--> QUESTION NUMBER _ 401 _ about (MC)
QUESTION: "Increased intracranial pressure is suspected in a 4-year-old child exhibiting a decreased level of consciousness. Which of the following assessment findings would also be of most concern to the nurse? "
CHOICES
( O ) a.) Blood pressure of 122/74 mm Hg.
( X ) b.) Pulse of 86 bpm.
( X ) c.) Respiratory rate of 24 breaths/minute.
( X ) d.) Temperature of 100.2%F (37.9%C).
RATIONALE: A blood pressure of 122/74 mm Hg is above the 95th percentile for a 4-year-old child. Increased blood pressure is a common sign of increased intracranial pressure. A pulse rate of 86 bpm is within the normal range for a 4-year old child. Typically a decrease in pulse rate would suggest increased intracranial pressure. A respiratory rate of 24 breaths per minute is within normal limits for this age. Decreased or increased respiratory rate with irregularity may indicate increased intracranial pressure. Temperature of 100.2%F (37.9%C) in a child with an infectious process is not related to increased intracranial pressure. However, indications of poor temperature control manifested by rapid temperature changes, for example, may be a sign of increasing intracranial pressure in older infants and children. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 402 _ about (MC)
QUESTION: "During assessment of a small infant admitted with a diagnosis of meningitis, the infant becomes less responsive to stimuli and exhibits bradycardia, slight hypertension, irregular respirations, and a temperature of 103.2%F (39.5%C). The infant's fontanel also seems more tense than at the last assessment. Which of the following would the nurse do first?"
CHOICES
( X ) a.) Ask another nurse to verify the findings.
( X ) b.) Notify the physician of the findings.
( O ) c.) Raise the head of the bed.
( X ) d.) Administer an antipyretic.
RATIONALE: Signs such as a decrease in the level of consciousness, bradycardia, hypertension, irregular respirations, and tense fontanel strongly suggest increased intracranial pressure. The first action should be to attempt to lower the pressure by raising the head of the bed, which should improve venous return and decrease the pressure. Asking another nurse to verify the findings is unnecessary because temperature, pulse, and respirations are fairly objective data and not subject to interpretation. Additionally, asking for verification would waste valuable time. After elevating the infant's head via raising the bed, then the nurse can notify the physician and administer the antipyretic. After elevating the infant's head via raising the bed, then the nurse can notify the physician and administer the antipyretic. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 403 _ about (MC)
QUESTION: "While in the emergency department, an adolescent who has been in a motorcycle accident less than 1 hour ago remains conscious but is agitated and anxious. The nurse observes that his pulse and respirations are increasing and his blood pressure is decreasing. The nurse suspects that the adolescent is developing which of the following? "
CHOICES
( X ) a.) Autonomic dysreflexia.
( X ) b.) Increased intracranial pressure.
( X ) c.) Metabolic alkalosis.
( O ) d.) Spinal shock.
RATIONALE: Spinal shock occurs 30 to 60 minutes after a spinal cord injury owing to the sudden disruption of central and autonomic pathways. This disruption causes flaccid paralysis, loss of reflexes, vasodilation, hypotension, and increased pulse and respiratory rates. Autonomic dysreflexia occurs only after the return of spinal reflexes and is characterized by hypertension. Increased intracranial pressure is associated with widened pulse pressure and decreased pulse and respiratory rates. Metabolic alkalosis, manifested by vomiting, elevated plasma and urine pH, and elevated plasma bicarbonate levels, does not occur with spinal shock. Rather, hydrogen ion loss leading to metabolic alkalosis would occur with pyloric stenosis, diuretic therapy, and potassium depletion. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 404 _ about (MC)
QUESTION: "Physical examination of an adolescent reveals an abnormally convex angulation in the curvature of the thoracic spine. The nurse would document this finding as which of the following?"
CHOICES
( X ) a.) Equinovarus.
( O ) b.) Kyphosis.
( X ) c.) Lordosis.
( X ) d.) Scoliosis.
RATIONALE: An abnormally increased convex angulation in the curvature of the thoracic spine is kyphosis. The most common cause of kyphosis in children is related to poor posture. Equinovarus refers to the foot being pointed downward and inward. Lordosis is the excessive anterior curvature of the lumbar spine due most often to an underlying neuromuscular disease or spinal deformity. Scoliosis is a lateral curvature of the spine. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 405 _ about (MC)
QUESTION: "The mother of a child with flat feet asks the nurse why her child needs to wear corrective shoes. When responding to the mother, which of the following would the nurse include as the reason for the shoes?"
