Practice test 4

An eight-year-old child who has type 1 diabetes wants to play soccer. Which of the following recommendations would a nurse emphasize? "It would be best for you to play a non-contact sport." "Take extra insulin an hour before playing." "Eat an extra sugar exchange during the game." "Drink at least a quart of water after the game."

"Eat an extra sugar exchange during the game." Explanation: Client Need: Physiological Integrity Rationale: C. Hypoglycemia can develop with rigorous exercise. To avoid this, a child is instructed to take an additional carbohydrate exchange. A. It is not necessary for the child to restrict his activities to non- contact sports. B. Extra insulin would further decrease the blood sugar during strenuous activity. D. Fluids should be encouraged but the essential element in the teaching is that the child eats an extra carbohydrate exchange to counteract the hypoglycemia that can occur with strenuous exercise.

Which of the following statements made by a four-year-old child whose brother just died of cancer, would be age-appropriate? "I know I'll never see my brother again." "I'm glad my brother isn't crying anymore." "I can't wait to go get pizza with my brother." "know where my brother is buried."

"I can't wait to go get pizza with my brother." Explanation: Client Need: Health Promotion and Maintenance Rationale: C. The principles of magical thinking and omnipotence affect preschoolers when a sibling becomes critically ill or dies. They conceive of illness as a punishment for their thoughts or actions. If they are in any way accused or suspected of harboring ill feelings toward the sibling, they may feel guilty and responsible for the sibling's death. A and B. Anger and jealousy are not predominant feelings in a child whose sibling is ill D. A four-year-old child may have experiences of guilt from past wrongs, but the child is too young to have remorse.

A patient who has begun taking a tricyclic antidepressant is given instructions regarding its use. Which of the following comments would indicate that the patient understands the information? "I like active exercise, but I won't be able to do it while I'm on this medicine." "This medicine will make my ears ring, but I guess I can tolerate that." "won't eat cheese if one of my visitors bring me some." "I don't feel any better, but I've only been taking the medicine for a week"

"I don't feel any better, but I've only been taking the medicine for a week" Explanation: Client Need: Physiological Integrity Rationale: D. It takes two to four weeks for tricylic antidepressants to achieve therapeutic blood levels. The patient demonstrates that he understands that he will not feel better until therapeutic levels are reached. A. Exercise is not contraindicated for patients taking tricylic antidepressants. B. Ringing in the ears is a symptom of Aspirin toxicity and is not a side effect of tricylic antidepressant therapy. C. Food restrictions are indicated for the patient taking monoamine oxidase inhibitors for depression, but are not indicated for those on tricyclics

Which of the following instructions would a nurse include in the teaching plan for a patient who is taking furosemide (Lasix)? "Restrict foods that are high in cholesterol." "Take supplemental calcium." "Decrease complex carbohydrates." "Increase your dietary intake of potassium.

"Increase your dietary intake of potassium." Explanation: Client Need: Physiological Integrity Rationale: D. The patient taking Lasix should be instructed to eat a diet high in potassium since Lasix causes excretion of potassium. A, B and C. Dietary alterations for a patient taking furosemide include restriction of sodium and an increase in dietary potassium.

A nurse has given patient instructions about taking levothyroxine sodium (Synthroid). Which of the following patient statements indicate that the patient has understood the instructions? "I can discontinue this medication once my pulse rate is normal." "I will stop taking this medication if I gain weight." "I realize that I must take this medication for the rest of my life." "I only need to take this medication when I feel tired."

"I realize that I must take this medication for the rest of my life." Explanation: Client Need: Physiological Integrity Rationale: C. The patient is aware that levothyroxine does not cure hypothyroidism. This therapy is lifelong and must be continued on a daily basis. A, B and D. The patient should be instructed to take this medication exactly as prescribed and not to discontinue it without consulting the physician.

Anurse would expect a patient to describe the symptoms of arterial insufficiency in the lower extremities by which of the following statements? "My legs feel weak when I get up to walk." "My legs hurt when I walk, but they feel better when I sit down." "My feet and ankles become swollen after walking." "My feet burn if I walk on a hard surface"

"My legs hurt when I walk, but they feel better when I sit down." Explanation: Client Need: Physiological Integrity Rationale: B. A patient with arterial insufficiency develops intermittent claudication, which is pain in the calf muscles when walking. The pain subsides with rest. A. Weakness in the legs is often related to neuromuscular disease C. Dependent edema may be a sign of congestive heart failure or peripheral vascular disease. D. Tendonitis may occur from walking or running on hard surfaces.

A mother makes all of the following comments about her 14-month-old son's behavior. Which behavior should the nurse discourage? "My son loves to feed himself slices of peeled apple." "My son takes his favorite blanket with him whenever he leaves the house." "My son gets up on his knees and tocks himself to sleep." "My son takes a bottle of juice to bed with him and sucks on it if he wakes during the night."

"My son takes a bottle of juice to bed with him and sucks on it if he wakes during the night." Explanation: Client Need: Health Promotion and Maintenance Rationale: D. Giving the child a juice bottle at night encourages the formation of dental caries. Water would be a better choice of solution rather than a glucose-based fluid. At 15 to 18 months of age the child should be totally weaned. A. Feeding self is normal at 14 months of age and should not be discouraged. B. Items such as favorite blankets provide security for the child and should not be discouraged. C. Rocking helps to calm the child and is normal behavior in the 14 month old.

A patient who has had an ileostomy says to the nurse. "I will have to be isolated for the rest of my life because no one will be able to stand this terrible odor." Which of the following responses by the nurse would MOST therapeutic? "The odor will gradually become less noticeable." "I understand your concern, but remaining in isolation does not reduce the odor." "There are techniques that can reduce the odor." "The odor is a normal part of your condition and will not offend people."

"There are techniques that can reduce the odor." Explanation: Client Need: Physiological Integrity Rationale: C. There are techniques that the nurse can use to reduce the odor of the ileostomy, such as placing charcoal in the ileostomy bag. The charcoal will absorb the odor in the bag. A. The odor does not gradually become less noticeable unless steps are taken to reduce it. B. While it is important to help the patient ventilate, this response does not address the issue of the odor. D. This statement is not necessarily true. Others may be offended by the odor. Teaching the patient measures that will help to reduce the odor will be most beneficial.

A patient who has been given a prescription for daily thyroid extract also should be given which of the following instructions? "You may have skin irritation due to the medication." "You may become sluggish if the medication dosage is too high." "You will take the medication for the rest of your life." "You will need to take the medication with food."

"You will take the medication for the rest of your life." Explanation: Client Need: Physiological Integrity Rationale: C. Thyroid hormone replacement is necessary for the duration of the patient's life. Stopping the medication will result in recurrence of the hypothyroidism. A. Skin irritation is not identified as a side effect of thyroid extract. B. Insomnia, headache and tremors are central nervous system side effects of thyroid extract. The patient should be told to report anxiety, irritability and excitability since they may indicate too high a dose of the medication. D. There is no indication that this medication should be taken with food.

A patient is to receive heparin sodium 20,000 units in 1000 ml of solution intravenously. The fluid is to be regulated to deliver 50 ml of solution each hour. At this rate, the patient should receive how many units of heparin each hour? 500 1000 1500 2000

1000 Explanation: Client Need: Physiological Integrity Rationale: B. First determine the amount of Heparin in one millIliter. The patient is to receive 50 ml/ hour. The total amount of heparin received in one hour is 1000 units. 50 ml/hour × 20 units/ml = 1000 units/ hour

Which of the following clients would the nurse prepare for an emergency cesarean delivery? A woman who has a prolapsed cord. A woman with a twin gestation. A woman who has meconium-stained amniotic fluid. A woman who has a non-reactive non-tress test.

A woman who has a prolapsed cord Explanation: Client Need: Health Promotion and Maintenance Rationale: A. A prolapsed umbilical cord is an indication for cesarean birth. B. Twin gestation is not necessarily an indication for a cesarean section C. Stained amniotic fluids is to be monitored carefully along with fetal well-being but this is not automatically an indication for cesarean section. D. A non-reactive stress test in a concern, but a biophysical profile should be done prior to delivery to document poor fetal well- being.

A patient is taking digoxin (Lanoxin). Which manifestations would indicate that a nurse should carefully assess the patient before administering the next dose? Shortness of breath Urinary frequency Hypertension Anorexia

Anorexia Explanation: Client Need: Physiological Integrity Rationale: D. Manifestations of digitalis toxicity include nausea, anorexia, vomiting, confusion, dysrhythmias, hypotension, bradycardia, heart block and visual changes. A. Shortness of breath is not considered a side effect of digitals toxicity. The nurse should assess the patient but the digitoxin does not have to be held. B. Urinary frequency is not a side effect of digitalis therapy. C. Hypotension, rather than hypertension, is a side effect of digoxin.

A four-month-old infant is for surgical correction of congenital hip dysplasia. Which of the following homecare instructions would a nurse include in the teaching plan for the infant's family? "Apply double diapers when changing the infant." "Perform passive range-of-motion on the lower extremities." "Support the legs in an adducted position with pillows during sleep." "Avoid placing the infant in an upright position."

Apply double diapers when changing the infant Explanation: Client Need: Physiological Integrity Rationale: A. Multiple diapers can be used prior to surgery to effectively separate the child's legs and hold the legs in an abducted, externally rotated position. B. Passive range- of- motion is not indicated. The infant's legs should be abducted using extra diapers C. The legs should be abducted rather than adducted to keep the hip in alignment D. The child may be placed in an upright position and does not have to remain flat in bed.

