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Before a routine checkup in the pediatrician’s office, an 8-month-old infant sits contentedly on the mother’s lap, chewing on a toy When preparing to examine this infant, what should the nurse plan to do first?
  1. Measure the head circumference
  2. Auscultate the heart and lungs.
  3. Elicit the pupillary reaction
  4. Weigh the child
Correct Answer: 2 RATIONALES: Heart and lung auscultation rarely distresses an infant, so it should be done early in the assessment Placing a tape measure on the infants head, shining a light in the eyes, or undressing the infant before weighing may cause distress, making the rest of the examination more difficult.
The nurse is caring for a toddler with Down syndrome. To help the toddler cope with painful procedures, the nurse can:
  1. prepare the child by positive self-talk.
  2. establish a time limit to get ready for the procedure
  3. hold and rock him and give him a security object
  4. count and sing with the child
Correct Answer:3 RA11ONALES: The child with Down syndrome may have difficulty coping with painful procedures and may regress during his illness Holding, rocking, and giving the child a security object may be comforting to the child An older child or a child without Down syndrome may benefit from positive self-talk, time limits, and diversionary tactics, such as counting and singing; however, the success of these tactics depends on the child.
A nurse is caring for a 5-year-old child who is in the terminal stages of cancer. Which statements are true? Select all that apply:
  1. The parents may be at different stages in dealing with the childs death.
  2. The child is thinking about the future and knows he may not be able to participate.
  3. The dying child may become clingy and act like a toddler.
  4. Whispering in the chilcrs room will help the child to cope.
  5. The death of a child may have long-term disruptive effects on the family.
  6. The child doesn fully understand the concept of death.
Correct Answer: 1,3,5,6 RATIONALES: When dealing with a dying child, parents may be at different stages of grief at different times. The child may regress in his behaviors. The stress of a child’s death commonly results in divorce and behavioral problems in siblings. Preschoolers see death as temporary — a type of sleep or separation. They recognize the word “dead” but don’t fully understand its meaning. Thinking about the future is typical of an adolescent facing death, not a preschooler. Whispering in front of the child only increases his fear of death.
A client is prescribed seriraline (Zoloft), a selective serotonin reuptake inhibitor. Which information about this drug’s adverse effects would the nurse include when creating a medication teaching plan? Select all that apply:
  1. Agitation
  2. Agranuloctosis
  3. Sleep disturbance
  4. Intermittent tachycardia
  5. Dry mouth
  6. Seizures
Correct Answer: 1,3,5 RATIONALES: Common adverse effects of sertraline are agitation, sleep disturbance, and dry mouth Agranulocytosis, intermittent tachycardia. and seizures are adverse effects of clozapine (Clozaril).
A chronically ill school-age child is most vulnerable to which stressor?
  1. Mutilation anxiety
  2. Anticipatory grief
  3. Anxiety over school absences
  4. Fear of hospital procedures
Correct Answer: 3 RATIONALES: The school-age child is becoming industrious and attempts to master school-related activities Therefore, school absences are likely to cause extreme anxiety for a school-age child who’s chronically ill Mutilation anxiety is more common in adolescents. Anticipatory grief is rare in a school-age child. Fear of hospital procedures is most pronounced in preschool-age children.
When teaching the parent of a school-age child about signs and symptoms of fever that require immediate notification of the physician, which description should the nurse include?
  1. Burning or pain with urination
  2. Complaints of a stiff neck
  3. Fever disappearing for longer than 24 hours, then returning
  4. History of febrile seizures
Correct Answer: 2 RATIONALES: A child with a fever and a stiff neck should be evaluated immediately for meningitis. All other symptoms should be addressed by the physician but can wait until office hours.
A client is admitted to the psychiatric hospital with a diagnosis of catatonic schizophrenia During the physical examination, the client’s arm remains outstretched after the nurse obtains the pulse and blood pressure, and the nurse must reposition the arm. This client is exhibiting:
  1. suggestibility.
  2. negativity.
  3. waxy flexibility.
  4. retardation.