CHOICES
( O ) a.) Keeping the legs in proper alignment.
( X ) b.) Delaying the development of femoral anteversion.
( X ) c.) Preventing the development of internal tibial torsion.
( X ) d.) Strengthening the arches of the feet.
RATIONALE: Although there is no treatment for flat feet, corrective shoes are often prescribed to keep the legs in proper alignment. Femoral anteversion (toeing in) is not associated with flat feet. Corrective shoes will have no effect on changing weight bearing on the feet. Corrective shoes will have no effect on strengthening the arches of the child's feet. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 406 _ about (MC)
QUESTION: "When developing a teaching plan for the mother of a child diagnosed with spastic cerebral palsy, which of the following descriptions would the nurse include?"
CHOICES
( O ) a.) Increased muscle tone and stretch reflexes.
( X ) b.) Slow, wormlike writhing movements.
( X ) c.) Wide-based gait and poor muscle coordination.
( X ) d.) Tremors and lack of active movement.
RATIONALE: Spastic cerebral palsy, the most common clinical type, represents an upper motor neuron muscular impairment resulting in increased muscle tone and stretch reflexes, persistent reflexes, and a lack or delay of postural control. Slow, wormlike writhing movements are characteristic of dyskinetic or athetoid type of cerebral palsy. Ataxic type cerebral palsy is the least common type. Children have a wide-based gait and perform rapid repetitive movements poorly. With the common athetoid type, children have tremors and lack active movement. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 407 _ about (MC)
QUESTION: "When assessing a toddler diagnosed with spastic cerebral palsy, which of the following would the nurse expect to find?"
CHOICES
( O ) a.) Toe-walking.
( X ) b.) Drooling.
( X ) c.) Facial grimacing.
( X ) d.) Wide-based gait.
RATIONALE: Spasticity can cause the toddler to stand or walk on his toes due to an upper motor neuron type of muscular weakness resulting in increased muscle tone. Drooling is associated with dyskinetic or athetoid cerebral palsy due to poor tongue and swallowing movements. Facial grimacing is found with dyskinetic or athetoid cerebral palsy due to involuntary movements of the facial muscles. A wide-based gait is typical of children with ataxic cerebral palsy. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 408 _ about (MC)
QUESTION: "While gently abducting the hips during a newborn assessment, the nurse feels the femoral head slip into the acetabulum. The nurse interprets this positive finding as which of the following?"
CHOICES
( X ) a.) Barlow's test.
( X ) b.) Galeazzi sign.
( O ) c.) Ortolani's sign.
( X ) d.) Trendelenburg's sign.
RATIONALE: Ortolani's sign refers to the feeling of the femoral head slipping forward into the acetabulum when forward pressure is exerted from behind the greater trochanter and the knee is held laterally. This sign indicates hip dislocation. A positive Barlow's test, evidenced by the femoral head slipping out over the acetabulum when pressure is applied then slipping back into place when the pressure is released, indicates that the hip is unstable with increased risk of dislocation. Typically a click is heard. Galeazzi's sign refers to shortening of the affected limb in congenital hip dysplasia. It is elicited by flexing the infant's hips and knees while the infant lies supine. The soles of the feet are placed flat near the buttocks and the knee heights are assessed for equality. Trendelenburg's sign refers to a downward tilting of the pelvis toward the normal side when a child with a dislocated hip stands on the affected side with the uninvolved leg elevated. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 409 _ about (MC)
QUESTION: "Three weeks after the application of the spica cast following surgery, the mother calls the nurse because the infant's toes are swollen and cool to the touch. Which of the following would the nurses suspect?"
CHOICES
( X ) a.) Child's feet were in a dependent position.
( O ) b.) Child has outgrown the spica cast.
( X ) c.) Cotton wadding lining of the cast has shrunk.
( X ) d.) An infection has developed under the cast.
RATIONALE: Infants grow rapidly. A cast adequate for a infant after surgery may be outgrown in less than 1 month. The cast becomes too tight, impairing circulation evidenced by toe swelling and coolness to touch. When feet are dependent in a cast, decreased venous return may occur. Reduced venous return along with decreased feet and leg movement subsequently leads to edema. The cotton wadding used to line the cast does not shrink over time. If the child had surgery, the chances of infection are minimal after a 3- to 4-week period. In addition, other symptoms of infection, such as fever and possibly a hot spot on the cast would be present. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 410 _ about (MC)
QUESTION: "In the immediate period following application of a plaster cast to correct congenital clubfoot, which of the following interventions would be most appropriate?"
