment is necessary when interleukins are used.

The nurse caring for an infant with craniosynostosis, specifically positional plagiocephaly, should prioritize which activity? a. moving the infant's head every 2 hours b. giving the infant small feedings whenever he is fussy c. measuring the intake and output every shift d. massaging the scalp gently every 4 hours Ricci Chapter 38

a. Moving the infant's head every 2 hours Rationale: Positional plagiocephaly can occur because the infant's head is allowed to stay in one position for too long. Because the bones of the skull are soft and moldable, they can become flattened if the head is allowed to remain in the same position for a long period of time. Massaging the scalp will not affect the skull. Measuring the intake and output is important but has no effect on the skull bones. Small feedings are indicated whenever an infant has increased intracranial pressure, but feeding an infant each time he fusses is inappropriate care.

A client with acute myeloid leukemia has a fever. What pathophysiological process does the nurse recognize is the cause of the client's fever? a. Neutropenia b. Thrombocytopenia c. Pancytopenia d. Anemia Hinkle Chapter 30

a. Neutropenia

The nurse is planning care for a child with idiopathic thrombocytopenic purpura. Which client education should be included? a. Not to pick or irritate the nose b. To apply a soothing cream to lesions c. To use mainly cold water to wash d. What foods are high in folic acid Ricci Chapter 46

a. Not to pick or irritate the nose

The nurse assesses a child and notes the following: oral temperature 102.1°F (39°C), plethora, and new onset difficulty speaking. Which health care provider prescription will the nurse request? Select all that apply. a. Obtain computed tomography (CT) scan. b. Give dose of erythropoietin subcutaneously. c. Call laboratory for complete blood count (CBC). d. Administer acetaminophen every 4 hours. e. Initiate intravenous (IV) normal saline. Ricci Chapter 46

a. Obtain computed tomography (CT) scan. c. Call laboratory for complete blood count (CBC). d. Administer acetaminophen every 4 hours. e. Initiate intravenous (IV) normal saline.

The nurse is evaluating the effectiveness of teaching provided to the parents of a school-age child prescribed liquid ferrous sulfate for iron-deficiency anemia. Which observations indicate that teaching has been effective? Select all that apply. a. Parent provides liquid-prepared medication to the child with a straw. b. Child goes to the bathroom to brush teeth immediately after taking the medication. c. Parent provides medication with a glass of milk. d. Child consumes fresh raw fruit and drinks water. e. Parent places medication in orange juice. Ricci Chapter 46

a. Parent provides liquid-prepared medication to the child with a straw. b. Child goes to the bathroom to brush teeth immediately after taking the medication. d. Child consumes fresh raw fruit and drinks water. e. Parent places medication in orange juice.

The hospitalized client is experiencing gastrointestinal bleeding with a platelets at 9,000/mm³. The client is receiving prednisone and azathioprine. What action will the nurse take? a. Perform a neurologic assessment with vital signs. b. Request a prescription of diphenoxylate and atropine for loose stools. c. Teach the client to vigorously floss the teeth to prevent infections. d. Use contact precautions with this client. Hinkle Chapter 30

a. Perform a neurologic assessment with vital signs.

Which of the following drugs may be used after a seizure to maintain a seizure-free state? a. Phenobarbital b. Ativan c. Cerebyx d. Valium Hinkle Chapter 61

a. Phenobarbital

A patient with polycythemia vera has a high red blood cell (RBC) count and is at risk for the development of thrombosis. What treatment is important to reduce blood viscosity and to deplete the patient's iron stores? a. Phlebotomy b. Radiation c. Chelation therapy d. Blood transfusions Hinkle Chapter 30

a. Phlebotomy Rationale: The objective of management is to reduce the high RBC count and reduce the risk of thrombosis. Phlebotomy is an important part of therapy (Fig. 34-5). It involves removing enough blood (initially 500 mL once or twice weekly) to reduce blood viscosity and to deplete the patient's iron stores, thereby rendering the patient iron deficient and consequently unable to continue to manufacture hemoglobin excessively.

Which is the most common cause of esophageal varices? a. Portal hypertension b. Jaundice c. Ascites d. Asterixis Hinkle Chapter 43

a. Portal hypertension

The nurse is teaching a group of 13-year-old boys and girls about screening and prevention of reproductive cancers. Which subjects would be included in the nurse's teaching plan? Select all that apply. a. Provide information regarding the benefits of receiving the human papillomavirus (HPV) vaccine. b. Sexually transmitted infections are a risk factor for cervical cancer. c. Self-examination is an effective screening method for testicular cancer. d. Testicular cancer is one of the most difficult cancers to cure. e. A Papanicolaou test does not require parent consent in most states. Ricci Chapter 46

a. Provide information regarding the benefits of receiving the human papillomavirus (HPV) vaccine. b. Sexually transmitted infections are a risk factor for cervical cancer. c. Self-examination is an effective screening method for testicular cancer. e. A Papanicolaou test does not require parent consent in most states.

The nurse is caring for a client following an aneurysm coiling procedure. The nurse documents that the client is experiencing Korsakoff syndrome. Which set of symptoms characterizes Korsakoff syndrome? a. Psychosis, disorientation, delirium, insomnia, and hallucinations b. Severe dementia and myoclonus c. Tremor, rigidity, and bradykinesia d. Choreiform movement and dementia Hinkle Chapter 62

a. Psychosis, disorientation, delirium, insomnia, and hallucinations Rationale: Advances in technology have led to the introduction of interventional neuroradiology for the treatment of aneurysms. Endovascular techniques may be used in selected clients to occlude the blood flow from the artery that feeds the aneurysm with coils or other techniques to occlude the aneurysm itself. Postoperative complications are rare but can occur. Potential complications include psychological symptoms such as disorientation, amnesia, and Korsakoff syndrome (disorder characterized by psychosis, disorientation, delirium, insomnia, hallucinations, and personality changes). Creutzfeldt-Jakob disease results in severe dementia and myoclonus. The three cardinal signs of Parkinson disease are tremor, rigidity, and bradykinesia. Huntington disease results in progressive involuntary choreiform (dancelike) movements and dementia.

A client is awaiting test results to diagnose Hodgkin lymphoma. The nurse knows that which result is the hallmark for the diagnosis of this condition? a. Reed-Sternberg cells b. Misshaped red blood cells c. Increased basophils d. Elevated platelet count Hinkle Chapter 30

a. Reed-Sternberg cells Rationale: The malignant cell of Hodgkin lymphoma is the Reed-Sternberg cell, a gigantic tumor cell that is morphologically unique and thought to be of immature lymphoid origin. These cells arise from the B lymphocyte. They may have more than one nucleus and often have an owl-like appearance. The presence of Reed-Sternberg cells is the pathologic hallmark and essential diagnostic criterion. Basophils, platelets, or red blood cells are not used to diagnose Hodgkin lymphoma.

The geriatric advanced practice nurse (APN) is doing client teaching with a client who has had a cerebrovascular accident (CVA) and the client's family. One concern the APN addresses is a potential for falls related to the CVA and resulting muscle weakness. What would be most important for the APN to include in teaching related to this concern? a. Remove throw rugs and electrical cords from home environment. b. Need for support group due to decreased self image related to restricted mobility. c. Leg exercises to strengthen muscle weakness. d. Use of tripod cane. Hinkle Chapter 62

a. Remove throw rugs and electrical cords from home environment.

A nurse is providing discharge teaching to the parent of a child hospitalized after experiencing respiratory arrest. The parent expresses concerns about the child's well-being. Which action(s) is appropriate for the nurse take? Select all that apply. a. Review signs and symptoms of respiratory distress with the parent. b. Reinforce when the health care provider should be called. c. Encourage the parent to discuss specific concerns about the child. d. Reassure the parent that the child's infection has been cured. e. Tell the parent that the child's provider will address any concerns during the follow-up visit. Ricci Chapter 51

a. Review signs and symptoms of respiratory distress with the parent. b. Reinforce when the health care provider should be called. c. Encourage the parent to discuss specific concerns about the child.

The nurse is assessing a patent with polycythemia vera. What skin assessment data would the nurse determine is a normal finding for this patient? a. Ruddy complexion b. Jaundice skin and sclera c. Pale skin and mucous membranes d. Bronze skin tone Hinkle Chapter 30

a. Ruddy complexion

Which nursing assessment data should be given the highest priority for a child with clinical findings related to meningitis? a. Signs of increased intracranial pressure (ICP) b. Occurrence of urine and fecal contamination c. Onset and character of fever d. Degree and extent of nuchal rigidity Ricci Chapter 38

a. Signs of increased intracranial pressure (ICP)

Gynecomastia is a common side effect of which of the following diuretics? a. Spironolactone b. Nitroglycerin (IV) c. Furosemide d. Vasopressin Hinkle Chapter 43

a. Spironolactone

A client with liver cirrhosis develops ascites. Which medication will the nurse prepare teaching for this client? a. Spironolactone b. Furosemide c. Ammonium chloride d. Acetazolamide Hinkle Chapter 43

a. Spironolactone The use of diuretic agents along with sodium restriction is successful in 90% of clients with ascites. Spironolactone, an aldosterone-blocking agent, is most often the first-line therapy in clients with ascites from cirrhosis. When used with other diuretic agents, spironolactone helps prevent potassium loss. Oral diuretic agents such as furosemide may be added but should be used cautiously because long-term use may induce severe hyponatremia (sodium depletion). Acetazolamide and ammonium chloride are contraindicated because of the possibility of precipitating hepatic encephalopathy and coma.

The nurse is caring for a 6-month-old infant who was admitted to the emergency department 24 hours ago with signs of severe diarrhea. The infant's rectal temperature is 104°F (40°C), with weak and rapid pulse and respirations. The skin is pale and cool. The child is on IV rehydration therapy, but the diarrhea is persisting. The infant has not voided since being admitted. Which is the priority nursing intervention? a. Take a stool culture b. Administer IV potassium c. Feed the child a cracker d. Administer antibiotic therapy Ricci Chapter 42

a. Take a stool culture

A child with Addison disease has been admitted with a history of nausea and vomiting for the past 3 days. The client is receiving IV glucocorticoids. Which intervention will the nurse perform? a. Take glucometer readings as ordered. b. Monitor sodium and potassium levels. c. Weigh daily. d. Measure intake and output. Ricci Chapter 48

a. Take glucometer readings as ordered.

A child with Addison disease has been admitted with a history of nausea and vomiting for the past 3 days. The client is receiving IV glucocorticoids. Which intervention will the nurse perform? a. Take glucometer readings as ordered. b. Weigh daily. c. Monitor sodium and potassium levels. d. Measure intake and output. Ricci Chapter 48

a. Take glucometer readings as ordered.

During the recovery phase of a neurologic deficit, assessment tools may be used to help identify a client's level of functioning. Which tool is used to measure performance in activities of daily living (ADL)? a. The Barthel Index b. The National Institute for Health Stroke Scale c. Hamilton Assessment Scale d. The American Heart Association's Stroke Outcome Classification Hinkle Chapter 62

a. The Barthel Index

The nurse is caring for a 7-year-old client who suffered extensive burns from a house fire. Which finding in the client's history most concerns the nurse? a. The child was home alone when the fire started. b. The child appears withdrawn and frightened. c. The child was trapped in a burning bedroom. d. The child's clothing was burned when exiting the home. Ricci Chapter 51

a. The child was home alone when the fire started.

When caring for a child who has a history of seizures, which nursing interventions would be appropriate? Select all that apply. a. The nurse positions the child on the side during a seizure. b. The nurse has oxygen available to use during a seizure. c. The nurse teaches the caregivers regarding seizure precautions. d. The nurse stays with the child and calls for help when a seizure begins. e. The nurse places a washcloth in the mouth to prevent injury during seizure. f. The nurse pads the crib or side rails before a seizure. Ricci Chapter 38

a. The nurse positions the child on the side during a seizure. b. The nurse has oxygen available to use during a seizure. c. The nurse teaches the caregivers regarding seizure precautions. d. The nurse stays with the child and calls for help when a seizure begins. f. The nurse pads the crib or side rails before a seizure.

A nurse is assisting with a bone marrow aspiration and biopsy for a 6-year-old child. Which would be most important? a. Using aseptic technique for the procedure. b. Asking the parents to leave the room for the procedure. c. Placing a folded blanket or pillow under the head to raise it. d. Positioning the child on the side. Ricci Chapter 46

a. Using aseptic technique for the procedure.

The nurse is caring for a client with acute lymphocytic leukemia (ALL) who is Philadephia chromosome negative. Which medications will the nurse anticipate providing to the client during initiation of pharmacological therapies? Select all that apply. a. Vincristine b. Fludarabine c. Adalimumab d. Dexamethasone e. Imatinib Hinkle Chapter 30

a. Vincristine d. Dexamethasone

A mother brings her 3-year-old son to the ER and tells the triage nurse that he has been vomiting blood. A medical history determines that the 3-year-old has no history of GI disturbances and his only symptoms are a slightly elevated fever and vomiting bright red blood. Based on these symptoms, what condition might the nurse suspect? a. acute upper GI bleeding b. intussusception c. GI tract obstruction d. gastroesophageal reflux Ricci Chapter 42

a. acute upper GI bleeding

A nurse is reading a journal article about stroke and the underlying causes associated with this condition. The nurse demonstrates understanding of the information when identifying which subtype of stroke as being due to atrial fibrillation? a. cardio embolic b. large-artery thrombotic c. cryptogenic d. small, penetrating artery thrombotic Hinkle Chapter 62

a. cardio embolic

The nurse is explaining to a group of parents about the long-term effects of radiation therapy on children. Depending on the location of the therapy, what does the nurse include in this teaching session? Select all that apply. a. chronic malabsorption in the GI tract b. asymmetrical bone growth c. demyelination of the brain d. bronchopulmonary dysplasia (chronic lung disease) e. growth retardation f. infertility Ricci Chapter 46

a. chronic malabsorption in the GI tract b. asymmetrical bone growth c. demyelination of the brain e. growth retardation f. infertility

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has: a. cirrhosis. b. cholelithiasis. c. appendicitis. d. peptic ulcer disease. Hinkle Chapter 43

a. cirrhosis Muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendencies are all symptoms of cirrhosis. The client may also have mild fever, edema, abdominal pain, and an enlarged liver.

A child is sent to pediatric intensive care following surgery for a brain tumor. Which prescription would the nurse question? a. elevate head of bed 90 degrees b. position on nonsurgical side c. phenytoin d. docusate sodium Ricci Chapter 46

a. elevate head of bed 90 degrees

The nurse has developed a nursing plan for the care of a 6-year-old girl with congenital hydrocephalus whose shunt has become infected. The most important discharge teaching point for this family is: a. ensuring the parents know how to properly give antibiotics. b. maintaining effective cerebral perfusion. c. establishing seizure precautions for the child. d. encouraging development of motor skills. RIcci Chapter 38

a. ensuring the parents know how to properly give antibiotics.

The nurse knows that disorders of the pituitary gland depend on the location of the physiologic abnormality. In caring for a child that has issues with the anterior pituitary, the nurse knows that this child has issues with which hormone? a. growth hormone b. vasopressin c. antidiuretic hormone d. oxytocin Ricci Chapter 48

a. growth hormone

The nurse is interpreting the negative feedback system that controls endocrine function. What secretion will the nurse correlate as decreasing while blood glucose levels decrease? a. insulin b. adrenocorticotropic hormone c. glucagon d. glycogen Ricci Chapter 48

a. insulin

The nurse is evaluating the complete blood count of a 7-year-old child with a suspected hematological disorder. Which finding is associated with an elevated mean corpuscular volume (MCV)? a. macrocytic red blood cells (RBCs) b. hemoglobin (Hgb) of 11.2 g/dl (112 g/L) c. platelet count of 250,000 d. decreased white blood cells (WBCs) Ricci Chapter 46

a. macrocytic red blood cells (RBCs)

A 14-year-old client has just been diagnosed with Graves disease. Which symptom(s) is likely to be noted in the assessment? Select all that apply. a. moist skin b. nervousness c. exophthalmos d. obesity e. lethargy f. increased basal metabolic rate Ricci Chapter 48

a. moist skin b. nervousness c. exophthalmos f. increased basal metabolic rate

A child is hospitalized with dehydration as a result of rotavirus. When reviewing the plan of treatment, what can the nurse anticipate will be included? Select all that apply. a. monitor of intake and output b. IV fluid administration c. antidiarrheal agents d. daily weight assessment e. antibiotic therapy Ricci Chapter 42

a. monitor of intake and output b. IV fluid administration d. Daily weight assessment Rotavirus is viral in nature. Antibiotic therapy is not used in the care and treatment of a viral infection. Antidiarrhea medications are not utilized as they are not effective. Intake and output will be observed. Daily weight will aid in the determination of hydration status. IV fluids may be indicated in the rehydration process.

The nurse is using the pediatric Glasgow Coma Scale to assess a child's level of consciousness. What would the nurse assess? Select all that apply. a. motor response b. eye opening c. verbal response d. fontanels (fontanelles) e. posture Ricci Chapter 38

a. motor response b. eye opening c. verbal response

The nurse caring for an 18-month-old infant with Meckel diverticulum knows that the most common clinical manifestation of this condition is: a. painless rectal bleeding. b. ischemia. c. dehydration. d. respiratory distress. Ricci Chapter 42

a. painless rectal bleeding.

A parent brings a 10-year-old child to the emergency room with reports of abdominal pain. The nurse performing a physical assessment notes the following symptoms: upper right quadrant pain that radiates to the back; fever; nausea; and abdominal distention. Which disease would the nurse suspect? a. pancreatitis b. ulcerative colitis c. appendicitis d. Crohn disease Ricci Chapter 42

a. pancreatitis

The nurse is caring for an infant with increased intracranial pressure. The mother is preparing to feed the child. What action by the mother indicates an understanding of the proper care of this infant? a. placing the infant in an infant car seat after feeding the infant b. placing the infant supine in the crib after feeding the infant c. placing the infant prone in the crib after feeding the infant d. placing the infant in a Sims position in the crib after feeding the infant RIcci Chapter 38

a. placing the infant in an infant car seat after feeding the infant

The nurse is discussing disorders of the hematopoietic system when a client asked about erythrocytosis. What disease will the nurse mention with a primary characteristic of erythrocytosis? a. polycythemia vera b. sickle cell disease c. aplastic anemia d. pernicious anemia Hinkle Chapter 30

a. polycythemia vera

The nurse is caring for a teenager recently diagnosed with Addison disease. Which findings can be anticipated by the nurse? Select all that apply. a. potassium level 5.6 mEq/L (5.6 mmol/L) b. muscular weakness c. rapid weight gain d. facial acne e. sodium level 128 mEq/L (128 mmol/L) Ricci Chapter 48

a. potassium level 5.6 mEq/L b. muscular weakness e. sodium level 128 mEq/L Hyponatermia, hyperkalemia and muscle weakness are all symptoms of Addison disease. Rapid weight gain and acne are present in Cushing disorder, not Addison.

A 3-month-old is admitted with severe diarrhea. Yesterday, the infant weighed 11 pounds (5 kg). Today, this infant weighs 9 pounds, 8 ounces (4.3 kg). Based on this information the nurse documents that the infant has: a. severe dehydration. b. malabsorption syndrome. c. risk for fluid volume deficit. d. failure to thrive. Ricci Chapter 42

a. severe dehydration.

The nurse is caring for a 6-year-old girl with leukemia who is having an oncologic emergency. Which signs and symptoms would indicate hyperleukocytosis? a. tachycardia and respiratory distress b. respiratory distress and poor perfusion c. bradycardia and distinct S1 and S2 sounds d. wheezing and diminished breath sounds Ricci Chapter 46

a. tachycardia and respiratory distress

A client with severe chronic anemia is receiving ongoing transfusion therapy. The nurse frequently assesses the client for what major complication of this therapy? a. toxic iron overload b. chronic idiopathic thrombocytic purpura c. fibrin clots d. vaso-occlusive crisis Ricci Chapter 46

a. toxic iron overload Explanation:The major complication of an ongoing transfusion therapy program is the development of toxic iron overload, which leads to pathologic changes in body systems, including the hepatic, endocrine, and cardiac systems.

A 3-year old child is brought to the emergency department by the parents. Assessment reveals bruising and bleeding from the nose and mouth. The nurse suspects which condition? a. von Willebrand disease (vWD) b. chronic iron deficiency anemia c. hemophilia d. disseminated intravascular coagulation (DIC) Ricci Chapter 46

a. von Willebrand disease (vWD)

A nurse is working on a neurological unit with a nursing student who asks the difference between primary and secondary headaches. The nurse's correct response will include which of the following statements? a. "A migraine headache is an example of a secondary headache." b. "A secondary headache is associated with an organic cause, such as a brain tumor." c. "A secondary headache is located in the frontal area." d. "A secondary headache is one for which no organic cause can be identified." 61

b. "A secondary headache is associated with an organic cause, such as a brain tumor."

A 2-year-old client is at the office for a follow-up visit. The client has had excessive hormone levels in recent bloodwork and the parents question why this was not found sooner. What is the best response by the nurse? a. "Endocrine disorders are hard to detect and you are lucky that we have found it when we did." b. "As endocrine functions become more stable throughout childhood, alterations become more apparent." c. "Have there been signs and symptoms that you should have reported to the doctor?" d. "It takes time to determine the level of functioning of endocrine glands." Ricci Chapter 48

b. "As endocrine functions become more stable throughout childhood, alterations become more apparent."

