A nurse needs to explain a procedure to an adolescent with the use of the analogy instructional method. Which of these actions should the nurse take?
... [Show More] Select all that apply.
Incorrect 1
Demonstrating the procedure to the client
Incorrect 2
Verbally explaining the procedure to the client
Incorrect 3
Posing a pertinent problem for the client to solve
Correct 4
Using images to describe the procedure to the client
Correct 5
Asking the client about previous experience with the procedure
*While using analog instruction method, the nurse should provide verbal instructions with familiar images that make complex information more real and understandable to the client. The nurse should follow the rule of knowing the client’s past experience. The nurse uses demonstration as an instructional method when teaching the adolescent client about psychomotor skills such as preparation of a syringe, bathing an infant, crutch walking, or taking a pulse. When using preparatory instruction as the instructional method, the nurse should verbally tell the client about the procedure. The nurse using the simulation instruction method should pose a pertinent problem for the client to solve.
Which assessment question is appropriate when collecting a developmental history for an adolescent who is new to the pediatric practice?
Correct 1
"What grades do you get in school?"
Incorrect 2
"Have your wisdom teeth erupted yet?"
3
"What was your approximate height at 4 years of age?"
4
"What was your approximate weight at 5 years of age?"
*While all of these assessment questions are appropriate, only the question regarding scholastic performance (grades in school) is a question that is appropriate for a developmental history. Asking questions regarding wisdom tooth eruption and approximate height and weight at 4 and 5 years of age respectively is more appropriate when collecting a growth history.
Which is likely to impact a child’s drawing near the end of the preschool stage of development? Select all that apply.
Culture
2
Disease
Environment
Incorrect 4
Physical growth
Incorrect 5
Hand dominance
*Culture and environment are thought to impact a child’s drawing near the end of the preschool stage of development as all drawings tend to look the same until the end of this stage. Disease, physical growth, and hand dominance are not thought to impact a child’s drawing.
A preterm newborn appears to have a strong sucking reflex. How should the nurse plan to feed the infant to prevent respiratory compromise?
1
Through a nasogastric feeding tube
2
Every 2 to 3 hours with diluted formula
3
Every 4 to 6 hours with a special nipple
Correct 4
With small amounts of breast milk at each feeding
*Feeding small amts of breast milk at each feeding prevents the neonate’s stomach from becoming too distended and pressing upward against possibly compromised lungs. A nasogastric feeding tube will not prevent respiratory embarrassment. The infant with a strong sucking reflex should be fed with a nipple; otherwise the sucking reflex will diminish. Four to 6 hours is too long between feedings; a preterm infant should be fed every 2 to 3 hours because it takes this long for the preterm infant’s stomach to empty. Preterm infants need the full caloric value of breast milk with fortification.
The nurse is assisting the primary healthcare provider during a renal ultrasonography. Arrange the steps involved in the procedure in correct sequence.
1. Place client in prone position
2. Apply gel over skin
3. Move transducer across skin
4. Wipe cotton pad over gel
*The client undergoing renal ultrasonography should first be placed in the prone position. Then the sonographic gel should be applied on the client’s skin over the back and flank regions. Then the transducer is moved across the client’s skin to measure the echoes. The images are visualized on the display screen. At the end of the procedure the gel is removed from the client’s skin by using a piece of wet cotton or cloth over the gel.
An adolescent is found to have type 1 diabetes. The nurse plans to teach the adolescent that dietary control and exercise can help regulate the disorder. What additional information should the nurse include in the teaching plan? Select all that apply.
Correct 1
Insulin therapy
2
Prophylactic antibiotics
Correct 3
Blood glucose monitoring
4
Oral hypoglycemic agents
Correct 5
Adherence to the treatment regimen
*Because clients with type 1 DM have little or no endogenous insulin, they must take insulin. Blood glucose monitoring is an important aspect of therapy because it aids evaluation of the effectiveness of diabetic control. Dietary control and exercise reduce the amount of exogenous insulin needed. Although adhering to the diabetic regimen is difficult, especially for adolescents who need to identify with their peers, its importance in promoting euglycemia should be discussed. Although infection increases insulin requirements, prophylactic antibiotics are not needed. Oral hypoglycemic are ineffective in stimulating insulin secretion in clients with type 1DM.
A nurse is reinforcing previous learning about cystic fibrosis and its treatment with a 9-year-old child. What is the most suitable information for a child of this age?
1
"The postural drainage will help you feel better."
2
"The dietitian says this meal schedule is best for you."
Correct 3
"Your mucus is thick because of the way your mucous glands work."
4
"You have to take your medicine with meals because that's how it was prescribed."