The nurse is caring for a patient who is diagnosed with glaucoma. Which of the following medications, if ordered for this patient, should the nurse question? atropine sulfate (Isopto Atropine) pilocarpine (Isopto Carpine) timolol (Timoptic) acetazolamide (Diamox)

Atropine sulfate (Isopto Atropine) Explanation: Client Need: Safe Effective Care Environment Rationale: A. Glaucoma is an increase in intraocular pressure due to either excess production of aqueous humor or obstruction of the drainage of aqueous humor in the eye. The goals of the therapy are to improve drainage and decrease production of aqueous humor. Atropine sulfate causes papillary dilation, which further obstructs the drainage of aqueous humor. The nurse should question this order. B. Pilocarpine is a miotic agent that causes papillary constriction and improves the drainage of aqueous humor. C. Timolol (Timoptic) is a beta adrenergic blocker that decreases aqueous humor production. D. Diamox is a carbonic anhydrase inhibitor that decreases aqueous humor production.

A patient is brought to the psychiatric unit. Which of the following activities would be performed by the registered nurse (RN) rather than the licensed practical nurse (LPN)? Administering a stat dose of lorazepam (Ativan) 2 mg intramuscularly (IM) Admitting the patient to the psychiatric unit Asking the patient whether he hears voices other people do not hear Drawing a blood sample for a lithium level

Asking the patient whether he hears voices other people do not hear Explanation: Client Need: Psychosocial Integrity Rationale: C. The mental status examination, done as part of the admission interview, should be conducted by the registered nurse rather than the licensed practical nurse. Part of the mental status examination is determining if the patient is in touch with reality or is delusional and/ or hallucinating. A. The licensed practical nurse and the registered nurse can both administer medications. B. The licensed practical nurse can admit the patient, take vital signs and orient the patient to the unit. The mental status examination must be conducted by the registered nurse. D. The registered nurse and the licensed practical nurse can draw a blood sample for a lithium level.

Which of the following plans is particularly important in the care of a patient who has Alzheimer's disease? Using behavior modification techniques Assessing the patient's abilities on an on-going basis Helping the patient explore emotional conflicts Implementing a bowel-training program

Assessing the patient's abilities on an on-going basis Explanation: Client Need: Psychosocial Integrity Rationale: B. Since Alzheimer's disease progresses from a subtle deterioration in memory to a more profound memory loss, it is important to do an on-going assessment of the patient's abilities. A. A patient with Alzheimer's disease who experiences memory loss is unable to participate in a behavior modification program. C. Since recent events and new information cannot be recalled, helping the patient to explore emotional conflicts would be difficult. D. Implementing a bowel-training program is beyond the cognitive abilities of the Alzheimer's patient.

A nurse would expect a patient who has ulcerative colitis to report which of the following manifestations? Abdominal distention Bloody diarrhea Esophageal diarrhea Flank pain

Bloody diarrhea Explanation: Client Need: Physiological Integrity Rationale: B. The major manifestation of ulcerative colitis are bloody diarrhea and abdominal pain. A, C and D. Abdominal distention, flank pain and esophageal reflux are not indicators of ulcerative colitis.

Because a newborn is suspected of having necrotizing enterocolitis, which of the following assessment is essential that a nurse should perform? Probe the anus for patency. Percuss the liver to determine size. Palpate the abdomen for rebound tenderness. Check the stool for occult blood.

Check the stool for occult blood. Explanation: Client Need: Physiological Integrity Rationale: D. Necrotizing enterocolitis (NEC) is a multifactorial disorder involving ischemic necrosis of the alimentary tract in the absence of predisposing anatomic or functional abnormalities. The manifestations range from feeding intolerance to evidence of sepsis, shock and peritonitis. The usual presentation includes abdominal distention, bilious vomiting and bloody stools. A. Patency of the anus is not related to NEC. However, the anus should be inspected for fissures with blood are found in the stool to determine the etiology of the blood. B. The abdomen may be distended and the liver not palpable. C. The abdomen may not be tender even if the child has NEC.

A nurse performs a physical assessment to a two-month-old infant. Which of the following findings would require FURTHER investigation? Closed anterior fontanel Bilateral strabismus Multiple Mongolian spots Prominent extrusion reflex

Closed anterior fontanel Explanation: Client Need: Health Promotion and Maintenance Rationale: A. The anterior fontanel closes between 12 and 18 months. A closed anterior fontanel at two months of age would require further investigation. B. Strabismus is a normal finding because of the lack of binocularity in the newborn. C. Mongolian spots are usually noted in the sacral and gluteal regions and are seen predominantly in newborns of African, Native American, Asian and Hispanic descent. D. This is a normal finding. When an infant's tongue is touched or depressed, the infant responds by forcing the tongue outward. This reflex disappears by age four months.

The nursing staff on a psychiatric unit consists of registered nurses (RN), licensed practical nurses (LP) and unlicensed assistive personnel (UAP). Which of the following activities ca be safely delegated to unlicensed assistive personnel (UAP)? Observing a patient after electroconvulsive therapy (ECT) Monitoring a patient who is on suicide precautions Conducting a group activity Doing an intake interview of a new patient

Conducting a group activity Explanation: Client Need: Safe Effective Care Environment Rationale: C. Unlicensed assistive personnel can conduct selected activity groups under the guidance of professional staff. A. Post- ECT care requires patient assessment and should not be delegated to unlicensed assistive personnel. C. Monitoring a patient on suicide precautions requires in - depth assessment of the physical and psychological needs of the patient and should not be performed by unlicensed assistive personnel. D. The intake interview is conducted when a patient is admitted to the psychiatric unit. It includes a mental status examination that should be conducted by the professional nurse.

A six-year-old child who is admitted to a hospital for suspected sexual molestation tells a nurse, "I do not like it when my step dad takes a bath with me." Based on this information, which of the following actions should the nurse take? Ask the child to explain to you what takes place during bath time. Interview the child further by using anatomically correct dolls. Contact the facility's designated child abuse interviewer. Approach the step-father to clarify the child's statement.

Contract the facility's designated child abuse interviewer Explanation: Client Need: Health Promotion and Maintenance Rationale: C. Children's reports may vary from contradictory stories to unwavering versions of the experience. While their stories may sound contradictory, this may reflect the child's experiences in several instances of abuse. Also, children who repeatedly tell identical facts may have been prompted to do so. Increasing evidence suggest that the types of interrogation that children are exposed to following reports of sexual abuse shape their thinking. In interviewing the child, every effort is made to coordinate the number of interviewers and to assign a primary professional to work with the child. Videotaping or audio taping can be used to limit the number of traumatic events. A. The nurse should contact the designated interviewer to interview the child. B. Controversy exists over the validity of suing anatomically correct dolls, finding shave shown that the interviewer could influence the shape the child's behavior with these dolls. In addition, some studies have shown that children who have not been abused may manipulate the dolls in sexually suggestive ways. D. When children report sexually abusive experiences, their reports need to be taken seriously, but also cautiously, to avoid harming the child or falsely accusing a person.

In the immediate postoperative period following a hip replacement, the patient should be assisted to perform which of the following exercises on the affected extremity? Leg raising Dorsiflexion and extension of the foot Flexion and extension of the knee Quadriceps setting

Dorsiflexion and extension of the foot Explanation: Client Need: Physiological Integrity Rationale: B. In the immediate postoperative period following hip replacement, the patient should dorsiflex and extend the foot to prevent thrombosis, which is a serious complication following joint surgeries. A. One day postoperatively, the patient should begin exercises to restore strength and tone in the hip muscles, such as leg raising and abduction exercises. C. Using a postoperative abduction pillow following hip replacement interferes with flexion and extension of the knee. D. In addition to leg raises and abduction exercises, patient with a hip replacement should begin quadriceps and gluteal muscle setting exercises.

A patient is in the acute stage of gout. Which of the following measures would a nurse encourage the patient to take in order to minimize complications? Drinking a minimum of 3000 ml of fluid per day Eating a minimum of 2500 calories per day Walking at least three miles per day Resting at least three hours per day

Drinking a minimum of 3000ml of fluid per day Explanation: Client Need: Physiological Integrity Rationale: A. In addition to purine restriction, the patient requires at least 3000 ml of fluid per day to discourage the formation of renal stones. B. Dietary restrictions include avoiding foods containing purine and alcohol. Weight control is also recommended. C. During acute attacks the patient is placed on bedrest. D. During acute attacks bed rest and joint immobilization are maintained.

A patient who has ulcerative colitis does not respond to the prescribed therapy and is admitted to the hospital for a total colectomy and creation of an ileostomy. Which of the following measures should be given PRIORITY in the patient's preoperative care plan? Promoting the patient's acceptance of an ileostomy Monitoring the patient's emotional state Preventing the patient from developing pressure sores Correcting the patient's fluid imbalance

Correcting the patient's fluid imbalance Explanation: Client Need: Physiological Integrity Rationale: D. Patients who have ulcerative colitis with severe diarrhea develop fluid and electrolyte imbalance. Therefore, it is important to correct any imbalances prior to surgery. A. Promoting acceptance of the ileostomy should be instituted preoperatively, but fluid and electrolyte balance would be the priority. B. The patient's emotional state can influence the outcome of the surgery and should be attended to preoperatively. But again, the priority of care would be fluid and electrolyte balance. C. Since the patient with ulcerative colitis is not usually on bedrest, pressure areas are unlikely to develop.

When discussing methods of stress reduction with a patient, the nurse should use which of following approaches FIRST? Explain to the patient the physiological effects of stress. Teach the patient relaxation techniques that reduce stress. Determine if the patient is able to identify sources of stress. Describe to the patient the benefits of active exercise in coping with stress.

