Quiz #1

A nurse is planning to provide preoperative teaching to a 12-year-old child who is to undergo ostomy surgery. What should the nurse do before formulating a teaching plan? 1. Assess the child's development 2. Determine the family's comprehension of the procedure 3. Provide a list of available community resources to the family 4. Collaborate with the school in ensuring the child's smooth return

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

A nurse is assessing the urine of a client with a urinary tract infection. For which characteristic should the nurse assess each specimen of urine? 1. Clarity 2. Viscosity 3. Glucose level 4. Specific gravity

1. Clarity Cloudy urine usually indicates purulent drainage (pyuria) associated with infection. Viscosity is a characteristic that is not measurable. Urinary glucose levels are not affected by urinary tract infections. Specific gravity yields information related to fluid balance.

A nurse is teaching a school-aged child with impaired renal function about the prescribed diet. What food choices should the nurse include in the teaching plan? 1. Corn on the cob, baked chicken, rice, apple, and milk 2. Baked potato, hamburger, canned carrots, banana, and buttermilk 3. Canned green beans, baked ham, bread and butter, peach, and milk 4. Hot dog on a bun, potato chips, dill pickle slices, brownie, and buttermilk

1. Corn on the cob, baked chicken, rice, apple, and milk Explanation: Corn on the cob, baked chicken, rice, apples, and milk are all permitted on a low-sodium, low-potassium diet, which is recommended for individuals with kidney disease. Foods high in potassium and sodium should be avoided by a child with impaired kidneys. Canned carrots are high in sodium, banana is high in potassium, and buttermilk is high in sodium and potassium. Foods high in sodium should be avoided by a child with impaired kidneys. Canned beans and ham are high in sodium. A hot dog and bun, potato chips, dill pickle slices, a brownie, and buttermilk are all high in sodium, potassium, or both and should be avoided by a child with impaired kidneys.

A 10-year-old child is receiving oxygen 2 L/min by way of nasal cannula. The health care provider asks that pulse oximetry be started. What is the appropriate placement for the oximetry probe in a child of this age? 1. Great toe 2. Index finger 3. Radial pulse point 4. Popliteal pulse point

1. Great toe Explanation: When pulse oximetry is instituted for a child or adult, the index finger is used because the probe is easy to apply and an accurate reading is obtained. The great toes of most 10-year-olds are too large for the probe; the great toes of infants are used for pulse oximetry. The probe must be placed on tissue away from a pulse point.

A nurse is interviewing a child with attention deficit disorder. For which major characteristic should the nurse assess this child? 1. Overreaction to stimuli 2. Continued use of rituals 3. Delayed speech development 4. Inability to use abstract thought

1. Overreaction to stimuli A universal characteristic of children with attention deficit disorder is distractibility. They are highly reactive to any extraneous stimuli. Rituals are uncommon, although these children do use repetition in language and movement. Delayed development of language skills is not the major problem, but children with attention deficit disorder may exhibit dyslexia (reading difficulty), dysgrammatism (speaking difficulty), dysgraphia (writing difficulty), or delayed speech. Loss of abstract thought is not a universal characteristic associated with children with attention deficit disorder.

A school-aged child is being observed overnight for responses to a closed head injury sustained when the child fell off a piece of playground equipment. The nurse knows to call the health care provider immediately if: 1. The child begins vomiting 2. The child's pupils measure 3 mm 3. The respiratory rate is 24 breaths/min 4. The systolic blood pressure falls below 110 mmHg

1. The child begins vomiting Vomiting is a sign of increased intracranial pressure. The systolic blood pressure range for a school-aged child is 80 to 120 mm Hg. The expected respiratory rate for a school-aged child is 20 to 30 breaths/min. Normal pupil size ranges from 2.0 to 5.0 mm.

An older female client who is confused and often does not recognize her children is admitted to a nursing home. The client appears slovenly, often soiling her clothing with feces and urine. How can the nurse best manage this problem? 1. Toileting the client every 2 hours 2. Placing the client in orientation therapy 3. Supervising the client's bathroom activities closely 4. Explaining to the client how offensive her behavior is to others

1. Toileting the client every 2 hours This client needs toileting every 2 hours to prevent soiling; physically seating the client on the toilet often prevents accidents and negates the need for disposable pads or underwear. The client has cognitive impairment, and reality orientation will probably be ineffective. The client needs more than just supervision. The client may be unable to control the incontinence, and telling her that her behavior is offensive is demeaning.