*Explaining why the mucus is thick explains what is happening in terms that the child can understand. Telling the child that postural drainage will make the child feel better is too general and does not explain why the child will feel better. Tell the child that the dietitian says that a particular meal schedule is best is too authoritarian; the child needs information that will increase comprehension of the regimen. Telling the child that the medicine must be taken with meals because that is what has been prescribed is too authoritarian; the child is old enough to understand information that will increase the likelihood of adherence to the regimen.
The parents of a toddler with a right ventriculoperitoneal (VP) shunt for the treatment of hydrocephalus are taught about postoperative positioning. The nurse concludes that they understand the teaching when they state that they will place the infant in what position?
1
In the position that provides the most comfort
2
On the back with a small support beneath the neck
3
On the abdomen with the head turned to the left side
Correct 4
Flat on the left side with the head and back supported
*The side-lying position on the unaffected side and the use of supports to help prevent pressure on the shunt; the horizontal position prevents too-rapid drainage of cerebrospinal fluid. Basing the infant’s placement in the immediate postoperative period solely on comfort is unsafe. Neck supports should not be used for infants because they flex the neck, which can cause airway occlusion. The prone position is contraindicated; turning the head to the side puts pressure on the shunt.
A client is scheduled to receive general anesthesia during an upcoming surgery. The nurse provides education about common side effects of general anesthesia. The nurse concludes that the teaching has been effective when the client has which response?
1
"I may have an elevated temperature."
2
"I may have paroxysmal hiccoughs."
3
"I may have transient headaches."
Correct 4
"I may have a sore throat."
*A general anesthetic is delivered via an endotracheal tube that irritates the posterior pharynx and larynx, producing a sore throat. Elevated temperature, hiccoughs, and transient headaches are systemic effects and are not side effects of general anesthesia.
A nurse is assessing a client at 16 weeks' gestation. Where does the nurse expect the fundal height to be located?
1
Above the umbilicus
2
At the level of the umbilicus
Correct 3
Half the distance to the umbilicus
4
Slightly above the symphysis pubis
*Considering the growth of the fetus, this is the expected height of the fundus at 16 weeks’ gestation. The height of the fundus in centimeters is approximately the same as the number of weeks of gestation if the woman’s bladder is empty at the time of measurement. Above the umbilicus is where the fundus should be palpated from after 24 weeks’ gestation until term. At the level of the umbilicus is where the fundus should be palpated at 22 to 24 weeks’ gestation. Between 12 and 14 weeks’ gestation, the uterus outgrows the pelvic cavity and can be palpated just above the symphysis pubis.
After a long history of recurrent thrombophlebitis with extensive varicose veins of the lower extremities, surgical intervention is suggested to the client. When asked about the procedure, what should the nurse explain that this surgery involves?
Correct 1
Removing the dilated superficial veins
Incorrect 2
Bypassing the varicosities with artificial veins
3
Stripping the cholesterol deposits from the veins
4
Creating fistulas between superficial and deep veins
*The saphenous vein is ligated at its juncture with the femoral vein; injection sclerotherapy is used as the method of choice, but in chronic venous insufficiency and recurrent thrombophlebitis, surgery may be necessary. A bypass is unnecessary; the deep veins compensate for the removed saphenous vein. Cholesterol plaques are characteristic of atherosclerosis, an arterial, no venous disease. Communicating veins normally exist between the superficial and deep veins; they are ligated to prevent further engorgement and varicosities.
Which organism would the nurse explain is consistent with a protozoal infection in clients with acquired immunodeficiency syndrome (AIDS)?
1
Candidiasis
2
Tuberculosis
3
Cryptococcosis
Correct 4
Toxoplasmosis
*Toxoplasmosis is a protozoal infection in the AIDS client and an AIDS-defining condition in adults. Candidiasis is an indication of fungal infection. Tuberculosis is a bacterial infection. Cryptococcosis is a fungal infection.
A child is admitted to the pediatric intensive care unit with acute bacterial meningitis. What is the nurse's priority intervention?
1
Offering clear fluids whenever the child is awake
Correct2
Checking the child's level of consciousness hourly
3
Assessing the child's blood pressure every four hours
Incorrect4
Administering the prescribed oral antibiotic medication
*Checking the level of consciousness is part of a total neurological check. it can reveal increasing ICP, which may occur as a result of cerebral inflammation. the child is too ill to ingest anything by mouth; also, vomiting is likely. hydration is maintained intravenously. taking the blood pressure and other vital signs every four hrs is insufficient monitoring; many changes can occur in this time span. intravenous antibiotics have a rapid system effect and are preferable to those administered by way of the oral route.