Determine if the patient is able to identify sources of stress. Explanation: Client Need: Psychosocial Integrity Rationale: C. The patient should be able to identify signs and symptoms of stress or anxiety so that the techniques of stress reduction can be used effectively. A. Explaining the physiological effect of stress might be done in later teaching session. The first priority is helping the patient to identify the manifestations of stress. B. Teaching relaxation exercises is part of stress management but the patient must be able to recognize the signs and symptoms of stress so that he/ she is aware of when to use the techniques. D. Active exercise is a means of controlling stress. However, identification of stressors should take priority.

Following a subtotal gastrectomy, a nasogastric tube attached to low, intermittent suction was inserted. Eight hours after the surgery, the patient complains of being nauseated. The nurse should take which of the following actions FIRST? Instruct the patient to take deep breaths. Apply a cool cloth to the patient's forehead. Administer antiemetic medication to the patient. Determine the patency of the patient's nasogastric tube.

Determine the patency of the patient's nasogastric tube. Explanation: Client Need: Physiological Integrity Rationale: D. The purpose of a nasogastric tube following a subtotal gastrectomy is to drain the stomach or intestinal tract to prevent postoperative vomiting, obstruction of the intestinal tract and distention of the stomach or intestinal tract caused by fluid or gas. The first action when a patient complains of nausea would be to determine the patenc of the patient's nasogastric tube. A. Instructing the patient to take a deep breathes does not relieve nausea caused by abdominal distention. It may cause the patient to swallow more air leading to increased abdominal distention. B. A cool cloth to the patient's forehead is a treatment to relieve a headache, not nausea. C. Administering an antiemetic medication is an appropriate nursing intervention. However, determining the patency of the patient's nasogastric tube would be the first action.

A patient is to be transfused with a unit of whole blood. If the patient develops an allergic reaction, the nurse would expect the physician to order which of the following drugs? diphenhydramine hydrochloride (Benadryl) chlorpheniramine maleate (Chlortrimeton) pseudoephedrine hydrochloride (Sudafed) promethazine hydrochloride maleate (Phenegran)

Diphenhydramine hydrochloride (Benadryl) Explanation: Client Need: Physiological Integrity Rationale: A. Benadryl is an antihistamine that is used in the treatment of allergic reactions. It can be administered intravenously for a quick response. B. Chlortrimeton is used for allergy symptoms and rhinitis. C. Sudafed has its primary effect on the respiratory mucosal membrane. It is a nasal decongestant that can be used with antihistamines. D. Phenergan is used for control of motion sickness and nausea. It also is used to potentiate the effects of medications such as Demerol.

Following a prostatectomy, the pathology report reveals that the patient has cancer of the prostate. Which of the following blood test results would support this diagnosis? Decreased uric acid Decreased creatinine Elevated bicarbonate Elevate acid phosphatase

Elevate acid phosphatase Explanation: Client Need: Physiological Integrity Rationale: D. Acid phosphatase is elevated in advanced Paget's disease, cancer of the prostate and hyperparathyroidism. A. Uric acid levels are decreased with the administration of uricosuric drugs. B. Creatinine levels are increased in renal failure. C. Bicarbonate is elevated in metabolic alkalosis.

A woman who is at 32 week's gestation has had ruptured membranes for 26 hours. A nurse would assess the woman for which of the following manifestations? Proteinuria Dependent edema Constipation Elevated temperature

Elevated temperature Explanation: Client Need: Health Promotion and Maintenance Rationale: D. After spontaneous rupture of membranes, maternal temperature and vaginal discharge are assessed every one to two hours for early identification of infection. A. Proteinuria is not relevant if the patient does not have pregnancy induced hypertension (P|H) B. Dependent edema is associated with pregnancy and , in and of itself, is not worrisome. C. Constipation is a normal complaint of pregnancy and is not related to rupture of membranes.

In which of the following situation should the charge nurse intervene when a patient repeatedly talks about the past? Help the patient to establish goals for the future. Give the patient a diversional activity. Ask the patient to think of recent pleasures. Encourage the patient to share memories.

Encourage the patient to share memories. Explanation: Client Need: Physiological Integrity Rationale: D. Encouraging the patient to share memories can provide a way of working through unresolved issues from the past. The nurse can validate the patient's feelings and help the patient come to terms with painful issues. This helps the patient attain a sense of positive identity. A. The patient needs to resolve issues from the pat before he/ she can set goals for the future. B. Giving a diversional activity minimizes the importance of the patient's feelings. C. Asking the patient to think of recent pleasures also minimizes the importance of what the patient wants to focus on with the nurse.

The bowel retraining program for a patient who has had a cerebrovascular accident should include which of the following measures? Checking for impaction daily. Increasing the intake of milk products. Utilizing incontinent pads until control. Establishing a consistent time of elimination.

Establishing a consistent time of elimination. Explanation: Client Need: Physiological Integrity Rationale: D. Bowel retraining is established by providing a consistent time for evacuation each day. A. Checking for impaction daily is not indicated and can interfere with sphincter control. B. Fluids should be increased to at least 3000 ml per day, unless contraindicated by cardiac or renal disease. High- fiber foods such as oat bran, fruits and vegetables should be encouraged. Milk products are not high in fiber. C. Using incontinent pads does not help in bowel retraining and may encourage incontinence.

The purpose of performing a biophysical profile on a woman who is experiencing a high-risk pregnancy is to: identify the location of the placenta. evaluate the well-being of the fetus. validate the presence of fetal abnormalities. detect the presence of fetal abnormalities.

Evaluate the well-being of the fetus Explanation: Client Need: Health Promotion and Maintenance Rationale: B. The biophysical profile is performed as a fetal risk assessment. It can be viewed as giving the fetus a physical examination and measures fetal breathing movement, gross body movements, heart tones and amniotic fluid volume. A. The placenta will be visualized via ultrasound but it is not the bases of the testing C. Biophysical profiles are done to assess fetal well- being. Fetal age assessments are performed using ultrasound. D. Fetal abnormalities can be detected in the biophysical profile but are not the basis for the testing.

A patient who has a borderline personality disorder asks the nurse on a psychiatric unit if she may stay up beyond the designated bedtime. When the nurse says no, the patient says, "The nurse on duty last night let me stay up late." Which of the following responses by the nurse would be therapeutic? "You shouldn't have been given that privilege" "Everyone is required to go to bed now." "You can stay up for one more hour." "Why do you want to stay up?"

Everyone is required to go to bed now Explanation: Client Need: Psychosocial Integrity Rationale: B. The patient with borderline personality disorder engages in splitting of the staff or "playing" one staff member against another. The nurse should not respond directly to the patient's comment but, instead, should consistently enforce unit rules. A. This response focuses on the other nurse's behavior rather than the patient's. C. Consistency in carrying out the treatment plan, which includes adherence to unit rules, is essential to prevent manipulation of the staff by the patient. D. This response allows the patient to think that he will be allowed to break the unit rules. The best response is to remind the patient of the rules and that they are in place for all patients.

A patient says to the nurse "I have something important to tell you, but you must promise not to tell anyone else." The nurse's BEST response would be to: explain that the patient should share this information with her physician instead. explain that the information may need to be shared with the treatment team but will be held confidential. commit to keeping the confidence. commit to conditionally keeping the confidence.

Explain that the information may need to be shared with the treatment Explanation: Client Need: Safe Effective Care Environment Rationale: B. Confidential information may be shared with the treatment team directly involved in the care of the patient. A. This purpose implies that only the physician should be told confidential information, rather than the treatment team. C. The nurse needs to make the patient aware of the fact that she will share information pertinent to the care of the patient with the treatments team. D. The nurse should not conditionally agree to keep a confidence and should inform the patient hat she cannot do so. The patient can then determine if he wishes to share confidential information that the nurse may have an obligation to share with other members of the treatment team.

Which of the following approaches would a nurse take FIRST when preparing to insert an intravenous catheter into an eight-year-old boy? Have an assistant restrain the boy for the procedure. Request that the parents leave the room during the procedure. Explain to the boy what he will feel during the procedure. Reassure the boy that the procedure will be over quickly.

Explain to the boy what he will feel during the procedure. Explanation: Client Need: Physiological Integrity Rationale: C. Preparing children for procedures decreases their anxiety, promotes their cooperation, supports their existing coping skills and may teach them new ones and facilitates a feeling of mastery in experiencing a potentially stressful event. A. The nurse can suggest ways for the school- age child to maintain control during procedures (deep breathing, relaxation, counting). Restraining should be a last resort. B. The nurse should provide privacy from peers during procedures on school- age children to maintain self esteem. Parents should be allowed to remain with their child. D. The nurse should emphasize the end of the procedure and any pleasurable events afterward be honest with the child about unpleasant aspects of the procedure. It is best not to tell the child that a procedure will be over quickly because the child's perception of time may not be that of the nurse's.

An infant is born at 30 week's gestation. A nursing assessment of the newborn is MOST likely to reveal: defined pinnae that recoil quickly. extremities that abduct when lying supine. sole creases that extend over the entire foot. five-millimeter bilateral breast buds.

Extremities that abduct when lying supine Explanation: Client Need: Health Promotion and Maintenance Rationale: B. A 30-week-old fetus is usually in a slightly flexed position. With increasing maturity comes more flexion. A. Quick recoil of the ears is a sign of a mature infant. C. Soles of the feet with creases indicate a mature infant. D. A five-millimeter breast bud is consistent with a preterm infant.

A patient with a diagnosis of chronic renal failure was admitted to the hospital. The nurse should assess the patient for which of the following manifestations? Hypotension Fatigue Flushed skin Painful urination

Fatigue Explanation: Client Need: Physiological Integrity Rationale: B. Anemia occurs in renal failure due to decreased production of erythropoietin. This lead to fatigue in the patient. A. Hypertension, which is usually caused by sodium retention and increased extracellular fluid volume, is present in chronic renal failure, and not hypotension. C. The most noticeable change in the integumentary system is a yellowish discoloration of the skin that results from the absorption and retention of urinary chromogens that normally give the characteristic color to urine. D. The patient with chronic renal failure has oliguria or anuria rather than dysuria.