CHOICES
( O ) a.) Changing the client's position at least every 2 hours.
( X ) b.) Coating the cast with a clear acrylic spray finish.
( X ) c.) Drying the cast rapidly with a hair dryer.
( X ) d.) Handling the cast with the fingertips.
RATIONALE: Complete drying of a plaster cast takes several hours. Thus, turning the child with a newly applied cast at least every 2 hours helps the cast to dry uniformly. The cast must not be coated with any substance that would inhibit moisture evaporation from the plaster. Dryers are not used to dry the cast because they dry the cast on the surface but not underneath. Furthermore, heat may be conducted to the tissues through the wet cast, causing burns. The drying cast must be handled with the palms only, to prevent finger indentations that could cause pressure areas. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 411 _ about (MC)
QUESTION: "When developing a plan of care with the family of a child with juvenile rheumatoid arthritis, which of the following interventions should be included to alleviate joint stiffness?"
CHOICES
( O ) a.) Applying moist heat to affected joints as needed.
( X ) b.) Teaching the child to keep joints flexed while in bed.
( X ) c.) Performing repetitive weight-bearing exercises with affected joints.
( X ) d.) Using a soft comfortable mattress to support the joints.
RATIONALE: Applying moist heat to affected joints at any time may facilitate joint movement. Heat increases circulation, decreases pain, and increases mobility. When in bed, the child should be taught to keep the joints extended to prevent flexion deformities. Although exercise is important, weight bearing on affected joints is restricted when joints are affected by the disease, as evidenced by pain and edema. The mattress should be firm to provide better support of the joints. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 412 _ about (MC)
QUESTION: "After teaching the mother of a child with a spica cast about skin care, which of the following measures demonstrated by the mother would indicate the need for additional teaching?"
CHOICES
( O ) a.) Application of powder to the skin under the cast.
( X ) b.) Inspection of the cast edges for smoothness.
( X ) c.) Application of plastic film to cover perineal cast area.
( X ) d.) Inspection of areas inside the cast.
RATIONALE: Powder should not be applied to skin beneath the cast because powder can cause irritation and skin breakdown. The mother would need further teaching about avoiding this measure. Checking the smoothness of the cast edges is appropriate for the child with a spica cast to help prevent skin breakdown. Covering the cast around the perineum is appropriate for the child with a spica cast to help prevent skin breakdown. Inspecting inside the cast is appropriate for the child with a spica cast to help prevent skin breakdown. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 413 _ about (MC)
QUESTION: "Which of the following would the nurse suspect when the immobile adolescent with a recent fractured femur suddenly develops chest pain, dyspnea, diaphoresis, and tachycardia?"
CHOICES
( X ) a.) Atelectasis.
( X ) b.) Pneumonia.
( X ) c.) Pulmonary edema.
( O ) d.) Pulmonary emboli.
RATIONALE: Chest pain and dyspnea in an immobilized adolescent with a large bone fracture suggest a fat embolus. With this condition, fat droplets, rather than a thrombus, are transferred from the marrow into the general blood stream by the venous-arterial route, possibly reaching the lung or brain. Atelectasis may develop; however, the onset of signs and symptoms is usually more gradual and subtle. Pneumonia can occur; however, the signs and symptoms usually do not develop suddenly. Pulmonary edema should not be a problem in a healthy adolescent who has sustained a fracture. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 418 _ about (MC)
QUESTION: "Which of the following areas to monitor would the nurse include in the plan of care for a preterm neonate subjected to repeated blood withdrawals for laboratory specimens?"
CHOICES
( O ) a.) Amount of blood drawn for each specimen.
( X ) b.) Color of each blood specimen.
( X ) c.) Vital signs before each blood draw.
( X ) d.) Time of last feeding before each specimen.
RATIONALE: When repeated blood specimens are obtained from a preterm neonate, keeping a record of the amount of blood taken for each specimen is essential. The total blood volume of a preterm neonate is small, and repeated blood collections can deplete blood volume. A record of the amount of blood taken for specimens is a guide to help determine if the neonate needs a transfusion. The color of the specimen is not a reliable indicator of the neonate's blood volume status. With repeated blood specimen collections from a preterm neonate, total blood volume may be depleted. Vital signs are not a reliable indicator of blood volume. With repeated blood specimen collections from a preterm neonate, total blood volume may be depleted. The time of last feeding may be related to glucose levels, not blood volume. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 428 _ about (MC)
QUESTION: "The mother of an infant being admitted to the hospital is crying and very upset. Which of the following would be the nurse's best response? "
CHOICES
( X ) a.) "Please don't worry, everything is going to be all right."