Correct Answer: 3 RATIONALES: Waxy flexibility, the ability to assume and maintain awkward or uncomfortable positions for long periods, is characteristic of catatonic schizophrenia. Clients commonly remain in these awkward positions until someone repositions them Clients with dependency problems may demonstrate suggestibility, a response pattern in which one easily agrees to the ideas and suggestions of others rather than making independent judgments. Negativity (for example. resistance to being moved or being asked to cooperate) and retardation (slowed movement) also occur in catatonic clients.
The nurse is assessing a client who has just been admitted to the emergency department. Which signs would suggest an overdose of an antianxiety agent?
  1. Combativeness, sweating, and confusion
  2. Agitation, hyperactivity, and grandiose ideation
  3. Emotional lability, euphoria, and impaired memory
  4. Suspiciousness, dilated pupils, and increased blood pressure
Correct Answer: 3 RATIONALES: Signs of antianxiety agent overdose include emotional lability, euphoria, and impaired memory. Phencyclidine overdose can cause combativeness, sweating. and confusion. Amphetamine overdose can result in agitation, hyperactivity, and grandiose ideation Hallucinogen overdose can produce suspiciousness, dilated pupils, and increased blood pressure.
A client tells the nurse that he is hang suicidal thoughts every day. In conferring with the treatment team, the nurse should make which recommendation?
  1. A no-suicide contract
  2. Weekly outpatient therapy
  3. A second psychiatric opinion
  4. Intensive inpatient treatment
Correct Answer: 4 RATIONALES: Inpatient care is the best intervention for a client who is thinking about suicide every day. Implementing a no-suicide contract is an important strategy, but this client requires additional care. Weekly therapy wouldn’t provide the intensity of care that this case warrants. Obtaining a second opinion would take time; this client requires immediate intervention.
Which sign is least likely to indicate abuse in a 4-year-old child?
  1. Conflicting stories about the accident or injuryfrom the parents
  2. History inconsistent with the childs developmental level
  3. Disheveled parental appearance and low socioeconomic status
  4. Exaggerated or absent emotional response by the caregiver
Correct Answer: 3 RATIONALES: The physical appearance and income level of parents aren’t indicators of expected or potential abuse. Nurses must be aware of their biases regarding child abuse. Conflicting stories about the accident or injury from the parents, history inconsistent with the child’s developmental level, and an inappropriate response by the parents, such as an exaggerated or absent emotional response, are warning signs of abuse.
Two nurses are discussing a client’s condition in the elevator. The employer of the mentioned client overhears the conversation and fires the client. The nurses may be liable for which accusation?
  1. Assault
  2. Battery
  3. Neglect
  4. Breach of confidentiality
Correct Answer: 4 RATIONALES: Breach of confidentiality occurs when a nurse shares information that can cause harm to an individual. Assault is an act that results in fear that one will be touched without consent. Battery involves unconsented touching of another person. Neglect is the failure to do what is deemed reasonable in a situation.
A 4-year-old child is ordered to receive 25 ml/hour of I.V. solution. The nurse is using a pediatric microdrip chamber to administer the medication. For how many drops per minute should the microdrip chamber be set?
Correct Answer: 25 RATIONALES: When using a pediatric microdrip chamber, the number of milliliters per hour equals the number of drops per minute. If 25 ml/hour is ordered, the I.V. should infuse at 25 drops/minute.
Which of the following is the recommended immunization schedule for diphtheria, tetanus, and pertussis (DTP)?
  1. Birth, 2 months, 6 months, 15 to 18 months, and 10 to 12 years
  2. 1 month, 2 months, 6 months, 15 to 18 months, and 4 to 6 years
  3. 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years
  4. Birth, 3 months, 6 months, 12 months, and 4 to 6 years
Correct Answer: 3 RATIONALES: According to the American Academy of Pediatrics and the Committee on Infectious Diseases, the DTP vaccine should be administered at 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years (before the start of school). The other options are incorrect.
A woman seeking help at a community mental health center complains of fatigue, sensitivity to criticism, decreased libido, and feeling self-conscious. She also has aches and pains. A nursing diagnosis for this client might include:
  1. Delayed growth and development.
  2. Ineffective role performance.
  3. Posttrauma syndrome.
  4. Situational low self-esteem.
Correct Answer: 4 RATIONALES: All symptoms define a disturbance in self-esteem. There isn’t enough information to determine delayed growth and development. The question doesn’t describe the client’s ability to perform in her roles. Posttrauma syndrome occurs after experiencing a traumatic event and doesn’t coincide with the data in the scenario.