Which of the following observations would be MOST definitive symptom of post-traumatic stress disorder? Substance abuse Aggression Flashbacks Depression

Flashbacks Explanation: Client Need: Psychosocial Integrity Rationale: C. Criteria for the diagnosis of posttraumatic stress disorder include acting or feeling as if the traumatic event were recurring. This phenomenon is termed "flashback." A, B and D. Aggression, substance abuse and depression are commonly seen as concurrent behaviors in posttraumatic stress disorder patients who have limited coping skill for dealing with the anxiety caused by the trauma.

Three hours after receiving an insulin injection (Regular Insulin), a patient becomes diaphoretic. Which of the following actions should the nurse take FIRST? Help the patient to put on a dry nightgown. Ask the patient for a urine specimen. Give the patient a glass of juice to drink. Instruct the patient to stay in bed until seen by the physician.

Give the patient a glass of juice to drink. Explanation: Client Need: Physiological Integrity Rationale: C. Regular insulin peaks in two to four hours. Since diaphoresis is a symptom of hypoglycemia, a glass of juice or skim milk should be given to the patient to raise blood sugar levels. A. Helping the patient to put on a dry nightgown can be done after the patient is given a carbohydrate to drink. B. When hypoglycemia occurs, a urine test for glucose is negative. However, a negative test does not always indicate hypoglycemia. D. Staying in bed until seen by a physician is not the first action to be taken and frequently is not indicated once a carbohydrate is given to correct the hypoglycemia.

A patient who has Alzheimer's disease was asked by the nurse to brush his teeth. He shouts angrily saying, "Tomato soup!" Which of the following actions by the nurse would be CORRECT? Focusing on the emotional reaction. Clarifying the meaning of this statement. Giving him step-by-step directions. Doing the procedure for him.

Giving him step-by-step directions Explanation: Client Need: Physiological Integrity Rationale: C. Patients with Alzheimer's disease require structure and direction to complete tasks. It is appropriate to give them step- by- step directions. A. Since Alzheimer's disease is a tvpe of dementia that is characterized by progressive deterioration in memory and other aspects of cognition, it is inappropriate to focus on the emotional reaction. B. Since recent events and new information cannot be recalled, the meaning of the statement is unimportant. D. The goal of care for patients with Alzheimer's disease is to have them maintain independence in the performance of activities of daily living for as long as possible.

The treatment plan for a 14-year-old child who has ulcerative colitis includes chronic use of high-dose corticosteroids. Because of the use of this medication, the child is at risk for: growth retardation. peripheral neuropathy. muscular degeneration. hyperkalemia.

Growth retardation Explanation: Client Need: Physiological Integrity Rationale: A. High dose corticosteroids can cause bone demineralization and impair cell division. They are decreased as soon as possible to minimize side effects such as altered body composition, growth retardation, osteoporosis and adrenal suppression. B. Peripheral neuropathy is not a side effect of steroid therapy. C. Steroids can cause muscular atrophy. D. High dose corticosteroids can cause hypokalemia.

A 27-year-old man is admitted to the psychiatric unit after striking his wife with a cooking utensil. He is hyperactive and is in handcuffs. Which of the following behaviors would indicate that the patient needs continued restraints? He pushes the attendant out of his way He shouts and curses the nurse He tears up his chart He makes obscene gestures

He pushes the attendant out of his way Explanation: Client Need: Psychosocial Integrity Rationale: A. A patient may be restrained who poses a threat of harm to self or others. Generally, less restrictive measures are tired initially, such as verbal intervention (talking the patient down) and chemical restraint (anti-anxiety or antipsychotic medication). Since this patient is not able to maintain control and pushes the attendant, restraints are indicated B. Shouting curses would not warrant restraints. Redirection should be tired initiallv. C. Tearing up his chart indicates a greater loss of control than shouting curses. The patient should be watched carefully and p.r.n. medication to control severe anxiety given. D. Making obscene gestures is behavior that requires redirection and possibly chemical restraint in the form of medication, if the patient's anxiety warrants.

A patient is taking theophylline (Theo-Dur) for the management of asthma. A nurse would advise the patient to report which of the following symptoms? Weight gain Excessive thirst Red- orange urine Heart palpitations

Heart palpitations Explanation: Client Need: Physiological Integrity Rationale: D. Adverse effects of theophylline include heart palpitations, headache, dizziness, nervousness, nausea, vomiting and epigastric pain. A. Weight gain is not a side effect of theophylline administration. The nausea and vomiting associated with theophylline may cause weight loss. B and C. Excessive thirst and red-orange urine are not adverse effects of theophylline.

A parent of a five-year-old child who was recently diagnosed with type 1 diabetes asks the nurse when the child can begin to self-administer insulin. The nurse would recommend that the child may begin this procedure at age of: six. nine. twelve. fifteen.

Nine Explanation: Client Need: Health Promotion and Maintenance Rationale: B. From about nine years of age, children can be taught to administer their own insulin. At this age they are able to understand the principles behind administration and determine the dosage of insulin. A. A child of six does not have the manual dexterity to administer the insulin or to calculate the dosage. C and D. Children can begin self- administration of insulin by age nine. They do not have to wait until ages 12 or 15.

A patient who has acquired immune deficiency syndrome (AIDS) has a nursing diagnosis of altered nutrition, less than body requirements. The nurse should instruct the patient to eat a diet that is high in protein high in potassium low in saturated fat low in sodium

High in protein Explanation: Client Need: Physiological Integrity Rationale: A. The nurse should encourage the nutritional intake of high-protein and high- caloric foods to prevent weight loss and malnutrition and to enhance immune function. B. The diet of the AIDS patient does not require an increase in potassium. C. A diet low in saturated fat is essential for patient with cardiac disease. It is not required for a patient with AIDS. D. The diet of the patient with AIDS does not have to be sodium Restricted. High Protein and high caloric foods are recommended for patients with AIDS.

A five-year-old child who has a celiac disease is being assessed in pediatric clinic. Which of the following nursing diagnoses should a nurse PRIORITIZE in the child's long- term care plan? Activity intolerance Self-concept disturbance High-risk for ineffective family coping Impaired skin integrity

High-risk for ineffective family coping Explanation: Client Need: Physiological Integrity Rationale: C. Because of the prolonged onset of celiac disease, the parent's ability to cope with the situation may be severely altered. A. Activity intolerance would be a concern at the time of diagnosis if the child is malnourished, but it is not a long - term problem. B. Self-concept disturbance is not a priority in the care of the patient with celiac disease. D. Impaired skin integrity would cause concern at the time of diagnosis, if the child does dehydrate at the time of malnourishment. It should not be a long- term problem.

A nurse is caring for a patient who underwent a transurethral resection of the prostate (TURP) several hours ago. The patient experiences nausea, confusion, elevated blood pressure and decreased pulse rate. The nurse would MOST likely suspect which of the following conditions? Bladder spasms Hyponatremia Dehydration Sepsis

Hyponatremia Explanation: Client Need: Physiological Integrity Rationale: B. Hyponatremia post-transurethral resection is due to the absorption of irrigating fluid during the after surgery. The patient's blood pressure increases, the pulse decreases and the patient become confused and nauseated. A. Bladder spasms can cause bleeding or hemorrhage, which can lead to shock. Signs of shock include an increase in pulse rate and decreased in blood pressure. C. Signs of dehydration include a decrease in blood pressure and an increase in heart rate. D. Sepsis also can lead to shock, which would be manifested by a decrease in blood pressure and an increased pulse rate.

Which of the following medications would a nurse keep at the bedside when administering an injection of heparin sodium? naloxone hydrochloride (Narcan) protamine sulfate phytonadione (Aquamephyton) phentonadionemesylate (Regitine)

Protamine sulfate Explanation: Client Need: Physiological Integrity Rationale: B. Protamine sulfate is the antidote for heparin toxicity and overdose. A. Narcan is a narcotic antagonist and is used to reverse respiratory depression due to narcotic overdose. C. Aquamephyton, or vitamin K, is the antidote for Coumadin overdose. D. Regitine is used to treat hypertension secondary to pheochromocytoma.

A pregnant woman has varicosities of her legs and is instructed about wearing elastic stockings. Which of the following comments made by the woman indicates that she understood the instructions? "I put the stockings on when my legs begin to swell." "I put the stockings on before I get out of bed in the morning." "I remove the stockings if I get cramps in my legs or feet." "I remove the stockings only when I bathe."

I put the stockings on before i get out of bed in the morning Explanation: Client Need: Health Promotion and Maintenance Rationale: B. Elastic stockings provide venous support to the legs. Therefore, the patient should elevate the legs prior to putting on the stockings to promote venous return. The stockings should be put on prior to getting out of bed. A. Elastic stockings are worn to prevent edema. They should be put on prior to the swelling. C. Cramps in the legs are due to arterial insufficiency, not venous insufficiency. The patient should be instructed to keep the stockings on. D. The stockings also should be removed at night when the patient goes to bed.

