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A client with agoraphobia has been symptom-free for 4 months. Classic signs and symptoms of phobias include: 1. insomnia and an inability to concentrate 2. severe anxiety and fear 3. depression and weight loss 4. withdrawal and failure to distinguish reality from fantasy
Correct Answer: 2 RATIONALES: Phobias cause severe anxiety (such as a panic attack) that is out of proportion to the threat of the feared object or situation. Physical signs and symptoms of phobias include profuse sweating, poor motor control, tachycardia, and elevated blood pressure. Insomnia, an inability to concentrate, and weight loss are common in depression. Withdrawal and failure to distinguish reality from fantasy occur in schizophrenia.
A 2-yearold child with a low blood level of the immunosuppressive drug cyclosporine comes to a liver transplant clinic for her appointment. The mother says the child hasn’t been vomiting and hasn’t had diarrhea, but she admits that her daughter doesn’t like taking the liquid medication. Based on knowledge of the drug, which of the following would the nurse instruct the mother to do? 1. Let your daughter take her medication only when she wants it; it’s okay for her to miss some doses 2. Offer the medication diluted with chocolate milk or orange juice to make it more palatable 3. Insert a nasogastric (NG) tube and administer the medication using the tube as ordered by the physician 4. Give the ordered dose a little bit at a time over2 hours to ensure administration of the medication
Correct Answer: 2 RATIONALES: Liquid cyclosporine has a very unpleasant taste. Diluting it will lessen the strong taste and help the child take the medication as ordered. It isn’t acceptable to miss a dose because the drug’s effectiveness is based on therapeutic blood levels, and skipping a dose could lower the level. Cyclosporine shouldn’t be given by NC tube because it adheres to the plastic tube and, thus, all of the drug may not be administered. Taking the medication over a period of time could negatively affect the blood level.
An adolescent, age 17, with acute lymphoblastic leukemia is discharged with written information about chemotherapy administration and the outpatient appointment schedule. The child now is in the maintenance phase of chemotherapy but has missed clinic appointments for blood work and admits to omitting some chemotherapy doses. To improve the client’s compliance, the nurse should include which intervention in the care plan? 1. Emphasizing the long-term consequences of noncompliance 2. Reprimanding the client for failing to comply 3. Letting the client participate in the planning and scheduling of treatments 4. Threatening to discontinue care if the client doesn’t comply
Correct Answer: 3 RATIONALES: Because the adolescent is striving for independence, health care providers should promote self-reliance whenever possible such as by letting the child participate in the planning and scheduling of treatments. The client can help establish realistic goals and evaluation outcomes as well as help schedule procedures and chemotherapy doses to minimize lifestyle disruptions. Adolescents are oriented in the present and have relatively little concern for the long-term consequences of their behavior. Reprimanding the client or threatening to discontinue care isn’t likely to improve compliance and isn’t in the client’s best interest.
The charge nurse on the pediatric unit informs the staff nurse that four of her clients require attention. Which client should the nurse see first? 1. An 8-year-old client admitted from the postanesthesia care unit who’s complaining of pain 2. A 10-year-old client with asthma whose oxygen saturation levels are dropping 3. A 7-year-old client whose mother is waiting for discharge instructions 4. A 9-year-old client with a broken leg who wants help moving from the bed to the chair
Correct Answer:2 RATIONALES: Decreasing oxygen saturation levels indicate difficulty breathing and increased work of breathing. Airway, breathing, and circulation always take priority. Administration of pain medication and reviewing discharge instructions can be delegated to another registered nurse. Moving a patient from the bed to the chair can be delegated to a nursing assistant.
A 26-year-old man reports losing his sight in both eyes. He’s diagnosed as having a conversion disorder and is admitted to the psychiatric unit. Which nursing intervention would be most appropriate for this client? 1. Not focusing on his blindness 2. Providing self-care for him 3. Telling him that his blindness isn’t real 4. Teaching eye exercises to strengthen his eyes
Correct Answer: 1 RATIONALES: Focusing on the client’s blindness can positively reinforce the blindness and further promote the use of maladaptive behaviors to obtain secondary gains. The client should be encouraged to participate in his own care as much as possible to avoid fostering dependency. To promote self-esteem, give positive reinforcement for what the client can do. Blindness and other physical symptoms in a conversion disorder aren’t under the client’s control and are real to him. Eye exercises won’t resolve the client’s blindness because no organic pathology is causing the symptoms.
