TTS4

A nurse is assessing an 11-month-old- infant. Which of the following manifestations is associated with a CNS infection?

Bulging fontanel A CNS infection causes increased intracranial pressure. Therefore, a bulging fontanel is a manifestation of a CNS infection.

A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following characteristicsare expected findings of OCD? (Select all that apply.) A. Difficulty relaxing B. Irrational fear of certain objects C. Rule-conscious behavior D. Unaware of compulsions E. Perfectionist behavior

A. Difficulty relaxing C. Rule-conscious behavior E. Perfectionist behavior

A nurse is providing anticipatory guidance about child development to the parents of a preschooler. Which of the following developmental tasks should the nurse include as being expected of a preeschooler?

Participates in imaginary play By 5 years of age, a preschooler should participate in imaginary and creative play, play cooperatively with peers, and speak in complete sentences.

A nurse in an emergency department is caring for an adolescent following a suicide attempt. After reviewing the client's history, the nurse should determine which of the following is the priority risk factor for suicide completion.

Previous suicide attempt

A nurse is assessing an 8 month-old infant for cerebral palsy.Which of the following findings is a manifestation of the condition?

Sits with pillow props Infants who have cerebral palsy require support when sitting upright.

A nurse is reviewing the history and physicality of an adolescent client who has conduct disorder. Which of the following is an expected finding?

Suspended from school several times in the past year Conduct disorder is an impulse-control disorder which includes a long-term pattern of violating the rights of others and performing violent or hostile acts.

A nurse is teaching a school-age child who has type 1 diabetes mellitus and his parents about illness management. Which of the following instructions should the nurse include?

Test the urine for ketones The parent or child should test the urine for ketones and report the presence of them in the urine. Ketonuria can indicate that the child does not have enough glucose for energy and is breaking down fats to provide glucose to cells.

A nurse is providing teaching about self-administration of insulin to the parent of a school-age child who has a new diagnosis of diabetes mellitus. Which of the following statements by the parents indicates a need for further teaching a. "I will be sure my child aspirates before injecting insulin" b. "the insulin can be injected anywhere where there is adipose tissue" c. "I will be sure by child rotates sites after 5 injections in one area" d. "the insulin should be injected at a 90 degree angle"

"I will be sure my child aspirates before injecting the insulin." It is not necessary to aspirate before injecting the insulin.

A nurse is caring for a 7 year old child who has an upper respiratory infection and type 1 diabetes. Which of the following statements by the mother indicates a need for further teaching? a. "I will encourage her to drink a half cup of water or sugar free fluids every 30 minutes" b. "I will report a change in her breathing or signs of confusion" c. "I will notify the doctor if her temperature is not controlled with acetaminophen" d. "I will continue to check his blood sugar 2 times per day

"I will continue to check his blood sugar two times every day." A client who has type 1 diabetes mellitus and is ill is at risk of developing DKA. DKA results in the breakdown of body fat for energy and the presence of ketones in the blood and urine. Because acute illness increases glucose levels, the child's glucose levels and the urine ketones should be checked every 3 hr. Checking the child's blood glucose two times per day is not enough to adequately monitor glucose levels.

A nurse is leading a family therapy session for a mother, father, and two adolescent siblings. Which of the following statements should the nurse recognize as an example of effective communication among family members?

"Can you tell me the reason you get upset each time I go to the mall?" This is an example of effective or healthy communication. Healthy communication expresses clear, understandable messages between family members. Each family member is encouraged to express his or her own feelings and thoughts. The family member is asking the member who is perceived to be upset to express feelings openly. The communication is clear, understandable, and direct. This promotes an open exchange of feelings and thoughts.

A nurse is teaching the parents of a school-age child who had ADHD about atomoxetine. Which of the following instructions should the nurse include in the teaching?

"Give the dose in the morning to help prevent insomnia" Insomnia is a common adverse effect of atomoxetine. Administering the dose in the morning will help prevent this adverse effect.

A nurse is collecting data from a child who has autism spectrum disorder. Which of the following findings should the nurse expect?

-Delayed language development -Spins a toy repetitively -Ritualistic behavior

A nurse is caring for a 4 year old child who has a new diagnosis of diabetes mellitus and is distressed after an insulin injection. Which of the following play activities should the nurse recognize is therapeutic in helping the child deal with the injection?

A needleless syringe and a doll Playing with a needleless syringe and a doll is an appropriate therapeutic activity for the child, because they will allow the child to act out feelings of anger and helplessness.

A nurse is caring for a school-age child who has a history of conduct disorder. Which of the following actions should the nurse take? (Select all that apply.) A. Introduce some humor during interactions with the child. B. Explain to the child the need to pick up crayons when thrown on the floor. C. Shorten a reading activity when the child appears to become frustrated. D. Place the child in a vest restraint when disruptive behavior occurs. E. Redirect with physical activities when the child's disruptive behavior begins.

A. Introduce some humor during interactions with the child. B. Explain to the child the need to pick up crayons when thrown on the floor. C. Shorten a reading activity when the child appears to become frustrated. E. Redirect with physical activities when the child's disruptive behavior begins.