Which condition may a 4-year-old child develop due to a failure in mastering sensorimotor integration?
1
Obesity
Incorrect2
Dyslalia
3
Sleep disturbance
Correct4
Developmental stuttering
*A failure in mastering sensorimotor integration may lead to stammering, which is also called developmental stuttering. Exposure to domestic violence may cause obesity in school-age children. Dyslalia may develop in children who are pressured into producing sounds ahead of their developmental level. Sleep disturbance is a common problem during preschool years.
The nurse is assessing the newborn in the first hour after birth. Which findings does the nurse identify as normal for the newborn? Select all that apply.
1
The newborn has a flat abdomen.
Correct2
The newborn weighs 6 lbs (2,700 g).
Correct3
The newborn’s hands and feet appear cyanosed.
4
The newborn does not blink in the presence of light.
Correct5
The circumference of the head is 33 cm (13 in).
*The average newborn weighs 6 to 9 lbs (2700 to 4000 g). The hands and feet of the newborn are usually cyanosed during the first 24 hours after birth. The average newborn has a head circumference of 33 to 35 cm (13 to 14 inches). Newborns generally have protuberant (NOT FLAT) abdomens. Newborns exhibit a blinking reflex when light is directed toward the eye.
The nurse plans to perform an abdominal assessment of a 10-year-old child with suspected appendicitis. List in order of priority the techniques the nurse should use when assessing this child's abdomen.
1. Asking where it hurts
2. Visually examining the abdomen
3. Warming of the Stethoscope’s diaphragm
4. Auscultating for bowel sounds
5. Assessing the abdomen by touch
*Asking the child where it hurts is the first step of the assessment; the answer may influence the subsequent assessment. Inspection is the second part of the assessment; it involves observing the contour and symmetry of the abdomen. Warming the stethoscope’s diaphragm before auscultation will help prevent tightening of the abdominal muscles. Auscultation is the next part of the assessment; it involves listening for bowel sounds and recording them as present, hypoactive, hyperactive, or absent; it must be done before palpation because touching the abdomen may alter the bowel sounds. Palpation is the final component of an abdominal assessment.
A client sustains a crushing injury to the lower left leg, and a below-the-knee amputation is performed. For which common clinical manifestations of a pulmonary embolus should the nurse assess this client? Select all that apply.
Correct1
Sharp chest pain
Correct2
Acute onset of dyspnea
3
Pain in the residual limb
4
Absence of the popliteal pulse
5
Blanching of the affected extremity
*Emboli can occur with crushing injuries of the extremities. Lodging of a thrombus in the pulmonary system results in a lack of oxygen to pulmonary tissues, causing localized sharp chest pain. Lodging of a thrombus in the pulmonary system will result in decreased breath sounds and dyspnea. Pain in the residual limb is related not to a pulmonary embolus but to severed nerve endings in the residual limb. A pulmonary embolus will not interfere with arterial circulation to a distal portion of an extremity. Blaching of the affected extremity is associated with interference with arterial circulation to an extremity.
A registered nurse is teaching a nursing student about skin assessment. Which statement made by the nursing student indicates the need for further teaching?
1
"Skin assessments are best performed in daylight."
2
"Skin assessments performed at cool room temperatures can result in cyanosis."
3
"Skin assessment performed at warm room temperatures can result in vasodilatation."
Correct4
"In the absence of sunlight, skin assessments are performed best with other sources of light instead of fluorescent light."
*Though skin assessments are best conducted in daylight, in the absence of sunlight, they are best performed in fluorescent lighting. Skin exposure during skin assessments in cool room temperature can result in cyanosis. Skin exposure during assessments made in warm room temperature can result in vasodilation.
The nurse is providing care to a 6-week-old infant who is hospitalized for poor growth. The infant is currently being breastfed and is diagnosed with failure to thrive (FTT). Which is the priority nursing assessment for this infant?
1
Family financial difficulties
Correct2
Uncoordinated suck and swallow
3
Neglect and abuse by the parents
4
Knowledge deficit related to nutritional intake
*Most cases of poor growth and FTT in the first two months of life occur due to an uncoordinated suck and swallow during feedings (formula or breast); therefore, this is the priority nursing assessment. Assessing for financial
difficulties, neglect and abuse, and a knowledge deficit are appropriate but not the priority in this situation.
An infant is admitted to the nursery after a difficult shoulder dystocia vaginal birth. Which condition should the nurse carefully assess this newborn for?