The nurse is preparing for the discharge of a client who has been hospitalized for paranoid schizophrenia. The client’s husband expresses concern over whether his wife will continue to take her daily prescribed medication. The nurse should inform him that: 1. his concern is valid, but his wife is an adult and has the right to make her own decisions 2. he can easily mix the medication in his wife’s food if she stops taking it. 3. his wife can be given a long-acting medication that is administered every 1 to 4 weeks. 4. his wife knows she must take her medication as prescribed to avoid future hospitalizations.
Correct Answer: 3 RATIONALES: Long-acting psychotropic drugs can be administered by depot injection every 1 to 4 weeks. These agents are useful for noncompliant clients because the client receives the injection at the outpatient clinic. A client has the right to refuse medication, but this issue isn’t the focus of discussion at this time. Medication should never be hidden in food or drink to trick the client into taking it; in addition to destroying the client’s trust, doing so would place the client at risk for overmedication or undermedication because the amount administered is hard to determine. Assuming the client knows she must take the medication to avoid future hospitalizations would be unrealistic.
The nurse is monitoring a client who appears to be hallucinating. The nurse notes paranoid content in the client’s speech, and he appears agitated. The client is gesturing at a figure on the television. Which nursing interventions are appropriate? Select all that apply: 1. In a firm voice, instruct the client to stop the behavior. 2. Reinforce that the client is not in any danger. 3. Acknowledge the presence of the hallucinations. 4. Instruct other team members to ignore the client’s behavior. 5. Immediately implement physical restraint procedures. 6. Use a calm voice and simple commands.
Correct Answer: 2,3,6 RATIONALES: Using a calm voice, the nurse should reassure the client that he is safe. The nurse shouldn’t challenge the client; rather, she should acknowledge his hallucinatory experience. It isn’t appropriate to request that the client stop the behavior. Implementing restraints isn’t warranted at this time. Although the client is agitated, no evidence exists that the client is at risk for harming himself or others.
The nurse suspects that a toddler, who is admitted to the pediatric unit, has been physically abused by his mother. What is the nurse required to do? 1. Talk with the child about she suspects. 2. Confront the mother with her suspicions 3. Discuss the case with another nurse during lunch break. 4. Report the case to local authorities
Correct Answer: 4 RATIONALES: Every state in the United States has laws for mandatory reporting of suspected child abuse and neglect. These cases are then referred to local agencies, such as Child Protective Services, for investigation. Social workers should be consulted before approaching a child and discussing child abuse. Confronting the mother could increase the risk of harm to the child and to the nurse. Discussing the case with another nurse breaches the client’s confidentiality.
After an upsetting divorce, a client threatens to commit suicide with a handgun and is involuntarily admitted to the psychiatric unit with major depression. Which nursing diagnosis takes highest priority for this client? 1. Hopelessness related to recent divorce 2. Ineffective coping related to inadequate stress management 3. Spiritual distress related to conflicting thoughts about suicide and sin 4. Risk for self-directed violence related to planning to commit suicide with a handgun
Correct Answer: 4 RATIONALES: Although all of these options may apply to this client, safety is the nurse’s first priority in caring for any suicidal client. The nurse can address the client’s hopelessness, ineffective coping, and spiritual distress later in therapy.
After the birth of her first neonate, a mother asks the nurse about the reddened areas (“stork bites”) at the nape of the neonates neck. How should the nurse respond? 1. ‘They’re normal and will disappear as the baby’s skin thickens” 2. ‘They’re a common congenital abnormality” 3. ‘They commonly result from a traumatic delivery” 4. ‘They’re caused by a blockage in the apocrine glands”
Correct Answer: 1 RATIONALES: Capillary hemangioma (“stork bites”) may appear on the neonate’s upper eyelids, the bridge of the nose, or the nape of the neck. They result from vascular congestion and disappear as the skin thickens. They aren’t associated with congenital abnormalities, traumatic delivery, or blocked apocrine glands.
The nurse is using drawing, puppetry, and other forms of play therapy while treating a terminally ill, schoolage child. The purpose of these techniques is to help the child: 1. internalize his feelings about death and dying. 2. accept responsibility for his situation 3. express feelings that he can’t articulate. 4. have a good time while he’s in the hospital.
Correct Answer: 3 RATIONALES: Children may not have the verbal and cognitive skills to express what they feel and may benefit from alternative modes of expression. It’s important for the child to find a way to express internalized feelings. The child must also know that he is not to blame for this situation. In the process of participating in play therapy, the child can also have fun, but that isn’t the main goal of therapy.
