PA and BCC

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An 18-month-old toddler who is inadequately immunized contracts tetanus after sustaining a puncture injury. The parents are concerned about how the disease will affect their child's intellectual abilities in the future. What is the best response by the nurse concerning the child's intellectual function? "There may be some damage." "Intellect should remain intact." "It depends on the severity of complications." "Development of the intellect may be delayed."

2

Which may cause a foreign body sensation in the eye? Herniated orbital fat Superficial corneal erosion Inflammation of anterior uveal tract Infection of sebaceous gland of eyelid

2

Which ophthalmic conditions can cause a client to have photophobia? Nystagmus Chalazion Trachoma Hordeolum Keratoconjunctivitis sicca

2, 3, and 5

A healthcare provider notices dermatitis on overlying surfaces of the skin of a client. Which abnormal condition does the nurse anticipate? Comedo Hirsutism Intertrigo Ecchymosis

3

A nurse discovers lower extremity pitting edema in a client with right ventricular heart failure. Which information should the nurse consider when planning care? Client has decreased plasma colloid osmotic pressure. Client has increased tissue colloid osmotic pressure. Client has increased plasma hydrostatic pressure. Client has decreased tissue hydrostatic pressure.

3

While working in a neuromuscular clinic the nurse monitors infants for symptoms of cerebral palsy. Which statements by infants' mothers indicate the need for further evaluation for cerebral palsy? "My baby doesn't make eye contact." "My baby seems to have a voracious appetite." "My baby was able to turn from front to back by 2 months of age." "I've noticed that this baby clings to me more than other children of the same age." "All of my other children were sitting alone by this age. This baby doesn't seem to be anywhere near sitting alone."

3 and 5

A nurse in the pediatric clinic suspects that Reye syndrome is developing in a 9-year-old child. For which early signs of Reye syndrome should the nurse assess the child? Diarrhea Jaundice Lethargy Vomiting Confusion

3, 4, and 5

A client who sustained burn injuries due to a fire and explosion has a carbon monoxide level of 14%. Which pathophysiologic risk is increased in the client? Stupor Vertigo Convulsions Slight breathlessness

4

After a craniotomy to remove a brain tumor, the client develops the syndrome of inappropriate secretion of antidiuretic hormone (ADH). For which clinical indicators should the nurse monitor the client? Multiple selection question Polyuria Insomnia Bradycardia Increased weight Decreased serum sodium Decreased level of consciousness

4, 5, and 6

Which of the following are congenital anomalies or birth defects seen in children? Dysplasias Disruptions Teratogens Deformations Malformations

1, 2, 4, and 5

A 2-year-old child with developmental dysplasia of the hip has a spica cast applied. The mother asks the nurse how to keep the cast clean. How should the nurse respond?\] "Tuck a folded diaper above the perineal opening." "Place plastic wrap or duct tape around the perineal edges of the cast." "Wipe the cast with a wet cloth and sprinkle it with baby powder." "Do the best you can because it will get soiled no matter what you do."

2

A client with colitis inquires as to whether surgery eventually will be necessary. When teaching about the disease and its treatment, what should the nurse emphasize? Medical treatment is curative; surgery is not required. For most clients, surgery is recommended only if nonsurgical treatments have been unsuccessful. For most clients, surgery is recommended early in the course of treatment. Medical treatment is all that will be needed if the client can maintain emotional stability.

2

Which clinical indicators does the nurse expect to identify when assessing a client with tic douloureux? . Multiple petechiae Excruciating facial pain Twitching of the mouth Unilateral muscle weakness Fine-motor tremors of the eyelid

2 and 3

A nurse inserts a nasogastric tube into a preterm infant's esophagus for feedings. Which assessment findings signify correct placement of the tube? The infant cries without noise. Aspiration produces a small quantity of light-yellow or light-green liquid. The tube is inserted to a depth from the ear to the tip of the nose to the sternum. A whooshing sound is auscultated in the epigastric area when air is introduced into the tube. Testing of the aspirate with the use of a Nitrazine strip reveals that the gastric fluid is acidic.

2 and 5

The blood report of a client with fungal infection reveals the presence of IgM and IgG antibodies. The skin test shows erythema and edema within 3 hours after injection. Which conditions does the nurse suspect in the client? Atopic dermatitis Rheumatoid arthritis Goodpasture syndrome Acute glomerulonephritis Systemic lupus erythematosus (SLE)

2, 4, and 5

An older adult client is diagnosed with postherpetic neuralgia and reports deep pain. Which skin infection does the nurse expect to observe in the client's electronic medical record? Cellulitis Candidiasis Herpes zoster Herpes simplex

3

Which clinical manifestation is found in a client with a deficiency of adrenocorticotropic hormone? Anovulation Dehydration Malaise and lethargy Menstrual abnormalities

3

While assessing a client, the nurse finds that the space between the client's medial malleoli is 4.5 cm and that the client has normal knees. Which conditions could cause this problem? Arthritis Poliomyelitis Cerebral palsy Congenital deformity Peroneal nerve injury

1, 2, and 4

A nurse is caring for a 2-year-old child with meningitis. For which clinical manifestations of increasing intracranial pressure should the nurse assess the child? Seizures Vomiting Bulging fontanels Subnormal temperature Decreased respiratory rate

1, 2, and 5

In caring for the client with burr holes for a subdural hematoma postoperatively on day 2, the nurse notes the client has an increased temperature to 101.3 F° (38.5° C). What does the nurse understand about this reaction? This is a normal assessment for the client with a subdural hematoma. This is a normal reaction day 2 postoperatively, and the nurse will administer acetaminophen as prescribed by the healthcare provider. Because the client has burr holes, this is not an accurate measurement. The client is exhibiting signs of an infection, and the healthcare provider needs to be notified.

4

Which autoantigens are responsible for the development of Crohn's disease? Crypt epithelial cells Thyroid cell surface Basement membranes of the lungs Basement membranes of the glomeruli

1

The nurse assesses for what patient symptoms that indicate hyperthermia? Vasodilation Dry and flushed skin Pale and cyanotic skin Decreased capillary refill Decreased urinary output

1, 2, and 5

A registered nurse is teaching a nursing student about structural factors that affect labor in adolescents. Which statements by the nursing student indicate effective learning? "Fetopelvic incompatibility results from the teenager's smaller stature." "Twelve-year-old girls generally have labors that are shorter than older women's." "Cephalopelvic disproportion is the main reason for cesarean births in adolescents." "Prolonged labor in an adolescent aged 13 years is the result of fetopelvic incompatibility." "The transition from pelvic disproportion to pelvic adequacy usually occurs around age 18."

1, 3, and 4

A registered nurse teaches a nursing student about the management of primary dysmenorrhea. Which statements made by the nursing student indicates effective learning? "I should perform effleurage." "I should avoid using a hot pad or heating bath." "I should include cranberry juice in the client's diet." "I should correct any myths the client has about menstruation." "I should avoid giving the client treatment options."

1, 3, and 4

A nurse obtains a health history from the parents of a toddler who is admitted to the pediatric unit with the diagnosis of acute lymphocytic leukemia (ALL). What problems does the nurse expect the parents to report? Loss of appetite Sores in the mouth Paleness of the skin Inability to fall asleep Purplish spots on the skin

1, 3, and 5


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