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mock final

Terms in this set (328)

The nurse is discussing the differences between a patient with a neurosis and one with a psychosis. What is true of the patient experiencing a neurosis?

The patient experiences a flight from reality.
The patient usually needs hospitalization.
The patient has insight that there is an emotional problem.
The patient has severe personality deterioration.
The patient has insight that there is an emotional problem.
When the patient with a psychosis is thought to be a danger to self or others, by what method should the patient be admitted to the hospital?

Probating
Family request
nurses request
health care providers order
family request
probating
What is the prognosis for a schizophrenic patient who is exhibiting positive behaviors?
a. Guarded
b. Poor
c. Good
d. Repeatable
good
The nurse asks a patient with schizophrenia if he had any visitors on Sunday. Which response indicates loose association?
"no"
"yes! I had 90 visitors who came from every state in the union!"
"sunday is the sabbath. Do we have visitors on the sabbath?"
"we visited yellowstone park last summer."
"we visited yellowstone park last summer:
The nurse is caring for a patient with a diagnosis of catatonic schizophrenia. What behavior is consistent with this diagnosis?
Talks excitedly about going home.
Suspiciously watches the staff.
Stands on one foot for 15 minutes.
States he has a cat under his bed that talks to him.
Stands on one foot for 15 minutes.
The home health nurse assesses a patient who creates elaborate excuses for not leaving home. Further questioning reveals the patient had not left home for 6 months. How should this be documented?
a. Mania
b. Depression
c. Agoraphobia
d. Anxiety
c. Agoraphobia
The patient complains of recurrent, multiple physical ailments for which there is no organic cause. How should the nurse assess this?
Obsessive-compulsive disorder
Phobia anxiety disorder
Somatic symptom disorder
Delusional disorder
Somatic symptom disorder
The nurse assesses an alcoholic patient carefully for signs of withdrawal. How soon after cessation of alcohol intake do withdrawal symptoms usually appear?
3 hours
4 hours
5 hours
6 hours
6 hours
What severe side effect will occur if an alcoholic patient consumes alcohol while taking disulfiram (Antabuse)?
a. Nausea
b. Blackouts
c. Headaches
d. Hypertension
nausea
What nursing intervention should be included in the plan of care for a baby born to a drug-addicted mother?
Swaddle the baby closely.
Place the baby in a brightly lit area.
Hold and rock the baby frequently.
Place the baby in a busy part of the nursery for stimulation.
Swaddle the baby closely.
Which question is likely to elicit the most valid response from the patient who is being interviewed about a neurologic problem?
"Do you have any sensations of pins and needles in your feet?"
"Does the pain radiate from your back into your legs?"
"Can you describe the sensations you are having?"
"Do you ever have any nausea or dizziness?"
"Can you describe the sensations you are having?"
A frantic family member is distressed about the flaccid paralysis of her son following a spinal cord injury several hours ago. What does the nurse know about this condition?
It is an ominous indicator of permanent paralysis.
It is possibly a temporary condition and will clear.
It degenerates into a spastic paralysis.
It will progress up the cord to cause seizures.
It is possibly a temporary condition and will clear.
The nurse is aware that the characteristic gait of the person with Parkinson disease is a propulsive gait, which causes the patient to:
stagger and need support of a walker.
shuffle with arms flexed.
fall over to one wide when walking.
take small steps balanced on the toes.
shuffle with arms flexed.
A patient is in which stage of Alzheimer's disease when she demonstrates "sundowning"?
Early stage
Second stage
Third stage
Final stage
Second stage
Why is the patient with suspected Guillain-Barre Syndrome (GBS) hospitalized immediately?
The infection needs to be treated with IV antibiotics to prevent paralysis.
The brain may swell quickly causing seizures.
The disease can rapidly progress into respiratory failure.
IV hydration is needed to prevent possible fatal hypotension.
The disease can rapidly progress into respiratory failure.
The nurse explains that the two divisions of the autonomic nervous system work to maintain homeostasis. Which is the first autonomic event?
Parasympathetic nervous system dominates
Extremely stressful or frightening event
Blood pressure, heart rate, and adrenaline output decrease
Sympathetic nervous system dominates
Heart rate and blood pressure rise, secretion of adrenaline
Extremely stressful or frightening event
What are the three signs of Cushing response? (Select all that apply.)
Increased pulse rate
Increased blood pressure
Widened pulse pressure
Bradycardia
Increased systolic blood pressure
Uncontrolled thermoregulation
Widened pulse pressure
Bradycardia
Increased systolic blood pressure
When should family members of a stroke victim expect to see some of the neurologic involvement disappear?
Within 2 to 3 weeks
Within 1 to 2 months
Within 3 to 6 months
Within 6 to 9 months
Within 3 to 6 months
What is the most common cause of dementia?
Multi infarct
Medications
Alzheimer's disease
Parkinson disease
Alzheimer's disease
Which symptom of diabetes distorts tactile sensation?
Proprioception
Loss of visual acuity
Progressive paresis
Peripheral neuropathy
Peripheral neuropathy
What is one positive aspect of Parkinson disease?
The disease does not alter ability to communicate.
Anti-Parkinson drugs have few side effects.
Intellectual function is not impaired.
Involuntary movements can be controlled.
Intellectual function is not impaired.
What is the mental health nurse referring to when using the term behavior?
An isolated incident
The manner in which a person performs
A product of a coping strategy
Failure to adapt
The manner in which a person performs
How many people in the United States will develop a mental disorder during their lifetime?
One in two
One in five
One in eight
One in ten
One in two
During the 17th and 18th centuries, care of patients with mental illness often was cruel. What type of care was used by Dr. Philippe Pinel to bring about change?
Personal care
Individual care
Behavior care
Humane care
Humane care
Which theorist believed that personality development was based on task mastery?
Sigmund Freud
Erik Erikson
Jean Piaget
Friedrich Nietzsche
Erik Erikson
What does any event that requires change stimulate?
a. Anger
b. Depression
c. Stress
d. Anxiety
stress
What action by a student before taking a test should indicate to a nursing instructor that the student is demonstrating signs of moderate anxiety?
Studies for 6 hours
Sleeps 6 hours because of fatigue
Vomits
Argues about the scheduling of the test
Vomits
A 40-year-old patient cries and has a tantrum when the health care provider refuses to give her a prescription for diet pills. The nurse realizes that this is the use of which defense mechanism?
a. Compensation
b. Denial
c. Regression
d. Repression
c. Regression
When assisting the older adult who is despondent about the need to leave his home, what technique should the nurse use?
Ask him if he has a drinking problem.
Explore the option of his moving in with someone.
Reminisce with the patient and review his life.
Assess for hopelessness and helplessness.
Reminisce with the patient and review his life.
Why is it important for the nurse to be observant of patient behavior?
Behavior is preformed.
Behavior is important.
Behavior is learned.
Behavior is repeated.
Behavior is learned.
During the final weeks of pregnancy, urinary frequency may return due to the enlarged uterus, compressing the bladder against the pelvic bones. What does the nurse suggest to aid in relieving the urinary frequency?
Decrease fluid intake.
Use the knee-chest position.
Sleep on her side.
Avoid fluid intake in evening.
Sleep on her side.
When can the sex of the fetus be confirmed?
Conception
2 weeks
6 weeks
9 weeks
9 weeks
What do the arteries in the umbilical cord carry?
Nutrients to the fetus from the placenta
Oxygenated blood to perfuse the placenta
Antibodies from the fetus to the mother
Deoxygenated blood back to the placenta
Deoxygenated blood back to the placenta
What does the increase in circulating blood volume during pregnancy cause in the mother?
Shortness of breath
Frontal headaches
Decreased white blood cell count
Decreased hemoglobin
Decreased hemoglobin
At what week of fetal development can the nurse expect to first hear fetal heart tones with an amplified stethoscope?
a. 10
b. 12
c. 14
d. 16
16
What area of the uterus provides the force during a contraction?
a. Lower portion
b. Middle portion
c. Upper portion
d. Cervical portion
c. Upper portion
What is the largest diameter of the fetal skull?
a. Temporal
b. Biparietal
c. Lateral
d. Frontal-occipital
b. Biparietal
What is the ideal attitude for the fetal body during labor?
a. Extension
b. Lateral
c. Flexion
d. Transverse
c. Flexion
During the second stage of labor, how often should the nurse should monitor the fetal heart rate?
Every 5 minutes
Every 15 minutes
Every 30 minutes
Every hour
Every 5 minutes
When observing the fetal heart monitor, the nurse recognizes the fetal heart rate (FHR) decreases to 120 beats/min at the beginning of a contraction and returns to a baseline of 155 beats/min at the end of the contraction. What should this indicate to the nurse?
Early deceleration due to head compression
That the fetus is in acute distress
Variable decelerations due to cord compression
That these are late decelerations
Early deceleration due to head compression
A woman is admitted in active labor, and the nurse assesses the fetal heart rate (FHR) at 124 beats/min. What action should the nurse take based on the assessment?
Position patient on her left side.
Start oxygen per nasal cannula.
Reassure the mother the rate is normal.
Notify the health care provider at once.
Reassure the mother the rate is normal.
A patient arrives at the hospital having contractions. How should the nurse determine that the patient is in true labor?
There is no dilation.
The contractions are in the fundus.
The cervix has softened and effaced.
The contractions are irregular.
The cervix has softened and effaced.
The nurse is alarmed as she assesses a protruding umbilical cord from the vagina. What immediate action should the nurse take?
Monitor intensity of contractions.
Place the patient in the knee-chest position.
Notify the charge nurse.
Ask the patient to perform a Valsalva's maneuver.
Place the patient in the knee-chest position.
A mother is in early labor and asks the nurse how long the labor will last. The nurse explains that the first stage of labor lasts from the beginning of regular contractions until when?