The nurse observes a play group of 2-year-old children. The nurse would expect to see: 1. four children playing dodgeball 2. three children playing tag 3. two children side by side in the sandbox building sand castles 4. one child digging a hole and another child blowing bubbles
Correct Answer: 3 RATIONALES: Two-year-olds exhibit parallel play; that is, they engage in similar activity, side by side. Playing dodgeball and tag are examples of interactive play, common to school-age children. A 2-year-old wouldn’t blow bubbles.
A child, age 5, takes theophylline orally three times a day to treat asthma. For the most accurate calculation of a safe dosage, the nurse should use: 1. the child’s weight in kilograms 2. Young’s rule based on the child’s age 3. Clark’s rule based on the child’s weight in pounds 4. the child’s body surface area
Correct Answer: 4 RATIONALES: Using a child’s body surface area may be the most accurate method for calculating safe drug dosages because body surface area is thought to parallel the child’s organ growth and maturation and metabolic rate. Using the child’s weight in kilograms, Young’s rule based on the child’s age, or Clark’s rule based on the child’s weight in pounds is likely to yield less accurate dosages.
In a client with a conversion disorder who reports blindness, ophthalmologic examinations reveal that no physiologic disorder is causing progressive vision loss. The most likely source of this client’s reported blindness is: 1. a family history of major depression 2. having been forced to watch a loved one’s torture 3. noncompliance with a psychotropic medication regimen 4. daily use of antianxiety agents and alcoholic beverages
Correct Answer: 2 RATIONALES: Conversion disorder, or hysterical neurosis, is characterized by alteration or loss of physical function with no physiological basis; the client’s symptoms result from psychological conflict. For example, a client may report blindness after having observed a distressing act, such as seeing a loved one tortured. None of the other options causes conversion disorder.
A 2-year-old child is brought to the emergency department with a history of upper airway infection that has worsened over the last 2 days. The nurse suspects the child has croup. Signs of croup include a hoarse voice, inspiratory stridor, and: 1. a barking cough 2. A high fever 3. sudden onset 4. dysphagia
Correct Answer: 1 RAT1ONALES: Croup is an acute viral respiratory illness characterized by a barking cough. Fever is usually low grade. Croup has a gradual onset, and dysphagia isn’t a symptom.
How should the nurse position an infant when administering an oral medication? 1. Seated in a high chair 2. Restrained flat in the crib 3. Held on the nurse’s lap 4. Held in the bottle-feeding position
Correct Answer: 4 RATIONALES: The nurse should hold an infant in the bottle-feeding position when administering an oral medication: place the child’s inner arm behind the back, support the head in the crook of the elbow, and hold the child’s free hand with the hand of the supporting arm. An infant can’t sit unsupported in a high chair. Administering medication to an infant lying flat could cause choking and aspiration. Holding the infant in the lap doesn’t prevent spilling the medication with either hand.
The nurse has developed a relationship with a client who has an addiction problem. Which information would indicate that the therapeutic interaction is in the working stage? Select all that apply: 1. The client addresses how the addiction has contributed to family distress. 2. The client reluctantly shares the family history of addiction. 3. The client verbalizes difficulty identifying personal strengths. 4. The client discusses the financial problems related to the addiction. 5. The client expresses uncertainty about meeting with the nurse. 6. The client acknowledges the addiction’s effects on the children.
Correct Answer: 1,3,6 RATIONALES: Options 1, 3 and 6 are examples of the nurse-client working phase of an interaction. In the working phase, the client explores, evaluates, and determines solutions to identified problems. Options 2, 4 and 5 address what happens during the introductory phase of the nurse-client interaction.
A preschool-age child refuses to take prescribed medication. Which nursing strategy would be most appropriate? 1. Mixing the medication in milk so the child isn’t aware that it’s there 2. Explaining the medication’s effects in detail to ensure cooperation 3. Making the child feel ashamed for not cooperating 4. Showing trust in the child’s ability to cooperate even with an unpleasant procedure
Correct Answer: 4 RATIONALES: To gain a preschooler’s cooperation, the nurse should show trust and express faith in the child’s ability to cooperate even with an unpleasant procedure. Hiding the medication in milk may foster mistrust. The nurse should provide simple, not detailed, explanations and should use terms the child can understand. Shaming the child is inappropriate and may lead to feelings of guilt.