Which of the following symptoms would a nurse expect to identify when assessing a patient who has chronic obstructive pulmonary disease (COPD)? Increased anterior-posterior chest diameter Decreased residual lung volume Bronchovesicular breath sounds Kussmaul respirations

Increased anterior-posterior chest diameter Explanation: Client Need: Physiological Integrity Rationale: A. The physical examination of a patient with chronic obstructive pulmonary disease (COPD) reveals an increase in the diameter of the anterior- posterior dimensions of the chest, which develops secondary to the overdistended lungs and the patient's attempt to remove the trapped air. B. Patients with COPD have an increased total lung capacity and residual volume due to air trapping. C. Diminished breath sounds or occasional coarse crackles and wheezing can be heard on auscultation. D. Kussmaul respirations are deep and rapid and associated with metabolic acidosis

Which of the following nursing diagnoses should a nurse give the highest PRIORITY for a patient who has an elevated serum carbon dioxide level following surgery? Urinary retention Impaired skin integrity Ineffective airway clearance Impaired physical mobility

Ineffective airway clearance Explanation: Client Need: Physiological Integrity Rationale: C. After anesthesia and surgery, patients experience a reduction in pulmonary function including a reduction in lung volume secondary to pain, anesthesia and immobility. There is also a decrease in the clearance of mucus secondary to anesthesia and narcotics. A, B and D. All of these nursing diagnoses may be applicable to the postoperative patient who has an elevated CO2 level. However, effective airway clearance should take priority.

Which of the following nursing diagnoses would a nurse PRIORITIZE in caring for a patient who has sustained serious facial and neck burns? Fluid volume deficit Body-image disturbance Ineffective thermoregulation Ineffective airway clearance

Ineffective airway clearance Explanation: Client Need: Safe Effective Care Environment Rationale: D. The patient with facial and neck burns is at high risk for ineffective airway clearance related to possible upper airway edema, secondary to inhalation of superheated air, smoke or noxious chemical. A, B and C. Immediate care of the patient following a burn involves maintaining a patient airway. In pre- hospital care the primary response of the medical team follows the ABC of emergency management A= airway, B= breathing and C= circulation. While body image, ineffective thermoregulation and fluid volume deficit are all appropriate nursing diagnoses for the patient with serous facial and neck burns, airway is the priority in this patient.

A patient who has Hodgkin's disease is receiving chemotherapy. It is important to assess the patient for symptoms of: thrombus formation. ascites. infection. splenomegaly.

Infection Explanation: Client: Physiological Integrity Rationale: C. Immunosuppression is an adverse reaction to chemotherapy; therefore, it is important to assess the patient for infection. A. Due to the thrombocytopenia secondary to chemotherapy, bleeding is a more common side effect than thrombus formation. B. Ascites is not usually a side effect of chemotherapy, but an indication of obstructive manifestations caused by the disease. D. If the chemotherapy is effective, the patient should not have splenomegaly.

Although a patient expresses fear about having electroconvulsive treatment, the patient's significant other gives permission for the therapy. As a patient advocate, the nurse should consider which of the following ethico-legal principles? Negligence Confidentiality Informed consent Privileged communication

Informed consent Explanation: Client Need: Safe Effective Care Environment Rationale: C. Most state laws specify that electroconvulsive therapy can be administered only if informed consent is obtained from the patient. In the case of an incompetent patient consent must be obtained from the guardian. The patient's right to refuse electroconvulsive therapy is specifically addressed in many state laws. A. Negligence is the act, or failure to act, that braches the duty of due care and results in, or is responsible for, a person's injuries. If the nurse fails to obtain an informed consent, then the nurse could be considered neglectful. B. Confidentiality prevents the nurse from disclosing privileged information without informed consent by the patient. D. In order for patients to feel comfortable disclosing personal information about themselves that may be vital to treatment, many states have privileged communication laws. Generally, if a patient nurse-patient relationship exists, the nurse cannot divulge information about the patient that has arisen during treatment, even if this information is needed to implicate the patient in a crime. These laws differ greatly among states

Which of the following manifestations would a nurse expect to observe in a school-age child immediately following a tonic-clonic generalized seizure? Hypersalivation Hypotonia Lethargy Tachypnea

Lethargy Explanation: Client Need: Physiological Integrity Rationale: C. In the post-ictal state children appear to relax, but may remain semiconscious and difficult to rouse. A. Hypersalivation may occur during the seizure but is generally not seen afterwards. B. The child's muscles relax after the seizures but are not hypotonic D. The child's respiratory rate will slow and breathing will become even.

Which of the following instructions would a nurse include in the discharge plan of a patient who had a transurethral resection of the prostate (TURP)? Limit the intake of caffeinated beverages. Resume normal activities of daily living. Maintain a diet low in fiber. Strain urine with each voiding.

Limit the intake of caffeinated beverages Explanation: Client Need: Physiological Integrity Rationale: A. The patient should be instructed to use alcohol, caffeinated beverages and spicy foods in moderation to avoid over stimulation of the bladder. B. Strenuous activities should be avoided for at least two to three weeks. C. Dietary intervention and stool softeners are important in the postoperative period to prevent the patient straining while moving his bowels. A diet high in fiber facilitates the passage of stool. D. This option is not identified as part of postoperative management following a prostatectomy. It is indicated for patients with renal calculi

A patient who has a spinal cord transection is in spinal shock. On the assessment, the nurse would expect the patient to describe which of the following findings in the lower extremities? Loss of sensation Complaints of tingling Excessive diaphoresis Constant tremors

Loss of sensation Explanation: Client Need: Physiological Integrity Rationale: A. A patient with a spinal cord transaction has no movement or feeling below the level of the injury. B. The patient with a spinal cord injury loses feeling and sensation below the level of the injury. Therefore, the patient would not have complaints of tingling. C. The patient with autonomic dysreflexia has marked diaphoresis above the level of the lesion. D. The patient with a spinal cord injury is unable to move below the level of the injury; therefore, the patient would not have tremors.

Which of the following measures should be included in the care plan, to promote the skin integrity of a patient who is in Russell's traction? Having the patient lie on the right side for 20 minutes every two to three hours. Placing pillows under the patient's sacral and scapular areas. Massaging the patient's back and buttocks frequently. Applying an antiseptic solution to the patient's bony prominences after bathing.

Massaging the patient's back and buttocks frequently. Explanation: Client Need: Physiological Integrity Rationale: C. Massaging the patient's back and buttocks frequently promotes skin integrity and should be included in the care plan of a patient in traction. A. The patient in Russell's traction is not able to turn on the side for 20 minutes B. Placing pillows under the patient's sacral and scapular areas will interfere with the line of traction. D. Using antiseptic solutions would dry the skin, increase the chances of the skin cracking and lead to open areas.

A six-year-old child is experiencing a series of absence seizures. Which of the following actions would the nurse take? Insert a padded tonque blade between the child's teeth. Place the child in a side-lying position. Administer oxygen to the child via face mask. Monitor the nature of the child's behavior.

Monitor the nature of the child's behavior. Explanation: Client Need: Physiological Integrity Rationale: D. The onset of absence seizures is abrupt and characterized by a brief loss of consciousness that appear without warning and lasts about five to 10 seconds. Absences seizures may occur up to 20 times or more daily. Slight loss of muscle tone may cause the child to drop objects, but eh child is able to maintain postural control. An episode can be mistaken for inattentiveness or daydreaming, especially during a group activity. A. Inserting a padded tonque blade between the child's teeth is not recommended for generalized seizures because of the danger of injuring the teeth. B. The child experiencing an absence seizures is not a risk for respiratory problems C. There is no cyanosis with this type of seizures.

A nurse is assessing a patient who is at risk for the development of compartment syndrome. Which of the following assessments would the nurse PRIORITIZE? Apical pulse Pupillary response Neurovascular status Deep-tendon reflexes

Neurovascular status Explanation: Client Need: Physiological Integrity Rationale: C. Careful monitoring of the neurovascular status of the extremities is crucial in the detection and prevention of compartment syndrome. This syndrome is a complication of fractures and is caused by the progressive development of arterial vessel compression and reduced blood supply to an extremity. Fracture of the forearm or tibia usually precedes the onset of muscle edema in the fasciar, which form compartments for the muscles of the forearm and lower leg. When there is severe trauma, such as in fractures or compression from a tight cast, muscle ischemia can occur. Irreversible ischemia can occur within six hours due to compression of the arteries, nerves and tendons entering the compartment. A. Peripheral pulses, rather than the apical pulse, should be given priority B. Pupillary response is not affected by compartment syndrome. D. Deep- tendon reflexes will be checked because of the compression of the tendons, but the compromise of the blood supply and the nerves takes priority.

A few hours after a plaster of spica cast is applied, the patient tells the nurse that she has tingling sensation in her leg and that her foot is asleep. Which of the following actions should the nurse take? Explain to the patient that such feelings are common while the cast is drying. Make sure that the patient's legs is elevated so that her toes are higher than her heart. Tell the patient that moving her toes frequently will increase the circulation in her leg. Notify the patient's physician.

Notify the patient's physician. Explanation: Client Need: Physiological Integrity Rationale: D. Paresthesias after a cast is applied indicate that the cast is too tight. The physician should be notified because paresthesia is an early sign of compartment syndrome. A. Paresthesias should not occur while the cast is drying. B. The symptoms indicate that the arterial circulation is impaired. Elevating the leg promotes venous return and is not indicated. C. Moving the toes is assessment of neurovascular function. It does not increase circulation to the leg.

Diphenoxylate hydrochloride with atropine sulfate (Lomotil) is prescribed for a patient. When the patient returns to the clinic, the nurse should evaluate the therapeutic effect of Lomotil by assessing the patient's: weight. number or daily bowel movements. amount of daily food intake. skin turgor.

Number or daily bowel movements Explanation: Client Need: Physiological Integrity Rationale: B. Lomotil inhibits gastric motility by acting on mucosal receptors responsible for peristalsis. It is used for acute nonspecific and acute exacerbation of chronic functional diarrhea. A. Lomotil does not affect weight unless the patient abuses the drug. C. Lomotil has no direct effect on daily food intake. D. When the patient's diarrhea improves, the dehydration should improve. Skin turgor also will improve, but his is a secondary effect of Lomotil.