A 9-month-old infant is admitted with diarrhea and dehydration. The nurse plans to assess the child’s vital signs frequently. Which other action would provide the most important assessment information?
  1. Measuring the infant’s weight
  2. Obtaining a stool specimen for analysis
  3. Obtaining a urine specimen for analysis
  4. Inspecting the infanf’s posterior fontanel
Correct Answer: 1 RATIONALES: Frequent weight measurement provides the most important information about fluid balance and the infant’s response to fluid replacement. Although the results of stool or urine analysis may provide some information, they typically aren’t available for at least 24 hours. The posterior fontanel usually closes from ages 6 to 8 weeks and therefore doesn’t reflect fluid balance in a 9-month-old infant.
The nurse notes that an infant develops arm movement before fine-motor finger skills and interprets this as an example of which pattern of development?
  1. Cephalocaudal
  2. Proximodistal
  3. Differentiation
  4. Mass-to-specific
Correct Answer: 2 RATIONALES: Proximodistal development progresses from the center of the body to the extremities, such as from the arm to the fingers. Cephalocaudal development occurs along the body’s long axis; for example, the infant develops control over the head, mouth, and eye movements before the upper body, torso, and legs. Mass-to-specific development, sometimes called differentiation, occurs as the child masters simple operations before complex functions and moves from broad, general patterns of behavior to more refined ones.
Mental health laws in each state specify when restraints can be used and which type of restraints are allowed. Most laws stipulate that restraints can be used:
  1. for a maximum of 2 hours.
  2. as necessary to control the client
  3. if the client poses a present danger to himself or others
  4. only with the client’s consent
Correct Answer: 3 RATIONALES: Most states allow restraints to be used if the client presents a danger to himself or others. This danger must be reevaluated every few hours. If the client is still a danger, restraints can be used until the violent behavior abates. No standing orders for restraints are allowed, and restraints are permitted only until more “humane” methods, such as sedatives, become effective. Violent clients who are intoxicated with drugs or alcohol present a problem because they can rarely be sedated until the drug or alcohol is metabolized. In such cases, restraints may be needed for a longer period, but the client must be closely observed. Obtaining consent isn’t always possible, especially when the client’s violent behavior results from a psychosis such as paranoid schizophrenia.
The nurse formulates a nursing diagnosis of Risk for infection for a child with Down syndrome. Which condition typically seen in children with this syndrome supports this nursing diagnosis?
  1. Muscular hypotonicity
  2. Muscle spasticity
  3. Increased mucus viscosity
  4. Hypothyroidism
Correct Answer: 1 RATIONALES: Several conditions make the child with Down syndrome highly vulnerable to respiratory infections. For example, the hypotonicity of chest muscles leads to diminished respiratory expansion and pooling of secretions, while an underdeveloped nasal bone impairs mucus drainage. Down syndrome isn’t associated with muscle spasticity or increased mucus viscosity. Although hypothyroidism is common in children with Down syndrome, it doesn’t increase the risk of infection.
Nursing preparations for a client undergoing electroconvulsive therapy (ECT) resemble those used for:
  1. physical therapy.
  2. neurologic examination.
  3. general anesthesia.
  4. cardiac stress testing.
Correct Answer 3 RATIONALES: The nurse should prepare a client for ECT in a manner similar to that for general anesthesia. For example, the client should receive nothing by mouth for 8 hours before ECT to reduce the risk of vomiting and aspiration. Also, the nurse should have the client void before treatment to decrease the risk of involuntary voiding during the procedure; remove any full dentures, glasses, or jewelry to prevent breakage or loss; and make sure the client is wearing a hospital gown or loose-fitting clothing to allow unrestricted movement. Usually, these preparations aren’t indicated for a client undergoing physical therapy, neurologic examination, or cardiac stress testing.
The mother of a school-age child reports that her child is having some problems in school. Which action would be the priority?
  1. Obtain more information from the mother and the child.
  2. Refer the child to the school psychologist for testing
  3. Talk to the child’s health care provider to understand the child better.
  4. Talk to the child’s teacher to gain a perspective on the situation
Correct Answer: 1 RATIONALES: In this situation, the nurse needs more information before proceeding and should question the mother and child about the problems. Referring the child to the school psychologist and talking to the child’s health care provider and teacher are all important components of a treatment plan, but obtaining more information comes first.