( X ) b.) "The doctor knows what he's doing, so be positive."
( O ) c.) "What is it that is making you cry right now?"
( X ) d.) "You did the right thing bringing him here when you did."
RATIONALE: The nurse's best response is an open-ended question that gives the mother an opportunity to verbalize fears, share concerns, and ask for information. In this situation, the mother is right to be worried. Telling her to not do so would be inappropriate. Telling the mother that the physician knows what he is doing and to be positive is inappropriate because this response ignores the mother's feelings at the present time. Telling the mother that she did the right thing to bring her infant to the clinic does not address her concerns or needs at this time. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 429 _ about (MC)
QUESTION: "A 5-month-old infant is brought to the clinic by his parents because he "cries too much" and "vomits a lot." The infant's birth weight was 6 pounds, 10 ounces, and his current weight is 7 pounds, 4 ounces, falling below the 5th percentile on a standard growth chart. Which of the following data would the nurse identify as the priority?"
CHOICES
( X ) a.) Frequency of regular checkups.
( O ) b.) Feeding pattern.
( X ) c.) Pattern of weight gain.
( X ) d.) Family dynamics.
RATIONALE: Because the infant falls below the 5th percentile on a standard growth chart, failure to thrive, a term applied to an infant who is not growing at an acceptable rate, must be considered. Information about feeding patterns, including types and amounts of food, is needed to determine the cause of failure to thrive. If a child does not receive sufficient calories, growth is slowed. Whether or not the infant has received regular checkups is important but not the priority because that information alone does not provide evidence or substantiation about the infant's growth patterns. The infant's pattern of weight gain is important but not the priority. Rather, the infant's pattern of weight gain provides valuable and useful information over a period of time. Information about family dynamics is important to provide data about family stresses that may affect or help explain the infant's failure to thrive. However, it is not the priority. This information needs to be viewed in conjunction with the infant's feeding patterns to gain a complete picture. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 430 _ about (MC)
QUESTION: "Which of the following information obtained during a health history would the nurse correlate as consistent with the diagnosis of failure to thrive in a 5-month-old infant? "
CHOICES
( O ) a.) Fussiness during feedings.
( X ) b.) Fear of strangers.
( X ) c.) Quiet when being held.
( X ) d.) Need to be awakened for feedings.
RATIONALE: Infants who have failure to thrive often are fussy during feedings. This fussiness maybe related to the caretaker not recognizing cues about what the infant needs or wants. Typically infants with failure to thrive are unafraid of strangers. This lack of fear would be abnormal for a 5-month-old. Although they protest being put down, infants with failure to thrive often are not content while being held because they are not used to it. Infants with failure to thrive often have difficulty sleeping for any length of time. They often awaken owing to hunger. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 431 _ about (MC)
QUESTION: "When observing the mother feed her infant diagnosed with failure to thrive, which of the following maternal behaviors would cause the nurse to be concerned? "
CHOICES
( X ) a.) Maintaining eye contact with the infant.
( X ) b.) Talking to the infant during the feeding.
( O ) c.) Placing the infant in the crib for the feeding.
( X ) d.) Sitting on the floor to feed the infant.
RATIONALE: Engagement with an infant is achieved through physical contact, eye contact, and voice contact during feeding. Most important of these is physical contact with the person feeding the infant. Holding the infant in a relaxed manner that provides the most physical contact is important. Thus, placing the infant in the crib for feeding would be a concern due to the lack of physical contact with the infant. Maintaining eye contact with the infant during feeding promotes engagement. Talking to the infant during feeding promotes engagement. The locale of feeding is unimportant as long as the infant's need for contact is met. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 432 _ about (MC)
QUESTION: "A mother expresses concern that picking up the infant whenever he cries will spoil him. Which of the following would be the nurse's best response?"
CHOICES
( X ) a.) "Allow him to cry for no longer than 45 minutes, then pick him up."
( O ) b.) "Babies need comforting and cuddling; meeting these needs will not spoil him."
( X ) c.) "Babies this young cry when they're hungry; try feeding him when he cries."
( X ) d.) "If it seems as if nothing is wrong, don't pick him up; the crying will stop eventually."