A 6-year-old has had a viral infection for the past 5 days and is having severe vomiting, confusion, and irritability, although he is now afebrile. During the assessment, the nurse should ask the parent which question? a. "What type of fluids did your child take when he had a fever?" b. "Did you use any medications, like aspirin, for the fever?" c. "Did you give your child any acetaminophen, such as Tylenol?" d. "How high did his temperature rise when he was ill?" RIcci Chapter 38

b. "Did you use any medications, like aspirin, for the fever?" Severe and continual vomiting, changes in mental status, lethargy, and irritability are some of the signs and symptoms of Reye syndrome, which can occur as a result of ingesting aspirin or aspirin-containing products during a viral infection. Tylenol (acetaminophen) is allowed for viral infections in the school-age child. The type of fluids consumed during the illness has nothing to do with Reye syndrome. The temperature rise would be important for a much younger child because of the chance of febrile seizures, but not in this age child.

A 15-year-old adolescent is scheduled for a pelvic ultrasound to evaluate for a possible ovarian cyst. Which instruction by the nurse would be most appropriate? a. "Limit your level of physical activity for one-half hour before the test." b. "Drink plenty of fluids because you need to have a full bladder." c. "You won't be able to drink any water before or during the test." d. "You need to remain very still for the entire test." Ricci Chapter 48

b. "Drink plenty of fluids because you need to have a full bladder." A full bladder is needed for an ultrasound of the pelvic region. The client needs to remain still for a computed tomography or magnetic resonance imaging scan, not an ultrasound. Water is withheld during a water deprivation test used to detect diabetes insipidus. Limiting stress and physical activity for 30 minutes before the test is required for the growth hormone stimulation test.

The mother of a toddler tells the nurse during a routine well-child appointment that she is concerned because, "It seems like my son is falling and hitting his head all of the time." What is the best response by the nurse? a. "I understand your concern, but toddlers fall and hit their heads a lot since they are not very coordinated yet." b. "Due to the size of their heads and immature neck muscles falling is common, but I will let the physician know your concerns." "c. You probably don't have anything to worry about. It is common for toddlers to fall." d. "Most mothers are concerned because their toddlers fall a lot. As long as your child seems to be developmentally normal it shouldn't be a concern." Ricci Chapter 38

b. "Due to the size of their heads and immature neck muscles falling is common, but I will let the physician know your concerns." The head of the infant and young child is large in proportion to the body, and is the fastest-growing body part during infancy and continues to grow until the child is 5 years old. In addition, the infant's and child's neck muscles are not well developed. Both of these differences lead to an increased incidence of head injury from falls. The nurse should still let the physician know the mother's concerns in case there is another issue causing the falls.

The nurse is caring for a 2-year-old boy with an umbilical hernia and is teaching the mother about this condition. Which response from the mother indicates a need for further teaching? a. "An incarcerated hernia is rare, but it can occur." b. "I can tape a quarter over the hernia to reduce it." c. "I need to watch for pain, tenderness, or redness." d. "My son could have some appearance-related self-esteem issues." Ricci Chapter 42

b. "I can tape a quarter over the hernia to reduce it." Rationale: The use of home remedies to reduce an umbilical hernia should be discouraged because of the risk of bowel strangulation. The mother needs to be aware that strangulation can occur, but it is rare with an umbilical hernia.

The nurse is caring for a child who has suffered a febrile seizure. While speaking with the child's parents, which statement by a parent indicates a need for further education? a. "I need to set an alarm to wake up and check his temperature during the night when he is sick." b. "I hate to think that I will need to be worried about my child having seizures for the rest of his life." c. "When he gets his next set of immunizations, I need to make sure I give him some ibuprofen so he doesn't spike a fever." d. "The next time he has a fever, I need to make sure I read the dosage on the acetaminophen bottle carefully." Ricci Chapter 38

b. "I hate to think that I will need to be worried about my child having seizures for the rest of his life." Rationale: Febrile seizures occur most often in preschool children but can occur as late as 7 years of age. They occur when the child has a rapid rise in temperature and are not associated with the development of seizures later in life. Administering correct dosages of acetaminophen and ibuprofen, checking temperatures at night, and anticipating fevers associated with the administration of live vaccines are all ways to prevent the development of febrile seizures.

The nurse is providing teaching to the parents of a child recently prescribed carbamazepine for a seizure disorder. Which statement by a parent indicates successful teaching? a. "I'm glad to know he will only need this medication for a short time to stop his seizures." b. "I need to watch for any new bruises or bleeding and let my health care provider know about it." c. "I will give the medication to him when I first wake him up in the morning." d. "This medication may cause him to have trouble sleeping. He may need something else to help him sleep." Ricci Chapter 38

b. "I need to watch for any new bruises or bleeding and let my health care provider know about it."

The nurse is teaching the mother of a 5-year-old boy with a history of impaction how to administer enemas at home. Which response from the mother indicates a need for further teaching? a. "He should retain the solution for 5 to 10 minutes." b. "I should position him on his abdomen with knees bent." c. "I should wash my hands and then wear gloves." d. "He will require 250 to 500 mL of enema solution." Ricci Chapter 42

b. "I should position him on his abdomen with knees bent." Rationale: A 5-year-old child should lie on his left side with his right leg flexed toward the chest. An infant or toddler is positioned on his abdomen. Using 250 to 500 mL of solution, washing hands and wearing gloves, and retaining the solution for 5 to 10 minutes are appropriate responses.

The parent of a 3-week-old infant brings the infant in for an evaluation. During the visit, the parent tells the nurse that the infant is spitting up after feedings. Which response by the nurse would be most appropriate? a. "Do not worry; you are just feeding your infant too much." b. "Infants this age commonly spit up." c. "Your child might have an allergy." d. "Thicken the formula by adding oat cereal." Ricci Chapter 42

b. "Infants this age commonly spit up."

What is the best response by the nurse to the parents of a child with leukemia who express guilt because they did not take immediate action when their child seemed to develop one respiratory infection after another? a. "Young children develop minor illness easily and often. Stop being hard on yourselves." b. "Keep in mind that the signs of leukemia are often subtle and difficult to recognize." c. "Don't feel bad. Children get lots of colds." d. "You need to focus on the present treatment now and not worry about the past." Ricci Chapter 46

b. "Keep in mind that the signs of leukemia are often subtle and difficult to recognize." Rationale: Pointing out that the signs and symptoms of leukemia are often difficult to recognize indicates to the parents that they were not neglectful, while also providing information about the disease. The other responses minimize the parents' feelings or tell them how they should feel and are not therapeutic.

The nurse is preparing to present an educational session on pediatric cardiopulmonary arrests. The nurse will include which statement in the teaching? a. "Obtaining an automated external defibrillator (AED) is vital to survival." b. "Most pediatric arrests stem from airway and breathing issues." c. "Activate the emergency response system first in an unwitnessed event." d. "Start cardiopulmonary resuscitation (CPR) in an infant if the heart rate is below 75 beats per minute." Ricci Chapter 51

b. "Most pediatric arrests stem from airway and breathing issues."

A nurse is caring for a 6-year-old girl recently diagnosed with celiac disease and is discussing dietary restrictions with the girl's mother. Which response indicates a need for further teaching? a. "There are many types of flour besides wheat." b. "My daughter can eat any kind of fruit." c. "There is gluten hidden in unexpected foods." d. "My daughter is eating more vegetables." Ricci Chapter 42

b. "My daughter can eat any kind of fruit." While most fruits and fruit juices are allowed, the nurse needs to make sure the mother knows that some fruit pie fillings and dried fruit may contain gluten.

A nurse is providing dietary interventions for a 5-year-old with an iron deficiency. Which response indicates a need for further teaching? a. "He will enjoy tuna casserole and eggs." b. "Red meat is a good option; he loves the hamburgers from the drive-thru." c. "There are many iron fortified cereals that he likes." d. "I must encourage a variety of iron-rich foods that he likes." Ricci Chapter 46

b. "Red meat is a good option; he loves the hamburgers from the drive-thru."

A couple is expecting a child. The fetus undergoes genetic testing and the couple discover the fetus has sickle cell disease. The couple ask the nurse how most commonly happens. Which statement is accurate for the nurse to provide? a. "Sickle cell disease occurs from a random genetic mutation." b. "Sickle cell disease is passed to a fetus when both parents have the gene." c. "Sickle cell diseas can be passed to the fetus in many ways. We will know more at birth." d. "Sickle cell disease is passed to a fetus when one of the parents has the gene." Ricci Chapter 46

b. "Sickle cell anemia is passed to a fetus when both parents have the gene." Explanation:Sickle cell anemia is an inherited disease. The recessive gene is passed from both parents who either have the disease or the trait

After explaining the causes of hypothyroidism to the parents of a newly diagnosed infant, the nurse should recognize that further education is needed when the parents ask which question? a. "So, hypothyroidism can be only temporary, right?" b. "So, hypothyroidism can be treated by exposing our baby to a special light, right?" c. "Are you saying that hypothyroidism is caused by a problem in the way the thyroid gland develops?" d. "Do you mean that hypothyroidism may be caused by a problem in the way the body makes thyroxine?" Ricci Chapter 48

b. "So, hypothyroidism can be treated by exposing our baby to a special light, right?" Congenital hypothyroidism can be permanent or transient and may result from a defective thyroid gland or an enzymatic defect in thyroxine synthesis. Only the last question, which refers to phototherapy for physiologic jaundice, indicates that the parents need more information

A child who has been having seizures is admitted to the hospital for diagnostic testing. The child has had laboratory testing and an EEG, and is scheduled for a lumbar puncture. The parents voice concern to the nurse stating, "I don't understand why our child had to have a lumbar puncture since the EEG was negative." What is the best response by the nurse? a. "A lumbar puncture is a routine test that is performed anytime someone has a seizure disorder." b. "The lumbar puncture can help rule out any infection in fluid surrounding the brain and spinal cord as the cause of the seizures." c. "I know it must be frustrating not having a diagnosis yet, but you have to be patient. Seizure disorders are difficult to diagnose." d. "Since the EEG was negative there must be some other cause for the seizures. The lumbar puncture is necessary to determine what the cause is." Ricci Chapter 38

b. "The lumbar puncture can help rule out any infection in fluid surrounding the brain and spinal cord as the cause of the seizures."

The nurse is assessing a child diagnosed with Cushing syndrome. Which statement by the parents demonstrates a need for further teaching? a. "We need to pay close attention to any wounds our child gets to monitor for adequate healing." b. "This disorder is most likely due to an infection my child had recently." c. "My child may experience excessive weight gain." d. "My child's round, full face appearance is reversible with appropriate treatment." Ricci Chapter 48

b. "This disorder is most likely due to an infection my child had recently."

The nurse is preparing a client for surgery and the client asks, "What does it mean when they say they are going to reduce my abdominal hernia?" Which response by the nurse is most appropriate? a. "If you do not understand this, I need to cancel your surgery and have the health care provider come back." b. "This means the hernia contents will be manipulated back into your peritoneal cavity during surgery." c. "All this means is that the herniated intestines are twisted and edematous, which is why you need surgery." d. "The health care provider will remove about half of the herniated contents during the procedure." Ricci Chapter 42

b. "This means the hernia contents will be manipulated back into your peritoneal cavity during surgery." Rationale: A hernia in the abdominal region is considered reducible when its contents are easily manipulated back through the inguinal ring into the peritoneal cavity. The nurse would reinforce this education, already provided by the primary health care provider when the surgery was explained, to the client. It is not necessary to cancel surgery when the nurse can provide education to the client. Reducing does not mean the intestines are twisted and edematous. Nor does it mean half of the contents will be removed.

The nurse has told the 14-year-old adolescent with diabetes that the doctor would like to have a hemoglobin A1C test performed. Which comment by the client indicates that she understands what this test is for? a. "The normal level for my hemoglobin A1C is between 60 to 100 mg/dl." b. "This will tell my doctor what my average blood glucose level has been over the last 2 to 3 months." c. "I monitor my own blood glucose every day at home. I don't see why the doctor would want this done." d. "That is the test that I take after I have fasted for at least 8 hours." Ricci Chapter 48

b. "This will tell my doctor what my average blood glucose level has been over the last 2 to 3 months."

The nurse is taking a history on a 10-year-old child who has a diagnosis of hypopituitarism. Which question is important for the nurse to ask the parents? a. "Is your child taking vasopressin IM or SC?" b. "What time each day does your child take his growth hormone?" c. "Does your child get upset about being taller than friends?" d. "How often do you test your child's blood glucose?" Ricci Chapter 48

b. "What time each day does your child take his growth hormone?"

A nurse in the school office is seeing a 7-year-old child with type 1 diabetes after gym class. The child is jittery and appears sweaty. Which intervention would the nurse advise the child to do? a. "You will need to have an extra shot of regular insulin." b. "You will need to drink this 6-ounce bottle of orange juice." c. "You will need to skip your next dose of insulin." d. "You will need to sit in the office and rest after gym class." Ricci Chapter 48

b. "You will need to drink this 6-ounce bottle of orange juice."

The nurse is preparing a presentation for a local parent group about nutritional measures to prevent anemia. The group of parents have children between the ages of 4 and 8. The nurse would recommend a daily iron intake of which amount? a. 15 mg b. 10 mg c. 6 mg d. 12 mg Ricci Chapter 46

b. 10 mg

Cerebral edema peaks at which time point after intracranial surgery? a. 12 hours b. 24 hours c. 48 hours d. 72 hours Hinkle Chapter 61

b. 24 hours

The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the priority nursing intervention? a. Assess for weight loss. b. Administer corticosteroids as ordered. c. Document signs and symptoms of inflammation. d. Give acetaminophen per orders. Hinkle Chapter 61

b. Administer corticosteroids as ordered.

The nurse in the emergency department is caring for a 10-year-old female child with sickle cell crisis. Child rates pain 10 on a scale of 0 to 10. Vital signs: 99.8°F (37.6°C); heart rate, 122 beats/min; blood pressure, 92/50 mm Hg; respiratory rate, 26 breaths/min; oxygen saturation, 92% on room air. The nurse receives orders for the child. Click to highlight the order(s) that needs to be implemented immediately. a. Administer acetaminophen for headache or temperature greater than 101°F (38.3°C). b. Administer oxygen to maintain oxygen saturation greater than 95%. c. Start normal saline continuous intravenous (IV) infusion at 200 ml/hr. d. Administer 100 mcg/kg morphine IV for pain prn q4 hours. e. Initiate a regular diet as tolerated. Ricci Chapter 46

b. Administer oxygen to maintain oxygen saturation greater than 95%. c. Start normal saline continuous intravenous (IV) infusion at 200 ml/hr. d. Administer 100 mcg/kg morphine IV for pain prn q4 hours.

The nurse is to obtain a stool specimen from a 4-year-old child who has very liquid stool. The child is ambulatory but weak. Which collection method would be most effective for the nurse to use? a. Use a tongue blade to scrape a specimen from a diaper. b. Apply a urine bag to the anal area. c. Have the child defecate into a container in the toilet. d. Use a clean bedpan to collect the specimen. Ricci Chapter 42

b. Apply a urine bag to the anal area. With very liquid stool, applying a urine bag to the anal area is most effective in collecting the specimen. Using a tongue blade to scrape a specimen from a diaper would be appropriate if the stool is formed. However, putting a diaper on a 4-year-old would be demeaning. Defecating into a collection container that sits at the back of the toilet would be more appropriate for an older child who is ambulatory. A bedpan would be appropriate if the child was bedridden.

A child presents to the emergency department via ambulance in critical condition following a traumatic motor vehicle collision. What action will the nurse take first? a. Update the parent and obtain consent to treat. b. Assess the child's airway and manage airway patency. c. Begin circulation/cardiac assessment and count the pulse. d. Remove the child's clothing to assess for injury. Ricci Chapter 51

b. Assess the child's airway and manage airway patency.

An elderly client is hospitalized for induction of chemotherapy to treat leukemia. The client reports fatigue to the nurse. What nursing intervention would best address the client's fatigue? a. Talk to the family about not visiting so the client can obtain rest. b. Assist the client to sit in a chair for meals. c. Have the client maintain complete bedrest. d. Provide sedentary activities only, such as watching television. Hinkle Chapter 30

b. Assist the client to sit in a chair for meals.

A child being treated for leukemia is diagnosed with neutropenia. What nursing instructions directly prevent client infections? Select all that apply. a. Increase the intake of fresh fruits and vegetables. b. Avoid large crowds. c. Stay away from people who have obvious colds, rashes, or other infections. d. Remove house plants, flowers, and goldfish from the home environment. e. Inspect the skin daily for scratches or scrapes. Ricci Chapter 46

b. Avoid large crowds. c. Stay away from people who have obvious colds, rashes, or other infections. d. Remove house plants, flowers, and goldfish from the home environment. e.Inspect the skin daily for scratches or scrapes. Explanation:Strategies to prevent infections in a child with neutropenia include avoiding large crowds; inspecting the skin daily for scratches or scrapes; removing house plants, flowers, and goldfish from the home environment; and staying away from people who have obvious colds, rashes, or other infections. The child's intake of fresh fruits and vegetables should be limited because this could be a source for bacteria.

Which nursing action should be included in the care plan to promote comfort in a 4-year-old child hospitalized with meningitis? a. Rock the child frequently. b. Avoid making noise when in the child's room. c. Have the child's 2-year-old brother stay in the room. d. Keep the lights on brightly so that he can see his mother. Ricci Chapter 38

b. Avoid making noise when in the child's room. Rationale: Meningeal irritation may cause seizures and heightens a child's sensitivity to all stimuli, including noise, lights, movement, and touch. Frequent rocking, presence of a younger sibling, and bright lights would increase stimulation.

Which of the following is the most common side effect of tissue plasminogen activator (tPA)? a. Headache b. Bleeding c. Increased intracranial pressure (ICP) d. Hypertension Hinkle Chapter 62

b. Bleeding

A newborn exhibits significant jittery movements, convulsions, and apnea. Hypoparathyroidism is suspected. What would the nurse expect to be administered? a. Hydrocortisone b. Calcium gluconate c. Desmopressin d. Levothyroxine Ricci Chapter 48

b. Calcium gluconate Intravenous calcium gluconate is used to treat acute or severe tetany. Hydrocortisone is used to treat congenital adrenal hyperplasia and Addison disease. Desmopressin is used to control diabetes insipidus. Levothyroxine is a thyroid hormone replacement used to treat hypothyroidism.

The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following? a. Cerebral aneurysm b. Cardiogenic emboli c. Arteriovenous malformation d. Intracerebral hemorrhage Hinkle Chapter 62

b. Cardiogenic emboli Rationale: Aneurysms, hemorrhages, and malformations are all examples of a hemorrhagic stroke. An embolism can block blood flow, leading to ischemia.

The nurse is caring for a client with chronic myeloid leukemia (CML) who is taking imatinib mesylate. In what phase of the leukemia does the nurse understand that this medication is most useful to induce remission? a. Accelerated b. Chronic c. Blast crisis d. Transformation Hinkle Chapter 30

b. Chronic

A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode? a. Recent stress level b. Compliance with the prescribed medication regimen c. Recent weight gain and loss d. The type of anticonvulsant prescribed to manage the epileptic condition Hinkle Chapter 61

b. Compliance with the prescribed medication regimen Rationale: The most common cause of status epilepticus is sudden withdraw of anticonvulsant therapy.

The nurse is assigned an infant with a possible neurological disorder. Which assessment finding would the nurse communicate to the health care provider as a late sign of increased intracranial pressure? a. Dizziness and irritability b. Decorticate posturing and fixed and dilated pupils c. Decreased pupil reaction and decreased respiration. d. Headache and sunset eyes Ricci Chapter 38

b. Decorticate posturing and fixed and dilated pupils Rationale: Decerebrate or decorticate posturing and fixed and dilated pupils are late signs of increased intracranial pressure. Decreased pupil reaction, decreased respirations, headache, sunset eyes, dizziness, and irritability are early signs of increased intracranial pressure.

The nurse is seeing a new client in the clinic who reports polyuria and polydipsia. These conditions are indicative of which endocrine disorder? a. Precocious puberty b. Diabetes insipidus (DI) c. Hypopituitarism d. Syndrome of inappropriate antidiuretic hormone (SIADH) secretion Ricci Chapter 48

b. Diabetes insipidus (DI)

A client is receiving radiation therapy for lesions in the abdomen from non-Hodgkin's lymphoma. Because of the effects of the radiation treatments, what will the nurse assess for? a. Hair loss b. Diarrheal stools c. Laryngeal edema d. Adventitious lung sounds Hinkle Chapter 30

b. Diarrheal stools

A patient has been diagnosed with myasthenia gravis. The nurse documents the initial and most common manifestation of: a. Generalized fatigue. b. Diplopia. c. Dysphoria. d. Facial muscle weakness. Hinkle Chapter 61

b. Diplopia.

The nurse is caring for a child admitted with gastroesophageal reflux (GER). Which clinical manifestation would likely be seen in this child? a. Severe constipation with occasional ribbon-like stools b. Effortless vomiting just after the child has eaten c. Forceful vomiting followed by the child being eager to eat again d. Bouts of diarrhea with failure to gain weight Ricci Chapter 42

b. Effortless vomiting just after the child has eaten Rationale: Almost immediately after feeding, the child with gastroesophageal reflux vomits the contents of the stomach. The vomiting is effortless, not projectile in nature.

A nurse examining a neonate is unable to identify the fetal stomach. The nurse knows that this sign strongly indicates which condition? a. pyloric stenosis b. esophageal atresia (EA) c. hernia d. duodenal atresia Ricci Chapter 42

b. Esophageal atresia (EA) Rationale: Inability to identify the fetal stomach strongly suggests EA. The upper abdomen is typically distended in pyloric stenosis and duodenal atresia. Hernias typically present as a bulge in the groin area.

A nurse prepares a client for a bone marrow biopsy who is suspected of having acute myeloid leukemia. What results from the bone marrow biopsy does the nurse expect? a. Deficiency of erythrocytes b. Excess of immature leukocytes c. Deficiency of neutrophils d. Excess of immature erythrocytes Hinkle Chapter 30

b. Excess of immature leukocytes Rationale: The bone marrow biopsy of a client with acute myeloid leukemia will reveal an excess of immature leukocytes.