As an adolescent is receiving care, he’s inadvertently injured with a warm compress. The nurse completes an incident report based on the knowledge that identification of which of the following is not a goal of the report?
  1. Staff involved so they’re reprimanded for their actions
  2. Learning needs of staff to prevent recurrence of incidents
  3. Patterns of client care problems
  4. Facts surrounding each incident
Correct Answer: 1 RATIONALES: The main goal of an incident report following an adventitious event isn’t punishment for those involved in the incident. The purpose of an incident report is threefold: to identify ways to prevent recurrences of incidents, to identify patterns of care problems, and to identify facts surrounding each incident.
When assessing the chest of a 4-month-old infant, the nurse identifies which ratio of the anteroposterior-to-lateral diameter as normal?
  1. 1:1
  2. 1:3
  3. 2:1
  4. 3:1
Correct Answer: 1 RATIONALES: In an infant, the anteroposterior diameter normally equals the lateral diameter. In a toddler, the anteroposterior diameter should be less than the lateral diameter.
The nurse is preparing to administer the first dose of tobramycin (Nebcin) to an adolescent with cystic fibrosis. The order is for 3 mg/kg I.V. daily in three divided doses. The client weighs 95 lb. How many milligrams should the nurse administer per dose?
Correct Answer: 43.2 RATIONALES: To perform this dosage calculation, the nurse should first convert the client’s weight to kilograms using this formula: 1 kg/2.2 lb = X kg/951b 2.2X = 95 X = 43.2 kg Then, she should calculate the client’s daily dose using this formula: 43.2 kg x 3mg/kg = 129.6 mg Lastly, the nurse should calculate the divided dose: 129.6 mg ÷ 3 doses = 43.2 mg/dose
A client with bipolar disorder has been taking lithium carbonate (Lithonate), as prescribed, for the past 3 years. Today, family members brought this client to the hospital. The client hasn’t slept, bathed, or changed clothes for 4 days; has lost 10 lb (4.5 kg) in the last month; and woke the entire family at 4 a.m. with plans to fly them to Hawaii for a vacation. Based on this information, what can the nurse assume?
  1. The family isn’t supportive of the client.
  2. The client has stopped taking the prescribed medication
  3. The client hasn’t accepted the diagnosis of bipolar disorder
  4. The lithium level should be measured before the client receives the next lithium dose
Correct Answer: 4 RATIONALES: Measuring the lithium level is the best way to evaluate the effectiveness of lithium therapy and begin to assess the client’s current status. The other options may contribute to the client’s manic episode, but the nurse can’t assume them to be true until after assessing the client and family more fully.
On the second day of hospitalization, the client is discussing with the nurse concerns about unhealthy family relationships. During the nurse-client interaction, the client changes the subject to a job situation. The nurse responds, “Let’s go back to what we were just talking about.” What therapeutic communication technique did the nurse use?
  1. Reflecting
  2. Restating
  3. Focusing
  4. Summarizing
Correct Answer: 3 RATIONALES: The therapeutic communication technique used by the nurse to direct a client back to the original topic of discussion is called focusing. Focusing fosters the client’s self-control and helps avoid vague generalizations, so the client can accept responsibility for facing problems. Reflecting directs the idea back to the client. Restating involves repeating the main idea back to the client. This technique lets the client know what the nurse heard. With summarizing, the nurse gives a brief synopsis of what was covered in the conversation.
A client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, the nurse asks him when he had his last alcoholic drink. He says that he had his last drink 6 hours before admission. Based on this response, the nurse should expect early withdrawal symptoms to:
  1. not occur at all because the time period for their occurrence has passed
  2. begin anytime within the next 1 to 2 days
  3. begin within 2 to 7 days
  4. begin after 7 days.
Correct Answer: 2 RATIONALES: Acute withdrawal symptoms from alcohol may begin 6 hours after the client has stopped drinking and peak 1 to 2 days later. Alcohol withdrawal delirium may occur 2 to 4 days — even up to 7 days — after the last drink.
A client who reportedly consumes 1 qt of vodka daily is admitted for alcohol detoxification. To try to prevent alcohol withdrawal symptom, the physician is most likely to prescribe which drug?