The cervix is completely effaced.
The baby is in position.
The cervix is fully dilated.
The woman begins pushing.
The cervix is fully dilated.
A primigravida patient is admitted to the labor and delivery unit. During initial assessment, the baby is found to be engaged. Which statement is true?
The narrowest diameter of the presenting part has reached the pelvic outlet.
The descending part is being initiated through the midpelvis.
The widest diameter of the presenting part crosses the pelvic inlet.
The narrowest diameter of the presenting part is at the ischial spines.
The widest diameter of the presenting part crosses the pelvic inlet.
Why is oxytocin administered in the third stage of labor?
To stimulate lactation
To relieve postpartum pain
To stimulate uterine contractions
To sedate the mother so she can rest
To stimulate uterine contractions
An infant presents 5 minutes after delivery with a heart rate of 105, is crying, has some flexion in the arms, sneezes, and has a pink body and blue limbs. What Apgar score should be assigned to this infant?
a. 5
b. 7
c. 8
d. 10
8
When the nurse performs the Nitrazine test on vaginal secretions of a patient who thinks her membranes have ruptured, the paper turns yellow. What does this finding indicate?
Acidic discharge, membranes intact
Acidic discharge, membranes have ruptured
Neutral, not enough discharge to measure
Alkaline, membranes have ruptured
Acidic discharge, membranes intact
The postpartum mother with a third degree laceration tells the nurse she is afraid to have a bowel movement because of her painful episiotomy. What should the nurse do?
Offer a suppository or enema.
Encourage ambulation.
Offer stool softeners as prescribed.
Offer pain medication before defecating.
Offer stool softeners as prescribed.
The nurse identifies that the newborn is jaundiced within the first 24 hours of birth, with jaundice occurring over bony prominences of the face and the mucous membrane. What type of jaundice does this represent?
a. Physiologic
b. Normal
c. Pathologic
d. Transitory
c. Pathologic
Which tests are performed to detect inborn errors of metabolism in the newborn?
Blood glucose
Phenylketonuria (PKU)
Blood urea nitrogen (BUN)
Prothrombin time (PT)
Phenylketonuria (PKU)
What should be included when discussing the care of a circumcised infant after discharge from the hospital?
Gently remove the yellow exudate from the foreskin.
Apply sterile petroleum gauze after each diaper change.
Wipe the circumcision with alcohol each day.
Avoid the use of cloth diapers until the foreskin has healed.
Apply sterile petroleum gauze after each diaper change.
Which finding should the nurse suspect as abnormal in the newborn during the initial assessment?
Eyes crossed at times
Persistent high-pitched cry
Arms and legs flexed
Slight bluish tinge of the extremities
Persistent high-pitched cry
A patient is admitted to the hospital with hyperemesis gravidarum. The patient is malnourished and severely dehydrated. The care plan should be altered to include which interventions?
Hyperalimentation
IV fluids and electrolyte replacement
Hormone replacement therapy
Vitamin supplements
IV fluids and electrolyte replacement
What complication of delivery should the nurse expect with the birth of multiple fetuses?
An ectopic tendency
Difficulty with breast-feeding
A vaginal delivery
Loss of uterine tone
Loss of uterine tone
What percent of first-trimester pregnancies spontaneously abort?
5% to 10%
10% to15%
20% to 25%
40% to 50%
10% to15%
A patient in her second trimester of pregnancy arrives at the hospital complaining of bright red, painless vaginal bleeding. What condition should the nurse immediately suspect?
Abruptio placentae
Hemorrhage
Placenta previa
Placentitis
Placenta previa
A pregnant woman visits a clinic visit during her 21st week of pregnancy. The nurse identifies edema, hypertension, and proteinuria. What condition does the nurse suspect?
Allergy
Protein deficiency
Circulatory problem
Gestational hypertension
Gestational hypertension
A pregnant patient who has type 2 diabetes (NIDDM) may require insulin. Why is the insulin necessary?
The growing baby will require more glucose.
Oral hypoglycemic agents may be teratogenic.
Increased hormone levels raise blood glucose.
Oral hypoglycemics do not reach the fetus.
Oral hypoglycemic agents may be teratogenic.
A 14-year-old pregnant adolescent arrives at the hospital in early labor. The nurse should recognize that the adolescent is at a greater risk for which problem?
Calcium deficit
Cephalopelvic disproportion
Bleeding tendency
Low hemoglobin levels
Cephalopelvic disproportion
What is the single most preventable cause of death and disease in the United States today?
Drug use
Alcohol addiction
Cigarette smoking
Malnutrition
Cigarette smoking
Approximately half of all new HIV cases are among people under what age?
50 years
40 years
30 years
25 years
25 years
A major dental problem among very young children is bottle mouth caries. What is a preventive measure the nurse should suggest?
Juice at bedtime
Milk at bedtime
A sugar-coated pacifier
Water at bedtime
Water at bedtime
What is the third leading cause of accidental death in children 1 to 4 years of age?
a. Falls
b. Asphyxiation
c. Poisonsd.
d. Burns
d. burns
The nurse sets up a sample physical activities schedule to fit the FDA's Dietary Guidelines for Americans that recommends that children get at least how many minutes of physical activity per day?
a. 15
b. 30
c. 45
d. 60
d. 60
The nurse explains to the parents of a child with developmental hip dysplasia that the application of a Pavlik harness is necessary. In what position will the harness hold the child's femur?
A. Adduction
B. Flexion
C. Abduction
D. Extension
C. Abduction
When selecting patient problems for the 4-year-old child with nephrosis, what should be a priority for the nurse?
A. Nutritional deficit
B. Skin impairment
C. Injury
D. Impaired body image
B. Skin impairment
The parents of a child who has been diagnosed with sickle cell anemia ask why their child experiences pain. What is the most likely cause of the pain?
A. Overhydration
B. Obstructed blood flow
C. Inflammation of the vessels
D. Stress-related headaches
B. Obstructed blood flow
What is the most common clinical manifestation of coarctation of the aorta?
A. Loud systolic ejection murmur
B. Pedal edema and portal congestion
C. Upper extremity hypertension
D. Clubbing of the digits
C. Upper extremity hypertension
What is the best time to administer pancreatic enzyme replacement?
Before meals and snacks
Before bedtime
Early in the morning
After meals and snacks
Before meals and snacks
Which is a causative factor of Hirschsprung disease?
Frequent evacuation of solids, liquid, and gases
Excessive peristaltic movement
The absence of parasympathetic ganglion cells in a portion of the colon
One portion of the bowel telescoping into another
The absence of parasympathetic ganglion cells in a portion of the colon
When caring for a 7-week-old infant with hypothyroidism, the nurse explains that the prevention of what complication is dependent on the administration of oral thyroid replacement therapy and is critical for the child?
Excessive growth
Cognitive impairment
Damage to the nervous system
Damage to the urinary system
Cognitive impairment
A child with Duchenne muscular dystrophy rises from the floor by walking up the thighs with the hands. How should the nurse record this observation?
Hand assistance
Leg crawling
Gowers sign
Bright sign
Gowers sign
Which signs/symptoms would be considered classical signs of meningeal irritation?
Positive Kernig sign, diarrhea, and headache
Negative Brudzinski sign, positive Kernig sign, and irritability
Positive Brudzinski sign, positive Kernig sign, and photophobia
Negative Kernig sign, vomiting, and fever
Positive Brudzinski sign, positive Kernig sign, and photophobia
What are priority nursing interventions designed to do for a 4-year-old child with cerebral palsy?
Assist with referral to specialized education.
Support the child with independent toileting.
Assist the child to develop effective communication.
Encourage the child to ambulate independently.
Encourage the child to ambulate independently.
When speaking to young parents, the nurse states that lead poisoning is one of the most common preventable health problems affecting children. What condition occurs when the level of lead ingested exceeds the amount that can be absorbed by the bone?
Malnutrition
Anemia
Bone pain
Diarrhea
Anemia
What are early signs of varicella disease?
High fever over 101°F (38.3°C)
General malaise
Increased appetite
Crusty sores
General malaise
The nurse explains that cognitive impairment is categorized by four levels that depend on the intelligence quotient (IQ). How is a child with an IQ of 45 classified?
Within the normal low range
Educable
Trainable
Severe
Trainable
What is the most common method of attempted suicide?
Hanging
Drug overdose
Gunshot
Slashing the wrists
Drug overdose
A woman who is 38 weeks' pregnant tells the nurse that the baby has dropped and she is having urinary frequency again. What do these symptoms describe?
Lightening
Braxton-Hicks contractions
Initiation of labor
Engagement
Lightening
What method is used to visualize soft tissue and to determine adequacy of the pelvis with no detrimental effects to the fetus?
a. Pelvimetry
b. Palpation
c. Ultrasonography
d. X-ray
c. Ultrasonography
The first-time mother has been told by the nurse that the first stage of labor is the longest. What would be an appropriate nursing intervention for comfort during this time?
Cool fluids to drink
A backrub in the sacral area
Assisting to lie in a supine position
Decreasing illumination in the room
A backrub in the sacral area
The health care provider has decided to induce labor with prostaglandin gel and an amniotomy. When should the nurse expect that labor will start?
1 hour
4 hours
8 hours
12 hours
1 hour
A mother has entered the second stage of labor. When does the second stage of labor end?
a. When the mother begins to push
b. When the baby's head crowns
c. With delivery of the baby
d. With delivery of the placenta
c. With delivery of the baby
Which assessment findings suggest probable fetal distress? (Select all that apply.)
Fetal heart rate (FHR) of 120
Meconium-stained amniotic fluid
Decreased FHR during contractions
Strong contractions 10 seconds apart
Slow return of FHR to baseline
Meconium-stained amniotic fluid
Slow return of FHR to baseline
The new mother calls the nurse to her room to show how her baby is jerking around when she changes his position. The nurse understands that the baby is exhibiting which normal reflex?