The nurse is caring for a client with an inoperable brain tumor. What teaching is important for the nurse to do with these clients? a. Offering family support groups b. Explaining hospice care and services c. Optimizing nutrition d. Managing muscle weakness Hinkle Chapter 61

b. Explaining hospice care and services

Aneurysm rebleeding occurs most frequently during which time frame after the initial hemorrhage? a. First 48 hours b. First 12 hours c. First 72 hours d. First 24 hours Hinkle Chapter 62

b. First 12 hours

Which type of deficiency results in macrocytic anemia? a. Vitamin K b. Folic acid c. Vitamin A d. Vitamin C Hinkle Chapter 43

b. Folic acid

After hospital discharge, the parent of a child newly diagnosed with type 1 diabetes mellitus telephones the nurse because the child is acting confused and very sleepy. Which emergency measure would the nurse suggest the parent carry out before bringing the child to see the health care provider? a. Give the child one unit of regular insulin. b. Give the child a glass of orange juice. c. Give the child a glass of orange juice with one unit regular insulin in it. d. Give the child nothing by mouth so that a blood sugar can be drawn at the health care provider's office. Ricci Chapter 48

b. Give the child a glass of orange juice.

A pediatric nurse is discharging a 1-month-old infant. The infant was diagnosed with congenital hypothyroidism on this admission and will be treated with levothyroxine. The nurse knows it is important to teach the parent about medication administration. Which process will the nurse include in the teaching? a. Explain that this treatment is administered until the child is 3 years of age. b. Give the crushed medication in a syringe mixed with a small amount of formula. c. Administer the medication every other day. d. Crush the medication and put it in the full bottle of formula so it tastes better. Ricci Chapter 48

b. Give the crushed medication in a syringe mixed with a small amount of formula.

A client is demonstrating an altered level of consciousness from a traumatic brain injury. Which assessment will the nurse use as a sensitive indicator of neurologic function? a. Cranial nerve function b. Glasgow Coma Scale c. Mental status evaluation d. Cerebellar function Hinkle Chapter 61

b. Glasgow Coma Scale

A client diagnosed with multiple myeloma (MM) is prescribed long-term corticosteroid therapy. Which assessment(s) will the nurse prioritize to monitor for possible complications? Select all that apply. a. Hair growth disorders b. Glucose levels c. Skin disorders d. Vision problems e. Sleeping patterns Hinkle Chapter 30

b. Glucose levels d. Vision problems e. Sleeping patterns

During an assessment of an adolescent child, the nurse notes that the child has a protuberant tongue, fatigued appearance, poor muscle tone, and exophthalmos. What medical diagnosis would the nurse expect the child to have? a. Cushing disease b. Graves disease c. diabetes d. syndrome of inappropriate antidiuretic hormone secretion (SIADH) Ricci Chapter 48

b. Graves disease Symptoms of Graves disease include an increased rate of growth; weight loss despite an excellent appetite; hyperactivity; warm, moist skin; tachycardia; fine tremors; an enlarged thyroid gland or goiter; and ophthalmic changes including exophthalmos.

During an assessment of an adolescent child, the nurse notes that the child has a protuberant tongue, fatigued appearance, poor muscle tone, and exophthalmos. What medical diagnosis would the nurse expect the child to have? a. Cushing disease b. Graves disease c. syndrome of inappropriate antidiuretic hormone secretion (SIADH) d. diabetes Ricci Chapter 48

b. Graves disease Symptoms of Graves disease include an increased rate of growth; weight loss despite an excellent appetite; hyperactivity; warm, moist skin; tachycardia; fine tremors; an enlarged thyroid gland or goiter; and ophthalmic changes including exophthalmos.

A 12-year-old child has hyperthyroidism. The nurse understands that the most common cause of hyperthyroidism in children is: a. Cushing syndrome. b. Graves disease. c. Addison disease. d. Plummer disease. Ricci Chapter 48

b. Graves disease.

A client has an elevated serum ammonia concentration and is exhibiting changes in mental status. The nurse should suspect which condition? a. Portal hypertension b. Hepatic encephalopathy c. Asterixis d. Cirrhosis Hinkle Chapter 43

b. Hepatic encephalopathy Hepatic encephalopathy is a central nervous system dysfunction resulting from liver disease. It is frequently associated with an elevated ammonia concentration that produces changes in mental status, altered level of consciousness, and coma. Portal hypertension is an elevated pressure in the portal circulation resulting from obstruction of venous flow into and through the liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.

A nurse is caring for a client with multiple myeloma. Which laboratory value is the nurse most likely to see? a. Hypermagnesemia b. Hypercalcemia c. Hyperkalemia d. Hypernatremia Hinkle Chapter 30

b. Hypercalcemia Rationale: Calcium is released when bone is destroyed, causing hypercalcemia. Multiple myeloma doesn't affect potassium, sodium, or magnesium levels.

The assessment of a client admitted with increased ascites related to cirrhosis reveals the following: pulse 86 beats per minute and weak, respirations 28 breaths per minute, blood pressure 130/88 mm Hg, and pulse oximetry 90%. Which nursing diagnosis should receive top priority? a. Imbalanced nutrition: less than body requirements b. Ineffective breathing pattern c. Excess fluid volume d. Fatigue Hinkle Chapter 43

b. Ineffective breathing pattern

A nurse is teaching the parents of a child with sickle cell disease about factors that predispose the child to a sickle cell crisis. The nurse determines that the teaching was successful when the parents identify what as a factor? a. Pallor b. Infection c. Respiratory distress d. Fluid overload Ricci Chapter 46

b. Infection Explanation:Factors that may precipitate a sickle cell crisis include: fever, infection, dehydration, hot or humid environment, cold air or water temperature, high altitude, or excessive physical activity. Respiratory distress and pallor are general signs and symptoms of a sickle cell crisis.

The nurse is caring for a child who has suffered a head injury and has had an ICP monitor placed. Which prescription by the health care provider would the nurse question? a. Administer dexamethasone, dosage determined by the pharmacist. b. Initiate an IV of 0.9% NS to run at 250 ml/hr. c. Administer mannitol IV, dosage determined by the pharmacist. d. Place in an indwelling urinary catheter. Ricci Chapter 38

b. Initiate an IV of 0.9% NS to run at 250 ml/hr.

An emergency department nurse is interviewing a client who is presenting with signs of an ischemic stroke that began 2 hours ago. The client reports a history of a cholecystectomy 6 weeks ago and is taking digoxin, warfarin, and labetalol. What factor poses a threat to the client for thrombolytic therapy? a. Surgery 6 weeks ago b. International normalized ratio greater than 2 c. Two hour time period of the stroke d. Taking digoxin Hinkle Chapter 62

b. International normalized ratio greater than 2 Rationale: The client is at risk for further bleeding if the international normalized ratio is greater than 2. Thrombolytic therapy must be initiated within 3 hours in clients with ischemic stroke. The client is not eligible for thrombolytic therapy if she has had surgery within 14 days. Digoxin and labetalol do not prohibit thrombolytic therapy.

The nurse is educating a group of people newly diagnosed with migraine headaches. What information should the nurse include in the educational session? Select all that apply. a. Sleep no more than 5 hours at a time. b. Keep a food diary. c. Use St. John's Wort. d. Exercise in a dark room. e. Maintain a headache diary. Hinkle Chapter 61

b. Keep a food diary. e. Maintain a headache diary. Rationale: The patients should be encouraged to keep a food and headache diary to identify triggers, and to track frequency and characteristics of the migraines. The patients should maintain a routine sleep pattern and avoid fatigue. Limiting sleep to 5 hours may cause fatigue. The associated symptoms of a migraine are nausea, vomiting, and photophobia. Being in a dark room may ease the photophobia, but the exercise may worsen the headache and associated symptoms. Patients who are taking medications specific for migraines should avoid St. John's Wort due to potential drug interactions

A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication? a. Lamisil b. Lamictal c. Lomotil d. Labetalol Hinkle Chapter 61

b. Lamictal

What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke? a. Slow, cautious behavior b. Left visual field deficit c. Aphasia d. Altered intellectual ability Hinkle Chapter 62

b. Left visual field deficit

A previously healthy adult's sudden and precipitous decline in health has been attributed to fulminant hepatic failure, and the client has been admitted to the intensive care unit. The nurse should be aware that the treatment of choice for this client is what? a. Lobectomy b. Liver transplantation c. IV administration of immune globulins d. Transfusion of packed red blood cells and fresh-frozen plasma (FFP) Hinkle Chapter 43

b. Liver transplantation Liver transplantation carries the highest potential for the resolution of fulminant hepatic failure. This is preferred over other interventions, such as pharmacologic treatments, transfusions, and surgery.

The nurse is called to attend to a patient having a seizure in the waiting area. What nursing care is provided for a patient who is experiencing a convulsive seizure? Select all that apply. a. Opening the patient's jaw and inserting a mouth gag b. Loosening constrictive clothing c. Restraining the patient to avoid self injury d. Positioning the patient on his or her side with head flexed forward e. Providing for privacy Hinkle Chapter 61

b. Loosening constrictive clothing d. Positioning the patient on his or her side with head flexed forward e. Providing for privacy

A client presents reporting headache that she describes as "throbbing pain on the left side of my head and sensitivity to light and motion." The nurse asks the client to describe the sequence of events before the onset of the headache. Which signs and symptoms described by the client are characteristic of the prodrome phase of a migraine headache? Select all that apply. a. Fatigue b. Loss of appetite c. Seeing flashing lights d. Frequent yawning e. Neck stiffness Ricci Chapter 38

b. Loss of appetite d. Frequent yawning e. Neck stiffness Rationale: The prodrome phase includes experiencing signs and symptoms that occur hours or days before the onset of the headache. Stiffness of the neck muscles, frequent yawning, or loss of appetite are common during the prodrome (or preheadache) phase. Seeing flashing lights is an aura, which is a warning sign of the impending onset of a migraine headache. Fatigue is common during the postdrome portion of a migraine.

A female client who reports recurring headaches, accompanied by increased irritability, photophobia, and fatigue is asked to track the headache symptoms and occurrence on a calendar log. Which is the best nursing rationale for this action? a. Headaches are the most common type of reported pain. b. Migraines often coincide with menstrual cycle. c. Cluster headaches can cause severe debilitating pain. d. Tension headaches are easier to treat. Hinkle Chapter 62

b. Migraines often coincide with menstrual cycle.

When providing care for a child immediately after a bone marrow aspiration, which nursing action is priority? a. Allow the child to play with a doll and syringe. b. Monitor the site dressing and vital signs. c. Educate the family on proper handwashing. d. Evaluate pain and administer medication. Ricci Chapter 46

b. Monitor the site dressing and vital signs.

A nurse is assessing a patient's urinary output as an indicator of diabetes insipidus. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator? a. 100 to 150 mL/h b. More than 200 mL/h c. 50 to 100 mL/h d. 150 to 200 mL/h Hinkle Chapter 61

b. More than 200 mL/h Rationale: For patients undergoing dehydrating procedures, vital signs, including blood pressure, must be monitored to assess fluid volume status. An indwelling urinary catheter is inserted to permit assessment of renal function and fluid status. During the acute phase, urine output is monitored hourly. An output greater than 200 mL per hour for 2 consecutive hours may indicate the onset of diabetes insipidus.

A client is scheduled to have a laparoscopic cholecystectomy as an outpatient. The client asks the nurse when the client will be able to resume normal activities. What information should the nurse provide? a. Normal activities may be resumed the day after surgery. b. Normal activities may be resumed in 1 week. c. Normal activities may be resumed in 1 month. d. Normal activities may be resumed in 2 weeks. Hinkle Chapter 43

b. Normal activities may be resumed in 1 week. A prolonged recovery period usually is unnecessary. Most clients resume normal activities within 1 week.

A client is about to be discharged after undergoing surgery for the treatment of a brain tumor and has a referral in place for medical and radiation oncology. Which component(s) should be included in the discharge teaching for this client? Select all that apply. a. Electromyography b. Nutritional support c. Medication regimen d. Adverse effects of chemotherapy or radiation and techniques for managing them e. Appointments for chemotherapy or radiotherapy Hinkle Chapter 61

b. Nutritional support c. Medication regimen d. Adverse effects of chemotherapy or radiation and techniques for managing them e. Appointments for chemotherapy or radiotherapy

The nurse is caring for a teenager diagnosed with acute pancreatitis. Which order would the nurse question? a. NPO b. PO pain management c. nasogastric tube placed to suction d. serum amylase levels Ricci Chapter 42

b. PO pain management Maintain NPO status and nasogastric tube suction and patency. Administer intravenous fluids to keep the child hydrated and correct any alterations in fluid and electrolyte balance. Pain management is crucial in children with pancreatitis; due to NPO status, medications are typically prescribed intravenously. Serial monitoring of serum amylase levels will determine when oral feeding may be restarted.

A client with polycythemia vera has a basophil count of greater than 2. Which assessment finding will the nurse expect to assess in this client? a. Ruddy complexion b. Pruritis c. Early satiety d. Dizziness Hinkle Chapter 30

b. Pruritis

Which liver function study is used to show the size of the liver and hepatic blood flow and obstruction? a. Magnetic resonance imaging (MRI) b. Radioisotope liver scan c. Electroencephalography (EEG) d. Angiography Hinkle Chapter 43

b. Radioisotope liver scan

A child who has type 1 diabetes mellitus is brought to the emergency department and diagnosed with diabetic ketoacidosis. What treatment would the nurse expect to administer? a. Detemir b. Regular insulin c. NPH d. Lispro Ricci Chapter 48

b. Regular insulin Insulin for diabetic ketoacidosis is given intravenously. Only regular insulin can be administered by this route

The nurse is caring for a preschooler who has developed a high fever and has just had a seizure. What is the best action by the nurse? a. Administer acetaminophen by mouth as prescribed. b. Remove any blankets or heavy clothing and replace with a thin sheet c. Place the child in a bathtub filled with cool water. d. Apply ice packs to the child's axillary and groin area. Ricci Chapter 38

b. Remove any blankets or heavy clothing and replace with a thin sheet

A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? a. Maintaining adequate hydration b. Restricting fluid intake and hydration c. Hyperoxygenation before and after tracheal suctioning d. Administering prescribed antipyretics Hinkle Chapter 61

b. Restricting fluid intake and hydration Rationale: Fluid restriction may be necessary if the client develops cerebral edema and hypervolemia from SIADH. Antipyretics are administered to clients who develop hyperthermia. In addition, it is important to maintain adequate hydration in such clients. A client with neurological infection should be given tracheal suctioning and hyperoxygenation only when respiratory distress develops.

The nurse has been asked to participate in a community health teaching session. Which interventions would the nurse include to help achieve the 2030 National Health Goals to reduce the incidence of anemias? Select all that apply. a. Examine strategies for elderly community members to improve the quality of life. b. Review foods that are rich in iron that should be a part of a school-age child's diet. c. Explain the importance of healthy eating for adolescent participants. d. Emphasize ways to reduce unintentional injuries at home, work, and play. e. Instruct pregnant women to take iron supplementation as prescribed. Ricci Chapter 46

b. Review foods that are rich in iron that should be a part of school-age children's diets. c. Explain the importance of healthy eating for adolescent participants. e. Instruct pregnant women to take iron supplementation as prescribed.

When developing the postoperative plan of care for a child with sickle cell anemia who has undergone a splenectomy, which would the nurse identify as the priority? a. Risk for delayed growth and development b. Risk for infection c. Deficient fluid volume d. Impaired skin integrity Ricci Chapter 46

b. Risk for infection Explanation: Removal of the spleen places the child at significant risk for infection. Although the child's skin integrity is disrupted due to the surgery, this is not the priority nursing diagnosis. Loss of fluids occurs during surgery and adequate hydration is important to prevent a sickle cell crisis, but this diagnosis is not the priority in the postoperative period. Although the child is at risk for delayed growth and development, the priority postoperatively is to prevent infection.

A client with suspected multiple myeloma is reporting back pain. What is the priority nursing action? a. Have the client lie on a hard surface. b. Send the client for a spinal x-ray study. c. Have the client rest. d. Encourage ambulation. Hinkle Chapter 30

b. Send the client for a spinal x-ray study.

A 9-year-old boy is suffering from headaches but has no signs of physical or neurologic illness. Which intervention would be most appropriate? a. Have the child sleep without a pillow under his head. b. Teach the child and his parents to keep a headache diary. c. Review the signs of increased intracranial pressure with parents. d. Have the parents call the doctor if the child vomits more than twice. Ricci Chapter 38

b. Teach the child and his parents to keep a headache diary. Rationale: A headache diary can help identify any triggers so that the child can avoid them. Triggers can include foods eaten, amount of sleep the night before, or activities at home or school that might be causing stress.

While assessing a child with a suspected skull fracture, the nurse notes clear fluid draining from the child's nose. What is the priority action by the nurse? a. Document the finding as otorrhea. b. Test the fluid with a glucose reagent strip. c. Provide the child with tissues to wipe the nose with instructions not to blow the nose. d. Ask the child to blow the nose forcefully to clear the fluid. Ricci Chapter 51

b. Test the fluid with a glucose reagent strip.

An adolescent is diagnosed with hepatitis A. Which problem should be considered when planning care? a. The adolescent will be very irritable and perhaps require sedation. b. The adolescent will become fatigued easily. c. The adolescent's urine will be dark and infectious. d. Hypothermia is common. Ricci Chapter 42

b. The adolescent will become fatigued easily. Rationale: Hepatitis A is transmitted via the oral-fecal route; it is water borne and often occurs in areas of poor sanitation. The adolescent with hepatitis A will exhibit flu-like symptoms, a headache, anorexia and fatigue. The urine is not infectious and fever may be present as opposed to hypothermia. Irritability is not one of the symptoms of hepatitis A. The client is usually lethargic or listless.

A 6-year-old child has been found to have a stage II brain tumor. The parent asks the nurse to explain what "stage II" means. Which information would the nurse provide? a. Tumors have spread systemically throughout the body. b. The cancer has spread in the brain itself but the chance of complete surgical removal is good. c. The tumor has not extended into the surrounding tissue and can be completely removed surgically. d. Cancer cells have spread to local lymph nodes. Ricci Chapter 46

b. The cancer has spread in the brain itself but the chance of complete surgical removal is good.

A 9-year-old child with Graves disease is seen at the pediatrician's office reporting sore throat and fever. The nurse notes in the history that the child is taking propylthiouracil. Which of the following would concern the nurse? a. The child may not be taking the medication. b. The child may have developed leukopenia. c. The child must be participating in sports. d. The child needs to be started on an antibiotic drug. Ricci Chapter 48

b. The child may have developed leukopenia. Graves' disease is defined as an overproduction of thyroid hormones. Propylthiouracil is used to suppress thyroid function. A complication of Graves' disease is leukopenia.

The young boy was involved in a motor vehicle accident and was admitted to the pediatric intensive care unit with changes in level of consciousness and a high-pitched cry. Which are late signs of increased intracranial pressure? Select all that apply. a. The child states that he feels a little "dizzy." b. The child's heart rate is 56 beats per minute. c. The child's toes are pointed downward, his head and neck are arched backwards, and his arms and legs are extended. d. The sclera of the eyes is visible above the iris. e. The child's pupils are fixed and dilated. Ricci Chapter 38

b. The child's heart rate is 56 beats per minute. c. The child's toes are pointed downward, his head and neck are arched backwards, and his arms and legs are extended. e. The child's pupils are fixed and dilated.

When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke? a. The day before the patient is discharged b. The day the patient has the stroke c. After the nurse has received the discharge orders d. After the patient has passed the acute phase of the stroke Hinkle Chapter 62

b. The day the patient has the stroke

A school-age child is diagnosed as having Cushing syndrome from long-term therapy with oral prednisone. What assessment finding is consistent with this child's diagnosis and treatment? a. Child appears pale and fatigued. b. There are purple striae on the abdomen. c. The child is excessively tall for chronologic age. d. The child is demonstrating signs of hypoglycemia. Ricci Chapter 48

b. There are purple striae on the abdomen.

A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following? a. A ruptured arteriovenous malformation will cause deficits until it is stopped. b. Thrombolytic therapy has a time window of only 3 hours. c. A ruptured intracranial aneurysm must quickly be repaired. d. Intracranial pressure is increased by a space-occupying bleed. Hinkle Chapter 62

b. Thrombolytic therapy has a time window of only 3 hours.

Which of the following diagnostics are beneficial to detect intracranial stenosis? a. Magnetic resonance imaging (MRI) b. Transcranial Doppler (TCD) c. Computed tomography (CT) d. CT with contrast Hinkle Chapter 62

b. Transcranial Doppler (TCD)

A 6-year-old boy has a moon-face, stocky appearance but with thin arms and legs. His cheeks are unusually ruddy. He is diagnosed with Cushing syndrome. What is the most likely cause of this condition in this child? a. Tumor of the parathyroid b. Tumor of the adrenal cortex c. Tumor of the thyroid d. Tumor of the pancreas Ricci Chapter 48

b. Tumor of the adrenal cortex Cushing syndrome is caused by overproduction of the adrenal hormone cortisol; this usually results from increased ACTH production due to either a pituitary or adrenal cortex tumor. The peak age of occurrence is 6 or 7 years. The overproduction of cortisol results in increased glucose production; this causes fat to accumulate on the cheeks, chin, and trunk, causing a moon-faced, stocky appearance. Cortisol is catabolic, so protein wasting also occurs. This leads to muscle wasting, making the extremities appear thin in contrast to the trunk, and loss of calcium in bones (osteoporosis). Yet other effects are hyperpigmentation (the child's face to be unusually red, especially the cheeks).