A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?

Administer antibiotics when available. The priority nursing action is to administer antibiotics when available. Bacterial meningitis is an acute inflammation of the meninges and the CNS. Antibiotic therapy has a marked effect on the course and prognosis of the illness.

A nurse is reviewing medications for a newly admitted client who has bipolar disorder and is experiencing mania. Which of the following client prescriptions should the nurse realize is expected to reduce the client's mania?

Carbamazepine Carbamazepine, an antiseizure medication and a mood stabilizer, is prescribed to treat and prevent mania in clients who have bipolar disorder.

A charge nurse is conducting a staff education in service about depressive disorders. Which of the following should the nurse identify as a risk factor for depression?

Chronic illness Having a medical illness, especially one that is chronic, is a primary risk factor for depression.

A nurse is caring for a child who is post operative following ventriculoperitoneal (VP) shunt placement. In which of the following positions should the nurse place the client?

D) On the unoperated side (The nurse should position the child flat on the on operated side to prevent a rapid reduction of intracranial fluid and to protect the child from injuring the operative site)

A nurse is performing a psychosocial assessment on an adolescent client. Which of the following should indicate to the nurse a potential risk for suicide? (Select all that apply.)

Death of a parent at a young age Recent or impending move Low parental expectations Sudden decline in school performance

A nurse is caring for a client who has autism spectrum disorder. Which of the following findings should the nurse expect?

Echolalia Echolalia is a fundamental sign of autism spectrum disorder and is manifested through thought patterns that are not based on reality.

A nurse is planning care for a 10 year old child who will be hospitalized for an extended period of time. Which of the following actions should the nurse include in the plan of care to meet the client's psychosocial needs according to Erkison?

Encourage the client to complete school work. Erikson's stage of psychosocial development for a 10-year-old child is industry vs. inferiority. By providing school-age children the opportunity to keep up with their school work, they can continue to develop skills and knowledge and maintain a sense of accomplishment.

A nurse in a special education program is planning care for a child who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan of care?

Establish a reward system for positive behavior. Children who have autism spectrum disorder benefit from a reward system for positive behavior.

A nurse is planning care for a 2-month-old infant following a surgical procedure. Which of the following pain rating scales should the nurse plan to use to determine the infant's level of pain?

FLACC scale The FLACC scale is used for children 2 months to 7 years. It uses facial expressions, leg movement, activity, cry, and consolability to assess the client's level of pain.

A nurse is assessing an adolescent who has an exacerbation of Grave's disease. What finding should the nurse expect?

Heat intolerance An exacerbation of Graves' disease can cause heat intolerance due to an increased metabolic rate, which leads to warm flushed moist skin and extreme diaphoresis.

A nurse is caring for a newly admitted client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first?

Identify precipitating factors for ritualistic behaviors. This is the priority intervention when taking the nursing process approach to client care.

A nurse is assessing a 3 month old infant. Which of the following findings should the nurse report to the provider?

Inability to raise head when in prone position A 3-month-old infant should be able to raise her head and shoulders from prone position; therefore, the nurse should report this finding to the provider.

A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse should teach the client that which of the following factors puts her at risk for lithium toxicity?

The client runs 4 miles outdoors every afternoon. Strenuous exercise in outdoor heat, which can lead to dehydration, puts the client at risk for lithium toxicity. Mild to moderate exercise will not lead to lithium toxicity, but if the client engages in strenuous exercise during hot weather, she should take care to replace any water and sodium that have been lost through profuse sweating. This also applies to other factors that can cause the client to become dehydrated, such as having diarrhea or taking diuretics.

A nurse is assessing a 15 month old toddler. Which of the following findings should the nurse report to the provider?

The toddler cannot stand upright without support. The nurse should expect a 15-month-old toddler to be able to stand upright without support. The nurse should report this finding to the provider as this can indicate a developmental delay.

A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? SATA

assess the clients airway patency remove objects from the clients bed place the client in a side lying position

A nurse is providing teaching to an adolescent who has type 1 diabetes. Which of the following should the nurse include? a. administer glucagon for hyperglycemia b. obtain an influenza vaccine yearly c. inject insulin in the deltoid muscle d. take glyburide with breakfast

b. obtain an influenza vaccine yearly

a nurse is caring for an adolescent who is experiencing indications of depression. which of the ff findings should the nurse expect? (select all that apply)

irritability Insomnia Chronic pain low self esteem

The nurse is making a home visit for a 16 year old who attempted suicide. which of the following behaviors should alert the nruse that the adolescent still has suicidal intent?

lanning to give his CD collection to his girlfriend. Warning signs of suicide include giving away possessions the person cherishes, talking about his own death, and describing himself as worthless.

A school nurse is speaking to the mother of a 16 year old male adolescent. The mother has concerns about her son. Which of the following statements by the mother should indicate to the nurse that the adolescent is at risk for suicide?