  1. clozapine (Clozani)
  2. thiothixene (Navane)
  3. lorazepam (Ativan)
  4. lithium carbonate (Eskalith)
Correct Answer: 3 RATIONALES: The best choice for preventing or treating alcohol withdrawal symptoms is lorazepam, a benzodiazepine. Clozapine and thiothixene are antipsychotic agents, and lithium carbonate is an antimanic agent; these drugs aren’t used to manage alcohol withdrawal syndrome.
When a preschooler’s family displays high levels of mistrust, monitors everyone’s performance, wants high levels of information, and asks for rule changes, which strategy would be inappropriate?
  1. Ask their opinion and use their suggestions.
  2. Be positive about building a trusting relationship
  3. Be flexible regarding rules.
  4. Show support while controlling the care of the child.
Correct Answer: 4 RATIONALES: When a family shows high levels of mistrust, monitors everyone’s performance, requires high levels of information, and requests rule changes, the nurse should attempt to build a partnership with the family to reach the goal of mutually caring for the child. Attempting to control care with this family will alienate the family, stress the relationship, and be counterproductive for the child. Good strategies for working with this family would be to ask their opinion, use their suggestions, be positive about building a trusting relationship, and be flexible regarding rules.
A client chronically complains of being unappreciated and misunderstood by others. She is argumentative and sullen. She always blames others for her failure to complete work assignments. She expresses feelings of envy toward people she perceives as more fortunate. She voices exaggerated complaints of personal misfortune. The client most likely suffers from which personality disorder?
  1. Dependent personality
  2. Passive-aggressive personality
  3. Avoidant personality disorder
  4. Obsessive-compulsive disorder
Correct Answer: 2 RATIONALES: The client with passive-aggressive personality disorder displays a pervasive pattern of negative attitudes, chronic complaints, and passive resistance to demands for adequate social and occupational performance. The client with a dependent personality is unable to make everyday decisions and allows others to make important decisions. In addition, the client with a dependent personality often volunteers to do things that are unpleasant so that others will like him. The avoidant personality displays a pervasive pattern of social discomfort, fear of negative evaluation, and timidity. The obsessive-compulsive personality displays a pervasive pattern of perfectionism and inflexibility.
A preschool-age child is admitted to the facility with nephrotic syndrome. Nursing assessment reveals a blood pressure of 100/60 mm Hg, lethargy, generalized edema, and dark, frothy urine. After prednisone (Deltasone) therapy is initiated, which nursing action takes highest priority?
  1. Monitoring the child for hypertension
  2. Turning and repositioning the child frequently
  3. Providing a high-sodium diet
  4. Discussing the adverse effects of steroids with the parents
Correct Answer: 2 RATIONALES: The child with nephrotic syndrome is at risk for skin breakdown from generalized edema. Because this syndrome typically impairs independent movement, the nurse must turn and reposition the child frequently to help prevent skin breakdown. Frequent turning also helps prevent respiratory infections, which may arise during the edematous phase of nephrotic syndrome. The syndrome typically causes hypotension, not hypertension, from significant loss of intravascular protein and a subsequent drop in oncotic pressure. Dietary sodium should be restricted because it worsens edema. Although the nurse should discuss the adverse effects of steroids with the parents, this isn’t a priority at this time.
The nurse is assessing an 8-month-old during a wellness checkup. Which action is a normal developmental task for an infant this age?
  1. Sitting without support
  2. Saying two words
  3. Feeding himself with a spoon
  4. Playing patty-cake
Correct Answer: 1 RATIONALES: According to the Denver Developmental Screening Test, most infants should be able to sit unsupported by age 7 months. A 15-month-old child should be able to say two words. By 17 months, the toddler should be able to feed himself with a spoon. A 10-month-old should be able to play patty-cake.
An infant, age 10 months, is brought to the well-baby clinic for a follow-up visit. The mother tells the nurse that she has been having trouble feeding her infant solid foods. To help correct this problem, the nurse should:
  1. point out that tongue thrusting is the infant’s way of rejecting food.
  2. instruct the mother to place the food at the back and toward the side of the infant’s mouth.
  3. advise the mother to puree foods if the child resists them in solid form.