Traction reflex
Babinski reflex
Tonic neck reflex
Moro reflex
Moro reflex
Following delivery of the newborn, which nursing intervention should be carried out immediately?
Weigh the infant.
Warm the infant.
Bathe the infant.
Inoculate the infant.
Warm the infant.
What is the term for the cream cheese like substance that protects the infants skin from amniotic fluid?
a. Lanugo
b. Meconium
c. Desquamation
d. Vernix caseosa
d. Vernix caseosa
Which newborn assessment finding can suggest a chromosomal disorder?
Epstein pearls
Gynecomastia
Babinski reflex
Simian crease
Simian crease
Why is vitamin K given by injection to the newborn?
Most mothers have a vitamin K deficiency that develops during pregnancy.
Bacteria that synthesize vitamin K are not present in newborns.
Vitamin K prevents the synthesis of prothrombin.
The newborn does not store vitamin K.
Bacteria that synthesize vitamin K are not present in newborns.
What is a characteristic of a normal breast-fed infants stool?
Green and loose
Dark green and sticky
Pale yellow and frequent
Light brown and pasty
Pale yellow and frequent
The nurse is giving a bath demonstration for a group of new mothers. What should be included in the demonstration?
Apply baby powder generously to keep baby dry.
Cleanse perineum from front to back.
Use scented soap to make baby smell good.
Partially submerge head in water when shampooing.
Cleanse perineum from front to back.
The newborn infant has oxygenation problems and a lack of subcutaneous fat. What should the nurse determine as the gestational age of this infant?
20 to 37 completed weeks of pregnancy
38 to 41 completed weeks of pregnancy
14 to 36 completed weeks of pregnancy
42 or more completed weeks of pregnancy
20 to 37 completed weeks of pregnancy
A neonate is born with weak muscle tone, froglike extremities, and ears that fold easily. From these observations, what gestational age should the nurse give this infant?
Full term
Small for gestational age
Preterm
Postterm
Preterm
The nurse is assessing the newborn and discovers a yellowing of the skin. What is true for jaundice that appears at birth?
Within normal limits
Pathologic
A result of iron deficiency
Indicating possible hepatitis
Pathologic
Cognitive impairment, facial abnormalities, and growth retardation are characteristics of which abnormality in a fetus?
Fetal dependency
Fetal immaturity
Malnutrition dependency
Fetal alcohol syndrome
Fetal alcohol syndrome
What should be specifically monitored in a patient who is hospitalized with gestational hypertension?
Blood sugar
Temperature
Level of consciousness
Deep tendon reflexes
Deep tendon reflexes
What is the usual treatment for severe postpartum depression?
Improved nutrition
Vitamin therapy
Pharmacologic interventions
Support group therapy
Pharmacologic interventions
When should the gestational age of the infant be determined?
Within 5 to 10 minutes of delivery
Within 1 to 2 hours of delivery
Within 2 to 8 hours of delivery
Within 12 to 24 hours of delivery
Within 2 to 8 hours of delivery
What condition is a possible cause of gestational hypertension?
Too much salt
A toxin
Renal disease
Diabetes
...
Compared to older infants of comparable weight, how much higher is the morbidity and mortality rate for preterm infants?
One to two times
Two to three times
Three to four times
Four to five times
Three to four times
A patient with hyperemesis gravidarum asks the nurse what would have happened if she had not come to the hospital. What result is the best response by the nurse?
A large for gestational age infant
Anorexia nervosa
Preterm delivery
Maternal or fetal death
Maternal or fetal death
How should twins who share a placenta and come from one fertilized ovum be identified?
Dizygotic
Trizygotic
Genetically different
Monozygotic
Monozygotic
A patient is admitted to the hospital with signs of an ectopic pregnancy. What should the plan of care include for the patient?
Long-term bed rest
Episodes of extreme hypertension
Surgery to remove the embryo/fetus
Treatment for dehydration
Surgery to remove the embryo/fetus
What symptom, no matter what stage of pregnancy, should be reported immediately?
Backache
Urinary frequency
Vaginal bleeding
Uterine tightening
Vaginal bleeding
A pregnant woman comes to the hospital 3 weeks before her estimated date of birth (EDB) complaining of severe pain and a rigid abdomen. What should the nurse immediately suspect as the cause of the pain?
Appendicitis
Ectopic pregnancy
Abruptio placentae
Placenta previa
Abruptio placentae
A patient presents with symptoms of abruptio placentae. To facilitate uterine-placental perfusion, in what position would the nurse place the patient?
Prone position
Trendelenburg's position
Supine position
Modified side-lying position
Modified side-lying position
What condition is a possible cause of gestational hypertension?
Too much salt
A toxin
Renal disease
Diabetes
Renal disease
What should the nurse hope to identify be keeping a record of a patients blood pressure during prenatal visits?
Ketoacidosis
Placenta previa
Gestational diabetes
Gestational hypertension
Gestational hypertension
The nurse is assessing a kick coun for a patient with gestational hypertension. What result should be a cause for concern?
Less than three kicks per hour
Less than five kicks per hour
Less than seven kicks per hour
Less than nine kicks per hour
Less than three kicks per hour
When discussing toxoplasmosis infection during pregnancy, what should the nurse caution the patient to avoid?
Contacting with an infected person
Emptying cat litter boxes bare-handed
Having unprotected sex
Eating excessive amounts of shellfish
Emptying cat litter boxes bare-handed
What is a major complication of gestational diabetes that affects the infant?
Lack of nutrition
Dehydration
Hypoglycemia
Hyperglycemia
Hypoglycemia
Why is the fetus dependent on the mother for glucose control?
The insulin requirements are higher.
Insulin is destroyed by the placenta.
Insulin does not cross the placenta.
Insulin is absorbed by the fetus.
Insulin does not cross the placenta.
A patient with a history of rheumatic heart disease is being admitted to the labor and delivery unit. To prevent further stress on the heart, what should the nurse anticipate to be ordered?
Oxygen administration
Administering large amount of IV fluids
Positioning the patient on her back
Encouraging activity between contractions
Oxygen administration
A primigravida is Rh negative and her husband is Rh positive. She is concerned about the health of the fetus. The nurse explains that there is little danger to the fetus if it is Rh positive; however, the mother would become sensitized during delivery. If this were the case, the mother would produce what in subsequent pregnancies?
Rh-negative blood cells
Rh-positive blood cells
Rh-negative antibodies
Rh-positive antibodies
Rh-positive antibodies
The nurse assures a patient who has become sensitized to the Rh antigen that she can be protected for future pregnancies by receiving what injection?
Iron
Vitamin B12
RhoGAM
Type O blood
RhoGAM
What test is used to identify the maternal level of Rh antibodies in the mothers blood?
Indirect Coombs test
Hemolytic test
Rh antibody test
Direct Coombs test
Indirect Coombs test
A nursery nurse is implementing phototherapy for a jaundiced infant. What is the purpose of the phototherapy?
It is initiated when the bilirubin level reaches 5 mg/dL.
It converts bilirubin to a water-soluble form to be excreted in the urine.
It changes bilirubin to a bile salt to be excreted through the bowel.
It requires eye patches to remain in place 24 hours a day.
It converts bilirubin to a water-soluble form to be excreted in the urine.
Why do alcohol and illegal drugs endanger the fetus?
Both are absorbed into the bloodstream.
Both affect the mother.
Both cross the placental barrier.
Both increase the heart rate of the fetus.
Both cross the placental barrier.
What is the antidote for magnesium sulfate toxicity?
Vitamin K
Calcium gluconate
Potassium sulfate
Calcium carbonate
Calcium gluconate
What is a prominent feature of postpartum depression?
Failure to thrive
Rejection of the infant
Inability to care for the baby
Problems with the baby's father
Rejection of the infant
Following an abruptio placentae, the patient suddenly becomes dyspneic, complains of chest pain, and begins to ooze blood from her IV insertion site. The nurse assesses these as indicators of disseminated ______________ coagulation.
intravascular
The nurse explains that severe _________________ needs to be controlled because it can develop into another syndrome called HELLP (Hypertension, Elevated Liver enzymes, and Low Platelets).
preeclampsia
A woman who is 14 weeks pregnant calls the clinic nurse to report that after a brief bleeding episode a week ago, her uterus seems to have gotten smaller, but her periods have not begun. The nurse assesses the indicators for a _____________ abortion.
missed
A patient, age 45, is to have a myelogram to confirm the presence of a herniated intervertebral disk. Which nursing action should be planned with respect to this diagnostic test?
Obtain an allergy history before the test.
Ambulate the patient when returned to the room after the test.
Use heated blanket to keep patient warm after procedure.
Keep NPO for 6 to 8 hours after the test.
Obtain an allergy history before the test.
A family member of a patient who has just suffered a tonic-clonic seizure is concerned about the patient's deep sleep. What is this behavior called?
Convalescent period
Neural recovery period
Sombulant period
Postictal period
Postictal period
How would a nurse record the behavior when a patient with Alzheimer's disease attempts to eat using a napkin rather than a fork?
a. Apraxia
b. Agnosia
c. Aphasia
d. Dysphagia
b. Agnosia
Which symptom is specific to migraine headaches?
Tachycardia
They become worse in the evening
They involve the entire head
They are preceded by an aura
They are preceded by an aura
The nurse assures an anxious family member of a 92-year-old patient who is demonstrating signs of dementia that many causes of dementia are reversible and preventable. What is one example?
Hypotension
Alzheimer's disease
Diabetes
Parkinson disease
Hypotension
What is the nurse assessing when asking the patient, "Who is the president of the United States?" during a level of consciousness assessment?