A client diagnosed with Huntington disease is on a disease-modifying drug regimen and has a urinary catheter in place. Which potential complication is the highest priority for the nurse while monitoring the client? a. Severe depression b. Urinary tract infection c. Emotional apathy d. Choreiform movements Hinkle Chapter 61

b. Urinary tract infection

The nurse is preparing clients for diagnostic testing for cancer. Which test is used to differentiate a neuroblastoma from other tumors? a. Complete blood count (CBC) with differential b. Urine catecholamine metabolites, homovanillic acid (HVA), and vanillylmandelic acid (VMA) c. Urinalysis d. Serum chemistries Ricci Chapter 46

b. Urine catecholamine metabolites, homovanillic acid (HVA), and vanillylmandelic acid (VMA) Rationale: Neuroblastomas produce catecholamines. Urine catecholamine metabolites, homovanillic acid (HVA), and vanillylmandelic acid (VMA) differentiate neuroblastomas from other tumors. This exam is done by collecting a 24-hour urine specimen. Urinalysis provides general information about renal function. Serum chemistries help to evaluate the body's response to the cancer process. CBC with differential determines abnormal loss or destruction of cells that may indicate cancer or bone marrow suppression.

A patient had a small pituitary adenoma removed by the transsphenoidal approach and has developed diabetes insipidus. What pharmacologic therapy will the nurse be administering to this patient to control symptoms? a. Phenobarbital b. Vasopressin c. Furosemide (Lasix) d. Mannitol Hinkle Chapter 61

b. Vasopressin Rationale: Manipulation of the posterior pituitary gland during surgery may produce transient diabetes insipidus of several days' duration (Hickey, 2009). It is treated with vasopressin but occasionally persists.Reference:Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 66: Management of Patients With Neurologic Dysfunction, Monitoring for Secondary Complications

A client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note: a. abdominal ascites. b. anorexia, nausea, and vomiting. c. eructation and constipation. d. severe abdominal pain radiating to the shoulder. Hinkle Chapter 43

b. anorexia, nausea, and vomiting.

A child with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. Which action would be the priority? a. measuring urine output b. checking vital signs c. weighing the client d. encouraging increased fluid intake Ricci Chapter 48

b. check vital signs. The large amount of fluid loss can cause fluid and electrolyte imbalance that should be corrected; the loss of electrolytes would be reflected in vital signs. Urine output is important but not the priority. Encouraging fluids will not correct the problem and weighing the client is not necessary at this time.

What is one of the earliest signs of increased ICP? a. coma b. decreased level of consciousness (LOC) c. Cushing triad d. headache Hinkle Chapter 61

b. decreased level of consciousness (LOC)

After teaching a group of students about endocrine disorders, the instructor determines that the teaching was successful when the students identify insulin deficiency, increased levels of counterregulatory hormones, and dehydration as the primary cause of which condition? a. ketone bodies b. diabetic ketoacidosis c. glucosuria d. ketonuria Ricci Chapter 48

b. diabetic ketoacidosis Insulin deficiency, in association with increased levels of counter regulatory hormones (glucagon, growth hormone, cortisol, catecholamines) and dehydration, is the primary cause of diabetic ketoacidosis (DKA), a life-threatening form of metabolic acidosis that is a frequent complication of diabetes. Liver converts triglycerides (lipolysis) to fatty acids, which in turn change to ketone bodies. The accumulation and excretion of ketone bodies by the kidneys is called ketonuria. Glusosuria is glucose that is spilled into the urine.

The nurse and an adolescent are reviewing the adolescent's record of her headaches and activities surrounding them. What activity would the nurse identify as a possible trigger? a. 11 p.m. bedtime; 6:30 a.m. wake-up b. drinking three cans of diet cola c. use of nonaccented soap d. swimming twice a week Ricci Chapter 38

b. drinking three cans of diet cola

Administration of which medication reverses the histamine release and hypotension that are seen in anaphylaxis? a. atropine b. epinephrine c. diphenhydramine d. cimetidine Ricci Chapter 51

b. epinephrine

The nurse is providing care for a 13-year-old child diagnosed with iron-deficiency anemia. The client's current hemoglobin level is 11 g/dL (110 g/L). Which intervention will the nurse anticipate including in the client's care? a. increasing the daily intake of fresh fruits and vegetables b. giving ferrous sulfate with orange juice between meals c. packed red blood cell transfusions d. providing a high dose of intravenous immunoglobulin weekly Ricci Chapter 46

b. giving ferrous sulfate with orange juice between meals

The nurse knows that the heads of infants and toddlers are large in proportion to their bodies, placing them at risk for what problem? a. positional plagiocephaly b. head trauma c. intracranial hemorrhaging d. congenital hydrocephalus Ricci Chapter 38

b. head trauma

A child with acute lymphoblastic leukemia (ALL) is starting treatment with methotrexate in an attempt to eradicate the leukemic cells. Which stage of therapy is the child undergoing? a. sanctuary stage b. induction stage c. delayed intensive-therapy stage d. consolidation stage Ricci Chapter 46

b. induction phase Explanation: An induction phase is the first attempt at eradicating the leukemic cells to induce or achieve a complete remission.

What is the recommended dietary treatment for a client with chronic cholecystitis? a. low-protein diet b. low-fat diet c. high-fiber diet d. low-residue diet Hinkle Chapter 43

b. low-fat diet

The nurse teaches a parent to differentiate between regurgitation and vomiting in the infant. The parent correctly states which characteristic of regurgitation? Select all that apply. a. timing unrelated to feeding b. no appearance of distress c. occurs with feeding d. forceful expulsion of stomach contents e. followed by dry retching Ricci Chapter 42

b. no appearance of distress c. occurs with feeding

A hospice nurse is providing at-home care to a child with end-stage cancer. The nurse is developing a plan of care to manage the child's pain. Which medications will the nurse likely include? a. mild analgesics b. opioids c. sedatives d. topical anesthetics Ricci Chapter 46

b. opioids

A child with a seizure disorder is being admitted to the inpatient unit. When preparing the room for the child, what should be included? Select all that apply. a. tongue blade b. oxygen gauge and tubing c. smelling salts d. padding for side rails e. suction at bedside Ricci Chapter 38

b. oxygen gauge and tubing d. padding for side rails e. suction at bedside

A nurse is assessing a client with multiple myeloma. Due to this condition, what will this client be at risk for? a. chronic liver failure. b. pathologic bone fractures. c. hypoxemia. d. acute heart failure. Hinkle Chapter 30

b. pathologic bone fractures Rationale: When caring for a client with multiple myeloma, the nurse should focus on relieving pain, preventing bone injury and infection, and maintaining hydration. Monitoring respiratory status and balancing rest and activity are appropriate interventions for any client. To prevent such complications as pyelonephritis and renal calculi, the nurse should keep the client well hydrated — not restrict fluid intake.

For a client with suspected increased intracranial pressure (ICP), an appropriate respiratory goal is to: a. lower arterial pH. b. promote carbon dioxide elimination. c. maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg. d. prevent respiratory alkalosis. Hinkle Chapter 61

b. promote carbon dioxide elimination.

The nurse is caring for a client with a diagnosis of portal hypertension. What should the nurse anticipate after the client begins treatment? Select all that apply. a. decreased fluid output b. reduced fluid accumulation c. inhibited blood coagulation d. slowed vitamin K production e. lower venous pressure Hinkle Chapter 43

b. reduced fluid accumulation e. lower venous pressure

A nurse in a rehabilitation facility is coordinating the discharge of a client who is tetraplegic. The client, who is married and has two children in high school, is being discharged to home and will require much assistance. Who would the discharge planner recognize as being the most important member of this client's care team? a. physical therapist b. spouse c. chaplain d. home care nurse Hinkle Chapter 62

b. spouse

Dexamethasone is often prescribed for the child who has sustained a severe head injury. Dexamethasone is a(n): a. anticonvulsant. b. steroid. c. diuretic. d. antihistamine. Ricci Chapter 38

b. steroid. Rationale: Increased intracranial pressure (ICP) may be caused by several factors: head trauma, birth trauma, hydrocephalus, infection, and/or tumors. Whatever the reason, the brain swells and becomes inflamed.Dexamethasone is a steroid.A steroid may be prescribed to reduce inflammation and pressure on vital centers of the brain.mannitol= may be used to decrease edema.An anticonvulsant= is used with increased ICP to prevent seizures.An antihistamine= would not be warranted for the treatment of a head injury.

A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is: a. elevated liver enzymes and low serum protein level. b. subnormal serum glucose and elevated serum ammonia levels. c. subnormal clotting factors and platelet count. d. elevated blood urea nitrogen and creatinine levels and hyperglycemia. Hinkle Chapter 43

b. subnormal serum glucose and elevated serum ammonia levels.

After teaching the parents of a child diagnosed with sickle cell disease, the nurse determines that the teaching was successful when the parents state that they will contact the primary health care provider if the child develops which signs or symptoms? Select all that apply. a. constipation b. sudden change in vision c. irritability d. chest pain e. severe dizziness Ricci Chapter 46

b. sudden change in vision d. chest pain e. severe dizziness

A 12-year-old client arrives at the emergency room experiencing nausea, vomiting, headache, and seizures. The client is diagnosed with bacterial meningitis. Other findings include a decrease in urine production, hyponatremia, and water intoxication. Which pituitary gland disorder is most associated with these symptoms? a. hyposecretion of somatotropin b. syndrome of inappropriate antidiuretic hormone (SIADH) c. diabetes insipidus (DI) d. hypersecretion of growth hormone Ricci Chapter 48

b. syndrome of inappropriate antidiuretic hormone (SIADH)

A 12-year-old client arrives at the emergency room experiencing nausea, vomiting, headache, and seizures. The client is diagnosed with bacterial meningitis. Other findings include a decrease in urine production, hyponatremia, and water intoxication. Which pituitary gland disorder is most associated with these symptoms? a. hypersecretion of growth hormone b. syndrome of inappropriate antidiuretic hormone (SIADH) c. hyposecretion of somatotropin d. diabetes insipidus (DI) Ricci Chapter 48

b. syndrome of inappropriate antidiuretic hormone (SIADH) Syndrome of inappropriate antidiuretic hormone (SIADH) is a rare condition in which there is overproduction of antidiuretic hormone by the posterior pituitary gland. This results in a decrease in urine production and water intoxication. As sodium levels fall in proportion to water, the child develops hyponatremia or a lowered sodium plasma level. It can be caused by central nervous system infections such as bacterial meningitis. As the hyponatremia grows more severe, coma or seizures occur from brain edema. Diabetes insipidus is characterized by polyuria, not decreased urine production. Hyposecretion of somatotropin, or growth h

A nurse is assessing a postoperative client for hemorrhage. What responses associated with the compensatory stage of shock should be reported to the healthcare provider? a. tachycardia and bradypnea b. tachycardia and tachypnea c. bradycardia and tachypnea d. bradycardia and bradypnea Hinkle Chapter 43

b. tachycardia and tachypnea

The nurse is teaching the parents of a 15-year-old boy who is being treated for acute myeloid leukemia about the side effects of chemotherapy. For which symptoms should the parents seek medical care immediately? a. difficulty or pain when swallowing b. temperature of 101°F (38.3°C) or greater c. earache, stiff neck, or sore throat d. blisters, ulcers, or a rash appear Ricci Chapter 46

b. temperature of 101°F (38.3°C) or greater

The nurse is using the pediatric Glasgow Coma Scale to assess a child's level of consciousness. What would the nurse assess? Select all that apply. a. fontanels (fontanelles) b. verbal response c. motor response d. posture e. eye opening Ricci Chapter 38

b. verbal response c. motor response e. eye opening

The nurse is caring for a 3-year-old boy who is experiencing seizure activity. Which diagnostic test will determine the seizure area in the brain? a. cerebral angiography b. video electroencephalogram c. computed tomography d. lumbar puncture Ricci Chapter 38

b. video electroencephalogram

While assessing an adolescent, the nurse notes pallor and a beefy red tongue. Upon questioning, the adolescent reports eating a vegetarian diet to help with weight loss. Which health care provider prescription will the nurse anticipate? a. hydroxyurea orally b. vitamin B12 injections c. ferrous sulfate daily d. folic acid supplement Ricci Chapter 46

b. vitamin B12 injections Explanation: Children with pernicious anemia have a vitamin B12 deficiency and have symptoms such as pallor, irritability, beefy red tongue, and diarrhea. Children with iron-deficiency anemia require ferrous sulfate. Folic acid is needed for children with macrocytic anemia. Hydroxyurea could be prescribed for a child with sickle cell anemia.

When assessing a female client with a disorder of the hematopoietic or the lymphatic system, which assessment is most essential? a. Menstrual history b. Age and gender c. Health history, such as bleeding, fatigue, or fainting d. Lifestyle assessments, such as exercise routines Hinkle Chapter 30

c) Health history, such as bleeding, fatigue, or fainting Rationale: When assessing a patient with a disorder of the hematopoietic or the lymphatic system, it is essential to assess the patient's health history. An assessment of drug history is essential because some antibiotics and cancer drugs contribute to hematopoietic dysfunction. Aspirin and anticoagulants may contribute to bleeding and interfere with clot formation. Because industrial materials, environmental toxins, and household products may affect blood-forming organs, the nurse needs to explore exposure to these agents. Age, gender, menstrual history, or lifestyle assessments, such as exercise routines and habits, do not directly affect the hematopoietic or lymphatic system.

The nurse is teaching a client about the development of leukemia. What statement should be included in the teaching plan? a. "In chronic leukemia, the minority of leukocytes are mature." b. "Acute leukemia develops slowly." c. "Chronic leukemia develops slowly." d. "In acute leukemia there are not many undifferentiated cells." Hinkle Chapter 30

c. "Chronic leukemia develops slowly."

The nurse is teaching the client about consolidation. What statement should be included in the teaching plan? a. "Consolidation occurs as a side effect of chemotherapy." b. "Consolidation is the term used when a client does not tolerate chemotherapy." c. "Consolidation therapy is administered to reduce the chance of leukemia recurrence." d. "Consolidation of the lungs is an expected effect of induction therapy." Hinkle Chapter 30

c. "Consolidation therapy is administered to reduce the chance of leukemia recurrence." Rationale: Consolidation therapy is administered to eliminate residual leukemia cells that are not clinically detectable and reduce the chance for recurrence. It is also termed post-remission therapy. It is not a side effect of chemotherapy, but the administration of chemotherapy.

The nurse is assessing a toddler and palpates a sausage-shaped mass in the upper mid abdomen. When taking the toddler's history, what question would the nurse ask the parent first? a. "Has your toddler been around anyone who has been sick?" b. "Can you describe any pain your toddler is having?" c. "Has your toddler been having different colored stools?" d. "How is your toddler's appetite?" Ricci Chapter 42

c. "Has your toddler been having different colored stools?"

The nurse is preparing to interview a client with cirrhosis. Based on an understanding of this disorder, which question would be most important to include? a. "Have you had an infection recently?" b. "Does your work expose you to chemicals?" c. "How often do you drink alcohol?" d. "What type of over-the-counter pain reliever do you use?" Hinkle Chapter 43

c. "How often do you drink alcohol?" The most common type of cirrhosis results from chronic alcohol intake and is frequently associated with poor nutrition. Although it can follow chronic poisoning with chemicals or ingestion of hepatotoxic drugs such as acetaminophen, asking about alcohol intake would be most important. Asking about an infection or exposure to hepatotoxins or industrial chemicals would be important if the client had postnecrotic cirrhosis.

The nurse has performed client education for a 15-year-old boy with Crohn disease and his parents regarding the cobblestone lesions in his small intestine. Which comment by the family indicates learning has occurred? a. "It's unusual for someone my age to get Crohn disease." b. "I have a lot of diarrhea every day because of how my small intestine is damaged." c. "I have to be careful because I am prone to not absorbing nutrients." d. "I may end up with a colectomy because the disease is continuous from the beginning to the end of my intestines." Ricci Chapter 42

c. "I have to be careful because I am prone to not absorbing nutrients." Rationale: Crohn disease typically affects the small intestine more than the large intestine and its onset is between the ages of 10 to 20 years. The cobblestone lesions in the small intestine prevent absorption of nutrients that normally occurs. The diarrhea is not directly related to the cobblestone lesions, and ulcerative colitis is characterized by the disease affecting the intestine(s) in a continuous pattern.

A nurse is providing care to a child hospitalized after an accident that resulted in a substantial loss of blood. The nurse is preparing to administer IV fluids using a 60-milliliter syringe attached to the child's IV site. The child's parent asks the nurse why there is no IV bag hanging. What is the best response for the nurse to make? a. "Your child is too young to receive IV fluids by that method." b. "Hanging an IV bag would cause the infusion to flow too quickly." c. "I need to administer small amounts of fluid as quickly as possible." d. "Children need much less fluid than adults." Ricci Chapter 51

c. "I need to administer small amounts of fluid as quickly as possible."

The nurse is speaking with the parents of a school-aged child recently diagnosed with diabetes regarding the differences between hypoglycemia and hyperglycemia. Which statement by a parent indicates a need for further teaching? a. "Dry flushed skin may be a sign if high blood sugar." b. "If my son says he feels shaky, his blood sugar may be low." c. "If I notice changes in my son like tearfulness or irritability, his blood sugar may be high." d. "When my son's breath smells fruity, it almost always indicates high blood sugar." Ricci Chapter 48

c. "If I notice changes in my son like tearfulness or irritability, his blood sugar may be high."

The nurse is teaching the parents of a 3-year-old girl with diabetes insipidus how to administer desmopressin acetate (DDAVP). Which comment indicates further need for teaching? a. "Once the tube is filled, I hold it closed until I insert it into her nostril." b. "I check the specific gravity of her urine to see if the drug is working." c. "If she sneezes the medicine out of her nose, I wait until the next dose." d. "First I suction her nostrils, if necessary, to help the drug be absorbed." Ricci Chapter 48

c. "If she sneezes the medicine out of her nose, I wait until the next dose."

A mother asks the nurse why her infant who was born at 34 weeks' gestation is being prescribed ferrous sulfate. Which response by the nurse is most appropriate? a. "Infants with pyloric stenosis require ferrous sulfate." b. "Ferrous sulfate helps improve red blood cell formation." c. "Preterm infants are at risk for iron-deficiency anemia." d. "Your infant may have been having excessive diarrhea." Ricci Chapter 46

c. "Preterm infants are at risk for iron-deficiency anemia." Rationale: Infants born prematurely are at risk for iron-deficiency anemia because iron stores are built during the last few weeks of gestation. Although some infants with pyloric stenosis may require an iron supplement, such as ferrous sulfate, not all infants will. Infants with excessive diarrhea may develop iron-deficiency anemia, and ferrous sulfate helps improve red blood cell formation, but this does not explain why a preterm infant is being prescribed an iron supplement.

The nurse is caring for a 14-year-old client scheduled for magnetic resonance imaging (MRI). The nurse explains the test to the child and family. Which information would be most appropriate to include in the explanation? a. "The MRI uses sound waves to create images that visualize body structures and locate masses." b. "The MRI is a nuclear scanning test to rule out cancer involving the bones or determine extent of bone involvement." c. "The MRI uses radio waves and magnets to produce a computerized image of the body." d. "The MRI uses radiation to examine soft tissue and bony structures of the body." Ricci Chapter 46

c. "The MRI uses radio waves and magnets to produce a computerized image of the body."

A nurse is providing education about migraine headaches to a community group. The cause of migraines has not been clearly demonstrated, but is related to vascular disturbances. A member of the group asks about familial tendencies. The nurse's correct reply will be which of the following? a. "No familial tendency has been demonstrated." b. "There is a very weak familial tendency." c. "There is a strong familial tendency." d. "Only secondary migraine headaches show a familial tendency." Hinkle61

c. "There is a strong familial tendency."

A child is to receive an oral corticosteroid as part of the treatment regimen for leukemia. After teaching the child and family about this drug, the nurse determines the need for additional teaching when they state: a. "We should check our son's urine for glucose." b. "He might develop a rounded face from this drug." c. "We should administer the drug on an empty stomach." d. "We will need to gradually decrease the dosage." Ricci Chapter 46

c. "We should administer the drug on an empty stomach." Rationale :Corticosteroids are commonly administered with food to decrease the risk for gastrointestinal upset. Corticosteroids can disrupt glucose balance, so urine should be checked for glucose. A moon face is an adverse effect of corticosteroids. Corticosteroids need to be tapered gradually to reduce the risk of adrenal insufficiency.

A child is experiencing an acute exacerbation of Crohn disease for which she is prescribed prednisone. The nurse teaches the parents and child about this medication. Which statement by the parents indicates that the teaching was successful? a. "She might lose some weight initially." b. "This drug helps to control the abdominal cramping." c. "We should not stop this medication abruptly." d. "We might notice some of the medication in her stool." Ricci Chapter 42

c. "We should not stop this medication abruptly."

A 9-year-old child with leukemia is scheduled to undergo an allogeneic hematopoietic stem cell transplant. When teaching the child and parents, what information would the nurse include? a. "You'll need to have an incision in your hip area to instill the cells." b. "You won't need to receive the high doses of chemotherapy before the transplant." c. "We'll need to have a match to a donor." d. "The risk for rejection is much less with this type of transplant." Ricci Chapter 46

c. "We'll need to have a match to a donor."

A nurse is reviewing the laboratory test results of a 3-year-old child. Which absolute neutrophil count would the nurse identify as indicating neutropenia? a. 1.5 b. 2.0 c. 1.0 d. 2.5 Ricci Chapter 46

c. 1.0

The nurse is assessing a child with a suspected head injury. The child opens the eyes only in response to the nurse placing pressure in the child's nail bed. What score on the Glasgow coma scale for eye opening should the nurse assign based on this assessment finding? a. 3 b. 1 c. 2 d. 4 Ricci Chapter 51

c. 2

A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time? a. 2:00 p.m. b. 3:00 p.m. c. 4:00 p.m. d. 7:00 p.m. Hinkle Chapter 62

c. 4:00 p.m. Rationale: Tissue plasminogen activator (tPA) must be given within 3 hours after symptom onset. Therefore, since symptom onset was 1:00 pm, the window of opportunity ends at 4:00 pm.