  4. suggest that the mother force-feed the child if necessary.
Correct Answer: 2 RATIONALES: Placing the food at the back and toward the side of the infant’s mouth encourages swallowing. Tongue thrusting is a physiologic response to food placed incorrectly in the mouth. Offering pureed foods wouldn’t encourage swallowing, which is a learned behavior. Force-feeding may be frustrating for both the mother and child and may cause the child to gag and choke when attempting to reject the undesired food; also, it may lead to a higher-than-normal caloric intake, resulting in obesity.
The nurse manager of the pediatric unit is responsible for making sure that each staff member reviews the unit policies annually. What policy should the nurse manager emphasize with the clerical support staff?
  1. Proper documentation of a verbal order from a physician
  2. Policy changes in the administration of opioids
  3. New education materials for the management of diabetes
  4. Logging off a computer containing client information
Correct Answer: 4 RATIONALES: All members of the health care team are required to maintain strict patient confidentiality, including securing electronic patient information. Therefore, the clerical support staff should be instructed about the importance of logging off a computer containing client information immediately after use. Taking a verbal order, administering medications, and patient education aren’t within the scope of practice of the clerical support staff.
A 22-year-old male client diagnosed with antisocial personality disorder asks the nurse if he can have an additional smoke break because he’s anxious. Which response would be best?
  1. “Well okay, I have a few minutes. I’ll take you.”
  2. “I’m sorry but I can’t take you. I’m busy.”
  3. “Smoking is harmful to your health. I don’t want to contribute to your bad habits.”
  4. “Clients are permitted to smoke at designated times. You’ll have to follow the rules.”
Correct Answer: 4 RATIONALES: Consistency is essential when dealing with antisocial clients. They disregard social norms and don’t believe the rules apply to them. Option 1 would be detrimental to the client because it reinforces the client’s acting-out behaviors. Option 2 avoids the client’s attempt to manipulate. Option 3 is inappropriate because the nurse is lecturing the client.
The nurse knows that the physician has ordered the liquid form of the drug chlorpromazine (Thorazine) rather than the tablet form because the liquid:
  1. has a more predictable onset of action
  2. produces fewer anticholinergic effect
  3. produces fewer drug interactions
  4. has a longer duration of action
Correct Answer: 1 RATIONALES: A liquid phenothiazine preparation will produce effects in 2 to 4 hours. The onset with tablets is unpredictable.
A child, age 5, with an intelligence quotient (IQ) of 65 is admitted to the facility for evaluation. When planning care, the nurse should keep in mind that this child:
  1. is within the lower range of normal intelligence
  2. would have a diagnosis of mild mental retardation
  3. would have a diagnosis of moderate mental retardation.
  4. would have a diagnosis of severe mental retardation
Correct Answer: 2 RATIONALES: According to the American Association on Mental Deficiency, a person with an IQ between 50 and 70 is classified as mildly mentally retarded. One with an IQ between 36 and 50 is classified as moderately retarded. One with an IQ below 36 is severely impaired.
The nurse expects an infant to sit up without support at which age?
  1. 4 months
  2. 6 months
  3. 8 months
  4. 10 months
Correct Answer: 3 RATIONALES: Most infants can sit up without support by age 8 months. At age 4 months, the infant can lift the head off the mattress up to a 90-degree angle. Between ages 6 and 7 months, the infant can sit while leaning forward on the hands. At age 10 months, the infant typically can move from a prone to a sitting position and pull himself up to a standing position.
Which psychological or personality factor is most likely to predispose an individual to medication abuse?
  1. Low self-esteem and unresolved rage
  2. Desire to inflict pain upon one’s self
  3. Dependent personality disorder
  4. Antisocial personality disorder
Correct Answer: 1 RATIONALES: Low self-esteem and repressed rage as well as depression can predispose an individual to search for solace in addictive medications. Commonly, medications are used to minimize or blot out pain, rather than inflict additional pain. Personality disorders don’t predispose a client to medication abuse; however, personality disorders, especially the antisocial ones, may be intensified by abuse.
A toddler with hemophilia is hospitalized with multiple injuries after falling off a sliding board. X-rays reveal no bone fractures. When caring for the child, what is the nurse’s highest priority?