Orientation
Memory
Calculation
Fund of knowledge
Fund of knowledge
What Glasgow Coma Scale rating would a patient receive who opens the eyes spontaneously, but has incomprehensible speech and obeys commands for movement?
a. 8
b. 10
c. 11
d. 12
d. 12
What is the nurse aware of when assessing a person with a craniocerebral injury?
Most injuries of this type are irreversible.

Open injuries are always more serious than closed injuries.

Signs and symptoms may not occur until several days after the trauma.

Trauma to the frontal lobe is more significant than to any other area.
Signs and symptoms may not occur until several days after the trauma.
The nurse is caring for a home health patient who had a spinal cord injury at C5 3 years ago. The nurse bases the plan of care on the knowledge that the patient will be able to:
feed self with setup and adaptive equipment.
transfer self to wheelchair.
stand erect with full leg braces.
sit with good balance.
feed self with setup and adaptive equipment.
A patient with a spinal cord injury at T1 complains of stuffiness of the nose and a headache. The nurse notes a flushing of the neck and "goose flesh." What should be the primary nursing intervention based on these assessments?
Place patient in flat position and check temperature.
Administer oxygen and check oxygen saturation.
Place on side and check for leg swelling.
Sit upright and check blood pressure.
Sit upright and check blood pressure.
A frantic family member is distressed about the flaccid paralysis of her son following a spinal cord injury several hours ago. What does the nurse know about this condition?
It is an ominous indicator of permanent paralysis.
It is possibly a temporary condition and will clear.
It degenerates into a spastic paralysis.
It will progress up the cord to cause seizures.
It is possibly a temporary condition and will clear.
What does the nurse know about the stroke patient who has expressive aphasia?
Has difficulty comprehending spoken and written communication.
Cannot make any vocal sounds.
Has total loss and comprehension of language.
Can understand the spoken word, but cannot speak.
Can understand the spoken word, but cannot speak.
The nurse is aware that the drug t-PA (Activase), a tissue plasminogen activator, must be given in hours of the onset of symptoms to have maximum benefit.
3 hours
4 hours
6 hours
8 hours
3 hours
An 83-year-old patient has had a stroke. He is right handed and has a history of hypertension and "little" strokes. He presents with right hemiplegia. To afford him the best visual field, the nurse should approach him:
from the right side.
from the left side.
from the center.
from either side.
from the left side.
The newly admitted patient to the emergency room after a motorcycle accident has serosanguineous drainage coming from the nose. What is the most appropriate nursing response to this assessment?
Cleanse nose with a soft cotton-tipped swab.
Gently suction the nasal cavity.
Gently wipe nose with absorbent gauze.
Ask patient to blow his nose.
Gently wipe nose with absorbent gauze.
How would the nurse instruct a patieInt with Parkinson disease to improve activity level?
To use a soft mattress to relax the spine.
To walk with a shuffling gait to avoid tripping.
To walk with hands clasped behind back to help balance.
To sit in hard chair with arms for posture control.
To walk with hands clasped behind back to help balance.
What is the basic problem that prompts most of the early signs of Alzheimer's disease?
Changes in mood
Misplacing things
Memory loss that disrupts daily life
Problems with words in speaking
Memory loss that disrupts daily life
Why are the drugs neostigmine (Prostigmin) and pyridostigmine (Mestinon) helpful to the person with myasthenia gravis?
Improves speech.
Improves visual disturbances.
Reduces pain.
Promotes nerve impulse transmission.
Promotes nerve impulse transmission.
What should the nurse do when the child arrives on the floor with the diagnosis of bacterial meningitis?
Arrange for humidified oxygen per mask.
Place the child in respiratory isolation.
Inquire about drug allergy.
Hold NPO until orders arrive.
Place the child in respiratory isolation.
What is the purpose of a "drug holiday" in the treatment of Parkinson disease?
Change all drugs.
Allow the natural dopamine levels to rise.
Restart drugs at a lower dosage with favorable results.
Reduce the extrapyramidal symptoms.
Restart drugs at a lower dosage with favorable results.
What is the first sign of Bell's palsy?
Inability to wrinkle forehead and pucker lips on affected side
Sudden pain in nostril on affected side
Excessive salivation on the affected side
Excessive mucus running from nostril on affected side
Inability to wrinkle forehead and pucker lips on affected side
Following a myelogram the nurse should include in the postprocedure care assessment for:
elevation of blood pressure.
urine retention.
sensation in lower extremities.
slurred speech.
sensation in lower extremities.
Why is the patient with suspected Guillain-Barre Syndrome (GBS) hospitalized immediately?
The infection needs to be treated with IV antibiotics to prevent paralysis.
The brain may swell quickly causing seizures.
The disease can rapidly progress into respiratory failure.
IV hydration is needed to prevent possible fatal hypotension.
The disease can rapidly progress into respiratory failure.
Which foods should the person who suffers from migraine headaches avoid? (Select all that apply.)
Yogurt
Caffeine
Beef
Pears
Marinated foods
Milk
Yogurt
Caffeine
Marinated foods
Which of the following techniques are necessary for safely feeding a hemiplegic patient?
(Select all that apply.)
Mixing liquids and solid foods together
Taking the patient's dentures out to prevent choking
Checking the affected side of mouth for food accumulation
Offering small bites of food
Elevating the patient to no more than 30 degrees
Adding a thickening agent to liquids
Checking the affected side of mouth for food accumulation
Offering small bites of food
Adding a thickening agent to liquids
What is the reticular activating system (RAS) essential to? (Select all that apply.)
a. Concentration
b. Wakefulness
c. Speech
d. Attention
e. Memory
f. Introspection
a. Concentration
b. Wakefulness
d. Attention
f. Introspection
What are the effects of normal aging on the nervous system? (Select all that apply.)
Small vessel occlusion
Loss of neurons
Calcification of cerebrum
Reduction of cerebral blood flow
Lipofuscin
Decrease in oxygen use
Loss of neurons
Reduction of cerebral blood flow
Lipofuscin
Decrease in oxygen use
The nurse explains that the triad of signs of Parkinson disease is: _______, rigidity, and bradykinesia.
tremor
What is the result of a slowing of the impulse transmission in the nervous system?
Hypertension
Hearing deficit
Decrease in tactile sensations
Longer reaction time
Longer reaction time
When communicating with an older adult patient, the nurse becomes aware of the fact that the patient is well satisfied with his accomplishments over a lifetime and has no regrets concerning aging. Which of Erikson's developmental stages has the patient achieved?
Acceptance
Withdrawal
Ego integrity
Interaction
Ego integrity
Which areas are affected only minimally by age?
Physical activity
Productivity
Cognition
Sexuality
Cognition
The patient admitted to the hospital may adjust to illness by assuming a role in which everyday responsibilities are avoided. What is this role called?
Patient role
Illness role
Sick role
Dependent role
Sick role
What is a nursing intervention that helps to build trust, encourages the patient to have faith in the care being received, and meets psychosocial needs?
Developing a care plan
Implementing nurse orders
Patient education
Meeting patient goals
Patient education
A family is informed that the brain damage to their daughter is irreversible. The father is later overheard making vacation plans and discussing what the family will do when his daughter leaves the hospital. The nurse recognizes the father is in which crisis stage?
High anxiety
Denial
Reconciliation
Adaptation
Denial
When developing a care plan for a mentally ill patient, what should the nurse assess first?
Coping strategies
Emotional status
Medications taken
Nutritional status
Emotional status
When the patient is told that his insurance will no longer pay for his physical therapy, the nurse is aware that this obstruction to his goal may result in which concept?
a. Conflict
b. Adaptation
c. Frustration
d. Anxiety
c. Frustration
What is the most likely result when an attempt at adaptation fails?
a. Depression
b. Anger
c. Frustration
d. Anxiety
d. Anxiety
The nurse is assessing a nervous 18-year-old patient who has vital signs of P 120, R 30, and BP 160/90. The patient states that he feels something bad is about to happen. Based on this data alone, how should the nurse identify the patient's level of anxiety?
a. Mild
b. Moderate
c. Severe
d. Panic
c. Severe
A patient admitted to the hospital after a motorcycle crash that has left him paralyzed from the
waist down tells the nurse he has feelings of helplessness and hopelessness. What other
feelings may the patient have that should be recognized?
Isolation
Suicidal ideation
Fear
Anger
Suicidal ideation
Which event in the mental health care movement occurred first?
Establishment of Pennsylvania Hospital
Deinstitutionalization movement
Formation of Committee for Mental Health
Passage of Omnibus Budget Reconciliation Act (OBRA)
Dorothea Dix awakens public awareness of plight of mentally ill
Establishment of Pennsylvania Hospital
The Diagnostic and Statistical Manual of Psychiatric Disorders, V (DSM-V), is used by most hospitals and is the current tool used to examine mental health and illness. What approach does the DSM-V use to classify mental disorders?a. Holistic system
Hierarchical system
Multiaxial system
Evaluation system
Multiaxial system
When all five axes of the Diagnostic and Statistical Manual of Psychiatric Disorders, V, are used, it provides what type of assessment approach to comprehensive care?
a. Personalized
b. Individualized
c. Holistic
d. Organic
c. Holistic
A young man with malaria spikes a temperature of 105°F (40.5°C) and begins to hallucinate. How should the nurse assess this?
Delirium
Psychotic break
Possible stroke
Anxiety disorder
Delirium
A patient admitted for delirium demonstrates increased disorientation and agitation only during the evening and nighttime. What is the term applied to this type of delirium?
Disordered thinking
Schizophrenia
Dementia
Sundowning syndrome
Sundowning syndrome
Dementia is an organic mental disease secondary to what problem?
Chemical imbalance
Emotional problems
Circulatory impairment
Cerebral disease
Cerebral disease
A profound, disabling mental illness is characterized by bizarre, nonreality thinking. What is the illness?
