• The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which
nursing intervention is appropriate for this child?
A) Make
... [Show More] certain the child is maintained in correct body alignment.
B) Be sure the traction weights touch the end of the bed.
C) Adjust the head and foot of the bed for the child's comfort
D) Release the traction for 15-20 minutes every 6 hours PRN. The correct answer is A: Make certain the child is maintained in correct body alignment.
• The nurse is assessing a healthy child at the 2 year check up.
Which of the following
should the nurse report immediately to the health care provider?
A) Height and weight percentiles vary widely
B) Growth pattern appears to have slowed
C) Recumbent and standing height are different
D) Short term weight changes are uneven
The correct answer is A: Height and weight percentiles vary widely
• The parents of a 2 year-old child report that he has been holding his breath whenever
he has temper tantrums. What is the best action by the nurse?
A) Teach the parents how to perform cardiopulmonary resuscitation
B) Recommend that the parents give in when he holds his breath to prevent anoxia
C) Advise the parents to ignore breath holding because breathing will begin as a reflex
D) Instruct the parents on how to reason with the child about possible harmful effects
The correct answer is C: Advise the parents to ignore breath holding because breathing
will begin as a reflex
• A nurse has just received a medication order which is not legible. Which statement best
reflects assertive communication?
A) "I cannot give this medication as it is written. I have no idea of what you mean."
B) "Would you please clarify what you have written so I am sure I am reading it
correctly?"
C) "I am having difficulty reading your handwriting. It would save me time if you would
be more careful."
D) "Please print in the future so I do not have to spend extra time attempting to read your
writing."
The correct answer is B) "Would you please clarify what you have written so I am sure I
am
reading it correctly?"
• The nurse is assessing a client in the emergency room. Which statement suggests that
the problem is acute angina?
A) "My pain is deep in my chest behind my sternum."
B) "When I sit up the pain gets worse."
C) "As I take a deep breath the pain gets worse."
D) "The pain is right here in my stomach area."
The correct answer is A: "My pain is deep in my chest behind my sternum."
.
• In evaluating the growth of a 12 month-old child, which of these findings would the
nurse expect to be present in the infant?
A) Increased 10% in height
B) 2 deciduous teeth
C) Tripled the birth weight
D) Head > chest circumference
The correct answer is C: Tripled the birth weight
• A Hispanic client in the postpartum period refuses the hospital food because it is
"cold." The best initial action by the nurse is to
A) Have the unlicensed assistive personnel (UAP) reheat the food if the client wishesB) Ask the client what foods are acceptable or bad
C) Encourage her to eat for healing and strength
D) Schedule the dietitian to meet with the client as soon as possible
The correct answer is B: Ask the client what foods are acceptable
• The father of an 8 month-old infant asks the nurse if his infant's vocalizations are
normal for his age. Which of the following would the nurse expect at this age?
A) Cooing
B) Imitation of sounds
C) Throaty sounds
D) Laughter
The correct answer is B: Imitation of Sounds
• The nurse is assessing the mental status of a client admitted with possible organic brain
disorder. Which of these questions will best assess the function of the client's recentmemory?
A) "Name the year." "What season is this?" (pause for answer after each question)
B) "Subtract 7 from 100 and then subtract 7 from that." (pause for answer) "Now
continue to subtract 7 from the new number."
C) "I am going to say the names of three things and I want you to repeat them after me:
blue, ball, pen."
D) "What is this on my wrist?" (point to your watch) Then ask, "What is the purpose of
it?"
The correct answer is C: "I am going to say the names of three things and I want you to
repeat them after me: blue, ball, pen." [Show Less]