A client is brought to the psychiatric clinic by family members, who tell the admitting nurse that the client repeatedly drives while intoxicated despite their pleas to stop. During an interview with the nurse, which statement by the client most strongly supports a diagnosis of psychoactive substance abuse? 1. “I’m not addicted to alcohol. In fact, I can drink more than I used to without being affected” 2. “I only spend half of my paycheck at the bar” 3. “I just drink to relax after work.” 4. “I know I’ve been arrested three times for drinking and driving, but the police are just trying to hassle me”
Correct Answer: 4 RATIONALES: According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, diagnostic criteria for psychoactive substance abuse include a maladaptive pattern of such use, indicated either by continued use despite knowledge of having a persistent or recurrent social, occupational, psychological, or physical problem caused or exacerbated by substance abuse or recurrent use in dangerous situations (for example, while driving). For this client, psychoactive substance dependence must be ruled out; criteria for this disorder include a need for increasing amounts of the substance to achieve intoxication (option 1), increased time and money spent on the substance (option 2), inability to fulfill role obligations (option 3), and typical withdrawal symptoms.
A 2-year-old child in the cardiac step-down unit is experiencing supraventricular tachycardia. Which intervention should be attempted first? 1. Administering digoxin (Lanoxin) I.V. 2. Administering verapamil (Calan) I.V. 3. Administering synchronized cardioversion 4. Immersing the child’s hands in cold water
Correct Answer: 4 RATIONALES: Vagal maneuvers such as immersing the child’s hands in cold water are often tried first as a mechanism to decrease heart rate. Other vagal maneuvers include breath-holding, gagging, and placing the child’s head lower than the rest of the body. Synchronized cardioversion may be necessary if vagal maneuvers fail and drugs are ineffective. Verapamil isn’t recommended. Digoxin may be given after vagal maneuvers to help decrease heart rate.
A client on the behavioral health unit tells the nurse that she experiences palpitations, trembling, and nausea while traveling alone, outside her home. These symptoms have severely limited her ability to function and have caused her to avoid leaving home whenever possible. The nurse recognizes that this client has symptoms of what disorder? 1. Thanatophobia 2. Aerophobia 3. Hodophobia 4. Agoraphobia
Correct Answer: 4 RATIONALES: Agoraphobia is a phobia, or fear, and avoidance of open spaces accompanied by the concern that escape to safety would be difficult or embarrassing. It’s commonly accompanied by physical symptoms, such as palpitations, trembling, nausea, and shortness of breath. It’s also commonly accompanied or preceded by panic attacks. Thanatophobia is the fear of death; aerophobia, the fear of air; and hodophobia, the fear of traveling.
A mother tells the nurse that she wants to begin toilet training her 22-month-old child. The most important factor regarding toilet training that the nurse should stress to her is: 1. developmental readiness of the child 2. consistency in approach. 3. the mother’s positive attitude 4. developmental level of the child’s peers
Correct Answer: 1 RATIONALES: If the child isn’t developmentally ready, both child and parent will become frustrated. Consistency is important when toilet training is started. The mother’s positive attitude is important when the child is determined to be ready. Developmental levels of children are individualized and comparison to peers isn’t useful.
A school-age child has a fever, joint inflammation, and a nonpruritic rash. Knowing that these are signs of rheumatic fever, the nurse should ask the parents: 1. “Has your child recently been exposed to other children with rheumatic fever?” 2. “Has your child had strep throat recently?” 3. “Does your child have a congenital heart defect?” 4. “Is your child’s Haemophilus influenzae vaccine up to date?”
Correct Answer: 2 RATIONALES: Group A streptococcal infection typically precedes rheumatic fever. An inflammatory disease, rheumatic fever affects the heart, joints, and central nervous system. It isn’t infectious and can’t be transmitted from one person to another- Congenital heart defects don’t play a role in the development of rheumatic fever. H. influenzae vaccine doesn’t prevent streptococcal infection or rheumatic fever.
The charge nurse in an acute care setting assigns a client, who is on one-on-one suicide precautions, to a psychiatric aide. This assignment is considered: 1. poor nursing practice because a registered nurse should work with this client 2. reasonable nursing practice because one-on-one requires the total attention of a staff member 3. outside the responsibility of an aide 4. illegal to delegate to an aide
Correct Answer: 2 RATIONALES: A psychiatric aide may sit with the client and ensure safety. The nurse is still responsible for assessing the client and ensuring that one-on-one supervision occurs. Aides are capable of providing one-to-one observation. It isnt illegal to delegate observation to an aide.
To treat a child’s atopic dermatitis, a physician prescribes a topical application of hydrocortisone cream twice daily. After medication instruction by the nurse, which statement by the parent indicates effective teaching? 1. ‘I will spread a thick coat of hydrocortisone cream on the affected area and will wash this area once a week.” 2. “I will gently scrape the skin before applying the cream to promote absorption.” 3. “I will avoid using soap and water on the affected area and will apply an emollient cream on this area frequently.” 4. “I will apply a moisturizing cream sparingly and will wash the affected area frequently.”