Manic depressive
Schizophrenia
Paranoia
Bipolar
Schizophrenia
The patient talks with his dead brother and arranges furniture so that his brother will have a place to sit. How should the nurse document this behavior?
Disordered thinking
Anhedonia
Hallucination
Alogia
Hallucination
For the past 3 weeks, the nurse has observed a patient interacting with staff and other patients, helping decorate the dining room for a party, and leading the singing in the activity room. Today, the patient tearfully refuses to dress or get out of bed. The nurse recognizes these behaviors as evidence of whiNch pRsycIhiatGric dBi.soCrderM?
Unipolar depression
Dysthymic disorder
Hypomanic episode
Bipolar disorder
Bipolar disorder
The nurse recognizes that researchers have identified that hereditary factors account for what percentage of mood disorders?
10% to 15%
20% to 30%
35% to 50%
60% to 80%
60% to 80%
A home health nurse has a patient who is taking lithium. What should be included in the teaching plan?
Examine her skin closely for eruptions.
Take her blood pressure twice a day to check for hypertension.
Have her drug blood level checked every month.
Avoid aged cheese and red wine.
Have her drug blood level checked every month.
The nurse is assessing a female patient who has become rapidly and exceedingly anxious because her fingernail polish is chipped. What type of anxiety should the nurse conclude that
the patient is exhibiting?
Signal anxiety
General anxiety
Anxiety traits
Panic disorder
Anxiety traits
When a patient demonstrates accelerated heart rate, trembling, choking, and chest pain along with acute, intense, and overwhelming anxiety, the nurse should recognize that the patient is most likely experiencing what condition?
a. Terror
b. Fright
c. Fear
d. Panic
d. Panic
When a patient is experiencing a panic attack, how should the nurse best assist the patient?
Assist with reality orientation.
Aid in decision making.
Assist with rational thought.
Coach in deep breathing.
Coach in deep breathing.
A patient is frequently late for appointments because he goes back to his room numerous times to assure himself that none of his belongings have been stolen. What does this behavior represent?
Senseless behavior
Controlled repetition
Obsessive-compulsive
Anxiety tension
Obsessive-compulsive
A 14-year-old survivor of a school shooting screams and dives under a table when firecrackers go off. What does this behavior represent?
Phobia
Posttraumatic stress disorder
Obsessive-compulsive disorder
Disordered thinking
Posttraumatic stress disorder
What should the nurse preparing a patient for a scheduled appointment for electroconvulsive therapy (ECT) remind the patient to do?a. Drink plenty of fluids before ECT to ensure adequate hydration.
b. Bring a change of clothes in case of incontinence.
c. Be prepared for visual disturbances after the treatment.
d. Arrange for transportation to and from the appointment.
d. Arrange for transportation to and from the appointment.
The nurse is told that a patient believes he was born into the wrong body. What is the correct terminology for the desire to have the body of the opposite sex?
a. Homosexuality
b. Transsexualism
c. Heterosexuality
d. Bisexuality
b. Transsexualism
What disorder is a severe form of self-starvation that can lead to death?
Bulimia nervosa
Anorexia nervosa
Teenage nervosa
Obesity nervosa
Anorexia nervosa
What is the term for a long-term and intense form of psychotherapy developed by Sigmund Freud allows a patient's unconscious thoughts to be brought to the surface?
a. Adjunctive
b. Behavior
c. Psychoanalysis
d. Cognitive
c. Psychoanalysis
What is the typical schedule for electroconvulsive therapy (ECT)?
3 treatments over 2 weeks
6 treatments over 2 months
8 treatments over several weeks
10 treatments over several weeks
10 treatments over several weeks
Adjunctive therapies are used for which reasons? (Select all that apply.)
To increase self-esteem
To promote positive interaction
To enhance reality orientation
To stimulate communication
To increase energy
To increase self-esteem
To promote positive interaction
To enhance reality orientation
A 60-year-old man was admitted for cholecystitis that resulted in a cholecystectomy. On his third day of hospitalization, he begins to sweat profusely, tremble, and has a blood pressure of 160/100. Based on these findings, what focused assessment should the nurse complete?
Cardiac problems
Respiratory problems
Withdrawal problems
Circulatory problems
Withdrawal problems
What age of onset of alcohol consumption is most predictive of alcohol addiction?
8 or younger
10 or younger
12 or younger
14 or younger
14 or younger
Alcohol is involved in motor vehicle accidents, suicides, and homicides. Approximately how many deaths each year are related to alcohol consumption?
a. 58,000
b. 78,000
c. 88,000
d. 108,000
c. 88,000
What stage of dependence is described by a patient when he tells the nurse that he has tried to stop his drug habit, but he does not feel "normal" without it?
a. Early
b. Prodromal
c. Middle
d. Late
c. Middle
What must a patient in the late stages of dependence do in order to recover?
Gain insight into the addiction.
Receive treatment for substance abuse.
Pledge to lead a completely different lifestyle.
Seek a nondrug-oriented support system.
Receive treatment for substance abuse.
What is the best response by a nurse when a patient inquires how alcohol acts so quickly on his system?
Alcohol is digested quickly.
Alcohol is converted to glycogen immediately.
Alcohol is metabolized into ethanol rapidly.
Alcohol is excreted in urine slowly.
Alcohol is metabolized into ethanol rapidly.
The nurse reminds a group of high school students that most states have laws limiting blood alcohol levels of drivers. What is the legal blood alcohol serum level in most states?
a. 0.08%
b. 0.20%
c. 0.40%
d. 0.50%
a. 0.08%
A pregnant adolescent tells the nurse that she "only drinks a little." How many drinks per day can cause an adverse effect in an infant?
One drink a day
Two drinks a day
Three drinks a day
Four drinks a day
Two drinks a day
The nurse is performing an initial assessment on an alcoholic patient. Which of the following actions by the nurse would best ensure honest answers?
Not asking personal questions
Having a nonjudgmental attitude
Including the family
Promising the patient not to tell anyone
Having a nonjudgmental attitude
During the detoxification period, what does the nurse aim to achieve when designing interventions?
Enroll the patient in Alcoholics Anonymous (AA).
Keep the patient safe from aspiration and seizure.
Help the patient interact in nonaddictive activities.
Help the patient gain insight into the addiction.
Keep the patient safe from aspiration and seizure.
What should the entire health team focus on during the rehabilitation phase?
Establishing a support system
Seeking and maintaining employment
Abstaining from drug use
Addressing the problems related to addiction
Abstaining from drug use
What should the nurse do to decrease the patient's disorientation at night during the detoxification period?
Place the patient in a room with another recovering patient.
Instruct the patient to orient himself to his surroundings at bedtime.
Wake the patient up every 4 hours to eat a small snack.
Use nightlights and remove extra furniture from the room.
Use nightlights and remove extra furniture from the room.
The nurse explains that Alcoholics Anonymous (AA) consists of abstinent alcoholics who help other alcoholics become and stay sober. What is the foundation of AA?
Psychotherapy
A 12-step program
Treatment center
Individual counseling
A 12-step program
If the patient tells the nurse, "I'm not an alcoholic. I can stop whenever I want to," what should be the nurse's most therapeutic response?
"Well, why don't you?"
"Hasn't alcohol use interfered with your employment?"
"A positive attitude like that is a good start."
"What would you call alcoholism?"
"Hasn't alcohol use interfered with your employment?"
When a patient denies any problems related to addiction, what is the nurse's most therapeutic response?
"What do you call this hospitalization?"
"How can anybody help you if you don't see a problem?"
"Would your family agree that you have no problems?"
"Can you think of any time your behavior created an unpleasant situation in your
life?"
"Can you think of any time your behavior created an unpleasant situation in your
life?"
Which drug is often used in date rape?
a. Dalmane
b. Xanax
c. Narcan
d. Rohypnol
d. Rohypnol
A patient seems bewildered when he confides in the nurse that all of his friends and leisure time have been centered on a drug culture. Which would be the best response by the nurse?
"What other sort of activities might you enjoy?"
"You will need to get new friends."
"Returning to those activities will get you back here and in trouble."
"You need to get a hobby."
"What other sort of activities might you enjoy?"
When a patient is admitted with an overdose of an opioid narcotic, the nurse should anticipate an order for which drug to reverse the effects of the narcotic?
a. Clonidine
b. Narcan
c. Orlaam
d. Methadone
b. Narcan
The nurse concludes that a significant goal of the care plan for an alcoholic patient has been met when the patient makes which statement?
"I drink because I'm lonely."
"All my difficulties are related to my drinking."
"I wouldn't need to drink if I had my family back."
"My drinking helps me cope with the stress of my job."
"All my difficulties are related to my drinking."
While creating a methadone protocol for a patient rehabilitating from heroin addiction, the nurse explains that the patient will take methadone for what length of time?
Daily for the rest of his life.
Daily until stabilized, then gradually reduce the dose to zero.
Weekly for at least 6 months, then decrease the dose to once a month.
Monthly for 6 to 10 months, then decrease the dose to zero.
Daily until stabilized, then gradually reduce the dose to zero.
A 22-year-old patient presents in the emergency department with the characteristics of severe Parkinson disease. The nurse should suspect an overdose of what drug?
a. Marijuana
b. Cocaine
c. Amphetamines
d. Valium
c. Amphetamines
A college student has brought his hallucinating roommate to the college clinic. The young man says his roommate has been experimenting with phencyclidine (PCP). How long should the nurse expect the hallucinations to last?
30 to 60 minutes
1 to 4 hours
4 to 6 hours
6 to 12 hours
6 to 12 hours
The mother of a young woman being treated for amphetamine overdose asks the nurse when the manifestations will subside. What would be the most correct answer by the nurse?
"Usually in 8 to 10 hours."