A 10-year-old child is newly diagnosed with type 1 diabetes. The child's hemoglobin A1C level is being monitored. The nurse determines that additional intervention is needed with the child based on which result? a. 7.0% b. 6.5% c. 8.5% d. 7.5 % Ricci Chapter 48

c. 8.5% The goal for hemoglobin A1C in children between the ages of 6 and 12 years is less than 8%. Therefore, a result of 8.5% would indicate that additional intervention is needed to achieve the recommended goal.

A parent calls the pediatric oncology clinic about the child having headaches after chemotherapy. What is the nurse's best advice? a. Use an ice pack on the child's head. b. Administer oral hydrocodone as needed. c. Administer acetaminophen as needed. d. Administer ibuprofen every 6 hours. Ricci Chapter 46

c. Administer acetaminophen as needed. Caution parents, while children are receiving chemotherapy, not to give them nonsteroidal anti-inflammatory drugs because they may interfere with blood coagulation, a problem that may already be present because of lowered thrombocyte levels. Instead, suggest they use acetaminophen to relieve a headache. Ice packs are used to prevent hair loss and do not help with headaches. Hydrocodone is not needed for a headache.

A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP? a. Encourage coughing and deep breathing. b. Position the client with the head turned toward the side of the brain tumor. c. Administer stool softeners. d. Provide sensory stimulation. Hinkle Chapter 61

c. Administer stool softeners.

The school nurse notes that a child diagnosed with diabetes mellitus is experiencing an insulin reaction and is unable to eat or drink. Which action would be the most appropriate for the school nurse to take? a. Anticipate that the child will need intravenous glucose. b. Request that someone call 911. c. Administer subcutaneous glucagon. d. Dissolve a piece of candy in the child's mouth. Ricci Chapter 48

c. Administer subcutaneous glucagon If the child having an insulin reaction cannot take a sugar source orally, glucagon should be administered subcutaneously to bring about a prompt increase in the blood glucose level. This treatment prevents the long delay while waiting for a physician to administer IV glucose or for an ambulance to reach the child.

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)? a. Encouraging oral fluid intake b. Elevating the head of the bed 90 degrees c. Administering a stool softener as ordered d. Suctioning the client once each shift Hinkle Chapter 61

c. Administering a stool softener as ordered

The nurse is working with a child who is in sickle cell crisis. Treatment and nursing care for this child include which actions? Select all that apply. a. Administering platelets b. Promoting exercise and activity c. Administering analgesics d. Maintaining fluid intake e. Administering oxygen Ricci Chapter 46

c. Administering analgesics d. Maintaining fluid intake e. Administering oxygen

The nurse is caring for a client with acute myeloid leukemia (AML) with high uric acid levels. What medication does the nurse anticipate administering that will prevent crystallization of uric acid and stone formation? a. Asparaginase b. Filgrastim c. Allopurinol d. Hydroxyurea Hinkle Chapter 30

c. Allopurinol

The single modality of pharmacologic therapy for chronic type B viral hepatitis is: a. Epivir b. Baraclude c. Alpha-interferon d. Hepsera Hinkle Chapter 43

c. Alpha-interferon

The parents of a child who was diagnosed with diabetes insipidus ask the nurse, "How does this disorder occur?" When responding to the parents, the nurse integrates knowledge that a deficiency of which hormone is involved? a. Growth hormone b. Thyroxine c. Antidiuretic hormone d. Insulin Ricci Chapter 48

c. Antidiuretic hormone Diabetes insipidus results from a deficiency in the secretion of antidiuretic hormone (ADH). This hormone, also known as vasopressin, is produced in the hypothalamus and stored in the pituitary gland. Hypopituitarism or dwarfism involves a growth hormone deficiency. Diabetes mellitus involves a disruption in insulin secretion. Thyroxine is a thyroid hormone that if deficient leads to hypothyroidism.

Diabetes insipidus is a disorder of the posterior pituitary that results in deficient secretion of which hormone? a. Thyroid stimulating hormone (TSH) b. Luteinizing hormone (LH) c. Antidiuretic hormone (ADH) d. Adrenocorticotropic hormone (ACTH) Ricci Chapter 48

c. Antidiuretic hormone (ADH)

The nurse is called into a toddler's room. The toddler's parent says "My toddler is having trouble breathing." What should the nurse do first? a. Place on 100% oxygen. b. Apply a pulse oximeter to monitor oxygen levels. c. Assess patency of the airway. d. Notify the health care provider. Ricci Chapter 51

c. Assess patency of the airway.

A client who is undergoing chemotherapy for AML reports pain in the low back. What is the nurse's first action? a. Administer pain medication, as ordered. b. Place heating pads on the client's back. c. Assess renal function. d. Refer the client to a chiropractor. Hinkle Chapter 30

c. Assess renal function. Rationale: Chemotherapy results in the destruction of cells and tumor lysis syndrome. Uric acid and phosphorus concentrations increase, and the client is susceptible to renal failure. The nurse should assess renal function if the client complains of low-back pain, as this could be indicative of kidney stone formation. Heating pads, pain medication, and referrals could be instituted once the cause of the pain is determined. The priority is further assessment to rule out important problems.

A client has experienced an ischemic stroke that has damaged the temporal (lateral and superior portions) lobe. Which of the following deficits would the nurse expect during assessment of this client? a. Lack of deep tendon reflexes b. Limited attention span and forgetfulness c. Auditory agnosia d. Hemiplegia or hemiparesis Hinkle Chapter 62

c. Auditory agnosia

A nurse is caring for a client with a cerebral aneurysm. Which nursing interventions would be most useful to the nurse to avoid bleeding in the brain? Select all that apply. a. Use a well-lighted room for assessments every 2 hours. b. Follow the healthcare provider's orders to increase fluid volume. c. Avoid any activities that cause a Valsalva maneuver. d. Report changes in neurologic status as soon as a worsening trend is identified. e. Maintain the head of the bed at 30 degrees. Hinkle Chapter 62

c. Avoid any activities that cause a Valsalva maneuver. d. Report changes in neurologic status as soon as a worsening trend is identified. e. Maintain the head of the bed at 30 degrees. Rationale: Cerebral aneurysm precautions are implemented for the patient with a diagnosis of aneurysm to provide a nonstimulating environment, prevent increases in intracranial pressure, and prevent further bleeding. The patient is placed on bed rest in a quiet, nonstressful environment, because activity, pain, and anxiety are thought to elevate the blood pressure, which may increase the risk for bleeding. The head of the bed is elevated 30 degrees to promote venous drainage and decrease intracranial pressure. Any activity that suddenly increases the blood pressure or obstructs venous return is avoided. This includes the Valsalva maneuver, straining, forceful sneezing, pushing oneself up in bed and acute flexion or rotation of the head and neck (which compromises the jugular veins). Stool softeners and mild laxatives are prescribed to prevent constipation, which can cause an increase in intracranial pressure. Dim lighting is helpful for photophobia. Increasing fluid volume does not affect brain bleeding

A child is diagnosed with intussusception. The nurse anticipates that what action would be attempted first to reduce this condition? a. Surgery b. Upper endoscopy c. Barium enema d. Endoscopic retrograde cholangiopancreatography Ricci Chapter 42

c. Barium enema A barium enema is successful in reducing a large percentage of intussusception cases. Other cases are reduced surgically. Upper endoscopy is used to visualize the upper gastrointestinal tract from the mouth to the upper jejunum. Endoscopic retrograde cholangiopancreatography is used to view the hepatobiliary system.

A group of nursing students are studying information about childhood cancers in preparation for a class examination. They are reviewing how childhood cancers differ from adult cancers. The group demonstrates understanding of the information when they identify what location as an unlikely site for childhood cancer? a. Blood b. Kidney c. Bladder d. Brain Ricci Chapter 46

c. Bladder

When caring for a client with advanced cirrhosis and hepatic encephalopathy, which assessment finding should the nurse report immediately? a. Constipation for more than 2 days b. Weight loss of 2 pounds in 3 days c. Change in the client's handwriting and/or cognitive performance d. Anorexia for more than 3 days Hinkle Chapter 43

c. Change in the client's handwriting and/or cognitive performance The earliest symptoms of hepatic encephalopathy include mental status changes and motor disturbances. The client will appear confused and unkempt and have altered mood and sleep patterns. Neurologic status should be assessed frequently. Mental status is monitored by the nurse keeping the client's daily record of handwriting and arithmetic performance. The nurse should report any change in mental status immediately. Chronic fatigue, anorexia, dyspepsia, nausea, vomiting, and diarrhea or constipation with accompanying weight loss are regular symptoms of cirrhosis.

Individuals with hemophilia B have a deficiency in factor IX, which can cause excessive blood loss. What is another name for this clotting factor? a. Antihemophilic factor b. Proconvertin c. Christmas factor d. Stuart factor Ricci Chapter 46

c. Christmas factor Explanation: Factor IX is also known as plasma thromboplastin component or Christmas factor; factor X is Stuart factor; factor VIII is antihemophilic factor; and factor VII is proconvertin.

The nurse is assessing a client with cirrhosis of the liver. Which stool characteristic would the nurse expect the client to report? a. Blood tinged b. Black and tarry c. Clay-colored or whitish d. Yellow-green Hinkle Chapter 43

c. Clay-colored or whitish

Antibiotic therapy to treat meningitis should be instituted immediately after which event? a. Identification of the causative organism b. Admission to the nursing unit c. Collection of cerebrospinal fluid (CSF) and blood for culture d. Initiation of IV therapy Ricci Chapter 38

c. Collection of cerebrospinal fluid (CSF) and blood for culture Rationale: Antibiotic therapy should always begin immediately after the collection of CSF and blood cultures. After the specific organism is identified, bacteria-specific antibiotics can be administered if the initial choice of antibiotic therapy isn't appropriate. Admission and initiation of I.V. therapy aren't, by themselves, appropriate times to begin antibiotic therapy.

A woman in her first trimester of pregnancy has just been diagnosed with acquired hypothyroidism. The nurse is alarmed because this condition can lead to which pregnancy complication? a. Spina bifida in the fetus b. Gestational diabetes in the mother c. Decreased cognitive development of the fetus d. Congenital heart defects in the fetus Ricci Chapter 48

c. Decreased cognitive development of the fetus If acquired hypothyroidism exists in a woman during pregnancy, her infant can be born intellectually disabled, because there was not enough iodine present for fetal growth. It is important, therefore, that girls with this syndrome be identified before they reach childbearing age.

A child has been prescribed desmopressin acetate for the treatment of diabetes insipidus. The client and the parents ask the nurse how this drug works. What is the correct response by the nurse? a. Desmopressin acetate works on your pancreas to stimulate insulin production. b. Desmopressin acetate works to help your kidneys work more efficiently. c. Desmopressin acetate is a synthetic antidiuretic hormone that will slow down your urine output. d. Desmopressin acetate is a synthetic form of insulin used to lower your blood sugar. Ricci Chapter 48

c. Desmopressin acetate is a synthetic antidiuretic hormone that will slow down your urine output.

A nurse caring for an 8-year-old with a bleeding disorder documents the following nursing diagnosis: ineffective tissue perfusion related to intravascular thrombosis and hemorrhage. This diagnosis is most appropriate for a client with: a. Hemophilia b. von Willebrand disease c. Disseminated intravascular coagulation d. Iron-deficiency anemia Ricci Chapter 46

c. Disseminated intravascular coagulation

A nurse caring for an 8-year-old with a bleeding disorder documents the following nursing diagnosis: ineffective tissue perfusion related to intravascular thrombosis and hemorrhage. This diagnosis is most appropriate for a client with: a. von Willebrand disease b. Hemophilia c. Disseminated intravascular coagulation d. Iron-deficiency anemia Ricci Chapter 46

c. Disseminated intravascular coagulation

A client is receiving vasopressin for the urgent management of active bleeding due to esophageal varices. What most serious complication should the nurse assess the client for after the administration? a. Urinary output changes b. Liver enzyme changes c. Electrocardiogram changes d. Electrolytes level changes Hinkle Chapter 43

c. Electrocardiogram changes Vasopressin (Pitressin) is administered during the management of an urgent situation with an acute esophageal bleed because of its vasoconstrictive properties in the splanchnic, portal, and intrahepatic vessels. This medication also causes coronary artery constriction that may dispose clients with coronary artery disease to cardiac ischemia; therefore, the nurse observes the client for evidence of chest pain, ECG changes, and vital sign changes. Vasopressin will does not infer with urinary output, electrolytes, or liver enzymes.

An adolescent receiving chemotherapy has lost all hair and is sad about self-image. Which action should the nurse take to support this adolescent and involve the client in decision making? a. Refer the adolescent to a peer support group. b. Have a Child Life specialist work with the adolescent. c. Encourage the adolescent to select hats or wigs to fit one's personality. d. Support the adolescent's choice of comfortable clothing. Ricci Chapter 46

c. Encourage the adolescent to select hats or wigs to fit one's personality.

A newborn is discovered to have congenital adrenogenital hyperplasia. What will the nurse most likely observe when assessing this client? a. Divergent vision b. Abnormal facial features c. Enlarged clitoris d. Small for gestational age Ricci Chapter 48

c. Enlarged clitoris Congenital adrenal hyperplasia is a syndrome that is inherited as an autosomal recessive trait, which causes the adrenal glands to not be able to synthesize cortisol. Because the adrenal gland is unable to produce cortisol, the level of adrenocorticotropic hormone (ACTH) secreted by the pituitary in an attempt to stimulate the gland to increase function is increased. Although the adrenals enlarge under the effect of ACTH, they still cannot produce cortisol but rather overproduce androgen. Excessive androgen production during intrauterine life masculinizes the genital organs in a female fetus so that the clitoris is so enlarged it appears to be a penis. This disorder does not cause divergent vision. The child will not be born small for gestational age. This disorder does not cause abnormal facial features.

A client who is being treated for AML has bruises on both legs. What is the nurse's most appropriate action? a. Evaluate the client's INR. b. Ask the client whether they have recently fallen. c. Evaluate the client's platelet count. d. Keep the client on bed rest. Hinkle Chapter 30

c. Evaluate the client's platelet count. Rationale: Complications of AML include bleeding. The risk of bleeding correlates with the level and duration of platelet deficiency. Major hemorrhages may develop when the platelet count drops to less than 10,000 x mm3. The bleeding is usually unrelated to falling. Keeping the patient on bed rest will not prevent bleeding when the patient has a low platelet count. Assessment for other areas of bleeding is also a priority intervention.

A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take? a. Use one long sentence to say everything that needs to be said. b. Keep the television on while she speaks. c. Face the client and establish eye contact. d. Talk in a louder than normal voice. Hinkle Chapter 62

c. Face the client and establish eye contact.

A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to do perform which action? a. Speak at all b. Form understandable words c. Form understandable words and comprehend spoken words d. Comprehend spoken words Hinkle Chapter 62

c. Form understandable words and comprehend spoken words

A patient with acute myeloid leukemia (AML) is having hematopoietic stem cell transplantation (HSCT) with radiation therapy. In which complication do the donor's lymphocytes recognize the patient's body as foreign and set up reactions to attack the foreign host? a. Remission b. Bone marrow depression c. Graft-versus-host disease d. Acute respiratory distress syndrome Hinkle Chapter 30

c. Graft-versus-host disease

A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? a. Methyldopa b. Phenytoin c. Heparin sodium d. Dexamethasone Hinkle Chapter 62

c. Heparin sodium Rationale: Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. Therefore, the nurse should question this order to prevent additional hemorrhage in the brain. In a client with hemorrhagic stroke, the physician may use dexamethasone to decrease cerebral edema and pressure; methyldopa, to reduce blood pressure; and phenytoin, to prevent seizures.

During a physical examination of a 13-year-old boy, the nurse observes a single, enlarged, rubbery-feeling cervical lymph node in the armpit. The boy also reports unexplained loss of weight and malaise. Which condition should the nurse most suspect in this client? a. Non-Hodgkin lymphoma b. Acute myeloid leukemia (AML) c. Hodgkin lymphoma d. Acute lymphoblastic leukemia (ALL) Ricci Chapter 46

c. Hodgkin lymphoma Explanation:Symptoms of Hodgkin disease usually begin with the enlargement of only one painless, enlarged, rubbery-feeling cervical lymph node. Other nodes then become involved, along with the liver, spleen, bone marrow, and, eventually, the central nervous system. The child usually reports accompanying symptoms of anorexia, malaise, night sweats, and loss of weight. Fever may be present. Non-Hodgkin's lymphomas tend to involve the lymph glands of the neck and chest most commonly, although axillary, abdominal, or inguinal nodes may be the first involved. If mediastinal lymph glands are swollen, the child may notice a cough or chest "tightness." Because mediastinal nodes press on the veins returning blood from the head, edema of the face may result. The first symptoms of ALL in children usually are those associated with decreased RBC production (anemia) such as pallor, low-grade fever, and lethargy. Children with AML have the same symptoms as those with ALL.

A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include thickened liquids. Which of the following is the priority nursing diagnosis for this client? a. Decreased Fluid Volume Risk b. Aspiration Risk c. Impaired Swallowing d. Malnutrition Risk Hinkle Chapter 62

c. Impaired Swallowing

For a client with Hodgkin lymphoma, who is at a risk for ineffective airway clearance and impaired gas exchange, the nurse places the client in a high Fowler's position to a. reduce deficits in the blood oxygen concentration. b. detect compromised ventilation. c. increase lung expansion. d. anticipate the need for airway management. Hinkle Chapter 30

c. Increase the lung expansion. Rationale: For a patient with Hodgkin disease who is at a risk for an ineffective airway clearance and an impaired gas exchange, the nurse keeps the neck in midline and places the patient in a high Fowler's position if respiratory distress develops. Avoiding unnecessary pressure on the trachea and positioning for an increased lung expansion improve the air exchange. The nurse administers oxygen as per the physician's orders to reduce the deficits in the blood oxygen level. The nurse assesses the respiratory status in each shift to detect compromised ventilation. The nurse places an endotracheal tube, a laryngoscope, and a bag-valve mask at the bedside for intubation if the need for the airway management arises.

The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring? a. Increase in cerebral perfusion pressure b. Exacerbation of uncontrolled hypertension c. Increased ICP d. Infection Hinkle Chapter 61

c. Increased ICP

The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring? a. Increase in cerebral perfusion pressure b. Infection c. Increased ICP d. Exacerbation of uncontrolled hypertension Hinkle Chapter 61

c. Increased ICP Rationale: Increased ICP and bleeding are life threatening to the patient who has undergone intracranial surgery. An increase in blood pressure and decrease in pulse with respiratory failure may indicate increased ICP.

The assessment of a client admitted with increased ascites related to cirrhosis reveals the following: pulse 86 beats per minute and weak, respirations 28 breaths per minute, blood pressure 130/88 mm Hg, and pulse oximetry 90%. Which nursing diagnosis should receive top priority? a. Excess fluid volume b. Imbalanced nutrition: less than body requirements c. Ineffective breathing pattern d. Fatigue Hinkle Chapter 43

c. Ineffective breathing pattern

A 6-month-old infant is admitted with suspected bacterial meningitis. She is crying, irritable, and lying in the opisthotonic position. Which intervention should the nurse take initially? a. Educate the family about preventing bacterial meningitis. b. Encourage the mother to hold and comfort the infant. c. Institute droplet precautions in addition to standard precautions. d. Palpate the child's fontanels (fontanelles). Ricci Chapter 38

c. Institute droplet precautions in addition to standard precautions.

A physician orders spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect? a. Blood pH of 7.25 b. Serum potassium level of 3.5 mEq/L c. Loss of 2.2 lb (1 kg) in 24 hours d. Serum sodium level of 135 mEq/L Hinkle Chapter 43

c. Loss of 2.2 lb (1 kg) in 24 hours

A client with a traumatic brain injury is showing early signs of increasing intracranial pressure (ICP). While planning care for this client, what would be the priority expected outcome? a. Demonstrates optimal cerebral tissue perfusion b. Displays no signs or symptoms of infection c. Maintains a patent airway d. Attains desired fluid balance Hinkle Chapter 61

c. Maintains a patent airway

When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider? a. Ask the client about food intake. b. Provide the client with nonprescription laxatives. c. Measure abdominal girth according to a set routine. d. Report the condition to the physician immediately. Hinkle Chapter 43

c. Measure abdominal girth according to a set routine. If the abdomen appears enlarged, the nurse measures it according to a set routine. Measuring the abdominal girth is the most accurate method of determining an increase or decrease in abdominal distention. It is not essential for the client to take laxatives unless prescribed. The client's food intake does not affect the size of the abdomen in case of cirrhosis. The nurse would report to the physician about abdominal enlargement along with other parameters of the assessment.

A 14-year-old adolescent with Hodgkin disease is experiencing difficulty breathing and is sent for a radiograph. Which finding should the nurse expect to see on the x-ray report? a. Retinoblastoma b. Lymphadenopathy c. Mediastinal mass d. Tumor in the liver Ricci Chapter 46

c. Mediastinal mass Explanation: Difficulty breathing or respiratory distress may indicate a mediastinal mass (which may be seen on a radiograph) in the client with Hodgkin disease

A 14-year-old adolescent with Hodgkin disease is experiencing difficulty breathing and is sent for a radiograph. Which finding should the nurse expect to see on the x-ray report? a. Retinoblastoma b. Tumor in the liver c. Mediastinal mass d. Lymphadenopathy Ricci Chapter 46

c. Mediastinal mass Explanation:Difficulty breathing or respiratory distress may indicate a mediastinal mass (which may be seen on a radiograph) in the client with Hodgkin disease

The nurse is caring for a 13-year-old girl with delayed puberty. When developing the plan of care for this child, what would be the priority? a. Involving the child in her therapy to give her a sense of control. b. Encouraging the parents to discuss their concerns about the disorder. c. Monitoring for therapeutic and side effects of medication. d. Helping the child discuss her feelings about her condition. Ricci Chapter 48

c. Monitoring for therapeutic and side effects of medication. The child will be receiving hormone supplementation; therefore, monitoring for therapeutic results and possible side effects of medications is key. The physiological effects of the medications take priority over the psychosocial needs of the family or the child. Encouraging the parents to discuss their concerns about the disorder, involving the child in her therapy to give her a sense of control, and helping the child discuss her feelings about her condition would also be included in the plan of care but they would be addressed later on.