A nurse would instruct a patient who has had an ileostomy to avoid which of the following food selections? Potatoes Beef Popcorn Yogurt

Popcorn Explanation: Client Need: Physiological Integrity Rationale: C. Foods which can cause a potential obstruction in an ileostomy include nuts, raisins, popcorn, seeds, chocolate, raw vegetables, celery and corn. A, B and D. These foods are not contraindicated for patients who have an ileostomy.

Which of the following toys would a nurse select for a two-year-old child? 10-piece jigsaw puzzle Push- pull vacuum cleaner Paint-by numbers set Hand-held electronic game

Push-pull vacuum cleaner Explanation: Client Need: Health Promotion and Maintenance Rationale: B. Children of this age enjoy toys that encourage motor-like activity. A push-pull toy would be appropriate. A. This puzzle has too many pieces for a two-year-old. C. A paint by numbers set is too complicated of a two year old. D. A hand held electronic game is too complex for a child this age.

A patient who comes to the physician's office is suspected of having hypertrophy of the prostate. The nurse should expect that he will probably exhibit which of the following manifestation? Residual urine of more than 50 ml. Pain radiating of more scrotum. Urethral excoriation. Stress incontinence.

Residual urine of more than 50 ml Explanation: Client Need: Physiological Integrity Rationale: A. Hypertrophy of the prostate causes urinary outflow problems. The patient experiences retention of urine with overflow that produces dribbling of urine. When the patient is catheterized for residual urine, moderate amounts of urine are obtained. B. There is usually no pain associated with benign prostatic hypertrophy. Pain radiating to the scrotum is found in infections such as epididymitis. C. Urethral excoriation is not manifestation of hypertrophy of the prostate. D. Stress incontinence is involuntary urination as a result of increased pressure, such a when sneezing or coughing. It is usually related to weakness of sphincter control.

Anurse should recognize that cardiac arrest in a previously healthy infant is usually preceded by: ventricular arrhythmias. respiratory failure. generalized seizures. distributive shock.

Respiratory failure Explanation: Client Need: Physiological Integrity Rationale: B. Cardiac arrest in the pediatric population is less often of cardiac origin than from prolonged hypoxemia secondary to inadequate oxygenation, ventilation and circulation. A. Ventricular arrhythmias are rare in children. They are more common in adults C. Generalized seizures are rare in children D. Distributive shock results from a vascular abnormality that produces maldistribution of blood supply throughout the body. Common causes are neurogenic shock, anaphylactic shock and septic shock. All may result in cardiac arrest but are less common a cause than respiratory etiology.

When obtaining vital signs on a sleeping three-month-old infant, a nurse should obtain FIRST the: respiratory rate. apical pulse. axillary temperature. blood pressure.

Respiratory rate Explanation: Client Need: Psychosocial Integrity Rationale: A. This is the least intrusive assessment. The nurse does not have to touch t the patient so the rate will be more accurate. B, C and D. All of these assessments necessitate touching the patient and possibly disturbing the patient. This will alter the accuracy of vital signs as the three-month-old infant may fuss and cry.

A patient whose ventilation is inadequate should be observed for early symptoms of hypoxia, which include: pallor. restlessness. mottling of the extremities. disorientation.

Restlessness Explanation: Client Need: Physiological Integrity Rationale: B. Restless is one of the earliest symptoms of hypoxia. Poor concentration and tachycardia also are early clinical manifestations of hypoxia. A. Pallor is a manifestation of hypoxia that occurs when Pa02 levels fail below normal. C and D. Mottling of the extremities, disorientation, stupor, lethargy and depressed tensor reflexes are late signs of hypoxia.

Which of the following nursing diagnoses would a nurse give PRIORITY in caring for a patient who has myasthenia gravis? Ineffective individual coping Situational low self- esteem Ineffective thermoregulation Risk for aspiration

Risk for aspiration Explanation: Client Need: Safe Effective Care Environment Rationale: D. With myasthenia gravis, weakness of the bulbar muscle causes problems with chewing and swallowing, and presents a danger of choking and aspiration. Nursing diagnoses identified for the patient with myasthenia gravis are ineffective breathing pattern, impaired physical mobility and risk for aspiration related to weakness in the muscles. A and B. Ineffective individual coping and situational low self-esteem related to inability to maintain usual lifestyle and role responsibilities are potential diagnoses for this patient. They would not be as high a priority as ineffective breathing pattern and risk for aspiration are for this patient. C. Ineffective thermoregulation is not associated with myasthenia gravis unless the patient develops infection as a complication.

To screen for the presence of neural tube defects in the fetus, a nurse would expect a pregnant woman to have which of the following tests? Serum alpha-fetoprotein Biophvsical-profile Amniocentesis TORCH titers

Serum alpha-fetoprotein Explanation: Client Need: Health Promotion and Maintenance Rationale: A. Alpha- fetoprotein (AFP) is found in the fetal circulation, amniotic fluid and maternal fluid. Elevated levels have been found to reflect open neural tube defects such as spina bifida and anencephaly. B. A biophysical profile is an assessment of fetal well- being. C. Amniocentesis would provide information on neural tube defects but is far more risky and invasive. D. TORCH titers will give information regarding exposure to viral infections. The TORCH groups of infectious diseases are those that can cause serious harm to the developing fetus. These disease include toxoplasmosis (T), other infections such as syphilis (O), rubella (R), cytomegalovirus (C) and herpes simplex virus type 2 (H)

A 12-year-old girl has a long leg cast applied to her leg. She is being instructed regarding crutch-walking with no weight bearing on her left leg. Which of the following observation indicates that the girl needs FURTHER teaching? She is using the three-point gait. Her elbows are slightly flexed. She places the crutches approximately six to eight inches (15 to 20 cm) in front of her with each step. She is supporting her weight on the axillary bass and hand pieces of the crutches.

She is supporting her weight on the axillary bass and hand pieces of the crutches. Explanation: Client Need: Health Promotion and Maintenance Rationale: D. The axilla should not rest on the crutches. Such pressure may cause discomfort and nerve damage. The weight of the body should be borne by the hands. The girl needs further instruction in this area. A. Since the child is not allowed weight bearing on her left leg, a three-point gait is used for crutch- walking. The child should advance one crutch and then the other, followed by the unaffected leg. The unaffected leg should be advanced only as far as the crutches. Moving beyond the crutches can cause the child to lose her balance. B. Elbows should be flexed when using crutches and the weight of the body should be borne by the hands. The girl is using proper crutch-walking technique. C. The crutches should not be advanced further than six to eight inches in order to prevent loss of balance and falls. The girl is using proper crutch-walking technique.

The best time to administer p.r.n. lorazepam (Ativan) to a patient who is aggressive is when the patient: starts to pace in the hallway. stops pacing and starts making verbal threats. stops threatening and actually performs a violeNt act. is placed in restraints.

Starts to pace in the hallway Explanation: Client Need: Psychosocial Integrity Rationale: A. The patient's behavior should be carefully monitored and Ativan, an anti- anxiety agent, administered before the patient escalates. Pacing that becomes more rapid is a sign of increased agitation in the patient. B, C and D. Ativan should be administered before the patient's behavior becomes threatening.

An elderly man who has Alzheimer's disease calls the nurse by his wife's name. Which of the following measures by the nurse would be APPROPRIATE instead? Responding to whatever name he calls Asking him to remember the nurse's name Stating the nurse's name at each contact with him Allowing him extra time in which to remember the nurse's name

Stating the nurse's name at each contact with him Explanation: Client Need: Psychosocial Integrity Rationale: C. Since the patient with Alzheimer's diseases has problems with memory, it is important for the nurse to state his or her name at each contact with the patient. A. Responding to whatever name the patient calls the nurse does not provide reality orientation for the patient. B. Since the patient has difficulty with memory, especially short term memory, asking him to remember a name is not appropriate. D. Allowing extra time to remember will not enable the patient to recall the name and may agitate the patient since he has difficulty with memory.

A patient had a laryngectomy with a laryngeal tube placement. When suctioning the laryngeal tube, which of the following measure is CORRECT? Suctioning the laryngeal tube for about 10 seconds. Using a clean technique when suctioning the tube Applying suction while inserting the catheter into the tube Turning the patient's head to suction one side and then the other side

Suctioning the laryngeal tune for about 10 seconds Explanation: Client Need: Physiological Integrity Rationale: A. The laryngeal tube should be suctioned for 10 seconds. Suctioning for longer periods can result in hypoxia. B. This is an incorrect measure. Sterile techniques should be used when suctioning the laryngectomy tube to prevent infection. C. This is an incorrect measure. Suction should not be applied when inserting the suction catheter in order to prevent trauma to surrounding tissue. D. This is an incorrect response. Turning the head is done when suctioning a tracheostomy. It does not have to be done for the patient who has a laryngectomy.

A nurse suspects that a six-month-old infant has cystic fibrosis. Which of the following tests would confirm the diagnosis? Quantitative collection of stool for fecal fat Pulmonary function studies Serum sample for human leukocyte antigen Sweat chloride analysis

Sweat chloride analysis Explanation: Client Need: Physiological Integrity Rationale: D. The only reliable and valid test for cystic fibrosis (CF) is the sweat test by pilocarpine iontophoresis followed by the Gibson- Cooke quantification of chloride concentration. A. Quantitative collection of stool for fecal fat is not a definitive test for cystic fibrosis. It merely indicates malabsorption. B. Pulmonary function studies would aid in assessing lung function but would not diagnose cystic fibrosis. C. Human- leukocyte antigen is not diagnostic of cystic fibrosis

If a four-year-old child's growth and development is age-appropriate, a nurse would expect to observe which of the following behaviors? Talking with an imaginary playmate Drawing a stick figure with at least six parts Walking down stairs, one step at a time Counting backwards from the number 10

Talking with an imaginary playmate Explanation: Client Need: Health Promotion and Maintenance Rationale: A. Imaginary companions usually appear between the ages of two and three years. They are often relinquished when the child enters school. B. A four- year olds drawing of a human is just pictorial, a head with two arms attached. The child would not draw stick figure with parts. C. At 24 months, the child can go up and down stairs alone with two feet on each step. This behavior would not be appropriate for a four- year old. D. At age seven, the child can repeat three numbers backward and at age eight to nine can count backward from 20. The four year old would not be able to do this.