"She will snap out of it in a day or two."
"Usually in about 2 hours, but the effects will return in 2 to 3 days."
"The manifestations may be permanent."
"The manifestations may be permanent."
What is the greatest problem with lysergic acid diethylamide (LSD) use?
The drug is addictive.
The drug stimulates drug-seeking behavior.
The drug causes flashbacks.
The drug sets off hypertensive episodes.
The drug causes flashbacks.
What should the nurse do to decrease the damage of bruxism seen in a patient who has been abusing the drug ecstasy?
Turn the patient to his right side.
Elevate the head of the bed 30 degrees.
Provide the patient with a pacifier.
Administer a muscle relaxant.
Provide the patient with a pacifier.
What should the nurse do when suspecting a coworker of abusing drugs while at work?
Confront the abuser.
Report observations to a supervisor.
Call the state board of nursing.
Discuss the problem with another coworker.
Report observations to a supervisor.
Which statement describes the impaired nurse who is in a peer assistance program?
The nurse has a revoked nursing license.
The nurse does not have to notify her employer.
The nurse will be allowed to work as a nurse under supervision.
The nurse will be reported to the Healthcare Integrity and Protection Data Bank.
The nurse will be allowed to work as a nurse under supervision.
During the initial intake assessment of a drug user, the nurse should attempt to obtain which subjective data? (Select all that apply.)
Usual pattern of use
Specific drug
Previous arrests
Amount of drug used
Time of last use
Usual pattern of use
Specific drug
Amount of drug used
Time of last use
The nurse should assess a patient for which criteria of addiction? (Select all that apply.)
Excessive use of the substance
Increase in social function
Uncontrollable consumption
Increase in economic function
Psychological disturbances
Excessive use of the substance
Uncontrollable consumption
Psychological disturbances
A nurse suspects here a coworker is abusing drugs. Which of the following symptoms, noticed in the coworker, would contribute to the suspicions? (Select all that apply.)
Spending more time with coworkers
Frequently absent from the unit
Rapid changes in mood and performance
Increased somatic complaints
Patients report they did not receive their medications
Frequently absent from the unit
Rapid changes in mood and performance
Increased somatic complaints
Patients report they did not receive their medications
When assessing an alcoholic patient, the nurse notes short-term memory loss, painful extremities, foot drop, and muttered incoherent responses to questions. The nurse recognizes these symptoms as most likely related to a condition caused by long-term alcohol abuse, which is known as __________ syndrome.
Korsakoff
The nurse uses the CAGE questionnaire to assess a patient. The nurse suspects the patient is an alcoholic if there are affirmative answers for _____ items on the questionnaire.
2
The nurse cautions that a person who chronically abuses drugs may experience mental impairment. The area of the brain that can be affected and permanently damaged is the ________ system.
limbic
renal
endocrine
central nervous
limbic
The nurse stresses that regular physical activity has been identified as a leading health indicator. Regular physical activity has which positive effect on children?
Improves social skills.
Reduces fluid retention.
Increases bone and muscle strength.
Increases attention span.
Increases bone and muscle strength.
Smoking contributes to an increased risk of heart and lung disease in children by which methods?
Air pollution
Allergens in the environment
Environmental smoke
Lack of oxygen in the air
Environmental smoke
Which factor is mostly associated with problems such as domestic violence, sexually transmitted infections (STIs), school failure, and motor vehicle accidents (MVAs)?
Lack of supervision
Psychological problems
Substance abuse
Physiological problems
Substance abuse
Which children must be secured in the back seat in a rear-facing safety seat?
Children weighing up to 20 lb
Children weighing between 20 and 30 lb
Children weighing between 30 and 40 lb
Children weighing more than 40 lb
Children weighing up to 20 lb
The pediatric nurse reminds the parents of a 2-year-old that by this age the child should be protected against how many vaccine-preventable childhood diseases?\
a. 4
b. 6
c. 8
d. 10
10
What practice should be used by a pediatric nurse to remind parents of their responsibility in reducing the number of accidents involving children?
Child awareness
Good manners
Anticipatory guidance
Strict discipline
Anticipatory guidance
To prevent accidental poisoning of a child, where should medications be placed in the home?
In a dresser drawer
In the medicine cabinet
In a locked cupboard
On a high shelf
In a locked cupboard
What is the leading cause of fatal injury in children younger than 1 year old?
Burns
Poisons
Asphyxiation
Motor vehicle accidents
Asphyxiation
The school nurse recognizes that lack of physical activity and increased consumption of fast food by children are causative factors contributing to which of the following problems?
Nutritional disorders
Weight gain
Type I diabetes
Dental caries
Weight gain
What age group is experiencing the largest increase in drug use?
7- to 9-year-olds
10- to 12-year-olds
12- to 13-year-olds
15- to 17-year-olds
12- to 13-year-olds
Because the water in the infant's residential area is not fluoridated, when should the nurse suggest that the infant receive supplemental fluoride?
2 months old
4 months old
5 months old
6 months old
6 months old
What are reasons that a pediatric nurse should stress that health promotion activities must be ongoing? (Select all that apply.)
To identify health risks
To encourage healthy behavior
To strengthen family bonds
To improve nutrition
To prevent accidents
To identify health risks
To encourage healthy behavior
To improve nutrition
To prevent accidents
The school nurse collaborates with the physical education instructor to increase the amount of physical activity during the school day. What are major benefits of physical activity? (Select all that apply.)
Reduced death rates as adults
Reduced risk of cardiovascular disease
Reduced risk of hypertension
Reduced risk of diabetes
Reduced self-esteem
Reduced death rates as adults
Reduced risk of cardiovascular disease
Reduced risk of hypertension
Reduced risk of diabetes
Which are physical risks associated with excess weight? (Select all that apply.)
Poor eyesight
Heart disease
Arthritis
Stroke
Appendicitis
Heart disease
Arthritis
Stroke
Which of the following interventions should be included when teaching a healthy behaviors class for parents of adolescents? (Select all that apply.)
Always monitor the child's telephone conversations.
Insist on seatbelt use at all times.
Encourage tanning bed use versus exposure to the sun.
Maintain recommended immunization schedule.
Encourage good dental care.
Insist on seatbelt use at all times.
Maintain recommended immunization schedule.
Encourage good dental care.
What was one of the major strides in pediatric care made by Dr. Abraham Jacobi?
Pediatric wards in hospitals
Free inoculations against smallpox
Milk stations in the city of New York
Serving nutritious foods in orphanages
Milk stations in the city of New York
What was founded by Lillian Wald?
National Commission on Children
Henry Street Settlement
White House Conference
US Childrens Bureau
Henry Street Settlement
When the pediatric nurse is attempting to establish a trusting relationship with a child, what is the most important and lasting thing to do?
Convey respect.
Talk with the child.
Be honest.
Talk with family.
Be honest.
What is the special category that encompasses children who have congenital abnormalities, malignancies, gastrointestinal (GI) diseases, or central nervous system (CNS) anomalies?
Very dependent children
Children requiring special education
Children with special needs
Children requiring long-term care
Children with special needs
When measuring the head circumference of an infant, where should the nurse place the tape measure?
Across the eyebrows and around the occipital lobe
Over the zygomatic arches and around the parietal areas
Around forehead and around the crown of the head
Above the eyebrows and pinnas, and around the occipital lobe
Above the eyebrows and pinnas, and around the occipital lobe
What is the correct order for assessing vital signs in an infant to ensure the accuracy of measurements?
Respiration, temperature, pulse
Pulse, respiration, temperature
Temperature, pulse, respiration
Respiration, pulse, temperature
Respiration, pulse, temperature
Why does obtaining the respirations of an infant require a modified approach from that of an adult?
Infants breathe through their noses.
Infants have very rapid respirations.
Infants respirations are thoracic in nature
Infants respiratory movements are abndominal
Infants respiratory movements are abndominal
What is the correct way to assess for the presence of jaundice in an African-American child?
Examine the sclera.
Press the edge of the pinna.
Apply pressure to the gum.
Compare the color on the soles of the feet.
Apply pressure to the gum.
The parents ask about preparation of their toddler for hospital admission. When does the nurse suggest that the parents tell their toddler of the admission?
A week prior
2 weeks prior
The day of admission
Only 2 or 3 days before
Only 2 or 3 days before
What is the best time to bathe an infant?
At bedtime
Early in the morning
After a feeding
Before a feeding
Before a feeding
How should an infant be positioned after a feeding?
On the stomach
On the right side
On the left side
On the back
On the right side
When a safety reminder device (SRD) is used to protect a child, what is a responsibility of the nurse?
Apply it loosely.
Remove it every 2 hours.
Place it over clothing.
Apply only one type.
Remove it every 2 hours.
What should be done before initiating a gavage feeding?
Hold the feeding tube under water to check for bubbling.
Check for gastric distention.
Aspirate stomach contents.
Ensure the sterility of feeding equipment.
Aspirate stomach contents.
What is the purpose of a mist tent?
To provide a constant oxygen supply
To liquefy respiratory secretions
To aid in lowering temperature
to improve the infants hydration
To liquefy respiratory secretions
What is the maximum amount of time that a nurse should suction an artificial airway?
1 second
5 seconds
30 seconds
1 minute
5 seconds
What is a disadvantage of using a mist tent with a toddler?
The nurse must remove the restless child.
The wet bedding and clothing must be changed frequently.
The mist tent must be opened at least once every hour.
All objects must be kept outside of the tent.
The wet bedding and clothing must be changed frequently.
Why must the pediatric nurse be cautious about medicating infants and young children?
They are less susceptible to medication effects than adults.
They are more susceptible to medication effects than adults.
They are equally susceptible to medication effects as adults.
They are more susceptible to drug interactions than adults.
They are more susceptible to medication effects than adults.