Correct Answer: 3 RATIONALES: The parent should avoid washing the affected area with soap and water because this removes moisture from the horny layer of the skin. Applied in a thin layer, emollient cream holds moisture in the skin, provides a barrier to environmental irritants, and helps prevent infection. Topical steroid creams such as hydrocortisone should be applied sparingly as a light film; the affected area should be cleaned gently with water before the cream is applied. Scraping or abrading the skin may increase the risk of infection and alter drug absorption. Excessive application of steroidal creams may result in systemic absorption and Cushings syndrome. Frequent washing dries the skin, making it more susceptible to cracking and further breakdown.
An adolescent client is admitted to the adolescent unit with pain caused by sickle cell crisis. Who should be consulted first for this client’s care? 1. Nutritionist 2. Physical therapist 3. Pediatric pain specialist 4. Case manager
Correct Answer: 3 RATIONALES: Children hospitalized with sickle cell crisis are often in excruciating pain. Therefore, the pediatric pain specialist should be consulted first to help relieve the client’s pain. The client also requires hydration with I.V. fluids, but consulting a nutritionist isn’t important at this time. Bed rest is commonly ordered to minimize the client’s energy expenditure and oxygen demand; therefore, consulting a physical therapist isn’t necessary at this time. It isn’t necessary to consult the case manager first; pain relief is most important at this time.
The nurse is assisting in the discharge planning for a client with alcoholism. Which of the following should be included in the discharge plan? Select all that apply: 1. Strongly encourage participation in Alcoholics Anonymous (AA). 2. Provide nutritional information and counseling. 3. Establish an exercise program. 4. Discuss relapse prevention. 5. Have the client introduce himself slowly to people from his former lifestyle.
Correct Answer: 1,2,3,4 RATIONALES: AA is an outpatient support group for recovering alcoholics. It allows clients to share their problems and gain support from members of the group to avoid further alcohol abuse. Strongly encourage participation in this support group. Provide the client with nutritional information and counseling, particularly if the client is underweight or malnourished. Establish an exercise program appropriate for the client’s physical health. Discourage the client from reestablishing relationships with former “drinking friends,” because this could lead to relapse.
Which clinical condition meets the criteria for involuntary commitment? 1. A single parent who leaves her minor children unattended and stays out all night drinking 2. A person who lives alone and isn’t able to care for himself and has schizophrenia with delusions of persecution 3. A man who threatens to kill his wife 4. A person with depression who says he’s tired of living but doesn’t have a suicide plan
Correct Answer 3 RATIONALES: One of the criteria for involuntary commitment is an emergency in which the client is a threat to himself or others. A parent might have a child removed from the home because of neglect, but that doesn’t meet the criteria for involuntary commitment. Many individuals with schizophrenia can learn to live with hallucinations and delusions and don’t require hospitalization. To meet criteria for involuntary commitment, a depressed individual must have a suicide plan and be a direct threat to himself.
A client experiencing alcohol withdrawal is upset about going through detoxification. Which of the following goals is a priority? 1. The client will commit to a drug-free lifestyle. 2. The client will work with the nurse to remain safe 3. The client will drink plenty of fluids daily. 4. The client will make a personal inventory of strengths
Correct Answer: 2 RATIONALES: The priority goal in alcohol withdrawal is maintaining the client’s safety. Committing to a drug-free lifestyle, drinking plenty of fluids, and identifying personal strengths are important goals, but ensuring the client’s safety is the nurse’s top priority.
A 10-year-old child diagnosed with acute glomerulonephritis is admitted to the pediatric unit. The nurse should ensure that which of the following is a part of the child’s care? 1. Taking vital signs every 4 hours and obtaining daily weight 2. Obtaining a blood sample for electrolyte analysis every morning 3. Checking every urine specimen for protein and specific gravity 4. Ensuring that the child has accurate intake and output and eats a high-protein diet
Correct Answer: 1 RATIONALES: Because major complications — such as hypertensive encephalopathy, acute renal failure, and cardiac decompensation — can occur, monitoring vital signs (including blood pressure) is an important measure for a child with acute glomerulonephritis. Obtaining daily weight and monitoring intake and output also provide evidence of the child’s fluid balance status. Sodium and water restrictions may be ordered depending on the severity of the edema and the extent of impaired renal function. Typically, protein intake remains normal for the child’s age and is only increased if the child is losing large amounts of protein in the urine. Checking urine specimens for protein and specific gravity and daily monitoring of serum electrolyte levels may be done, but their frequency is determined by the child’s status. These are less important nursing measures in this situation.