A community health nurse makes a home visit to evaluate a mother's understanding of discharge instructions for her five- month -old infant who has chronic gastroesophageal reflux. Which of the following actions, if taken by the mother, indicates correct understanding of the instructions? The mother is restricting the child's fluids. The mother is burping the infant at the end of 6 oz (180 ml) feeding. The mother is administering prescribed cisapride (Propulsid) to the infant 15 minutes prior to feeding. The mother is placing the infant in a recumbent position 15 minutes after feeding.

The mother is administering prescribed cisapride (Propulsid) to the infant 15 minutes prior to feeding. Explanation: Client Need: Physiological Integrity Rationale: C. Propulsid is indicated for the treatment of heartburn from efflux esophagitis. A. Adequate calories and fluids are needed for growth and hydration. The mother should be instructed in the nutritional needs of the infant. B. Burping of the child should occur after every ounce of fluids is given. The mother should be instructed in the principles of feeding the infant. D. The head- elevated position helps to reduce episodes of reflux. The mother should be instructed in positioning techniques.

Which of the following observation on a patient who has pernicious anemia would indicate that the goal of care has been achieved? The patient's skin has absence of petechiae. The patient's tongue has lost its beefy red color. The patient's dependent edema disappears. The patient has a good appetite.

The patient's tongue has lots its beefy red color Explanation: Client Need: Physiological Integrity Rationale: B. Pernicious anemia is the absence of the intrinsic factor secreted by the gastric mucosa. It produces a beefy, red tongue. When treatment has been effective, the tongue loses this appearance. A. Patients with pernicious anemia do not have alterations in their platelet count and do not have petechiae. C. Patients with pernicious anemia do not characteristically develop dependent edema. D. Patients with pernicious anemia do not generally experience loss of appetite.

Which of the following comments would a patient with an antisocial personality be MOST likely to make? "The police are always arresting me for nothing." "'m feeling guilty because I've disappointed by family." "I'm becoming very anxious." "I've learned my lesson and I'll never do that again"

The police are always arresting me for nothing Explanation: Client Need: Psychosocial Integrity Rationale: A. Patients with an antisocial personality disorder fail to conform to social norms with respect to lawful behaviors. They see themselves as victims and do not accept the consequences of their behavior. B. Patients with antisocial personality disorders do not experience guilt over their behavior or the effects of their behavior on others. C. Patients with antisocial personality disorders do not experience anxiety because of their behavior. They do have a low tolerance for frustration, and can become furious and vindictive if thwarted. When things go their way, they can be cheerful, gracious and charming. D. Patients with antisocial personality disorders do not learn from experience. They act impetuously and are unable to delay gratification.

A 26-year-old woman is brought to the psychiatric unit because of 011 point suicidal thoughts. To determine if one- on-one observation is indicated for the woman, the nurse should determine if: anyone in the woman's family has attempted suicide. the woman has a plan for suicide. the woman has had a recent loss. the woman has a social support system.

The woman has a plan for suicide Explanation: Client Need: Psychosocial Integrity Rationale: B. A patient with a well- thought out plan and the means to carry out the plan is at extremely high risk for suicide. A. A family history of suicide increases an individual's risk, but the plan is a better indicator of suicidal intent. C. Experiencing a recent loss also increases an individual's risk for suicide. However, the plan is the better indicator of suicidal intent. D. Having a support system that one can rely on during periods of crisis decreases the risk for suicide.

A woman who is in preterm labor is receiving magnesium sulfate for which of the following purposes? To enhance fetal lung maturity To prevent seizures To improve urine output To control uterine contraction patterns

To control uterine contraction patterns Explanation: Client Need: Physiological Integrity Rationale: D. Magnesium sulfate decreases uterine activity. It is used as a tocolytic agent because it is safer for the woman than retordrine. A. Fetal lung maturity is enhanced with the administration of betaemethasone, not magnesium sulfate (MgSO4). Magnesium sulfate is used to prevent seizures in patients with eclampsia. B. A preterm labor patient does not routinely exhibit seizures. They are associated with eclamptic patients. C. Urine output must be monitored for decreases in hourly output. MgSO4 will not increase urine output. Rather, the patient may have retention of urine as a sign of MgSO4 toxicity.

When assessing a six-month-old baby girl, the nurse should expect the infant to exhibit which of the following abilities? Creeping on her hands and knees Pulling herself to a standing position Waving bye-bye Turning over completely

Turning over completely Explanation: Client Need: Health Promotion and Maintenance Rationale: D. The six month old can roll from back to abdomen and may sit alone without support. A. Creeping on the hands and knees is seen at nine months age. B. Pulling self to a standing position is seen at nine to ten months of age. C. Waving bye- bye is seen in the infant at 10 months of age.

A nurse would assess a woman in labor who is receiving continuous epidural analgesia for: temperature instability urinary retention persistent headache uterine hyperstimulation

Urinary retention Explanation: Client Need: Physiological Integrity Rationale: B. With an epidural block, the woman loses the sensation of her bladder filling. The nurse should remind the woman to void every two hours, monitor her intake and output and palpate her bladder for distention. A. Temperature instability is not generally associated with epidural blocks. C. Spinal headaches occur rarely after epidural anesthesia since those headaches are caused by leakage of cerebrospinal fluid from, or the instillation of air into, the cerebrospinal space. The cerebrospinal space is not entered with this technique. D. Uterine hyper-stimulation is not a complication of epidural anesthesia.

A patient who has had a laryngectomy is being prepared for discharge. Which of the following questions, if asked by the patient, would indicate an understanding of the instructions? "What type of humidified would you recommend?" "What are the best foods for a high fiber diet?" "How long would you suggest that I keep the plug for the laryngectomy tube in a disinfectant?" "How long do I have to worry that I may aspirate food?"

What type of humidified would you recommend Explanation: Client Need: Physiological Integrity Rationale: A. Since the nose normally humidifies the air, supplemental humidification is indicated for the patient with a laryngectomy. B. There are no dietary restrictions for the patient with a laryngectomy C. Laryngectomy tubes are not plugged D. There is no risk for aspiration by the laryngectomy patient, since there is no connection between the esophagus and the respiratory tract.

A woman who is dependent on alcohol is admitted to the detoxification unit. Which of the following questions is essential for the nurse to obtain from the patient immediately? How does her husband react to her problem? When did she have her last drink? How old she was when she began to drink? What did she eat in the past four hours?

When did she have her last drink? Explanation: Client Need: Psychosocial Integrity Rationale: B. Alcohol withdrawal begins within four to six hours of cessation of, or reduction in, heavy and prolonged alcohol use. By knowing when the patient had her last drink, the nurse can anticipate withdrawal symptoms and intervene appropriately A. This information will be of use when the individual begins counseling. If the patient has a husband who enables her drinking, it will be much more difficult for her to quit. C. Knowing how old the patient was when she started drinking provides information on the length of her addiction. However, it is not a question that needs to be asked immediately. D. The nurse should be aware of what the patient has eaten prior to admission since food may slow down the absorption of alcohol and thereby delay withdrawal, however, the most essential assessment for the nurse to make is determining when the patient had her last drink.

When a woman who is at 34 weeks gestation has non-reactive results to successive non-stress test, a nurse would prepare the woman for: an emergency cesarean delivery. indication of labor. internal fetal monitoring. a biophysical profile.

a biophysical profile. Explanation: Client Need: Health Promotion and Maintenance Rationale: D. A reactive pattern to a non-stress test (NST) demonstrates fetal well- being. Due to the high false positive rate for non-reactive findings, a biophysical profile also should be done. A. An emergency Cesarean section is not indicated at this time. B. Induction will be instituted only after the healthcare team is sure that there is a non-reactive fetus. C. Internal fetal monitoring can be accomplished only after the patient's membranes have ruptured.

A teenager with acne in the physician office says to the nurse, "Look at my face, I still get pimples." The nurse should explain to the teenager that a contributing cause of acne in adolescent is: eating a large amount of foods high in fat. eating foods that are high in complex carbohydrates. an increase in secretions of the sebaceous glands. an increase in secretions of the adrenal glands.

an increase in secretions of the sebaceous glands. Explanation: Client Need: Health Promotion and Maintenance Rationale: C. Acne develops at puberty when the secretion of sebum takes place. The sebum accumulates in the pilosebacious unit forming comedones, which may be invaded by bacteria. This results in overgrowth and inflammation. A. Eating large amounts of fat in the diet is associated with obesity and heart disease. It has not been implicated in the development of acne. B. Dietary habits such as eating complex carbohydrates, chocolate, ice cream and candy, has not been scientifically linked to development of ache. D. The adrenal glands secrete steroids and cathecholamines. These have not been implicated in the development of acne.

A nurse is leading a community meeting on an inpatient psychiatric unit. One of the group members complains that the hospital visiting hours are too short. The MOST APPROPRIATE action for the nurse is to: explain the reason for the visiting hours policy. explore with the patient why he is so upset. invite the nurse manager to the group to explain the policy. ask the other group members if they have similar concerns.

ask the other group members if they have similar concerns. Explanation: Client Need: Psychosocial Integrity Rationale: D. This response is an attempt to validate that the length of visiting hours is a group concern and not an individual issue. A. This response does not allow for exploration of group concerns B. There is no mention that the patient is very upset. C. Inviting the nurse manager to explain the policy tot eh group shifts responsibility away from the nurse and also does not allow for exploration of group concerns.