What is the preferred IM injection site for a 2-year-old?
Deltoid muscle
Upper thigh
Vastus lateralis
Gluteus
Vastus lateralis
Where is the typical IV insertion site in an infant younger than 9 months of age?
Radial vein
Scalp vein
Femoral vein
Brachial vein
Scalp vein
Following a lumbar puncture of a 2-year-old, what should the nurse do?
Keep the child flat for several hours.
Allow the child to play quietly at will.
Hold the child in a flexed position for 5 minutes.
Stand the child upright immediately.
Allow the child to play quietly at will.
When the nurse is inserting a feeding tube in an 8-month-old, what safety reminder device (SRD) should the nurse most likely use?
Mummy
Clove hitch
Jacket device
Elbow device
Mummy
After observing parental behavior that leads the nurse to suspect child abuse, when should the nurse report the abuse?
If the parent confesses to child abuse
If the child admits to being abused
Whenever maltreatment of a child is suspected
When the type of abuse can be determined
Whenever maltreatment of a child is suspected
The nurse clarifies that the family-centered care approach terminates which policies? (Select all that apply.)
Rigid visiting hours
Freedom to choose which medications to take
Exclusion of family during procedures
Discouraging family to stay overnight
Restricting parents from reading the chart
Exclusion of family during procedures
Discouraging family to stay overnight
Restricting parents from reading the chart
Rigid visiting hours
The newly diagnosed primigravida who is 6 weeks pregnant states, "I dont feel like I have a real baby inside me. To reassure the mother, the nurse provides reassurance that which of the following is functioning in the 6-week-old embryo?
a. Brain
b. Lungs
c. Hands
d. Heart
heart
Smoking by the mother can have what effect in the fetus?
a. Hearing deficits
b. Neuromuscular deformities
c. Cerebral palsy
d. Low birth weight
d. Low birth weight
When can the sex of the fetus be confirmed?
Conception
2 weeks
6 weeks
9 weeks
9 weeks
The health care provider decides to send the mother for a test to determine the fetal lung maturity. What is the name of this fetal well-being test?
Biophysical profile
Alpha-fetoprotein
Amniocentesis
Ultrasound
Amniocentesis
When the young primigravida asks about how to adjust her diet for her pregnancy, what should the nurse suggest the mother add to her diet?
Leafy green vegetables and fruit
Beef and poultry
Foods high in sodium and potassium
Bread and grains
Leafy green vegetables and fruit
What should a nurse instruct the patient to do before assessing fundal height?
Press her lower back against the examination table.
Empty her bladder.
Take a deep breath and hold it.
Bear down.
Empty her bladder.
The nurse concludes that the prenatal patient has no need for further instruction when she correctl states that amniocentesis can determine which of the babies characteristics? (Select all that apply)
Sex
Maturity
Approximate weight
Health
Genetic defects
Sex
Maturity
Health
Genetic defects
Which of the following demonstrate culturally competent care of the pregnant patient? (Select all that apply.)
Discuss beliefs with the patient and incorporate them in the plan of care.
Prohibit visits from anyone other than immediate family members.
Require the patients participation in every aspect of the health care system.
Maintain the patients modesty at all times.
Strive to maintain a harmonious environment for the patient.
Discuss beliefs with the patient and incorporate them in the plan of care.
Maintain the patients modesty at all times.
Strive to maintain a harmonious environment for the patient.
The nurse instructor reminds the nursing student that the Shiny Schults is a name given to the _____________ side of the placenta.
fetal
maternal
fetal
The nurse assesses a reactive result to a nonstress test when the fetal heart rate increases _____ beats/min.
15
7
20
50
15
A nurse is teaching a group of primigravidas that during delivery, pressure on the fetal skull may produce changes in the shape of the skull. What is the reshaping of the skull called?
Pressure response
Overlapping
Molding
Spacing
Molding
How do Braxton-Hicks contractions, which may begin in the first trimester and become increasingly stronger during the pregnancy, differ from labor contractions?
Last several minutes.
Are always regular.
Do not dilate the cervix.
Are only mild.
Do not dilate the cervix.
Why is the size and shape of the true pelvis more important than that of the false pelvis?
The fetal head must be able to pass through the true pelvis.
The true pelvis are the mother's measurements.
The size of the false pelvis can change.
The size of the true pelvis needs to be larger.
The fetal head must be able to pass through the true pelvis.
Using Leopold maneuvers to assess fetal position, the nurse finds a soft rounded prominence at the level of the fundus, a hard round prominence just above the symphysis pubis, and nodulations on the left side of the uterus. How should the nurse document the fetal position?
Right occiput anterior (ROA), vertex
Left occiput anterior (LOA), vertex
Right occiput transverse (ROT), breech
Left occiput anterior (LOA), breech
Right occiput anterior (ROA), vertex
Which type of monitor will assesses the intensity of contractions?
External monitor
Fetal monitor
Maternal monitor
Internal monitor
Internal monitor
The patient's membranes have just ruptured. What is the first priority of the nurse?
Turn the patient on the left side.
Perform a Nitrazine test.
Check the fetal heart rate (FHR).
Perform a vaginal examination.
Check the fetal heart rate (FHR).
A nurse is assessing the printout from the fetal monitor. What is the legal responsibility of the nurse?
a. Correctly identifying abnormal FHR patterns and prescribing medication
b. Correctly identifying abnormal FHR patterns and notifying the health care provider
c. The nurse is not legally responsible for fetal monitoring d. Providing technical assessment to the monitor technicians
b. Correctly identifying abnormal FHR patterns and notifying the health care provider
The nurse is admitting a patient to the labor and delivery unit. While performing the initial assessment, which assessment is the priority?
The number of previous pregnancies
When the baby is due
When the patient last ate
The timing of contractions
The timing of contractions
During labor, the patient screams at her husband to get out of her sight. What would be the most appropriate action for the nurse?
Ask the husband to leave the room.
Assure the husband that such behavior is normal.
Remind the patient that the husband wants to help.
Change the patient's position.
Assure the husband that such behavior is normal.
For the first hour following delivery, how often should the nurse assess the mother?
Every 5 minutes
Every 10 minutes
Every 15 minutes
Every 30 minutes
Every 15 minutes
Which assessment findings suggest probable fetal distress? (Select all that apply.)
Fetal heart rate (FHR) of 120
Meconium-stained amniotic fluid
Decreased FHR during contractions
Strong contractions 10 seconds apart
Slow return of FHR to baseline
Meconium-stained amniotic fluid
Slow return of FHR to baseline
A pregnant woman is discussing her desire to have her baby in a birthing center. Which factors could exclude the patient from delivering in a birthing center? (Select all that apply.)
The patient is a primigravida.
The patient will be having a planned cesarean delivery.
The mother has preeclampsia.
The baby is a boy.
The mother has no support system.
The patient will be having a planned cesarean delivery.
The mother has preeclampsia.
The nurse explains to the patient whose membranes ruptured an hour ago that delivery is usually accomplished in ____ to 24 hours postrupture.
29
18
4
12
18
A primigravida has a pelvis of the android type, which usually means the delivery will be a _______________.
cesarean
VBAC
natural
cesarean
A nurse shows the patient an x-ray of the fetal spine in parallel alignment with the mother's to demonstrate a ________ lie.
longitudinal
Which of the following measures could help prevent infant abduction? (Select all that apply.)
Only transport infants by carrying them.
Require staff members to wear appropriate identification badges.
Respond immediately when an alarm sounds.
Never leave infants unattended at any time.
Take all the infants to their mothers at the same time.
Require staff members to wear appropriate identification badges.
Respond immediately when an alarm sounds.
Never leave infants unattended at any time.
A new mother asks for advice on how to quiet her fussy newborn. Which responses would be appropriate to suggest to the mother? (Select all that apply.)
Prewarm the crib sheets with a hot water bottle
Swaddle the newborn tightly in a receiving blanket
Place the baby in a larger crib or infant bed
Offer a pacifier or allow the infant to suckle at the breast
Take the infant for a ride in the car
Prewarm the crib sheets with a hot water bottle
Swaddle the newborn tightly in a receiving blanket
Offer a pacifier or allow the infant to suckle at the breast
Take the infant for a ride in the car
After delivery of a 9-lb baby, the nurse assesses a perineal laceration extending through the muscles of the perineum. The nurse records this as a ________-degree laceration.
third
first
second
second
The nurse describes the return of the postpartum patients uterus to a pregravida state as ________________.
evolution
deflation
involution
involution
A pregnant patient with tuberculosis asks the nurse how the disease will affect her pregnancy and her newborn. What statements by the nurse are most appropriate? (Select all
that apply.)
"you have nothing to worry about. you will be disease free after you deliver."

"the tb can be transmitted to the fetus in rare occurrences"

"your newborn will be tested for tb after delivery."

"there is no approved treatment for the infant if she tests positive for this disease."

"you will not be able to hold your newborn until you have been cleared according to the health department guidelines."
"the tb can be transmitted to the fetus in rare occurrences"
"your newborn will be tested for tb after delivery."
"you will not be able to hold your newborn until you have been cleared according to the health department guidelines."
The patient who has taken the ovulation stimulant clomiphene (Clomid), and who has been determined to be pregnant, calls the clinic nurse to report that she is bleeding and has passed a small grapelike object. From this information the nurse suspects a hydatidiform ____________.
mole
etopic
tubal
mole
The newly admitted patient to the emergency room 30 minutes ago after a fall off a ladder has gradually decreased in consciousness and has slowly reacting pupils, a widening pulse pressure, and verbal responses that are slow and unintelligible. What is the most appropriate position for the patient?
Neck placed in a neutral position.
Head raised slightly with hips flexed.
Supine in gravity neutral position.
Turn on right side with head elevated.
Neck placed in a neutral position.