Which desired outcome demonstrates effective parent teaching about disciplining a toddler? 1. The parents will set flexible rules. 2. The parents will verbalize requests for behavior in negative terms. 3. The parents will raise their voices when reprimanding the child. 4. The parents will call immediate attention to undesirable behavior.
Correct Answer: 4 RATIONALES: The parents of a toddler should praise desirable behavior and call immediate attention to undesirable behavior. This helps the child learn socially acceptable behavior and maintain self-esteem and a positive self-concept while learning to adapt to the rules of the larger group and society. Rules should be established clearly and enforced consistently. To reinforce desirable behavior, parents should voice requests for behavior in positive terms and use a normal speaking voice and tone when talking to or reprimanding the child. Screaming and shouting should be minimized.
When assessing a child, age 3 months, who has been diagnosed with heart failure, the nurse expects which finding? 1. Bounding peripheral pulses 2. A gallop heart rhythm 3. Widened pulse pressure 4. Bradycardia
Correct Answer: 2 RATIONALES: Heart failure may cause a gallop rhythm in a child. Bounding peripheral pulses, widened pulse pressure, and bradycardia aren’t associated with heart failure.
A child is admitted to the pediatric unit with a serum sodium level of 118 mEq/L. Which nursing action takes highest priority at this time? 1. Replacing fluids slowly as ordered 2. Instituting seizure precautions 3. Administering diuretic therapy as prescribed 4. Administering sodium bicarbonate as prescribed
Correct Answer: 2 RATIONALES: A serum sodium level of 118 mEq/L indicates severe hyponatremia, which places the client at risk for seizures. Therefore, instituting seizure precautions takes highest priority. Fluid and sodium replacement should be done rapidly. Diuretic therapy isn’t indicated because it may cause additional sodium loss. In a child with hyperkalemia, administering sodium bicarbonate would be appropriate because it promotes movement of potassium into the intracellular spaces.
Sudden infant death syndrome (SIDS) is one of the most common causes of death in infants. At what age is the diagnosis of SIDS most likely? 1. 1 to2years 2. 1 week to 1 year, peaking at 2 to 4 months 3. 6 months to 1 year, peaking at 10 months 4. 6 to 8 weeks
Correct Answer: 2 RATIONALES: SIDS can occur anytime between ages 1 week and 1 year. The incidence peaks at ages 2 to 4 months.
Which parameter would not be an appropriate indicator of pain relief in an adolescent? 1. Intermittent sleeping 2. Change in behavior 3. Statement of decreased pain 4. Change in vital signs
Correct Answer: 1 RATIONALES: Sleeping isn’t a reliable indicator of pain relief because the teen may use sleep as a coping mechanism. Positive changes in behavior and vital signs and a statement of less pain are indicators of an effective response to pain medication.
The nurse is caring for a 2 ½ -year-old child with tetralogy of Fallot (TOF). Which abnormalities are associated with TOF? 1. Aortic stenosis, atrial septal defect, overriding aorta, and left ventricular hypertrophy 2. Pulmonic stenosis, intraventricular septal defect, overriding aorta, and right ventricular hypertrophy 3. Pulmonic stenosis, patent ductus arteriosus, overriding aorta, and right ventricular hypertrophy 4. Transposition of the great vessels, intraventricular septal defect, right ventricular hypertrophy, and patent ductus arteriosus
Correct Answer: 2 RATIONALES: TOF consists of four congenital anomalies: pulmonic stenosis, intraventricular septal defect, overriding aorta, and right ventricular hypertrophy. The other combinations of defects aren’t characteristic of TOF.
A client is receiving chlordiazepoxide (Librium) to control the symptoms of alcohol withdrawal. The chlordiazepoxide has been ordered as needed. Which symptom may indicate the need for an additional dose of this medication? Select all that apply: 1. Tachycardia 2. Mood swings 3. Elevated blood pressure and temperature 4. Piloerection 5. Tremors 6. Increasing anxiety
Correct Answer: 1,3,5,6 RATIONALES: Benzodiazepines are usually administered based on elevations in heart rate, blood pressure, and temperature as well as on the presence of tremors and increasing anxiety. Mood swings are expected during the withdrawal period and aren’t an indication for further medication administration. Piloerection isn’t a symptom of alcohol withdrawal.