An 18-month-old infant has received a diphtheria, tetanus toxoid and pertusis (DTP) vaccine in the anterior thigh. A nurse would instruct the infant's parent to contact the physician if the infant: displays a decreased interest in usual activities. refuses to walk. cries inconsolably. develops a rectal temperature of 102 OF (38.9 °C).

cries inconsolably. Explanation: Client Need: Safe Effective Care Environment Rationale: C. Crying uncontrollably could indicate possible neurological complications from the vaccine. A. It is not unusual to observe behavioral changes and decreased interest in usual activities in a child after vaccination. These effects are temporary. B. Often the child refuses to walk because of pain at the injection site. Such pain is an expected reaction. D. A temperature of 1020F would be normal after immunization.

A hospitalized patient has recovered from an acute exacerbation of his chronic mental illness and is demanding release. In planning the patient's discharge, the nurse should take into consideration that the patient: is used to being homeless and does not need much assistance. cannot be discharged until a suitable living arrangement is identified. will receive adequate aftercare at the community mental health center. has the right to be discharged.

has the right to be discharged. Explanation: Client Need: Safe Effective Care Environment Rationale: D. By law a patient has the right to appropriate treatment in the least restrictive setting. Liberty may be restricted only to the extent required by treatment needs. This patient has recovered from the acute exacerbation of his illness and has the right to be discharged. A. This is a false assumption on the part of the nurse. Because of the physical and psychological problems that accompany homelessness, the patient may require greater assistance. B. Staff should find suitable placement for the patient since he is eligible for discharge. C. The nurse should not assume that the patient will continue care post discharge

A child who has acute lymphoctic leukemia is receiving chemotherapeutic drugs. The healthcare provider (HCP) also ordered allopurinol (Zyloprim). The nurse should recognize that the purpose of Zyloprim for the child is to: stimulate erythropoietic activity. promote the deposit of calcium in the long bones. interfere with the production of leukemic cells. inhibit uric acid production.

inhibit uric acid production. Explanation: Client Need: Physiological Integrity Rationale: D. Zyloprim reduces uric acid synthesis and is indicated for hyperuricemia associated with malignancies. Antileukemic drugs can cause a rapid breakdown in the malignant cells, which raises the uric acid load that must be handled by the kidney. This increase load, combined with a state of dehydration caused by poor fluid intake and vomiting, causes renal injury. A. Zyloprim does not stimulate red blood cell formation. It is the action of epoetin (Epogen) instead. B. Zyloprim blocks purine metabolism and reduces the risk of kidney stone formulation. It does not promote the deposit of calcium in the long bones. C. Zvloprim control hyperuricemia. It does not interfere with the production of leukemic cells.

Diazepam (Valium) is prescribed for a patient with low back pain. The therapeutic action of Valium in this situation is to: reduce anxiety level. eliminate pain sensation. suppress the inflammatory process. lessen muscle spasticity.

lessen muscle spasticity. Explanation: Client Need: Physiological Integrity Rationale: D. Diazepam (Vitamin) is prescribed for a patient with low back pain to decrease muscle spasms. A. Valium is an anti- anxiety agent and may be used to reduce anxiety. However, in this situation, its purpose is to lessen muscle spasms. B. Valium has no direct effect on pain sensation. C. Valium does not affect the inflammatory process.

The MOST common side effect of electroconvulsive therapy (ECT) for which the nurse must plan interventions is: arrhythmia. physical injury. severe hypertension. memory loss.

memory loss. Explanation: Client Need: Psychosocial Integrity Rationale: D. Confusion and memory loss are the most common side effects of electroconvulsive therapy (ECT). The memory loss and confusion increase as the number of treatments increases. The nurse should plan interventions that address appropriate safety measures. A. Medical complications, such as arrhythmias, laryngopasm and circulatory insufficiency are infrequent and occur in approximately one out of 1400 treatments. ECT is contraindicated for patients with severe cardiac conditions. B. With the use of general anesthesia and muscle relaxants during ECT, physical injury is minimized, injury can result from the confusion that occurs post ECT. C. Hypertension is also a complication of ECT, but it will not be ordered if the patient has a history of hypertension as it's on of its contraindication.

A woman who is confirmed to be at 30 week's gestation, has sudden painless bright red vaginal bleeding. The nurse would suspect that the woman is experiencing: abruption placentae. an ectopic pregnancy. placenta previa. a molar pregnancy.

placenta previa. Explanation: Client Need: Health Promotion and Maintenance Rationale: C. Manifestations of placenta previa include minimal to severe bright red blood from the vagina and absence of pain. A. Abruptio placenta is manifested by uterine tenderness or pain and dark red or absent bleeding. B. Pain and dark red or no vaginal bleeding also is associated with a ruptured tubal pregnancy. D. Molar pregnancy is a uterine growth that contains no fetus, placenta or amniotic sac vaginal bleeding occurs in 45% of patients. The vaginal discharge may be dark brown or bright red, either scant or profuse. It may continue for a few days, or continue intermittently for weeks.

Because a woman is receiving magnesium sulfate for pregnancy-induced hypertension, it is essential for the nurse to assess the woman's: urine chemistry platelet count apical pulse rate respiratory rate

respiratory rate Explanation: Client Need: Physiological Integrity Rationale: D. Because magnesium sulfate is a central nervous system (CNS) depressant, the nurse should assess for signs and symptoms of magnesium toxicity, including loss of knee jerk reflexes, respiratory depression, oliguria, respiratory arrest and cardiac arrest. The woman's blood pressure, pulse and respiratory status are monitored every 15 minutes. A. Urine chemistry is not routinely done. Urine dipstick for protein would be appropriate. B. The platelet count will be assessed along with the routine complete blood count (CBC) C. The apical heart rate does not have to be assessed. Measurement of the radial pulse rate is acceptable. Vital signs and should be taken every 15 minutes.

When a patient who has diabetes mellitus experiences peripheral neuropathy, the PRIORITY nursing diagnosis would be: altered health maintenance. altered urinary elimination. risk for impaired skin integrity. noncompliance.

risk for impaired skin integrity. Explanation: Client Need: Physiological Integrity Rationale: C. Sensory neuropathy lead to loss of pain and pressure sensation. Autonomic neuropathy leads to increased dryness and fissuring of the skin. The typical sequence of event in the development of a diabetic foot ulcer begins with a soft- tissue injury of the foot and formation of a fissure between the toes or in an areas of dry skin. A, B and D. While these options may be potential nursing diagnoses for the patient with diabetes mellitus, they are not the priority when a patient has peripheral neuropathy.

When administering oral liquid medication to a six- month- old-infant, the nurse would mix the drug in the infant's formula and offer with the next feeding. sweeten the drug with honey and give from a teaspoon. quickly squirt the drug from a syringe to the back of the mouth. slowly squirt the drug from a syringe into the cheek pocket.

slowly squirt the drug from a syringe into the cheek pocket. Explanation: Client Need: Heath Promotion and Maintenance Rationale: D. Allowing the infant to suck drug that has been placed in an empty nipple or inserting the syringe or dropper into the side of the mouth, parallel to the nipple, while the infant nurses are methods of giving liquid drugs to infants. The syringe is best placed along the side of the infant's tongue and the drugs given slowly. A. Drugs are not added to an infant's formula feeding. B. The nurse should not mix drugs with high sugar content foods, such as honey, when giving drugs to infants because of the risk of botulism. C. Quickly squirting a drug from a syringe to the back of the mouth can lead to aspiration.

When taking a history from the parent of a nine-year-old child who has glomerulonephritis, a nurse would expect the parent to report a recent episode of: urinary tract infection acute gastroenteritis pneumocvstis carini pneumonia suppurative impetigo

suppurative impetigo Explanation: Client Need: Physiological Integrity Rationale: D. Most cases of glomerulonephritis have been associated with pneumococcal, streptococcal and viral infections. Glomerulonephritis secondary to pharyngitis is common in the winter or spring, but when associated with pyoderma, principally impetigo, may be more prevalent in the summer or early fall A and B. The organisms that cause urinary tract infections and gastroenteritis do not cause glomerulonephritis. C. Pneumocystis pneumonia is associated with AIDS and not glomerulonephritis

Solid foods can be started in infants at four months of age because by this time, the: moro reflex has disappeared. tonic neck reflex is stronger. swallowing reflex has matured. rooting reflex has receded.

swallowing reflex has matured. Explanation: Client Need: Health Promotion and Maintenance Rationale: C. Swallowing movements facilitating the ingestion of solid foods occur by four to six months of age. By this time, the oral cavity has grown and matures sucking and jaw motions have developed, indicating readiness to start solids. A. The Moro reflex or startle response is elicited by stating the infant with a loud noise. It does not determine when solid food should be introduced. B. The tonic neck reflex simulates the position assumed by someone preparing it fence. It disappears at about age six months. It does not determine the introduction of solid foods. D. The rooting reflex occurs when the infant's check is lightly stroked on the side of the mouth. It simulates the infant to turn its head in that direction in order to find food. This reflex disappears at nine to 12 weeks of age.

A patient who is receiving a digitalis preparation should be observed for symptoms of toxicity, which include: hypertension oliguria tinnitus vomiting

vomiting Explanation: Client Need: Physiological Integrity Rationale: D. A manifestation of digoxin toxicity is vomiting. Other gastrointestinal signs and symptoms of digoxin toxicity are nausea, anorexia, abdominal pain and diarrhea. A. Hypotension, not hypertension, is a side effect of digoxin. B and C. Oliguria and tinnitus are not identified as symptoms of digoxin toxicity.