The nurse is reviewing the medical record of a child with a cleft lip and palate. When reviewing the child's history, what would the nurse identify as a risk factor for this condition? a. maternal use of acetaminophen in third trimester b. preterm birth c. mother age 42 with pregnancy d. history of hypoxia at birth Ricci Chapter 42

c. Mother age 42 with pregnancy Advanced maternal age is a risk factor for cleft lip and palate. Drugs such as anti-convulsant, steroids, and other medication's during early pregnancy are considered risk factors.

A client is suspected of having had a stroke. Which is the initial diagnostic test for a stroke? a. Transcranial Doppler studies b. Electrocardiography c. Noncontrast computed tomography d. Carotid Doppler Hinkle Chapter 62

c. Noncontrast computed tomography

The nurse is caring for a child with disseminated intravascular coagulation (DIC). The nurse notices signs of neurologic deficit. Which nursing action is appropriate? a. Continue to monitor neurologic signs. b. Evaluate respiratory status. c. Notify the physician. d. Inspect for signs of bleeding. Ricci Chapter 46

c. Notify the physician If neurological deficits are assessed, immediate reporting of the findings is necessary to begin treatment to prevent permanent damage.

The nurse is assessing a 7-year-old girl with a headache, irritability, and vomiting. Her health history reveals she has had meningitis. Which intervention is priority? a. Restoring fluid balance with IV sodium. b. Monitoring urine volume and specific gravity. c. Notifying the physician of the neurologic findings. d. Setting up safety precautions to prevent injury. Ricci Chapter 48

c. Notifying the physician of the neurologic findings This child may have syndrome of inappropriate antidiuretic hormone (SIADH). Priority intervention for this child is to notify the physician of the neurologic findings. Remaining interventions will be to restore fluid balance with IV sodium chloride to correct hyponatremia, set up safety precautions to prevent injury due to altered level of consciousness, and monitor fluid intake, urine volume, and specific gravity.

The nurse is assessing a 3-year-old boy whose mother reports that he is listless and has been having trouble swallowing. Which finding suggests the child may have a brain tumor? a. Vital signs show blood pressure measures 120/80 mm Hg. b. Observation reveals a cough and labored breathing. c. Observation reveals nystagmus and head tilt. d. Examination shows temperature of 101.4° F (38.6°C) and headache. Ricci Chapter 46

c. Observation reveals nystagmus and head tilt.

The nurse is caring for a client with multiple myeloma. Why would it be important to assess this client for fractures? a. Osteopathic tumors destroy bone causing fractures. b. Osteolytic activating factor weakens bones producing fractures. c. Osteoclasts break down bone cells so pathologic fractures occur. d. Osteosarcomas form producing pathologic fractures. Hinkle Chapter 30

c. Osteoclasts break down bone cells so pathologic fractures occur.

Which term refers to an abnormal decrease in white blood cells, red blood cells, and platelets? a. Leukopenia b. Anemia c. Pancytopenia d. Thrombocytopenia Hinkle Chapter 30

c. Pancytopenia Rationale: Pancytopenia is marked by low counts of all three types of blood cells—red cells, white cells and platelets. This condition can be caused by certain medications and by infections. In some cases, it is caused by a cancer or precancerous condition.

After a transsphenoidal adenohypophysectomy, a client is likely to undergo hormone replacement therapy. A transsphenoidal adenohypophysectomy is performed to treat which type of cancer? a. Laryngeal carcinoma b. Colorectal carcinoma c. Pituitary carcinoma d. Esophageal carcinoma Hinkle Chapter 61

c. Pituitary carcinoma

The emergency department nurse is assessing a child who has presented with a 2-day history of nausea and vomiting with pain that is isolated to the right upper quadrant of the abdomen. Which action is most appropriate? a. Encourage fluid intake. b. Administer antacids as ordered. c. Prepare the child for admission to the hospital. d. Assess the child's usual urinary voiding pattern. Ricci Chapter 42

c. Prepare the child for admission to the hospital. Rationale: The child's presentation is consistent with cholecystitis, which necessitates surgery in most cases. The child should be kept NPO and antacids are of no benefit. Genitourinary involvement is atypical.

A nurse is caring for a client with multiple myeloma. Which nursing intervention is most appropriate for this client? a. Balancing rest and activity b. Monitoring respiratory status c. Preventing bone injury d. Restricting fluid intake Hinkle Chapter 30

c. Preventing bone injury Rationale: When caring for a client with multiple myeloma, the nurse should focus on relieving pain, preventing bone injury and infection, and maintaining hydration. Monitoring respiratory status and balancing rest and activity are appropriate interventions for any client. To prevent such complications as pyelonephritis and renal calculi, the nurse should keep the client well hydrated — not restrict fluid intake.

The nurse is caring for a child admitted with pyloric stenosis. Which clinical manifestation would likely have been noted in the child with this diagnosis? a. Severe abdominal pain b. Explosive diarrhea c. Projectile vomiting d. Frequent urination Ricci Chapter 42

c. Projectile vomiting Rationale: During the first weeks of life, the infant with pyloric stenosis often eats well and gains weight and then starts vomiting occasionally after meals. Within a few days the vomiting increases in frequency and force, becoming projectile. The child may have constipation, and peristaltic waves may be seen in the abdomen, but the child does not appear in severe pain. Urine output is decrease and urination is infrequent.

The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease? a. Gynecomastia and testicular atrophy b. Dyspnea and fatigue c. Purpura and petechiae d. Ascites and orthopnea Hinkle Chapter 43

c. Purpura and petechiae A hepatic disorder, such as cirrhosis, may disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Consequently, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.

Which liver function study is used to show the size of the liver and hepatic blood flow and obstruction? a. Electroencephalography (EEG) b. Magnetic resonance imaging (MRI) c. Radioisotope liver scan d. Angiography Hinkle Chapter 43

c. Radioisotope liver scan

The nurse is caring for a 12-year-old girl with hypothyroidism. Which information should be part of the nurse's teaching plan for the child and family? a. administering methimazole with meals b. how to recognize vitamin D toxicity c. reporting irritability or anxiety d. how to maintain fluid intake regimens Ricci Chapter 48

c. Reporting irritability or anxiety Side effects of hypothyroidism are restlessness, inability to sleep, or irritability. These should be reported to the physician. Educating how to recognize vitamin D toxicity is necessary for a child with hypoparathyroidism. Teaching parents how to maintain fluid intake regimens is important for a child with diabetes insipidus. Teaching the child and parents to administer methimazole with meals is necessary for hyperthyroidism.

A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? a. Administering prescribed antipyretics b. Hyperoxygenation before and after tracheal suctioning c. Restricting fluid intake and hydration d. Maintaining adequate hydration Hinkle Chapter 61

c. Restricting fluid intake and hydration Rationale: Fluid restriction may be necessary if the client develops cerebral edema and hypervolemia from SIADH. Antipyretics are administered to clients who develop hyperthermia. In addition, it is important to maintain adequate hydration in such clients. A client with neurological infection should be given tracheal suctioning and hyperoxygenation only when respiratory distress develops.

After undergoing a liver biopsy, a client should be placed in which position? a. Prone position b. Supine position c. Right lateral decubitus position d. Semi-Fowler's position Hinkle Chapter 43

c. Right lateral decubitus position

A child with acute lymphoblastic leukemia (ALL) is receiving methotrexate for therapy. Which nursing diagnosis would best apply during therapy? a. Risk for impaired mobility related to depressant effects of methotrexate b. Excess fluid volume related to effect of methotrexate on aldosterone secretion c. Risk for impaired skin integrity related to oral ulcerations associated with chemotherapy d. Risk for self-directed violence related to effect of methotrexate on central nervous system Ricci Chapter 46

c. Risk for impaired skin integrity related to oral ulcerations associated with chemotherapy

Clients with chronic liver dysfunction have problems with insufficient vitamin intake. Which may occur as a result of vitamin C deficiency? a. Beriberi b. Hypoprothrombinemia c. Scurvy d. Night blindness Hinkle Chapter 43

c. Scurvy

A client with multiple myeloma presents to the emergency department and reports excessive thirst and constipation. Family members report that the client has been confused for the last day. Which laboratory value is most likely responsible for this client's symptoms? a. Hemoglobin of 9.8 g/dl b. Platelet count 300,000/mm3 c. Serum calcium level 13.8 mg/dl d. Serum sodium level of 133 mEq/L Hinkle Chapter 30

c. Serum calcium level 13.8 mg/dl

The nurse is participating in a health fair for stroke prevention. Which will the nurse say is a modifiable risk factor for ischemic stroke? a. Advanced age b. Social drinking c. Smoking d. Thyroid disease Hinkle Chapter 62

c. Smoking

The nurse is caring for a 6-month-old infant with diarrhea and dehydration. The parent is concerned because the infant has some patches on the tongue. Which feature indicates a geographic tongue? a. There are also white patches on the erupted teeth. b. There are also plaques on the buccal mucosa. c. Some patches are light in color and other patches are dark in color. d. The patches are thick, white plaques on the tongue. Ricci Chapter 42

c. Some patches are light in color and other patches are dark in color.

The nurse is concerned about potassium loss when a diuretic is prescribed for a patient with ascites and edema. What diuretic may be ordered that spares potassium and prevents hypokalemia? a. Bumetanide (Bumex) b. Acetazolamide (Diamox) c. Spironolactone (Aldactone) d. Furosemide (Lasix) Hinkle Chapter 43

c. Spironolactone (Aldactone) Potassium-sparing diuretic agents such as spironolactone or triamterene (Dyrenium) may be indicated to decrease ascites, if present; these diuretics are preferred because they minimize the fluid and electrolyte changes commonly seen with other agents.

A client with hepatitis who has not responded to medical treatment is scheduled for a liver transplant. Which of the following most likely would be ordered? a. Chenodiol b. Ursodiol c. Tacrolimus d. Interferon alfa-2b, recombinant Hinkle Chapter 43

c. Tacrolimus (Prograf, FK506) In preparation for a liver transplant, a client receives immunosuppressants to reduce the risk for organ rejection. Tacrolimus and cyclosporine are two immunosuppressants that may be used. Chenodiol and ursodiol are agents used to dissolve gallstones. Recombinant interferon alfa-2b is used to treat chronic hepatitis B, C, and D to force the virus into remission.

The nurse is assessing a 10-day-old infant for dehydration. Which finding indicates severe dehydration? a. Blood pressure of 80/42 mm Hg b. Soft and flat fontanels (fontanelles) c. Tenting of skin d. Pale and slightly dry mucosa Ricci Chapter 42

c. Tenting of skin

The nurse is caring for a child who is suspected to have a growth hormone deficiency. Which finding after further testing supports this diagnosis? a. Magnetic resonance imaging shows a brain tumor. b. Computed tomography identifies a tumor on the child's kidney. c. The bone age is found to be two or more deviations below normal. d. Physical examination finds excessive foot and finger growth for age. Ricci Chapter 48

c. The bone scan would show bone age would be two or more deviations below normal. Diagnostic testing used in children with suspected GH deficiency include bone age will be two or more deviations below normal. CT or MRI scans would be used to rule out tumors or structural abnormalities, not bone scans.

The nurse is caring for 1-month-old girl with thyrotoxicosis. What finding would the nurse expect to assess? a. Observation reveals lethargy and irritability. b. Skin is cool, dry, and scaly to the touch. c. The child has a strong appetite but fails to thrive. d. The child is hypoactive and hypotonic. Ricci Chapter 48

c. The child has a strong appetite but fails to thrive.

A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation? a. The client is relaxed and not in pain. b. The client didn't take his morning dose of lactulose (Cephulac). c. The client's hepatic function is decreasing. d. The client is avoiding the nurse. Hinkle Chapter 43

c. The client's hepatic function is decreasing.

The nurse is preparing teaching materials for a family whose child is prescribed somatropin for a growth hormone deficiency. What should the nurse instruct the parents about the administration of this medication? a. This medication does not interact with any other types of medication. b. Hip or knee pain is an expected adverse effect of this medication. c. This medication must be given by injection. d. This medication must be given in the morning before school. Ricci Chapter 48

c. This medication must be given by injection.

A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following? a. A ruptured intracranial aneurysm must quickly be repaired. b. Intracranial pressure is increased by a space-occupying bleed. c. Thrombolytic therapy has a time window of only 3 hours. d. A ruptured arteriovenous malformation will cause deficits until it is stopped. Hinkle Chapter 62

c. Thrombolytic therapy has a time window of only 3 hours.

A client with carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should a nurse administer to the client before surgery? a. Oral bile acids b. Potassium c. Vitamin K d. Vitamin B Hinkle Chapter 43

c. Vitamin K Clients with carcinoma of the head of the pancreas typically require vitamin K before surgery to correct a prothrombin deficiency.

The nurse is assessing a toddler for motor function. Which activity will be the most valuable? a. Ask the child to kick the ball forward. b. Have the child catch a ball. c. Watch the child reach for a toy. d. Let the child look at a picture book. RIcci Chapter 38

c. Watch the child reach for a toy. Rationale: Watching the child reach for a toy would be most valuable for assessing motor function because the infant should be able to extend extremities to a normal stretch. Catching a ball is too advanced for a toddler to accomplish. Looking at a picture book would help assess visual acuity and eye movement. Eating potato chips would help assess sensor function for taste.

The nurse is providing education to the parents of a 3-year-old girl with hydrocephalus who has just had an external ventricular drainage system placed. Which question is best to begin the teaching session? a. "Why do you always keep her head raised 30 degrees?" b. "Do you understand why you clamp the drain before she sits up?" c. "What questions or concerns do you have about this device?" d. "What do you know about her autoregulation mechanism failing?" Ricci Chapter 38

c. What questions or concerns do you have about this device?" Rationale: Always start by assessing the family's knowledge. Ask them what they need to know. Knowing when to clamp the drain is important, but they might not be listening if they have another question on their minds. Autoregulation is too technical. Teaching should be based on the parents' level of understanding. Keeping her head elevated is not part of the information which would be taught regarding the drainage system.

The nurse is caring for a child with a suspected head injury. The nurse observes for what response to the child's eye reflex examination that would indicate potential increased intracranial pressure (ICP)? a. While stimulating the child's foot, the big toe points upward and other toes fan outward. b. While calling the child's name, the child stares straight ahead and does not turn to the sound. c. While assessing the child's pupils, there is no change in diameter in response to a light. d. While turning the child's head to the left, the eyes turn to the right. Ricci Chapter 38

c. While assessing the child's pupils, there is no change in diameter in response to a light. Rationale: To perform the child's eye reflex examination, the nurse will shine a penlight into the eyes and observe if the pupils constrict, which is a normal response. Lack of pupillary light reflex can indicate increased intracranial pressure (ICP). To perform the "doll's eye" reflex examination, the nurse will place the child in a supine position and move the head gently but rapidly to one side. During this movement, it is normal for the child's eye to move to the opposite side. If the child has increased ICP, this response will be absent. While the other options are potential signs of increased ICP, they do not demonstrate the child's eye reflex examination.

The nurse is caring for a near-term pregnant woman who has not taken prenatal vitamins or folic acid supplements. Which congenital defect is most likely to occur based on the mother's prenatal history? a. incomplete myelinization b. facial deformities c. a neural tube defect d. neonatal conjunctivitis Ricci Chapter 38

c. a neural tube defect Rationale: Folic acid supplementation has been found to reduce the incidence of neural tube defects by 50%. The fact that the mother has not used folic acid supplements puts her baby at risk for spina bifida occulta, one type of neural tube defect. Neonatal conjunctivitis can occur in any newborn during birth and is caused by virus, bacteria, or chemicals. Facial deformities are typical of babies of alcoholic mothers. Incomplete myelinization is present in all newborns.

The nurse is teaching the parents of a young client who has recently been diagnosed with diabetes insipidus about the disease. The child is not secreting enough of which hormone? a. luteinizing hormone (LH) b. thyroid stimulating hormone (TSH) c. antidiuretic hormone (ADH) d. adrenocorticotropic hormone (ACTH) Ricci Chapter 48

c. antidiuretic hormone (ADH)

A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis? a. swallowing b. smelling c. chewing d. tasting Hinkle Chapter 61

c. chewing

A newborn is born with hypothyroidism. If it is not recognized and treated, what complication is likely? a. dehydration b. muscle spasticity c. cognitive impairment d. blindness Ricci Chapter 48

c. cognitive impairment

The nurse is caring for a child admitted with suspected leukemia. The nurse has taken the child's history and performed an assessment. The nurse will plan to prepare the child for which additional diagnostic test first? a. magnetic resonance imaging (MRI) b. bone marrow aspiration c. complete blood cell count (CBC) d. urinalysis Ricci Chapter 46

c. complete blood cell count (CBC) Rationale: After obtaining the child's history and symptoms, the nurse would prepare the child for laboratory blood studies to assess the child's white blood cell (WBC) count. A complete blood cell (CBC) count will provide data on the child's WBC level. A bone marrow aspiration would be scheduled based on the results of the CBC as it is required to confirm the diagnosis of leukemia.

When the nurse observes that the client has extension and external rotation of the arms and wrists and plantar flexion of the feet, the nurse records the client's posture as a. normal. b. flaccid. c. decerebrate. d. decorticate. Hinkle Chapter 61

c. decerebrate.

A nurse taking a health history of a newborn notes that there is a maternal history of polyhydramnios. What GI condition might this history precipitate? a. pyloric stenosis b. cleft palate c. esophageal atresia (EA) d. hernia Ricci Chapter 42

c. esophageal atresia (EA) Rationale: A maternal history of polyhydramnios is usually present in one-third of cases of EA and in some cases of tracheoesophageal fistula (TEF).

The nurse is meeting with a parent and child at the pediatric clinic. Which statement made by the parent during the history would alert the nurse that there might be a possible malignancy in the child? a. swollen cervical lymph nodes with pharyngitis b. frequent stomach aches c. fever with no response to repeated antibiotics d. recurrent headaches while reading Ricci Chapter 46

c. fever with no response to repeated antibiotics Rationale: Abnormal duration of symptoms that have lingered or increased over an unusually long period (e.g., a fever that has not responded to antibiotics) and has lasted longer than expected for recovery from acute illness could be a sign of a malignancy. Frequent stomach aches could stem from a variety of issues, such as irritable bowel syndrome. Recurrent headaches while reading may relate to visual changes. Swollen cervical lymph nodes with pharyngitis are typically viral or bacterial in nature.

A pediatric client has just been diagnosed with diabetes insipidus. What is the primary consideration for this client? a. headache b. polydipsia c. fluid replacement d. weight loss Ricci Chapter 48

c. fluid replacement

The nurse is caring for a child with leukemia. Which nursing intervention would be the highest priority for this child? a. providing age-appropriate activities b. grouping nursing care c. following guidelines for reverse isolation d. encouraging the child to share feelings Ricci Chapter 46

c. following guidelines for reverse isolation The child with leukemia is susceptible to infection, especially during chemotherapy. Infections such as meningitis, septicemia, and pneumonia are the most common causes of death. To protect the child from infectious organisms, follow standard guidelines for reverse isolation.- Grouping nursing care to provide rest is important, but not the highest priority.- Encouraging the child to share feelings and providing age-appropriate activities are important, but psychological issues are a lower priority than physical.

An 18-month-old infant is brought to the emergency department with flu-like symptoms. The infant is diagnosed with pneumonia secondary to aspiration of stomach contents. The nurse explains to the parents that pneumonia is a condition that often occurs secondary to: a. inflammatory bowel disease. b. Hirschsprung disease. c. gastroesophageal reflux disease. d. cystic fibrosis. Ricci Chapter 42

c. gastroesophageal reflux disease. Rationale: The child with gastroesophageal reflux disease may present with the physical findings of pneumonia secondary to aspiration of refluxed stomach contents.

The nurse is conducting a physical examination of an infant with suspected pyloric stenosis. Which finding indicates pyloric stenosis? a. sausage-shaped mass in the upper mid abdomen b. abdominal pain and irritability c. hard, moveable "olive-like mass" in the upper right quadrant d. perianal fissures and skin tags Ricci Chapter 42

c. hard, moveable "olive-like mass" in the upper right quadrant A hard, moveable "olive-like mass" in the right upper quadrant is the hypertrophied pylorus. A sausage-shaped mass in the upper mid abdomen is the hallmark of intussusception. Perianal fissures and skin tags are typical with Crohn disease. Abdominal pain and irritability is common with pyloric stenosis but are seen with many other conditions.

A child is diagnosed with hypoparathyroidism. Which electrolyte imbalance would the nurse most likely expect to address? a. hyponatremia b. hyperkalemia c. hypocalcemia d. hypomagnesemia Ricci Chapter 48

c. hypocalcemia Hypoparathyroidism results in low production of PTH which in turn leads to hypocalcemia and hyperphosphatemia.

A child with cancer has developed neutropenia and is in isolation with neutropenic precautions. What nursing assessment takes priority for this child? a. vital signs b. mucositis c. infection symptoms d. bleeding Ricci Chapter 46

c. infection symptoms Rationale: The neutrophils are the primary means of fighting bacterial infection. When the neutrophil count is very low, the child has the potential to have an overwhelming bacterial infection. The child is at the greatest risk when the neutrophil count is less than 500/µL (0.50 ×109/L). The nurse's priority would be to assess for signs and symptoms of infection. A bacterial infection can be life-threatening for this child. This child would be placed in neutropenic precautions. This is a form of isolation where the child is protected from health care workers and outside visitors. Among other precautions, no plants or raw fruits or vegetables would be allowed in the room, and the child should have no rectal examinations or medications and not experience a urinary catheterization. To prevent an infection, the nurse would administer broad spectrum antibiotics. The vital signs should be assessed every 4 hours, and alterations could indicate more problems than just infection. Mucositis occurs when there is an ulcerated oral mucosa. It should be assessed but is not the priority. Bleeding would be more related to low platelet count and not neutrophils.