  1. Administering platelets as prescribed
  2. Taking measures to prevent infection
  3. Frequently assessing the child’s level of consciousness (LOC)
  4. Discussing a safe play environment with the parents
Correct Answer: 3 RATIONALES: In hemophilia, one of the factors required for blood clotting is absent, significantly increasing the risk of hemorrhage after injury. The nurse must assess the child frequently for signs and symptoms of intracranial bleeding, such as an altered LOC, slurred speech, vomiting, and headache. To manage hemophilia, the absent blood clotting factor is replaced via I.V. infusion of factor, cryoprecipitate, or fresh frozen plasma; this may be done prophylactically or after a traumatic injury. Platelet transfusions aren’t necessary. Hemophiliacs aren’t at increased risk for infection. Discussing a safe play environment with the parents is important but isn’t the highest priority.
A mother tells the nurse that her 22-month-old child says no to everything. When scolded, the toddler gets angry and starts crying loudly but then immediately wants to be held. What is the best interpretation of this behavior?
  1. The toddler isn’t coping with stress effectively.
  2. The toddler’s need for affection isn’t being met.
  3. This behavior is normal in a 2-year-old child.
  4. This behavior suggests the need for counseling.
Correct Answer: 3 RATIONALES: Toddlers are confronted with the conflict of achieving autonomy yet relinquishing their much-enjoyed dependence on — and affection of— others. Therefore, their negativism is a necessary assertion of self-control. Nothing about this behavior indicates that the child is under stress, isn’t receiving sufficient affection, or requires counseling.
When a toddler with croup is admitted to the facility, the physician orders treatment with a mist tent. As the parent attempts to put the toddler in the crib, the toddler cries and clings to the parent. What is the nurse’s best approach for gaining the child’s cooperation with the treatment?
  1. Turn off the mist so the noise doesn’t frighten the toddler
  2. Let the toddler sit on the parent’s lap next to the mist tent
  3. Encourage the parent to stand next to the crib and stay with the child
  4. Put the side rail down so the toddler can get into and out of the crib unaided
Correct Answer: 3 RATIONALES: By encouraging the parent to stand next to the crib and stay with the child, the nurse promotes compliance with treatment while minimizing the toddler’s separation anxiety. Because the mist helps thin secretions and make them easier to clear, turning off the mist or letting the toddler sit next to the mist tent defeats the treatment’s purpose. To prevent falls, the nurse should keep the side rails up and shouldn’t permit the toddler to climb into and out of the crib.
The nurse is preparing to administer short-acting insulin to a child with type 1 diabetes mellitus When should the nurse measure the child’s blood glucose level?
  1. Immediately before administering insulin
  2. 15 minutes after administering insulin
  3. 1 hour after administering insulin
  4. 4 hours after administering insulin
Correct Answer: 3 RATIONALES: Short-acting insulins peak in 30 minutes to 2 hours after administration. The nurse should check the child’s blood glucose level during this period, such as 1 hour after administration.
A disabled school-age child whose parents are overprotective may display which characteristics?
  1. Dependency, fearfulness, and lack of outside interests
  2. Extreme independence, defiance, and a high level of risk taking
  3. Shyness and loneliness
  4. Pride and confidence in one’s ability to cope
Correct Answer: 1 RATIONALES: Disabled children whose parents are overprotective tend to have marked dependency, fearfulness, inactivity, and lack of outside interests. Children who are raised by oversolicitous and guilt-ridden parents are often overly independent, defiant, and high-risk takers. Children who are reared by parents who emphasize the child’s deficits and tend to isolate the child may appear shy and lonely. Children who are reared by parents who establish reasonable limits have pride and confidence in their ability to cope successfully.
The nurse is caring for a toddler who was diagnosed with an inoperable brain tumor. The parents are having difficulty deciding on a course of action for their child. Why is it important to have the nurse involved in an ethical discussion about a planned course of treatment?
  1. The nurse is viewed as the authority on ethical issues at the hospital
  2. The nurse can act as a liaison between the client, the client’s parents, and the health care team.
  3. The nurse can easily make time to discuss issues with the parents
  4. It isn’t important to involve the nurse in this type of discussion.
Correct Answer: 2 RATIONALES: Because the nurse has the most direct contact with the client and his parents, she can listen to and communicate their wishes for treatment. She can also aid in interpreting information about the client’s condition and course of treatment, helping the parents to make an informed decision. Time shouldn’t be a factor when it comes to helping parents make decisions about their child’s care. Hospitals commonly employ ethicists who can help with ethical dilemmas.