To establish a good interview relationship with an adolescent, which strategy is most appropriate? 1. Asking personal questions unrelated to the situation 2. Writing down everything the teen says 3. Asking open-ended questions 4. Discussing the nurse’s own thoughts and feelings about the situation
Correct Answer: 3 RATIONALES: Open-ended questions allow the teen to share information and feelings. Asking personal questions not related to the situation jeopardizes the trust that must be established because the adolescent may feel as though he’s being probed with unnecessary questions. Writing everything down during the interview can be a distraction and won’t allow the nurse to observe how the adolescent behaves. Discussing the nurse’s thoughts and feelings may bias the assessment and is inappropriate when interviewing any client.
Which assessment would alert the nurse that a hospitalized 7-year-old child is at high risk for a severe asthma exacerbation? 1. Oxygen saturation of 95% 2. Mild work of breath 3. Intercostal or substernal retractions 4. A history of steroid-dependent asthma
Correct Answer: 4 RATIONALES: A history of steroid-dependent asthma, a contributing factor to making this a high-risk client, requires the nurse to treat the situation as a severe exacerbation regardless of the severity of the current episode. Decreased oxygen saturation, cyanosis, and retractions are all assessments of an asthma exacerbation and should be treated with oxygen, nebulized respiratory treatments, and steroids. However, if a significant history of high-risk factors is absent, the episode can be moderately treated and followed up with the pediatrician.
During the client-teaching session, which instruction should the nurse give to a client receiving alprazolam (Xanax)? 1. “Discontinue the medication immediately if you experience nausea” 2. “Notify the physician if you experience urine retention” 3. “Apply sunscreen to prevent photosensitivity” 4. “Inform the physician if you become pregnant or intend to do so”
Correct Answer: 4 RATIONALES: Because alprazolam is contraindicated during pregnancy, the client should be instructed to inform the physician if she becomes pregnant. Nausea, urine retention, and photosensitivity are adverse reactions that may occur, but aren’t contraindications.
The nurse is preparing to teach a 13-year-old client with asthma to administer his own breathing treatments. Which principle should the nurse keep in mind when planning the teaching session? 1. Adolescents are unable to follow detailed instructions. 2. Adolescents are worried about appearing different from their peers. 3. Adolescents’ fine motor coordination isn’t sufficiently developed to administer treatments. 4. Adolescents have a well-developed sense of self-identity.
Correct Answer: 2 RATIONALES: Adolescents have a strong need to belong, and they seek social approval from their peers. Knowing this will help the nurse construct an effective teaching plan. Adolescents are capable of following detailed instructions. According to Piaget, adolescents are at the formal operations stage and are capable of deductive, reflective, and hypothetical reasoning. Fine motor coordination is well developed by adolescence. According to Erikson’s stages of psychosocial development, adolescence is the stage of identity versus role confusion. During this stage, the adolescent strives toward establishing a sense of identity.
A client is admitted to the acute psychiatric care unit after 2 weeks of increasingly erratic behavior. The client has been sleeping poorly, has lost 8 lb (3.6 kg), is poorly groomed, exhibits hyperactivity, and loudly denies the need for hospitalization. Which nursing intervention takes priority for this client? 1. Providing adequate hygiene 2. Administering a sedative as prescribed 3. Decreasing environmental stimulation 4. Involving the client in unit activities
Correct Answer: 3 RATIONALES: This client is at increased risk for injuring himself or others. Decreasing environmental stimulation is a measure the nurse can take independently that may reduce the client’s hyperactivity. If this nursing intervention is ineffective, the nurse may administer a sedative, as prescribed. Providing adequate hygiene is an appropriate nursing intervention but isn’t the highest priority. Because the overall goal is to reduce the client’s hyperactivity, involving the client in unit activities is contraindicated.
A client with the nursing diagnosis of Fear, related to being embarrassed in the presence of others, exhibits symptoms of social phobia. What should the goals be for this client? Select all that apply: 1. Manage her fear in group situations. 2. Develop a plan to avoid situations that may cause stress. 3. Verbalize feelings that occur in stressful situations. 4. Develop a plan for responding to stressful situations. 5. Deny feelings that may contribute to irrational fears. 6. Use suppression to deal with underlying fears.
Correct Answer: 1,3,4 RATIONALES: Improving stress management skills, verbalizing feelings, and anticipating and planning for stressful situations are adaptive responses to stress. Avoidance, denial, and suppression are maladaptive defense mechanisms.