"His favorite teacher committed suicide a few weeks ago." Adolescents are at risk for a "copycat" suicide if a peer or a significant role model has recently committed suicide. Adolescents often act impulsively and can be easily frustrated. The fact that an admired person committed suicide is a stressor that could put the adolescent at risk for suicide.

A nurse is caring for an adolescent who has a history of violent behavior and has asked the nurse to keep confidential information about the desire to kill several classmates and a school teacher. Which of the following responses by the nurse is appropriate to give?

"I cannot promise that. I must share this information with other members of the team who are responsible for planning your care." The nurse should report issues that are potentially life-threatening to the treatment team. Although trust is the hallmark of the nurse-client relationship, confidentiality does not extend to these situations.

A nurse is caring for a child who has influenza. The nurse should identify that which of the following statements by the parent indicates the child has an increased risk for Reye syndrome?

"I give my child aspirin to reduce his fever" The administration of aspirin for fever associated with a viral illness increases the child's risk for Reye syndrome. Reye syndrome is a metabolic encephalopathy with manifestations of cerebral edema and fatty changes in the liver.

A nurse is providing teaching to a school age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates an understanding of the teaching?

"I should eat a snack half an hour before playing soccer." Exercise lowers blood glucose levels. The child should eat a snack half an hour prior to physical activity. If the exercise is prolonged, the child might require a snack during the activity.

A nurse is teaching a client who has depression about a new prescription for fluoxetine 20 mg daily. Which of the following statements by the client indicates understanding of the teaching?

"I should notify my provider if I develop a skin rash." Serious skin rashes, such as Stevens-Johnson syndrome, can occur while taking fluoxetine. The client should notify the provider if a rash occurs.

A nurse is providing discharge teaching to the parents of a child who has a new diagnosis of diabetes mellitus. Which of the following statements by the parents indicates an understanding of the teaching?

"My son might complain of feeling shaky when he has a low blood glucose level." A shaky feeling is a consistent finding of hypoglycemia.

A nurse is providing teaching to the parents of an adolescent who has a depressive disorder & a new prescription for trazodone. Which of the following information should the nurse include in the teaching?

"Trazodone can cause suicidal thoughts in adolescents." Trazodone includes a black box warning that it may cause suicidal ideation in children and adolescents.

A nurse is teaching a client who plans to take St. Johns wort to treat her depression. Which of the following information should the nurse include in the teaching?

"You may experience vivid dreams while taking St. John's wort." The nurse should include in the teaching that St. John's Wort can cause the client to have vivid dreams due to the CNS effects.

A nurse is caring for an adolescent client who has a new diagnosis of schizophrenia. The client's parents are tearful and express feelings of guilt. Which of the following statements should the nurse make?

"You said that you feel guilty about your daughter's diagnosis. Let's talk about what is causing you to feel this way." This statement is an example of clarification and promotes further discussion, which is a therapeutic communication technique.

A nurse is assessing an infant following a motor vehicle crash. Which of the following findings should the nurse monitor to identify increased intracranial pressure?

Increased sleeping Following a head injury, an infant's level of consciousness can deteriorate, show signs of excessive sleeping, and eventually go into a coma.

A nurse is caring for a client following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions is the nurse's priority?

Initiating suicide precautions Client safety is the nurse's priority. Therefore, the first action the nurse should take for this client is to initiate suicide precautions.

A nurse is assessing a school-age child whose blood glucose level is 280. Which of the following should the nurse expect?

Lethargy A blood glucose of 280 mg/dL is above the expected reference range indicating hyperglycemia. The nurse should expect the child to appear lethargic, leading to a decreased level of consciousness and confusion.

A nurse is caring for an adolescent client who has a conduct disorder. The client reports that she has received five speeding tickets in the past 6 months. Which of the following interventions should the nurse take?

Make a contract with the client not to drive over the speed limit. A behavior contract is appropriate to identify the expected behavior and consequences. The client, by signing the contract, assumes responsibility for her behavior.

A school nurse is assessing an adolescent who reports feeling shaky and is having difficulty speaking and concentrating on the questions the nurse is asking. The nurse checks the adolescent's blood glucose level and identifies a value of 55 mg/dL. Which of the following findings should the nurse expect?

Tachycardia A blood glucose level of 55 mg/dL is below the expected reference range and an adolescent with this blood glucose level is likely to have tachycardia due to increased circulating catecholamines and increased adrenergic activity.

A nurse is orienting a newly licensed nurse in the care of an infant who has myelomeningocele. Which of the following actions by the new nurse indicates the teaching has been effective?

Takes an axillary temperature Rectal temperatures should be avoided in infants who have spina bifida due to the risk for irritation and rectal prolapse.

A nurse is caring for a child who has Addison's disease. Which of the following actions should the nurse take?

Teach the parents about cortisol replacement therapy The nurse should plan to teach the child's parents about cortisol replacement therapy. Administration of glucocorticoids and mineralocorticoids is necessary because inadequate supplies or a sudden cessation of the medications can cause acute adrenal crisis.