The nurse is assessing a school-aged child with sickle-cell anemia. Which assessment finding is consistent with this child's diagnosis? a. enlarged mandibular growth b. increased growth of long bones c. lightly yellow sclera d. depigmented areas on the abdomen Ricci Chapter 46

c. lightly yellow sclera

To prevent further sickle cell crisis, the nurse would advise the parents of a child with sickle cell anemia to: a. encourage the child to participate in school activities, such as long-distance running. b. prevent the child from drinking an excess amount of fluids per day. c. notify a health care provider if the child develops an upper respiratory infection. d. administer an iron supplement daily. Ricci Chapter 46

c. notify a health care provider if the child develops an upper respiratory infection.

The nurse is reviewing the medical record of a child diagnosed with Hodgkin lymphoma at the asymptomatic stage. Which would the nurse identify as typically the first sign reported by the child? a. anorexia b. weight loss c. painless, enlarged lymph node d. night sweats Ricci Chapter 46

c. painless, enlarged lymph node Explanation:Children with Hodgkin lymphoma typically present with swollen, painless, and rubbery-feeling lymph nodes in the cervical or supraclavicular region. Depending on the extent of the disease at diagnosis, other symptoms may be present. However, this child was diagnosed in stage I (asymptomatic). If the lymph nodes of the chest are involved, the child has moved to the symptomatic stages and may experience dyspnea and cough. Chest pain may result from the pressure exerted by the enlarged nodes. General symptoms can also include fever, drenching night sweats, and weight loss.

A client who has worked for a company that produces paint and varnishing compounds for 24 years is visiting the clinic reporting chronic fatigue, dyspepsia, diarrhea, and a recently developing yellowing of the skin and sclera. The client reports clay-colored stools and frequent nosebleeds. Which type of cirrhosis is the likely cause of the client's symptoms? a. alcoholic b. respiratory c. postnecrotic d. biliary Hinkle Chapter 43

c. postnecrotic

A client who has worked for a company that produces paint and varnishing compounds for 24 years is visiting the clinic reporting chronic fatigue, dyspepsia, diarrhea, and a recently developing yellowing of the skin and sclera. The client reports clay-colored stools and frequent nosebleeds. Which type of cirrhosis is the likely cause of the client's symptoms? a. respiratory b. biliary c. postnecrotic d. alcoholic Hinkle Chapter 43

c. postnecrotic

A child is brought to the emergency department after experiencing a series of continuous seizures. The nurse is reviewing the orders for care and treatment. Which order would be of the highest priority? a. urinalysis b. white blood cell count c. serum glucose level d. hemoglobin level Ricci Chapter 38

c. serum glucose level

A client admitted to the emergency department is being evaluated for the possibility of a stroke. Which assessment finding would lead the nurse to suspect that the client is experiencing a hemorrhagic stroke? a. difficulty finding appropriate words b. slurred speech c. severe exploding headache d. left-sided weakness Hinkle Chapter 62

c. severe exploding headache

The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the a. Trendelenburg position. b. dorsal recumbent position. c. supine position with the head slightly elevated. d. prone position with the head turned to the unaffected side. Hinkle Chapter 61

c. supine position with the head slightly elevated.

The oncology nurse is alert for clients displaying signs and symptoms of disseminated intravascular coagulation (DIC). Which symptom would alert the nurse to this emergency condition? a. increased antithrombin III levels b. decreased D-dimer assay c. uncontrolled bleeding d. platelet count 10,000/mm3 (10 ×109/L) Ricci Chapter 46

c. uncontrolled bleeding

A nurse is leading a discussion with a group of new mothers about newborn nutrition and its importance for growth and development. One of the mothers asks, "Doesn't the baby get iron from me before birth?" Which response by the nurse would be most appropriate? a. "If the baby didn't use up what you gave him before birth, he excretes it soon after birth." b. "You give the baby some iron, but it is not enough to sustain him after birth." c. "The iron you give him before birth is different from what he needs once he is born." d. "Because the baby grows rapidly during the first months, he uses up what you gave him." Ricci Chapter 46

d. "Because the baby grows rapidly during the first months, he uses up what you gave him."

The nurse is caring for a child who has suffered a febrile seizure. While speaking with the child's parents, which statement by a parent indicates a need for further education? a. "When he gets his next set of immunizations, I need to make sure I give him some ibuprofen so he doesn't spike a fever." b. "The next time he has a fever, I need to make sure I read the dosage on the acetaminophen bottle carefully." c. "I need to set an alarm to wake up and check his temperature during the night when he is sick." d. "I hate to think that I will need to be worried about my child having seizures for the rest of his life." Ricci Chapter 38

d. "I hate to think that I will need to be worried about my child having seizures for the rest of his life." Rationale: Febrile seizure occur when the child has a rapid in temp and are not associated with development of seizure later in life.Administer correct acetaminophen and ibuprofen, checking temperatures at night, and anticipating fevers associated with the administration of live vaccines are all ways to prevent the development of febrile seizures.

The mother of an infant tells the nurse during a routine visit to the clinic that she often notices a bulging mass in the lower abdominal and groin area when her baby cries. She asks the nurse if this is normal. How should the nurse respond? a. "The muscle wall of infants are not yet strong so it isn't unusual to see this happening when the baby is crying or straining." b. "I will be sure to note this in your child's chart so it is something we will continue to monitor in future visits." c. "I didn't notice any masses while I was assessing your infant. It may just appear they have a mass due to pressure in the abdomen when crying." d. "I understand your concern. I will be sure to document this in your child's medical record and report this information to your child's physician immediately." Ricci Chapter 42

d. "I understand your concern. I will be sure to document this in your child's medical record and report this information to your child's physician immediately." Rationale: The mother is describing common symptoms of an inguinal hernia. It may be possible to visualize the mass, but often the mass is seen only during crying or straining, making it difficult to actually identify in the clinic setting. It is important to notify the physician so treatment can be initiated.

The nurse is caring for an infant recently diagnosed with oral candidiasis (thrush) who has been prescribed nystatin. Which statement by the infant's mother would suggest a need for further education? a. "I will use a cotton tipped applicator to apply the medication to her mouth." b. "I will make sure to clean all of her toys before I give them to her." c. "I will watch for diaper rash." d. "I will add the nystatin to her bottle four times per day." Ricci Chapter 42

d. "I will add the nystatin to her bottle four times per day."

The nurse is teaching a client with acute lymphocytic leukemia (ALL) about therapy. What statement should be included in the plan of care? a. "Side effects are rare with therapy." b. "The goal of therapy is palliation." c. "Treatment is simple and consists of single-drug therapy." d. "Intrathecal chemotherapy is used primarily as preventive therapy." Hinkle Chapter 30

d. "Intrathecal chemotherapy is used primarily as preventive therapy." Rationale: Intrathecal chemotherapy is a key part of the treatment plan to prevent invasion of the central nervous system. The therapy uses multiple drugs, with many side effects. The goal of therapy is remission.

The nurse is caring for a child with gastrointestinal concerns. What statement by the parent would indicate a need for the nurse to further assess the child for constipation? a. "My child eats vegetables and fresh fruit, but does not like beans." b. "My child does not have liquid stool or leak liquid stools that I am aware of." c. "My child only has a bowel movement about four times a week." d. "My child has such large bowl movements that it clogs the toilet." Ricci Chapter 42

d. "My child has such large bowl movements that it clogs the toilet." Constipation may manifest by bowel movements that are large enough to clog the toilet, fewer bowel movements than normal, and bowel movements that are hard and pellet-like. Constipation is not likely if the child eats fruits and vegetables, even when beans are not incorporated into the child's diet. Passage of liquid stools can be a sign of constipation.

The nurse is reinforcing dietary teaching with the caregiver of a child diagnosed with celiac disease. The caregivers make the following statements. Which statement indicates a need for further teaching regarding the dietary restrictions for the child with celiac disease? a. "I have learned to make my own bread with no gluten." b. "Even though milk and pudding are good for her, we don't give her those foods." c. "The soup we eat at our house is all made from scratch." d. "She loves hot dogs, and we always cut hers up into small pieces." Ricci Chapter 42

d. "She loves hot dogs, and we always cut hers up into small pieces."

The nurse is collecting data on a 2-year-old child admitted with a diagnosis of gastroenteritis. When interviewing the caregivers, which question is most important for the nurse to ask? a. "How long has your child been toilet trained?" b. "How many times a day does your child urinate?" c. "What foods has your child eaten during the last few days?" d. "Tell me about the types of stools your child has been having." Ricci Chapter 42

d. "Tell me about the types of stools your child has been having."

A client recently experienced a stroke with accompanying left-sided paralysis. His family voices concerns about how to best interact with him. They report the client doesn't seem aware of their presence when they approach him on his left side. What advice should the nurse give the family? a. "The client is feeling an emotional loss. He'll eventually start acknowledging you on his left side." b. "This condition is temporary." c. "The client is unaware of his left side. You need to encourage him to interact from this side." d. "The client is unaware of his left side. You should approach him on the right side." Hinkle Chapter 62

d. "The client is unaware of his left side. You should approach him on the right side."

A client being treated for non-Hodgkin lymphoma asks the nurse why they need to be monitored for additional forms of leukemia. Which is the nurse's best response? a. "These screening are health promotion activities that apply to everyone." b. "You don't want to develop a second cancer, do you?" c. "You need to do this just to be on the safe side." d. "These are seen among survivors like yourself." Hinkle Chapter 30

d. "These are seen among survivors like yourself."

A 7-year-old client has been complaining of headache, coughing, and an aching chest. The care provider makes a diagnosis of a viral infection. The child's mother tells the nurse that when she first said she had a headache, the child's father gave her half of an adult aspirin. The mother has heard of Reye syndrome and asks the nurse if her child could get this. Which statement would be the best response by the nurse? a. "This is unlikely to be a problem. Half an aspirin is not enough to cause harm. Reye syndrome generally only develops from prolonged use of aspirin in connection with a virus." b. "This is a serious problem. Aspirin is likely to cause Reye syndrome, and she should be admitted to the hospital for observation as a precaution." c. "This might or might not be a problem. Watch your daughter for signs of nasal discharge, sneezing, itching of the nose, or dark circles under the eyes. If you notice any of the

d. "This might or might not be a problem. Watch your daughter for signs of lethargy, unusual irritability, confusion, or vomiting. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome." Rationale: Reye syndrome usually occurs after a viral illness, particularly after an upper respiratory infection or varicella (chickenpox). Administration of aspirin during the viral illness has been implicated as a contributing factor. As a result, the American Academy of Pediatrics recommends that aspirin or aspirin compounds not be given to children with viral infections. The symptoms appear within 3 to 5 days after the initial illness: The child is recuperating unremarkably when symptoms of severe vomiting, irritability, lethargy, and confusion occur. Immediate intervention is needed to prevent serious insult to the brain, including respiratory arrest.

The nurse is educating the family of a 7-year-old with epilepsy about care and safety for this child. What comment will be most valuable in helping the parent and the child cope? a. "Bike riding and swimming are just too dangerous." b. "You'll always need a monitor in his room." c. "If he is out of bed, the helmet's on the head." d. "Use this information to teach family and friends." Ricci Chapter 38

d. "Use this information to teach family and friends."

A student accepted into a nursing program must begin receiving the hepatitis B series of injections. The student asks when the next two injections should be administered. What is the best response by the instructor? a. "You must have the second one in 2 weeks and the third in 1 month." b. "You must have the second one in 6 months and the third in 1 year." c. "You must have the second one in 1 year and the third the following year." d. "You must have the second one in 1 month and the third in 6 months." Hinkle Chapter 43

d. "You must have the second one in 1 month and the third in 6 months."

A 13-year-old adolescent has had a near-drowning experience. The nurse notices the client has labored breathing and a cough. What is the priority intervention? a. Check the client's capillary refill time. b. Perform postural drainage every hour. c. Have the client sit up straight in a chair. d. Administer 100% oxygen by mask. Ricci Chapter 51

d. Administer 100% oxygen by mask.

The toddler with a cancer diagnosis is seen for a well-child checkup. Which health maintenance activity will the nurse exclude? a. Assessing dietary intake by addressing "picky eating" and "food jags" b. Teaching the importance of taking water safety measures c. Plotting height and weight on a growth chart d. Administering the measles, mumps, rubella (MMR) vaccine Ricci Chapter 46

d. Administering the measles, mumps, rubella (MMR) vaccine Explanation: Live vaccines (viral or bacterial) should not be administered to an immune suppressed child because of the risk of causing disease. The other health maintenance activities are important for the health maintenance of the toddler and should be included during the well-child visit.

A community health nurse is giving an educational presentation about stroke and heart disease at the local senior citizens' center. What nonmodifiable risk factor for stroke should the nurse cite? a. Tobacco use b. Physical inactivity c. Hypertension d. Advanced age Hinkle Chapter 62

d. Advanced age

A client with liver and renal failure has severe ascites. On initial shift rounds, his primary nurse finds his indwelling urinary catheter collection bag too full to store more urine. The nurse empties more than 2,000 ml from the collection bag. One hour later, she finds the collection bag full again. The nurse notifies the physician, who suspects that a bladder rupture is allowing the drainage of peritoneal fluid. The physician orders a urinalysis to be obtained immediately. The presence of which substance is considered abnormal? a. Creatinine b. Chloride c. Urobilinogen d. Albumin Hinkle Chapter 43

d. Albumin Albumin is an abnormal finding in a routine urine specimen. Ascites present in liver failure contain albumin; therefore, if the bladder ruptured, ascites containing albumin would drain from the indwelling urinary catheter because the catheter is no longer contained in the bladder. Creatinine, urobilinogen, and chloride are normally found in urine.

The nurse observes the interactions of parents with their infant who was born with a cleft lip. The mother is attempting to feed the baby, but does not make eye contact. The father is watching television with his back turned to the mother and baby. What psychosocial nursing intervention would be most helpful to this family? a. Teach the mother the appropriate technique for breastfeeding an infant with cleft lip. b. Refer the family to a social worker or mental health practitioner. c. Explain to the parents that surgical intervention will fix the defect in the baby's lip. d. Ask the parents if they have any questions regarding the care of their child. Ricci Chapter 42

d. Ask the parents if they have any questions regarding the care of their

A client presents with peripheral neuropathy and hypoesthesia of the feet. What is the best nursing intervention? a. Keep the feet cool. b. Encourage ambulation. c. Elevate the client's legs. d. Assess for signs of injury. Hinkle Chapter 30

d. Assess for signs of injury.

The nurse is caring for a child diagnosed with hydrocephalus following ventriculoperitoneal shunt placement. The child is currently on a ventilator. Which nursing action is priority? a. Measure the client's head circumference. b. Educate the family on the shunt. c. Monitor the client for signs of infection. d. Assess the client's respiratory status. Ricci Chapter 38

d. Assess the clients respiratory status. Rationale: The nurse would place priority on monitoring the client's respiratory status since the client is on a ventilator and at risk for intracranial pressure. The nurse would educate the family on the shunt, monitor for infection, and measure head circumference; however, these actions are not priority over ensuring the client maintains a patent airway.

The nurse is caring for a patient with cirrhosis of the liver and observes that the patient is having hand-flapping tremors. What does the nurse document this finding as? a. Fetor hepaticus b. Ataxia c. Constructional apraxia d. Asterixis Hinkle Chapter 43

d. Asterixis Asterixis, an involuntary flapping of the hands, may be seen in stage II encephalopathy.

A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning? a. Teach the child that water is dangerous. b. Provide only partial baths to the toddler. c. Instruct the toddler not to go near the pool. d. Avoid unattended baths for the toddler. Ricci Chapter 51

d. Avoid unattended baths for the toddler The parents should not leave the toddler for an unattended bath. Toddlers are naturally inquisitive, and instructing them to stay away from the pool may make them more curious.

A child has been diagnosed with a basilar skull fracture. The nurse identifies ecchymosis behind the child's ear. This would be documented as: a. otorrhea. b. rhinorrhea. c. raccoon eyes. d. Battle sign. Ricci Chapter. 38

d. Battle sign. Rationale: Two signs of basilar skull fracture include Battle sign (bruising or ecchymosis behind the ear) and "raccoon eyes" (blood leaking into the frontal sinuses causing an edematous and bruised periorbital area). Rhinorrhea is CSF leakage from the nose. Otorrhea is CSF leaking from the ear.

What is one advantage of an implanted port (central venous access device) that the nurse will explain to an adolescent? a. No special procedure is necessary for removal. b. Flushing of the device is not necessary. c. No tunneling is needed when the port is inserted. d. Body appearance changes very little. Ricci Chapter 46

d. Body appearance changes very little.

A client is being tested for acute myeloid leukemia (AML). The nurse knows that which diagnostic test will be used as the hallmark for the diagnosis? a. Alkaline phosphatase level b. Complete blood count c. Clotting factors d. Bone marrow analysis Hinkle Chapter 30

d. Bone marrow analysis Rationale: To confirm the diagnosis of AML, laboratory studies need to be performed. A bone marrow analysis shows an excess or more than 20% of blast cells which is the hallmark of the diagnosis. Clotting factors are not used to diagnose AML. The complete blood count (CBC) commonly shows a decrease in both erythrocytes and platelets but is not as specific as the bone marrow analysis. The alkaline phosphatase level measures a liver enzyme.

A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom? a. Small artery thrombosis b. Large artery thrombosis c. Cardiogenic emboli d. Cerebral aneurysm Hinkle Chapter 62

d. Cerebral aneurysm

A nurse cares for a client with early Hodgkin lymphoma. While assessing the client, the nurse will most likely find painless enlargement of which lymph node? a. Popliteal b. Inguinal c. Axillary d. Cervical Hinkle Chapter 30

d. Cervical Rationale: Non0painful swelling of the cervical lymph nodes is the earliest symptom of Hodgkin lymphoma.

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first? a. Continue the assessment because no actions are indicated at this time. b. Document the reading because it reflects that the treatment has been effective. c. Contact the physician to review the care plan. d. Check the equipment. Hinkle Chapter 61

d. Check the equipment.

A child with a primary growth hormone deficiency is to receive biosynthetic growth hormone. The nurse would explain to the child and parents that this hormone would be given at which frequency? a. monthly b. weekly c. bi-monthly d. daily Ricci Chapter 48

d. Daily Biosynthetic growth hormone, derived from recombinant DNA, is given by subcutaneous injection. The weekly dosage is 0.2 to 0.3 mg/kg, divided into equal doses given daily for best growth.

A client with a traumatic brain injury has already displayed early signs of increasing intracranial pressure (ICP). Which of the following would be considered late signs of increasing ICP? a. Mental confusion and pupillary changes b. Complaints of headache and lack of pupillary response c. Loss of gag reflex and mental confusion d. Decerebrate posturing and loss of corneal reflex Hinkle Chapter 61

d. Decerebrate posturing and loss of corneal reflex

A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head? a. Elevated no more than 10 degrees b. Turned onto the operative side c. Flat d. Elevated 30 degrees Hinkle Chapter 61

d. Elevated 30 degrees

After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client? a. Checking stools for occult blood b. Keeping skin clean and dry c. Performing range-of-motion (ROM) exercises on the left side d. Elevating the head of the bed to 30 degrees Hinkle Chapter 62

d. Elevating the head of the bed to 30 degrees

The nurse is caring for a child who had a stem cell transplant and is being monitored for engraftment. Which nursing action is priority? a. Remind parents to contact the child's school. b. Monitor daily complete blood count (CBC). c. Encourage therapeutic play activities. d. Ensure neutropenic precautions are in place. Ricci Chapter 46

d. Ensure neutropenic precautions are in place. Explanation:With stem cell transplants, children are at greatest risk for infection and sepsis. The nurse should ensure neutropenic precautions are used to reduce the change of infection. Monitoring laboratory values, reminding the parent to contact the school, and encouraging therapeutic play are important, but preventing infection in the immunocompromised child is a priority.

A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe? a. Occipital b. Parietal c. Temporal d. Frontal Hinkle Chapter 62

d. Frontal Rationale: Frontal lobe damage results in impaired learning capacity, memory, and other higher cortical intellectual functions.

A parent brings a 2-year-old child to the health clinic with reports of diarrhea, vomiting, and abdominal pain. The father tells the nurse that he is a single parent and his child is enrolled in a local day care center. Based on this information, what gastrointestinal condition might the nurse suspect? a. Appendicitis b. Pancreatitis c. Hirschsprung disease d. Gastroenteritis Ricci Chapter 42

d. Gastroenteritis

A 12-year-old is being seen in the office and has hyperthyroidism; the nurse knows that the most common cause of hyperthyroidism is: a. Addison disease b. Plummer disease c. Cushing disease d. Graves disease Ricci Chapter 48

d. Graves disease Hyperthyroidism occurs less often in children than hypothyroidism. Graves' disease, the most common cause of hyperthyroidism in children, occurs in 1 in 5,000 children between 11 and 15 years of age. Hyperthyroidism occurs more often in females, and the peak incidence occurs during adolescence.

A client undergoes cerebral angiography for evaluation of a subarachnoid hemorrhage. Which findings indicate spasm or occlusion of a cerebral vessel by a clot? a. Tachycardia, tachypnea, and hypotension b. Difficulty breathing or swallowing c. Nausea, vomiting, and profuse sweating d. Hemiplegia, seizures, and decreased level of consciousness Hinkle Chapter 62

d. Hemiplegia, seizures, and decreased level of consciousness

The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient? a. Low in fat b. Restricts protein to 10% of daily caloric intake c. At least 50% carbohydrate d. High in protein and low in carbohydrate Hinkle Chapter 61

d. High in protein and low in carbohydrate Rationale: A dietary intervention, referred to as the ketogenic diet, may be helpful for control of seizures in some patients. This high-protein, low-carbohydrate, high-fat diet is most effective in children whose seizures have not been controlled with two antiseizure medications, but it is sometimes used for adults who have had poor seizure control.