1
Facial paralysis
2
Cephalhematoma
Correct3
Brachial plexus injury
4
Spinal cord syndrome
*Brachial plexus paralysis (Erb-Duchene palsy) is the most common injury associated with dystocia related to a shoulder presentation; it is caused by pressure and traction on the brachial plexus during the birth process. The newborn’s face is not involved with a shoulder presentation. Cephalhematoma is a soft-tissue injury of the head and is not related to shoulder dystocia. Spinal cord syndrome is associated with a breech presentation and is not related to shoulder dystocia.
An infant in the newborn nursery has cyanosis of the hands and feet and circumoral pallor when crying. In light of these assessment findings, which actions should the nurse consider taking next?
1
Taking no specific action, because both signs are expected in a newborn until 2 weeks of age
Correct2
Notifying the health care provider, because circumoral pallor may signal a cardiac problem
3
Taking no specific action, because circumoral pallor is a common finding for the first 72 to 96 hours
4
Notifying the health care provider, because cyanosis usually accompanies increased intracranial pressure
An infant in the newborn nursery has cyanosis of the hands and feet and circumoral pallor when crying. In light of these assessment findings, which actions should the nurse consider taking next?
1
Taking no specific action, because both signs are expected in a newborn until 2 weeks of age
Correct2
Notifying the health care provider, because circumoral pallor may signal a cardiac problem
3
Taking no specific action, because circumoral pallor is a common finding for the first 72 to 96 hours
4
Notifying the health care provider, because cyanosis usually accompanies increased intracranial pressure
*Cardiac pathology can be detected at an early age, and circumoral pallor may be a sign. Circumoral pallor is not expected in a healthy newborn, or in a person of any age. Cyanosis does not indicate increased ICP.
Menarche is the central event of puberty in females, indicating the new possibility for fertilization. When does menarche occur in young girls?
1
Six months after ovulation
Correct2
24 months after the beginning of the development of breasts
3
Six months after attaining peak weight velocity
Incorrect4
12 months after attaining peak height velocity
*Menarche in girls occurs 2 yrs after the appearance of breast buds, which indicates the start of breast development. Ovulation does not occur before menarche but occurs 6 to 14 months after menarche. Menarche occurs after attainment of 3 months of peak weight velocity and 9 months of peak height velocity.
Which of these thoughts in an individual correspond to the society-maintaining orientation stage? Select all that apply.
Correct1
"I should avoid parties where alcohol is served."
Correct2
"I should avoid risky driving and follow traffic rules."
3
"I should follow the rules or the teacher will punish me."
4
"I have to follow all state and federal laws."
5
"I should complete my homework so that the teacher will reward me."
*During the society-maintaining orientation stage, an individual’s thoughts are influenced by moral values and societal concerns. These individuals would avoid going to parties where alcohol is served, avoid risky driving, and follow traffic rules in order to be a good member of society. When an individual thinks that breaking the rule will lead to a physical punishment, this though corresponds to the punishment and obedience orientation stage. Under this stage, an individual’s moral dilemma is in terms of absolute obedience to authority and rules. When an individual thinks that he/she should follow all the laws formulated by the government, this thought corresponds to the universal ethical principle orientation. When an individual thinks that completing his/her homework will help win a reward, this thought corresponds to the good boy-nice girl orientation.
While completing an assessment, the nurse finds that a client has decreased thickness and excessive dryness of the epidermis. Which clinical finding is associated with this skin assessment?
1
Skin tears
2
Skin cancer
Correct3
Skin fragility
4
Skin hyperplasia
*The nurse may assess excessive skin dryness due to decreased epidermal thickness. It is associated with skin transparency and fragility. Skin tears may occur due to the flattening of the dermal-epidermal junction. Decreased mitotic homeostasis in the epidermis may cause skin cancer. Skin hyperplasia may occur due to sun-induced changes that cause a decrease in mitotic homeostasis.
The nurse is developing a care plan for a client with postpartum psychosis. Which priority intervention should the nurse implement?
1
Teaching the client about normal newborn care
2
Ensuring adequate bonding time with the infant
3
Giving the client time and space to express her feelings
Correct4
Referring the client to a psychiatric healthcare provider as prescribed
*Assessment and management of postpartum psychosis are beyond the scope of a maternity nurse. A mother who experiences this condition must be referred to a specialist for comprehensive therapy. Women with signs of postpartum psychosis need immediate medical attention to prevent suicide or infanticide. In light of this psychiatric emergency condition it would not be appropriate to plan bonding time for the client and infant, teach her about normal newborn care, or allow expression of her feelings.
A nurse is assessing an infant with suspected developmental dysplasia of the hip. What does the nurse expect the infant's orthopedic status to reveal?