A client is experiencing both tingling of the extremities and tetany. What should the nurse anticipate will be prescribed by the health care provider? 1. Dialysis 2. Calcium supplements 3. Mechanical ventilation 4. intravenous fluids with potassium

2. Calcium supplements Explanation: Calcium supplements are signs of hypocalcemia, which is corrected by the administration of calcium. Dialysis is indicated for hyperkalemia and renal failure. Mechanical ventilation is indicated for respiratory insufficiency. Intravenous fluids with potassium are indicated for hypokalemia.

A nurse on the high-risk unit is caring for a client with severe preeclampsia. What intervention is most effective in preventing a seizure? 1. Providing a plastic airway 2. Controlling external stimuli 3. Having emergency equipment available 4. Keeping calcium gluconate at the bedside

2. Controlling external stimuli Explanation: Reducing lights, noise, and stimulation minimizes central nervous system irritability, which can trigger a seizure. A plastic airway will not prevent a seizure. Available emergency equipment will not prevent a seizure, although oxygen and suction equipment may be useful after a seizure. Calcium gluconate is the antidote for magnesium sulfate toxicity; it does not prevent seizures.

A school nurse is planning to teach the importance of handwashing to the children in first grade. What is the most effective approach for this age group? 1. Showing a video of the correct handwashing technique 2. Demonstrating handwashing and asking for return demonstrations 3. Involving them in a discussion about the importance of handwashing 4. Describing how germs cause illness and how handwashing prevents disease

2. Demonstrating handwashing and asking for return demonstrations Six-year-old children are still in the perceptual phase of cognitive development. They base judgments on what they see rather than on what they reason; reasoning begins around age 7. These children are at the developmental stage when they want to show off their accomplishments; just watching the technique without feedback is not sufficient at this age. These children are too young to understand the abstract concepts involved in a discussion of the cause and effect regarding pathogens or to understand why handwashing is so important in preventing illness.

A client experiences a muscle sprain of the ankle. When assessing the injury, the nurse discovers that a hematoma is developing, edema is present and that the client reports tenderness when the ankle is palpated. The nurse anticipates that the plan of care will include the application of a(n): 1. Binder 2. Ice bag 3. Elastic bandage 4. Warm compress

2. Ice bag Application of ice directly to a soft tissue injury causes vasoconstriction, which results in decreasing hemorrhage, edema, and pain. Use of a binder or elastic bandage to the area of a soft tissue injury is contraindicated and may cause compartment syndrome (constriction resulting in decreased circulation and nerve function). A warm compress would result in vasodilation and cause increased hemorrhage (hematoma formation), edema, and pain.

An emergency department nurse is admitting a client after an automobile collision. The health care provider estimates that the client has lost about 15% to 20% of blood volume. Which assessment finding should the nurse expect this client to exhibit? 1. Urine output of 50 mL/hr 2. BP of 150/90 mm Hg 3. Apical HR of 142 beats/min 4. Resp rate (RR) of 16 breaths/min

3. Apical HR of 142 beats/min Explanation: In hypovolemic shock, tachycardia is a compensatory mechanism in an attempt to increase blood flow to body organs. Urine output would fall to less than 30 mL/hr because a decreased blood volume causes a decreased glomerular filtration rate. The blood pressure is decreased because of the decreased blood volume. Respiratory rate of 16 breaths/min is within the accepted range of 12 to 20 breaths/min; the respiratory rate is rapid with hypovolemic shock.

How should the nursing staff fulfill the nutritional needs of a client experiencing periods of extreme mania and hyperactivity? 1. Accepting that the client will eat when hungry 2. Allowing the client to prepare meals to eat when desired 3. Offering high-calorie snacks that the client can hold 4. Leaving food in the client's room that can be eaten when desired

3. Offering high-calorie snacks frequently that the client can hold Hyperactive clients burn up many calories, which must be replenished. Because such clients will not take the time to sit down to eat, providing them with food that they can carry sometimes helps. The client will probably not be aware of hunger and may go without food for a dangerously long time. The client is not capable of preparing food at this time. The client probably will not be aware of hunger and will not independently initiate eating.