RATIONALE: It is a common misconception that picking up an infant whenever he or she cries will spoil the child. Infants need to be cuddled and comforted when they are upset. Comforting may be as simple as feeding or changing a wet diaper. An infant typically cries because of a need; for example, being hungry, needing to be burped, or having a wet diaper. Responding to the infant's needs in a timely fashion helps to develop trust. Allowing the infant to cry for 45 minutes would be inappropriate and too long to wait. Assuming that the infant is hungry each time he cries could lead to overfeeding. The infant typically cries for a reason, such as a need that must be met. Picking up the crying child demonstrates an understanding of the infant's needs and helps the infant to develop trust in the caregivers. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 433 _ about (MC)
QUESTION: "When choosing nightclothes for an infant with atopic dermatitis, which of the following suggestions would be best?"
CHOICES
( X ) a.) A diaper and short-sleeved shirt.
( O ) b.) One-piece cotton pajamas with long sleeves.
( X ) c.) Two-piece flannel pajamas with short sleeves.
( X ) d.) A woolen sleeper with feet and mittens.
RATIONALE: Atopic dermatitis results in pruritus. The infant's skin should be covered as completely as possible to keep him from scratching himself. Cotton is the preferred material because it allows the skin to breathe and moisture to evaporate. A short-sleeved shirt would be inappropriate because the infant could scratch the uncovered arms, exacerbating the condition. Flannel may be too warm, causing the child to perspire, which will aggravate the condition. Because atopic dermatitis is often associated with allergies, wool garments should be avoided. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 434 _ about (MC)
QUESTION: "Which of the following instructions would the nurse include in the teaching plan about skin care for the mother of a child with atopic dermatitis?"
CHOICES
( X ) a.) Soaking the child in a tub for 30 minutes to soften the skin.
( O ) b.) Using a mild soap followed by patting the skin to dry it.
( X ) c.) Applying an antibacterial soap two times a week.
( X ) d.) Washing clothes in a strong detergent to prevent infections.
RATIONALE: Care of the skin is basic to the treatment of atopic dermatitis. Treatment includes: use of a mild soap, such as Dove; not allowing the child to soak in the tub, which dries the skin; and patting the skin with a towel after the bath to help keep moisture in the skin. Soaking in the tub would prolong the child's exposure to water, which has a drying effect on the skin. The goal of care is to keep the skin moist. An antibacterial soap is harsh and drying to the skin, possibly exacerbating the condition. Using a strong detergent for washing the child's clothes is inappropriate because soap left in the clothing may be harsh and irritating to the infant's skin. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 435 _ about (MC)
QUESTION: "When planning the home care for a 3-year-old child with eczema, which of the following would the nurse teach the mother to remove from the child's environment at home?"
CHOICES
( X ) a.) Metal toy trucks.
( X ) b.) Plastic figures.
( O ) c.) Stuffed animals.
( X ) d.) Wooden blocks.
RATIONALE: For the child with eczema which is often related to an allergic response, stuffed animals should be avoided because they tend to collect dust and are difficult to clean. Metal toy trucks are suitable toys for a 3-year-old child. They are easy to keep clean and dust-free. Plastic figures are suitable toys for a 3-year-old child. They are easy to keep clean and dust-free. Wooden blocks are suitable toys for a 3-year-old child. They are easy to keep clean and dust-free. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control
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--> QUESTION NUMBER _ 436 _ about (MC)
QUESTION: "Which of the following would be a priority nursing intervention for a 6-year-old child admitted with third-degree burns?"
CHOICES
( O ) a.) Starting an intravenous line.
( X ) b.) Administering ordered antibiotics orally.
( X ) c.) Inserting an indwelling urinary (Foley) catheter.
( X ) d.) Obtaining baseline laboratory studies.
RATIONALE: The child will need fluid replacement therapy as soon as possible, primarily due to the shift of plasma from intravascular to interstitial spaces at burn sites. Blisters and edema resulting from this process lead to fluid and electrolyte loss. Severe burns are usually sterile. Antibiotic treatment, if used at all, would not be a priority at this time. Insertion of an indwelling urinary (Foley) catheter would be done once the intravenous line is started. Laboratory studies would be drawn after the intravenous line is started. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 437 _ about (MC)
QUESTION: "For the child experiencing severe burns, the nurse identifies the nursing diagnosis of Deficit Fluid Volume related to an initial primary shift in plasma from which of the following? "
CHOICES
( X ) a.) Intracellular to intravascular spaces.
( O ) b.) Intravascular to interstitial spaces.
( X ) c.) Intracellular to interstitial spaces.
( X ) d.) Interstitial to intravascular spaces.