Which of the following medications would the nurse expect the physician to order to reverse a dystonic reaction?
  1. prochlorperazine (Compazine)
  2. diphenhydramine (Benadryl)
  3. haloperidol (Haldol)
  4. midazolam (Versed)
Correct Answer: 2 RATIONALES: Diphenhydramine, 25 to 50 mg I.M or I.V., would quickly reverse this condition. Prochlorperazine and haloperidol are both capable of causing dystonia, not reversing it. Midazolam would make this client drowsy.
A dystonic reaction can be caused by which medication?
  1. Diazepam (Valium)
  2. Haloperidol (Haldol)
  3. Amitriptyline (Elavil)
  4. Clonazepam (Klonopin)
Correct Answer: 2 RATIONALES: Haloperidol is a phenothiazine and is capable of causing dystonic reactions. Diazepam and clonazepam are benzodiazepines, and amitriptyline is a tricyclic antidepressant. Benzodiazepines don’t cause dystonic reactions; however, they can cause drowsiness, lethargy, and hypotension. Tricyclic antidepressants rarely cause severe dystonic reactions; however, they can cause a decreased level of consciousness, tachycardia, dry mouth, and dilated pupils.
The nurse is preparing to administer I.V. methylprednisolone sodium succinate (Solu-Medrol) to a child who weighs 42 lb. The order is for 0.03 mg/kg I.V. daily. How many milligrams should the nurse prepare?
Correct Answer: 0.6 RATIONALES: To perform this dosage calculation, the nurse should first convert the child’s weight to kilograms: 44 lb ÷ 2.2 kg/lb = 20 kg Then she should use this formula to determine the dose: 20 kg x 0.03 mg/kg = X mg X = 0.6 mg
During a group therapy session in the psychiatric unit, a client constantly interrupts with impulsive behavior and exaggerated stories that cast her as a hero or princess. She also manipulates the group with attention-seeking behaviors, such as sexual comments and angry outbursts. The nurse realizes that these behaviors are typical of:
  1. paranoid personality disorder
  2. avoidant personality disorder
  3. histrionic personality disorder
  4. borderline personality disorder
Correct Answer: 3 RATIONALES: This client’s behaviors are typical of histrionic personality disorder, which is marked by excessive emotionality and attention seeking. The client constantly seeks and demands attention, approval, or praise; may be seductive in behavior, appearance, or conversation; and is uncomfortable except when she is the center of attention. Typically, a client with paranoid personality disorder is suspicious, cold, hostile, and argumentative. Avoidant personality disorder is characterized by anxiety, fear, and social isolation. Borderline personality disorder is characterized by impulsive, unpredictable behavior and unstable, intense interpersonal relationships.
A client with anorexia nervosa tells the nurse, “When I look in the mirror, I hate what I see. I look so fat and ugly.” Which strategy should the nurse use to deal with the client’s distorted perceptions and feelings?
  1. Avoid discussing the client’s perceptions and feelings.
  2. Focus discussions on food and weight
  3. Avoid discussing unrealistic cultural standards regarding weight.
  4. Provide objective data and feedback regarding the client’s weight and attractiveness
Correct Answer: 4 RATIONALES: By focusing on reality, this strategy may help the client develop a more realistic body image and gain self-esteem. Option 1 is inappropriate because discussing the client’s perceptions and feeling wouldn’t help her to identify, accept, and work through them. Focusing discussions on food and weight would give the client attention for not eating, making option 2 incorrect. Option 3 is inappropriate because recognizing unrealistic cultural standards wouldn’t help the client establish more realistic weight goals.
When performing a physical assessment on a girl, age 10, the nurse keeps in mind that the first sign of sexual maturity in girls is:
  1. breast bud development
  2. pubic hair
  3. axillary hair
  4. menarche
Correct Answer: 1 RATIONALES: Breast bud development — elevation of the nipple and areola to form a breast bud — is the first sign of sexual maturity in girls. Sexual maturation continues with the appearance of pubic hair, axillary hair, and menarche, consecutively.
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