A client is admitted to the hospital with a diagnosis or Crohn's disease. What is most important for the nurse to include in the teaching plan for this client? 1. Controlling constipation 2. Meeting nutritional needs 3. Preventing increased weakness 4. Anticipating a sexual alteration

3. Preventing increased weakness Explanation: To avoid gastrointestinal pain and diarrhea, these clients often refuse to eat and become malnourished. The consumption of a high-calorie, high-protein diet is advised. Diarrhea, not constipation, is a problem with Crohn's disease. Preventing an increase in weakness is a secondary concern that results from malnutrition; correcting the malnutrition will increase strength. Anticipating a sexual alteration generally is not a problem with Crohn's disease.

An older adult is being admitted to a nursing home with the diagnosis of dementia. The history reveals confusion, difficulty recognizing family members, and nighttime wandering. What should the nurse include in the client's plan of care? 1. Ordering a vest restraint for the client to be applied at night 2. Obtaining a prescription for a sedative so the client will sleep better at night 3. Requesting that the family provide a companion to stay with the client at night 4. Assigning the client to a room near the nurses' station for closer supervision at night

4. Assigning the client to a room near the nurses' station for closer supervision at night Explanation: It is the nurse's responsibility to ensure the safety of clients; close supervision can help ensure that the client does not wander. Restraints should not be used without a practitioner's order; a restraint is too excessive an intervention to prevent wandering. The issue is not that the client does not sleep; the issue is that the client wanders. It is the responsibility of the facility, specifically the nurse, to meet the needs of and ensure the safety of clients.

A client admitted for uncontrolled hypertension and chest pain was prescribed a low sodium diet and started on furosemide (Lasix). The nurse should instruct the client to include which foods in the diet? 1. Cabbage 2. Liver 3. Apples 4. Bananas

4. Bananas Explanation: Furosemide is a loop diuretic that eliminates potassium by preventing renal absorption. Bananas have a significant amount of potassium. Bananas: 450 mg; cabbage: 243 mg; liver: 73.6 mg; apples: 100-120 mg.

What should a nurse conclude that a client is doing when he makes up stories to fill in blank spaces of memory? 1. Lying 2. Denying 3. Rationalizing 4. Confabulating

4. Confabulating The individual is unaware of gaps in memory and therefore uses stories in an attempt to deny or cover up the gaps. Lying is a deliberate attempt to deceive rather than a face-saving device for loss of memory. Denying is a blocking out of conscious awareness rather than a cover-up for loss of memory. Rationalization is used to explain and justify the behavior rather than to cover up the loss of memory.

A newborn male is admitted to the nursery. He weighs 10 lb 2 oz, which is 2 lb more than the birthweight of any of his siblings. What should the nurse do in relation to the baby's weight? 1. Document the findings 2. Place him in a heated crib 3. Delay starting oral feedings 4. Perform serial glucose readings

4. Perform serial glucose readings Explanation: A large newborn may be the result of gestational diabetes; it is necessary to check the neonate for hypoglycemia because maternal glucose is no longer available. The nurse should do more than document the findings; the health care provider should be notified after the serial glucose readings are taken. Placing the infant in a heated crib is indicated if the temperature is low and the newborn needs additional warmth. The infant may be hypoglycemic and require the glucose in an oral feeding immediately.

Enoxaparin (Lovenox) 40 mg subcutaneously daily is prescribed for a client who had abdominal surgery. The nurse explains that the medication is given to: 1. Control expected postoperative fever 2. Provide a constant source of mild analgesia 3. Limit the inflammatory response associated with surgery 4. Provide prophylaxis against postoperative thrombus formation

4. Provide prophylaxis against postoperative thrombus formation Enoxaparin (Lovenox), a low-molecular-weight heparin, prevents the conversion of fibrinogen to fibrin and prothrombin to thrombin by enhancing the inhibitory effects of antithrombin III. Enoxaparin is not an antipyretic. Enoxaparin is not an analgesic. Enoxaparin is not an antiinflammatory drug.

While inspecting her newborn a mother asks the nurse why her baby has flat feet. Before responding, what information should the nurse consider? 1. Flat feet are common in children, requiring them to wear orthotic shoes. 2. The newborn's feet are so small that it is difficult to determine whether there is an arch. 3. Flat feet are associated with deformities of the bones of the feet such as clubfoot. 4. The arch of the newborn's foot is covered with a fat pad, giving the foot the appearance of being flat.

4. The arch of the newborn's foot is covered with a fat pad, giving the foot the appearance of being flat. Newborns and infants have fat pads where the arch should be; the arch develops when the toddler begins to walk. Flat feet are no more common in children than in adults. The size of the feet is not relevant. Flat feet are not associated with foot deformity.