For several years, a client with chronic schizophrenia has received 10 mg of fluphenazine hydrochloride (Prolixin) by mouth four times per day. Now the client has a temperature of 102° F (389° C), a heart rate of 120 beats/minute, a respiratory rate of 20 breaths/minute, and a blood pressure of 210/140 mm Hg. Because the client also is confused and incontinent, the nurse suspects malignant neuroleptic syndrome. What steps should the nurse take? 1. Give the next dose of fluphenazine, call the physician, and monitor vital signs 2. Withhold the next dose of fluphenazine, call the physician, and monitor vital signs 3. Give the next dose of fluphenazine and restrict the client to the room to decrease stimulation. 4. Withhold the next dose of fluphenazine, administer an antipyretic agent, and increase the client’s fluid intake.
Correct Answer: 2 RATIONALES: Malignant neuroleptic syndrome is a dangerous adverse effect of neuroleptic drugs such as fluphenazine. The nurse should withhold the next dose, notify the physician, and continue to monitor vital signs. Although an antipyretic agent may be used to reduce fever, increased fluid intake is contraindicated because it may increase the client’s fluid volume further, raising blood pressure even higher.
A child’s physician prescribes a drug for home use. Before the child is discharged, the nurse should: 1. teach the family how to adjust the drug schedule according to the child’s needs. 2. provide the family with the drug’s name, dosage, route, and frequency of administration. 3. instruct the family to encourage the child to take responsibility for ensuring timely drug administration. 4. tell the family to avoid explaining the purpose of the medication to the child.
Correct Answer: 2 RATIONALES: The nurse should provide the family with essential facts: the drug’s name, dosage, route, and frequency of administration. Generally the physician, not the family or nurse, adjusts dosages. It’s unrealistic and unsafe to expect a child to take responsibility for ensuring timely administration of any drug. A child has a right to know the reasons for taking the drug.
Which of the following activities should a 2-year-old child to be able to do? 1. Build a tower of eight cubes 2. Point out a picture 3. Wash and dry his hands 4. Remove a garment
Correct Answer: 4 RATIONALES: According to the Denver Developmental Screening Test, most 2-year-olds are able to remove one garment. A 2 ½ -year-old can build a tower of eight cubes and point out a picture. A 3-year-old can wash and dry his hands.
A teenager was driving a car that slipped off an icy road, killing two of his friends. He repeatedly tells the nurse that he should be dead instead of his friends. The client’s behavior is an example of: 1. survivor’s guilt. 2. denial 3. anticipatory grief 4. repression
Correct Answer: 1 RATIONALES: Individuals who survive a traumatic experience in which others have died commonly report powerful feelings of guilt that they survived and others didn’t. This guilt is referred to as survivors guilt. In denial, a person refuses to accept that a situation or feeling exists. Anticipatory grief occurs when an individual experiences grief before a loss occurs. In repression, an individual involuntarily blocks an unpleasant experience, memory, or feeling from consciousness.
A client is receiving haloperidol (Haldol) to reduce psychotic symptoms. As he watches television with other clients, the nurse notes that he has trouble sitting still. He seems restless, constantly moving his hands and feet and changing position. When the nurse asks what is wrong, he says he feels jittery. How should the nurse manage this situation? 1. Ask the client to sit still or leave the room because he is distracting the other clients 2. Ask the client if he is nervous or anxious about something 3. Give an as needed dose of a prescribed anticholinergic agent to control akathisia 4. Administer an as needed dose of haloperidol to decrease agitation
Correct Answer: 3 RATIONALES: Akathisia, characterized by restlessness, is a common but often overlooked adverse reaction to haloperidol and other antipsychotic agents; it may be confused with psychotic agitation. To control akathisia, the nurse should give an as needed dose of a prescribed anticholinergic agent. The client can’t control the movements, so asking him to sit still would be pointless. Asking him to leave the room wouldn’t address the underlying cause of the problem. Encouraging him to talk about the symptoms wouldn’t stop them from occurring. Giving more antipsychotic medication would worsen akathisia.
According to Erikson’s psychosocial theory of development, an 8-year-old child would be in which stage? 1. Trust versus mistrust 2. Initiative versus guilt 3. Industry versus inferiority 4. Identity versus role confusion
Correct Answer: 3 RATIONALES: In middle childhood, the 6- to 12-year-old child is mastering the task of industry versus inferiority. The trust versus mistrust task is in infancy (birth to 1 year). In early childhood, the 1- to 3-year-old child is in the stage of initiative versus guilt. Identity versus role confusion occurs during adolescence. The nurse is leading group therapy with psychiatric clients. During the working phase, what should the nurse do? 1. Explain the purposes and goals of the group 2. Offer advice to help resolve conflicts 3. Encourage group cohesiveness 4. Encourage a discussion of feelings of loss regarding termination of the group.
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