Correct1
Apparent shortening of one leg
2
Limited ability to adduct the affected leg
3
Narrowing of the perineum with an anal stricture
4
Inability to palpate movement of the femoral head
*The affected leg appears to be shorter because the femoral head is displaced upward. The infant’s ability to abduct, NOT ADDUCT, the affected leg is affected. An anal stricture is not expected with developmental dysplasia of the hip. When the femoral head slips out of the acetabulum, it is easily palpable. Movement of the femoral head is NOT palpable in infants without this disorder.
Which concern may be specifically seen in middle adolescents?
1
Growth and development
2
Violence within social environment
3
School performance and future career
Correct4
Physical appearance and peer group acceptance
*Middle adolescents tend to have health-related concerns regarding physical appearance, peer-group acceptance, and relationship with friends. Young adolescents will be undergoing physical changes of puberty, so their concern will be mostly on growth and development. All adolescents experience issues with violence within their social environment. Older adolescents are mostly concerned with their school performances and future careers.
The nurse is caring for a client with a distal femoral shaft fracture. For which clinical indicator unique to a fat embolus should the nurse assess the client?
1
Oliguria
2
Dyspnea
Correct3
Petechiae
4
Confusion
*At the time of fracture or orthopedic surgery, fat globules may move from bone marrow into the bloodstream; also, increased catecholamines cause mobilization of fatty acids and the development of fat globules. In addition to obstructing vessels in the lung, brain, and kidneys with systemic embolization from fat globules, petechiae are noted in buccal membranes, conjunctival sacs, hard palate, chest, and anterior axillary folds; these indicators occur only with fat embolism. Oliguria is a clinical finding of an embolus but is not specific to a fat embolus. Dyspnea is not a clinical manifestation of a fat embolus, but an embolus. Confusion is a clinical manifestation of an embolus but is not specific to a fat embolus.
An adolescent who works out 6 hours a day reports not eating well, weight loss, and an absence of menses for the past few months. Which nursing intervention is most appropriate?
1
Ask the adolescent to stop exercising for a few days.
2
Talk to the client to find out any reasons for stress.
3
Perform a β-human chorionic gonadotropin pregnancy test.
Correct4
Modify the adolescent’s diet to incorporate more nutrients.
*If an athletic adolescent experiences symptoms of eating disorders, weight loss, and an absence of menses indicating female athlete triad syndrome, then her diet should be modified to incorporate more nutrients. Asking the adolescent to stop exercising for a few days would not solve the problem. Stress does not cause amenorrhea. Being an athlete and having eating disorders rules out the chances for becoming pregnant.
What is the nurse’s priority action when caring for a child with acute laryngotracheobronchitis?
1
Initiating measures to reduce fever
2
Ensuring delivery of humidified oxygen
3
Providing support to reduce apprehension
Correct4
Continually assessing the respiratory status
*Laryngeal spasms can occur abruptly; patency of the airway is ensured with constant assessments for signs of respiratory distress. Reducing fever, delivering humidified oxygen, and providing emotional support to the child are all important, but none is the priority.
A male adolescent going through puberty worries about breast enlargement. Which nursing interventions would benefit the adolescent? Select all that apply.
1
Suggest that the client consider plastic surgery
Correct2
Suggest that the client gets a medical evaluation
Correct3
Advise the adolescent to talk to his peers
Incorrect4
Anticipate a prescription for testosterone
Correct5
Assure the adolescent that the situation is temporary and benign
*A careful medical evaluation is recommended to rule out pathological conditions. The adolescent may benefit from talking to his peers and being assured that the situation is temporary and benign. Plastic surgery is recommended only if the situation persists. Testosterone has no effect on breast development or regression.
A 4-month-old infant is brought to the emergency department after 2 days of diarrhea. The infant is listless and has sunken eyeballs, a depressed anterior fontanel, and poor tissue turgor. The infant’s breathing is deep, rapid, and unlabored. The mother states that the infant has had liquid stools and no obvious urine output. What problem does the nurse conclude that the infant is experiencing?
1
Kidney failure
2
Mild dehydration
Correct3
Metabolic acidosis
4
Respiratory alkalosis
*Metabolic acidosis occurs with loss of alkaline fluid through diarrhea and is manifested by lethargy and Kussmaul breathing; all of the assessments indicate severe dehydration. The infant has not urinated because of excessive amounts of fluid have been lost in the loose stools; this indicates that the kidneys are functioning by compensating for the fluid loss. All data indicate a severe, not mild, fluid volume deficiency. Respiratory alkalosis is caused by an excessive loss of carbon dioxide, not diarrhea. [Show Less]