A client has developed drug-induced hepatitis from a drug reaction to antidepressants. What treatment does the nurse anticipate the client will receive to treat the reaction? a. Azathioprine b. Paracentesis c. Liver transplantation d. High-dose corticosteroids Hinkle Chapter 43

d. High-dose corticosteroids Drug-induced hepatitis occurs when a drug reaction damages the liver. This form of hepatitis can be severe and fatal. High-dose corticosteroids usually administered first to treat the reaction. Liver transplantation may be necessary. Paracentesis would be used to withdrawal fluid for the treatment of ascites. Azathioprine (Imuran) may be used for autoimmune hepatitis

A neonatal nurse teaches students how to recognize gastrointestinal disorders in infants. The nurse tells the students that failure of the newborn to pass meconium in the first 24 hours after birth may indicate what disease? a. Short bowel syndrome (SBS) b. Gastroenteritis c. Ulcerative colitis (UC) d. Hirschsprung disease Ricci Chapter 42

d. Hirschsprung disease

The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regimen, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is: a. Smoking b. Obesity c. Dyslipidemia d. Hypertension Hinkle Chapter 62

d. Hypertension

A nurse is preparing a 7-year-old girl for bone marrow aspiration. Which site should she prepare? a. Femur b. Anterior tibia c. Sternum d. Iliac crest Ricci Chapter 46

d. Iliac crest Bone marrow aspiration provides samples of bone marrow so the type and quantity of cells being produced can be determined. In children, the aspiration sites used are the iliac crests or spines (rather than the sternum, which is commonly used in adults) because performing the test at these sites is usually less frightening for children; these sites also have the largest marrow compartments during childhood. In neonates, the anterior tibia can be used as an additional site

The nurse is caring for a child with a diagnosis of pyloric stenosis during the preoperative phase of the child's treatment. What is the highest priority at this time? a. Promoting comfort b. Maintaining skin integrity c. Preparing family for home care d. Improving hydration Ricci Chapter 42

d. Improving hydration

A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings? a. Completed Stroke b. Transient ischemic attack (TIA) c. Right-sided cerebrovascular accident (CVA) d. Left-sided cerebrovascular accident (CVA) Hinkle Chapter 62

d. Left-sided cerebrovascular accident (CVA) Rationale: When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete.

A client with right upper quadrant pain and weight loss is diagnosed with liver cancer. For which treatment will the nurse prepare the client when it is determined that the disease is confined to one lobe of the liver? a. Radiation b. Chemotherapy c. Laser hyperthermia d. Liver resection Hinkle Chapter 43

d. Liver resection

Which term refers to a form of white blood cell involved in immune response? a. Granulocyte b. Thrombocyte c. Spherocyte d. Lymphocyte Hinkle Chapter 30

d. Lymphocyte

The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important? a. Monitoring for seizure activity b. Elevating the head of the bed to 30 degrees c. Administering a stool softener d. Maintaining a patent airway Hinkle Chapter 62

d. Maintaining a patent airway

A child with sickle cell disease is brought to the emergency department by his parents. He is in excruciating pain. A vaso-occlusive crisis is suspected and analgesia is prescribed. What would the nurse expect as least likely to be ordered? a. Hydromorphone b. Nalbuphine c. Morphine d. Meperidine Ricci Chapter 46

d. Meperidine Explanation: Meperidine is contraindicated for ongoing pain management in a child with vaso-occlusive crisis because it increases the risk for seizures. Analgesics such as morphine, nalbuphine, or hydromorphone are commonly used.

The nurse cares for an older adult client with unprovoked back pain and increased serum protein. Which hematologic neoplasm does the nurse suspect the client has? a. Chronic myeloid leukemia b. Non-Hodgkin lymphoma c. Hodgkin lymphoma d. Multiple myeloma Hinkle Chapter 30

d. Multiple myeloma Rationale: Any older adult with unprovoked or unexplained back pain and increased protein in the serum should be assessed for multiple myeloma. Bone pain occurs because of bone breakdown and the malignant cells of multiple myeloma increase the serum protein levels.

Which clinical manifestation would be exhibited by a client following a hemorrhagic stroke of the right hemisphere? a. Inability to move the right arm b. Neglect of the right side c. Expressive aphasia d. Neglect of the left side Hinkle Chapter 62

d. Neglect of the left side

The pediatric nurse is explaining to a new graduate nurse the differences in planning well-child maintenance for a child with cancer. Which statement by the new nurse demonstrates understanding of the teaching? a. Eliminate second-hand smoke within the home. b. Siblings and parents should not receive nonlive vaccines. c. Growth may be stunted due to chemotherapy. d. No routine live vaccines are administered while on chemotherapy. Ricci Chapter 46

d. No routine live vaccines are administered while on chemotherapy.

The nurse is completing the health history of a 6-month-old infant with retinoblastoma with the child's parents. Which symptom should the nurse expect that the parents have observed? a. The infant tugs and pulls at one ear. b. The infant's eye appears to be protruding. c. The infant always keeps her eyes tightly closed. d. One pupil appears white. Ricci Chapter 46

d. One pupil appears white.

The nurse is caring for a child recently diagnosed with hypoparathyroidism disorder. Which medication would the nurse expect to be ordered? a. oral potassium b. intravenous diuretic therapy c. oral corticosteroids d. oral calcium Ricci Chapter 48

d. Oral calcium Medical management for hypoparathyroidism includes intravenous calcium gluconate for acute or severe tetany, then intramuscular or oral calcium as prescribed. IV diuretics is used in treatment of hyperparathyroidism. Oral corticosteroids and oral potassium are not used in the treatment of hypoparathyroidism.

The nurse is caring for a client with multiple myeloma. Why would it be important to assess this client for fractures? a. Osteosarcomas form producing pathologic fractures. b. Osteolytic activating factor weakens bones producing fractures. c. Osteopathic tumors destroy bone causing fractures. d. Osteoclasts break down bone cells so pathologic fractures occur. Hinkle Chapter 30

d. Osteoclasts break down bone cells so pathologic fractures occur.

A patient is admitted to the hospital for management of an extrapyramidal disorder. Included in the physician's admitting orders are the medications levodopa, benztropine, and selegiline. The nurse knows that most likely, the client has a diagnosis of: a. Huntington disease. b. multiple sclerosis. c. seizure disorder. d. Parkinson disease. Hinkle Chapter 61

d. Parkinson disease.

The nurse is assisting the client with multiple myeloma to ambulate. What is the most important nursing intervention to help prevent fractures in the client? a. Increase mobility. b. Provide adequate hydration. c. Encourage adequate nutrition. d. Promote safety. Hinkle Chapter 30

d. Promote safety Rationale: Safety is paramount because any injury, no matter how slight, can result in a fracture. Mobility, hydration, and nutrition are important, but will not prevent fractures.

The nurse is assessing a 4-year-old girl with ambiguous genitalia. Which finding suggests congenital adrenal hyperplasia? a. pain from constipation on palpation b. hyperpigmentation of the skin c. irregular heartbeat on auscultation d. pubic hair and hirsutism Ricci Chapter 48

d. Pubic hair and hirsutism Pubic hair and hirsutism in a preschooler indicates congenital adrenal hyperplasia. Irregular heartbeat on auscultation and pain due to constipation on palpation may be signs of hyperparathyroidism. Hyperpigmentation of the skin suggests Addison disease.

A child is undergoing a series of diagnostic tests for a suspected malignancy. Which diagnostic test result is only present in Hodgkin disease? a. megakaryocyte cells b. elevated lymphocytes c. T-lymphocyte surface markers d. Reed-Sternberg cells Ricci Chapter 46

d. Reed-Sternberg cells

During the newborn examination, the nurse notes that an infant who is appropriate for gestational age by birth weight has a head circumference below the 10th percentile and the fontanels (fontanelles) are not palpable. What action would the nurse take? a. Document that the infant has microcephaly. b. Reassess the head circumference in 24 hours. c. Tell the parent the infant's brain is underdeveloped. d. Report the findings to the pediatric health care provider. Ricci Chapter 38

d. Report the findings to the pediatric health care provider. Rationale: These findings are consistent with craniosynostosis, or premature fusion of the cranial sutures. Intervention is needed to prevent damage to the growing brain. Waiting 24 hours to reassess will delay treatment. In microcephaly, the head circumference is small, but the fontanels and suture line are palpable.

A client with multiple myeloma reports severe paresthesia in the feet. When planning care for the client, which priority nursing diagnosis will the nurse choose? a. Impaired tissue integrity b. Acute pain c. Sensory-perception disturbance d. Risk for falls Hinkle Chapter 30

d. Risk for falls Rationale: A client with paresthesia in the feet is at risk for falls due to impaired sensation. Acute pain, impaired tissue integrity, and sensory-perception disturbance are all nursing diagnoses that are appropriate for the client; however, risk for falls is priority.

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: a. Confusion or change in mental status b. Weakness on one side of the body and difficulty with speech c. Foot drop and external hip rotation d. Severe headache and early change in level of consciousness Hinkle Chapter 62

d. Severe headache and early change in level of consciousness

A client with liver cirrhosis develops ascites. Which medication will the nurse prepare teaching for this client? a. Acetazolamide b. Furosemide c. Ammonium chloride d. Spironolactone Hinkle Chapter 43

d. Spironolactone

An adolescent has hepatitis B. What would be the most important nursing action? a. Strict calculation of caloric and vitamin B intake b. Close observation to detect cerebral hallucinations c. Conscientious collection of stool for ova and parasites d. Strict enforcement of standard precautions Ricci Chapter 42

d. Strict enforcement of standard precautions Rationale: Hepatitis B is spread through IV drug use, sex, contaminated blood and perinatally. The treatment is rest, hydration, and nutrition. Hospitalization is required if there is vomiting, dehydration, elevated bleeding times and mental status changes. The adolescent should be taught about good hygiene, safe sex practices, careful handwashing and blood/bodily fluid contact precautions. Using standard precautions of gloves and good handwashing will help prevent spread of the disease. Ova and parasites are not present with hepatitis B. A good diet with adequate protein and vitamins will help the body heal, so these should not be restricted. The nurse observes for mental status changes. These can occur as a complication, but preventing spread of the disease is the nursing priority.

The nurse is caring for a child admitted with focal onset impaired awareness seizure (complex partial seizure). Which clinical manifestation would likely have been noted in the child with this diagnosis? a. The child was dizzy and had decreased coordination. b. The child had jerking movements and then the extremities stiffened. c. The child had shaking movements on one side of the body. d. The child was rubbing the hands and smacking the lips. Ricci Chapter 38

d. The child was rubbing the hands and smacking the lips. Rationale: With the focal onset impaired awareness seizure, formerly called complex partial seizure, the child is confused or their awareness is affected during the seizure. The seizure begins in a small area of the brain and changes or alters consciousness. These seizures can have motor and non-motor symptoms. They cause memory loss and staring and nonpurposeful movements, such as hand rubbing, lip smacking, arm dropping, and swallowing. In the tonic phase of tonic-clonic seizures, the child's muscles contract, the child may fall, and the child's extremities may stiffen.4 During the prodromal period of the tonic-clonic seizure, the child might have a lack of coordination. Focal onset aware seizures (formerly called simple partial seizures) can either have motor or sensory symptoms. A focal onset motor seizure causes a localized motor activity such as shaking of an arm, leg, or other body part.

A client with polycythemia vera reports gouty arthritis symptoms in the toes and fingers. What is the nurse's best understanding of the pathophysiological reason for this symptom? a. Excess red blood cells produce extracellular toxins that build up. b. Excess red blood cells cause vascular injury in the joints. c. The dead red blood cells occlude the small vessels in the joints. d. The dead red blood cells release excess uric acid. Hinkle Chapter 30

d. The dead red blood cells release excess uric acid.

Ammonia, the major etiologic factor in the development of encephalopathy, inhibits neurotransmission. Increased levels of ammonia are damaging to the body. The largest source of ammonia is from: a. Severe infections and high fevers. b. Excessive diuresis and dehydration. c. Excess potassium loss subsequent to prolonged use of diuretics. d. The digestion of dietary and blood proteins. Hinkle Chapter 43

d. The digestion of dietary and blood proteins.

What occurs in the gastrointestinal system of the child with Hirschsprung disease? a. There is a relaxed sphincter in the lower portion of the esophagus. b. There is a severe narrowing of the lumen of the pylorus. c. There is an invagination or telescoping of one portion of the bowel into a distal portion. d. There is a partial or complete mechanical obstruction in the intestine. Ricci Chapter 42

d. There is a partial or complete mechanical obstruction in the intestine.

A child presents to the primary care setting with enuresis, nocturia, increased hunger, weight loss, and increased thirst. What does the nurse suspect? a. Syndrome of inappropriate diuretic hormone b. Diabetes insipidus c. Hypothyroidism d. Type 1 diabetes mellitus Ricci Chapter 48

d. Type 1 diabetes mellitus Signs and symptoms of type 1 diabetes mellitus include polyuria, polydipsia, polyphasia, enuresis, and weight loss.

The nurse cares for a 7-year-old child with new-onset seizure disorder. Which prescription will the nurse anticipate for this client? a. frequent temperature assessment b. vagus nerve stimulation c. ketogenic diet d. use of anticonvulsant medications Ricci Chapter 38

d. Use of anticonvulsant medications Rationale: Complete control of seizures can be achieved for most people through the use of anticonvulsant drug therapy. These medications are typically used first as treatment for seizure disorders. Frequent temperature assessment would only be useful in febrile seizures. Ketogenic diets (high in fat, low in carbohydrates, and adequate in protein) cause the child to have high levels of ketones, which help to reduce seizure activity. Diet is generally used when medications cannot control a child's seizure activity. Stimulating the left vagus nerve intermittently with electrical pulses may reduce seizure frequency. This requires surgically implanting a stimulator under the skin and is approved for children 12 and older.

Which method is used to help reduce intracranial pressure? a. Extreme hip flexion, with the hip supported by pillows b. Keeping the head of bed flat c. Rotating the neck to the far right with neck support d. Using a cervical collar Hinkle Chapter 61

d. Using a cervical collar

Which of the following is the most effective strategy to prevent hepatitis B infection? a. Avoid sharing toothbrushes b. Covering open sores c. Barrier protection during intercourse d. Vaccine Hinkle Chapter 43

d. Vaccine

Which medication is used to decrease portal pressure, halting bleeding of esophageal varices? a. Spironolactone b. Cimetidine c. Nitroglycerin d. Vasopressin Hinkle Chapter 43

d. Vasopressin Vasopressin may be the initial therapy for esophageal varices because it produces constriction of the splanchnic arterial bed and decreases portal hypertension. Nitroglycerin has been used to prevent the side effects of vasopressin. Spironolactone and cimetidine do not decrease portal hypertension.

The nurse is administering Cephulac (lactulose) to decrease the ammonia level in a patient who has hepatic encephalopathy. What should the nurse carefully monitor for that may indicate a medication overdose? a. Vomiting b. Asterixis c. Ringing in the ears d. Watery diarrhea Hinkle Chapter 43

d. Watery diarrhea

The nurse is caring for an obese 15-year-old girl who missed two periods and is afraid she is pregnant. Which finding indicates polycystic ovary syndrome? a. blurred vision and headaches b. increased respiratory rate c. hypertrophy and weakness d. acanthosis nigricans Ricci Chapter 48

d. acanthosis nigricans

A client diagnosed with a stroke is ordered to receive warfarin. Later, the nurse learns that the warfarin is contraindicated and the order is canceled. The nurse knows that the best alternative medication to give is a. ticlopidine. b. clopidogrel. c. dipyridamole. d. aspirin. Hinkle Chapter 62

d. aspirin.

The nurse is planning care for a school-aged child recovering from being hit by a motor vehicle while riding a bicycle. For what will the nurse assess to determine the onset of disseminated intravascular coagulation (DIC) in this child? a. nausea and vomiting b. blurred vision c. sudden onset of knee pain d. bleeding from intravenous sites Ricci Chapter 46

d. bleeding from intravenous sites

An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to a. reduce cellular metabolic demand. b. control fever. c. control shivering. d. dehydrate the brain and reduce cerebral edema. Hinkle Chapter 61

d. dehydrate the brain and reduce cerebral edema Rationale: Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid. Antipyretics and a cooling blanket are used to control fever in the patient with IICP. Although mannitol is a type of diuretic, it is not used to increase urine output. Medications such as barbiturates are given to the patient with IICP to reduce cellular metabolic demands.

A child is scheduled for a urea breath test. The nurse understands that this test is being performed for which reason? a. evaluate gastric pH b. confirm pancreatitis c. determine esophageal contractility d. detect Helicobacter pylori Ricci Chapter 42

d. detect Helicobacter pylori

A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include: a. decreasing blood pressure. b. pupillary changes. c. elevated temperature. d. diminished responsiveness. Hinkle Chapter 61

d. diminished responsiveness.

Which nursing objective is most important when working with neonates who are suspected of having congenital hypothyroidism? a. promoting bonding b. encouraging fluid intake c. allowing rooming in d. early identification Ricci Chapter 48

d. early identification

A nurse taking a health history of a newborn notes that there is a maternal history of polyhydramnios. What GI condition might this history precipitate? a. hernia b. cleft palate c. pyloric stenosis d. esophageal atresia (EA) Ricci Chapter 42

d. esophageal atresia (EA) A maternal history of polyhydramnios is usually present in one-third of cases of EA and in some cases of tracheoesophageal fistula (TEF).

A nurse is providing care to a client who has had a stroke. Which symptoms are consistent with left-sided stroke? a. problems with abstract thinking, impairment of short-term memory, poor judgment b. cautious behavior, deficits in left visual fields, misjudgment of distances c. impulsive behavior, poor judgment, deficits in left visual fields d. expressive aphasia, defects in the right visual fields, problems with abstract thinking Hinkle Chapter 62

d. expressive aphasia, defects in the right visual fields, problems with abstract thinking

A child has undergone a hematopoietic stem cell transplant. When assessing the child, the nurse notes the development of a maculopapular rash on the child's palms and bottoms of the feet. Which condition would the nurse suspect? a. graft failure b. disseminated intravascular coagulation c. veno-occlusive disease d. graft-versus-host disease Ricci Chapter 46

d. graft-versus-host disease Explanation: Graft-versus-host disease involves the development of a maculopapular rash on the palmar and plantar surfaces of the hand and feet evolving into erythematous rash over most of body (ranging from slight redness of the skin to complete skin desquamation. Disseminated intravascular coagulation would involve signs of bleeding, including bruising, petechiae and ecchymoses. Graft failure would be manifested by fever, infection and a decrease in blood counts. Veno-occlusive disease would be manifested by sudden, unexpected weight gain, thrombocytopenia, jaundice, hepatomegaly, right upper quadrant pain, ascites and encephalopathy.

Which type of jaundice seen in adults is the result of increased destruction of red blood cells? a. Obstructive b. Nonobstructive c. Hepatocellular d. Hemolytic Hinkle Chapter 43

d. hemolytic Hemolytic jaundice results because, although the liver is functioning normally, it cannot excrete the bilirubin as quickly as it is formed.

A client's spouse relates how the client reported a severe headache and then was unable to talk or move their right arm and leg. After diagnostics are completed and the client is admitted to the hospital, when would basic rehabilitation begin? a. after 1 week b. in 2 to 3 days c. upon transfer to a rehabilitation unit d. immediately Hinkle Chapter 62

d. immediately

The parent reports that the health care provider said that the infant had a hernia but cannot remember which type. When recalling what the health care provider said, the parent said that a surgeon will repair it soon and there is no problem with the testes. Which hernia type is anticipated? a. diaphragmatic hernia b. umbilical hernia c. hiatal hernia d. inguinal hernia Ricci Chapter 42

d. inguinal hernia

Preterm infants have more fragile capillaries in the periventricular area than term infants. This put these infants at risk for which problem? a. moderate closed-head injury b. congenital hydrocephalus c. early closure of the fontanels (fontanelles) d. intracranial hemorrhaging Ricci Chapter 38

d. intracranial hemorrhaging Rationale: Fragile capillaries in the periventricular area of the brain put preterm infants at risk for intracranial hemorrhage.

A 9-month-old infant presents to the emergency department with vomiting and abdominal pain. While assessing the client, the nurse notes the client screaming intermittently and drawing up legs toward chest a palpable mass in upper right quadrant (above). What does the nurse anticipate in this child's stools? a. foul-smelling, fatty stools b. narrow, ribbon-like stools c. loose, watery stools d. jellylike, bloody stools Ricci Chapter 42

d. jellylike, bloody stools

A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. This CPP reading is considered a. within normal limits. b. inaccurate. c. high. d. low. Hinkle Chapter 61

d. low.

The nurse is assessing a client admitted with a deep vein thrombosis with an elevated red blood cell count. The admitting diagnosis is polycythemia vera. What is the hallmark clinical sign of PV? a. peripheral edema b. weight gain c. pale body color d. splenomegaly Hinkle Chapter 30

d. splenomegaly Rationale: Splenomegaly is the hallmark of PV. Patients typically have a ruddy complexion and splenomegaly. Symptoms result from increased blood volume (headache, dizziness, tinnitus, fatigue, weight loss, paresthesias, and blurred vision). Edema, pale body color, and weight gain are not classic symptoms of PV.

The school nurse is providing information to parents of adolescents about prevention of cervical cancer. Which information is included in the teaching? a. abstinence from sexual intercourse b. use of condoms for sexually active teens c. Papanicolaou tests for adolescent girls d. vaccine against human papillomavirus (HPV) Ricci Chapter 46

d. vaccine against human papillomavirus (HPV)