What is the cardinal sign of increased intracranial pressure in a brain injured patient?
Pupil changes
Ipsilateral paralysis
Vomiting
Decrease in the level of consciousness
Decrease in the level of consciousness
The nurse is aware that when assessing a patient by the FOUR score coma scale, the patient is assessed in four categories: eye response, brainstem reflexes, motor response, and respiration. How are these results reported?
As a sum of the scores of the four categories
As part of the Glasgow Coma Scale
As individual scores in each category
As progressive scores during a 24-hour period
As individual scores in each category
As the result of a stroke, a patient has difficulty discerning the position of his body without looking at it. In the nurse's documentation, which would best describe the patient's inability to assess spatial position of his body?
a. Agnosia
b. Proprioception
c. Apraxia
d. Sensation
b. Proprioception
A patient has recently suffered a stroke with left-sided weakness and has problems with choking, especially when drinking thin liquids. What nursing interventions would be most helpful in assisting this patient to swallow safely?
Use a straw.
Tuck chin when swallowing.
Take a sip of liquid with each bite.
Turn head to the left.
Tuck chin when swallowing.
What is the reticular activating system (RAS) essential to? (Select all that apply.) a. Concentration
b. Wakefulness
c. Speech
d. Attention
e. Memory
f. Introspection
a. Concentration
b. Wakefulness
d. Attention
f. Introspection
Involuntary rhythmic movement of the eyes, with oscillations that may be horizontal, vertical, or mixed movements, is called ___________________.
tremor
siezure
nystagmus
nystagmus
Using the mental health continuum as a guide, the nurse observes behavior that usually places an individual on the illness end of the continuum. What is true of this behavior?
It causes extreme concern about health.
It results in inability to function in society.
It demonstrates that the person is out of touch with reality.
It results in inability to interact with people.
It demonstrates that the person is out of touch with reality.
The majority of people function in a relatively healthy manner. What can diminish their functional capacity?
Lack of a support system
Periods of crisis
Nutritional deficits
A physical disease process
Periods of crisis
What is the basis for classifying a person as having a mental illness?
Behavior exhibited and the context
Response of society to the behavior
Ability of the patient to conform
Patients history and previous behavior
Behavior exhibited and the context
Which role is an example of an ascribed role?
Sex
Occupation
Manner of dealing with stress
Attitude toward homosexuality
sex
The nurse is assessing a young woman who is a teacher, happily married, raising two children, taking care of her disabled mother, and going to school to get a masters degree. How should the behavior of the young woman be classified?
Ego-centered
Role integrated
High-level wellness
Unbounded energy
Role integrated
When the patient who overeats insists that weight gain is related to retained fluids, the nurse recognizes the patient is using which defense mechanism?
a. Compensation
b. Rationalization
c. Sublimation
d. Regression
b. Rationalization
The patient complains to the nurse that the health care provider does not like him and wants him to fail at following the diet prescribed. The nurse recognizes that the patient is using which defense mechanism?
Conversion
Projection
Introjection
Repression
Projection
the nurse uses a diagram to show how the four parts of "self" fit together. What are the four parts? (Select all that apply.)
Body image
Ego
Self-esteem
Role
Identity
Body image
Self-esteem
Role
Identity
A variety of factors influence the level of anxiety experienced by the patient faced by a stressful situation. Which would the nurse outline? (Select all that apply.)
How others perceive the event
The number of stressors present at one time
Degree of change the stressors require
Present role assumption
Previous experience with a similar situation
...
Adjunctive therapies are used for which reasons? (Select all that apply.)
To increase self-esteem
To promote positive interaction
To enhance reality orientation
To stimulate communication
To increase energy
To increase self-esteem
To promote positive interaction
To enhance reality orientation
The nurse should assess a patient for which criteria of addiction? (Select all that apply.)
Excessive use of the substance
Increase in social function
Uncontrollable consumption
Increase in economic function
Psychological disturbances
Excessive use of the substance
Uncontrollable consumption
Psychological disturbances
The nurse welcomes the presence of the family in a pediatric unit because it reduces the stressors of hospitalization. Which are common stressors for the hospitalized child? (Select all that apply.)
Separation
Lack of love
Fear of pain
Unfamiliar food
Loss of control
Separation
Fear of pain
Loss of control
The nurse is aware that visual acuity evaluation in a child is best assessed after the age of _____ years.
8
3
2
6
6
The pediatric nurse, along with the primary caregiver(s), has a special duty to ________ the child and the family.
teach
teach
When performing an assessment of a child with recurrent abdominal pain (RAP), the nurse recognizes the child will most likely experience what symptom?
Increased temperature
Constipation
Right quadrant pain
Exercise-associated pain
constipation
The nurse is recording a history for a child who has been diagnosed with recurrent abdominal pain (RAP). What is a finding that is characteristic of this disorder?
Morning headaches
Pain for 3 consecutive months
Febrile episodes in the late afternoon
Diaphoresis when attacks occur
Pain for 3 consecutive months
When assessing the laboratory values of a child with nephrosis, the nurse anticipates which results? (Select all that apply.)
High levels of protein in the urine
High serum lipid levels
Low serum protein levels
Low hemoglobin
High white blood cell count
High levels of protein in the urine
High serum lipid levels
Low serum protein levels
When the mother of a child with gastroesophageal reflux calls the clinic nurse to report that her baby is vomiting small amounts of blood, the nurse explains that the esophagus has been irritated by gastric ________.
juice
secretions
acid
acid
The nurse reassures the anxious mother of a child with pyloric stenosis who is to have surgery that the surgical procedure, called a __________, is quickly done and the child recovers almost immediately.
pyloromyotomy
pyloromyotomy
The parents of a child suffering from depression ask the nurse what causes depression in children. Which answer is an appropriate response by the nurse?
A. The causes of major depression are unknown.
B. Boys are more likely than girls to be depressed.
C. Major affective disorders in parents increase depression in children.
D. The prevalence rate is higher in prepubescent children.
A. The causes of major depression are unknown.
Autism is typically diagnosed at what age?
A. 8 to 10 years
B. 5 to 6 years
C. Before 1 years
D. 2 to 3 years
2 to 3 years
1. Which additional congenital malformation is expected in 80% of infants with a myelomeningocele?
A. Hydrocephalus
B. Cerebral palsy
C. Meningitis
D. Neuroblastoma
A. Hydrocephalus
1. Which is a priority nursing intervention for the cognitively impaired child?
A. The family will provide good nutrition.
B. The family will provide loving interactions.
C. There will be contact with peers.
D. Stimulation will improve.
B. The family will provide loving interactions
1. A new mother asks the clinic nurse if she must continue giving her baby nystatin for thrush since the white lesions on his tongue have disappeared. What response by the nurse is most appropriate?
A. "Yes. You should continue it for the full 7 days."
B. "Yes. The medication should be refilled for a second week of therapy."
C. "No. Thrush is a self-limiting disorder and nystatin is given for comfort only."
D. "No. When the lesions have gone you may stop the nystatin."
A. "Yes. You should continue it for the full 7 days."
1. When conducting a class for parents about sudden infant death syndrome (SIDS), the nurse instructs the class that the infant should be placed in which position to sleep?
A. Supine
B. Right side-lying
C. Left side-lying
D. Prone
supine
1. The parents of a child with acute lymphoblastic leukemia ask about the best approach for maintaining remission of the disease. What would be the most effective therapy?
A. Blood transfusions to replace ineffective red cells
B. Surgery to remove enlarged lymph nodes
C. Long-term chemotherapy
D. Nutritional supplements to enhance blood cell production
C. Long-term chemotherapy
1. What is the hallmark sign of intussusception?
A. Currant jelly-like stools
B. Mucus-like stools
C. Green, soft stools
D. Tarry, black stools
A. Currant jelly-like stools
1. The nurse instructs the parents of a child who has has a myringotomy to place the child in which position?
A. On the affected side
B. Supine
C. On the unaffected side
D. In Trendelenburg's position
A. On the affected side
1. Parents of a 6-month-old child, who has just been diagnosed with iron deficiency anemia, ask why it was not diagnosed earlier. What would be the best response by the nurse?
A. "The child may not have had it for a long time."
B. "Are you sure your child has iron deficiency anemia?"
C. "This anemia is caused by blood loss."
D. "This happens when the maternal stores of iron are depleted at about 6 months."
D. "This happens when the maternal stores of iron are depleted at about 6 months."
1. The nurse is caring for a newborn with a myelomeningocele. Before surgery, what should the nursing interventions include?
A. Leaving the lesion uncovered and placing the infant supine
B. Covering the lesion with a sterile, saline-soaked gauze
C. Applying lotion to the lesion to keep it moist
D. Covering the lesion with a dry, sterile gauze
B. Covering the lesion with a sterile, saline-soaked gauze
1. The mother of a child with acute laryngotracheobronchitis (LTB) ask why her child must be kept NPO. Which responses would be the most correct?
A. The child's rapid respirations pose a risk for aspiration.
B. The child is not hungry.
C. The epinephrine given causes nausea and vomiting.
D. The child is being hydrated with IV fluids.
A. The child's rapid respirations pose a risk for aspiration.
1. What should the therapeutic management of iron deficiency anemia include?
A. Iodine
B. Multivitamin
C. Calcium
D. Ferrous sulfate
D. Ferrous sulfate
1. What should the nurse caring for a 6-year-old child with acute glomerulonephritis anticipate as the most difficult part of the care to implement?
A. Increased feedings
B. Bed rest
C. Forced fluids
D. Frequent position changes
B. Bed rest
1. What is the main characteristic of cystic fibrosis?
A. Excessive, thick mucus
B. An overproduction of thin mucus
C. An underproduction of exocrine glands
D. Multiple upper respiratory infections
A. Excessive, thick mucus
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