RATIONALE: The primary fluid shift in burns is from the intravascular to interstitial spaces. First, capillaries and small vessels in the area dilate, leading to increased capillary permeability. Plasma seeps into the surrounding tissues, producing blisters and edema. There is also an exchange of sodium for the electrolyte potassium. The primary fluid shift in burns is from the intravascular to interstitial spaces. First, capillaries and small vessels in the area dilate, leading to increased capillary permeability. Plasma seeps into the surrounding tissues, producing blisters and edema. There is also an exchange of sodium for the electrolyte potassium. The primary fluid shift in burns is from the intravascular to interstitial spaces. First, capillaries and small vessels in the area dilate, leading to increased capillary permeability. Plasma seeps into the surrounding tissues, producing blisters and edema. There is also an exchange of sodium for the electrolyte potassium. The primary fluid shift in burns is from the intravascular to interstitial spaces. First, capillaries and small vessels in the area dilate, leading to increased capillary permeability. Plasma seeps into the surrounding tissues, producing blisters and edema. There is also an exchange of sodium for the electrolyte potassium. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 438 _ about (MC)
QUESTION: "Which of the following denotes the primary reason that the nurse inserts an indwelling urinary (Foley) catheter in a child with severe burns?"
CHOICES
( X ) a.) Monitoring for a urinary tract infection.
( O ) b.) Measuring urine output accurately.
( X ) c.) Preventing urinary retention.
( X ) d.) Assessing urine specific gravity.
RATIONALE: Accurate determination of urine output is a crucial factor in the care of a burn victim. The benefits of using an indwelling catheter to measure urine output to the nearest milliliter outweigh the risk of infection and other problems associated with use. An indwelling urinary catheter is inserted for the child with severe burns to ensure accurate urinary output measurement. Urinary tract infection usually is not a problem. However, insertion of the catheter may predispose the child to a urinary tract infection. Unless the burns cover the perineal area and make urination painful, urinary retention is usually not a problem. Determining urine specific gravity can be done to assess hydration, but this is not the primary rationale for inserting an indwelling urinary catheter. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 439 _ about (MC)
QUESTION: "Which of the following would the nurse interpret as indicating that a child is receiving too much intravenous fluid too rapidly?"
CHOICES
( X ) a.) Marked increase in abdominal girth.
( X ) b.) Evidence of protein in the urine.
( X ) c.) Dark amber colored urine.
( O ) d.) Moist crackles in the lung fields.
RATIONALE: Moist crackles in the lung fields are an indication that fluid is accumulating in the lungs due to overhydration or too-rapid delivery of fluids. Abdominal girth would not provide information about the child's fluid status. Protein in the urine may be due to a disease process, not fluid status. Dark amber colored urine would be an indication of underhydration. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 440 _ about (MC)
QUESTION: "On reviewing the child's laboratory results, the nurse notes a serum potassium level of 3.3 mEq/L. Which of the following would the nurse encourage the child to drink?"
CHOICES
( X ) a.) Cranberry juice.
( X ) b.) Apple juice.
( X ) c.) Grape juice.
( O ) d.) Orange juice.
RATIONALE: A serum potassium level of 3.3 mEq/L is low for a child; the normal range is 3.5 to 5.0 mEq/L. Because orange juice is the best source of potassium, the nurse would encourage its consumption. Additional sources of potassium are bananas, cantaloupe, grapefruit juice, tomato juice, honeydew melon, nectarines, and boiled and baked potatoes. A serum potassium level of 3.3 mEq/L is low for a child; the normal range is 3.5 to 5.0 mEq/L. Cranberry juice contains less potassium than orange juice does. A serum potassium level of 3.3 mEq/L is low for a child; the normal range is 3.5 to 5.0 mEq/L. Apple juice contains less potassium than orange juice does. A serum potassium level of 3.3 mEq/L is low for a child; the normal range is 3.5 to 5.0 mEq/L. Grape juice contains less potassium than orange juice does. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 441 _ about (MC)
QUESTION: "When receiving the 15th dose of an antibiotic intravenously, the child begins scratching at the intravenous site on the forearm and develops small, circumscribed, elevated areas on the same arm. Which of the following would the nurse do first? "
CHOICES
( X ) a.) Apply a cold compress to the area and continue to deliver the antibiotic.
( X ) b.) Assess the intravenous site for localized edema or redness.
( X ) c.) Remove the intravenous line and restart it in another area.
( O ) d.) Stop the infusion of the antibiotic but continue the intravenous fluids.
RATIONALE: Because the child has received multiple doses of the drug and the body needs to be exposed to an antigen to develop an allergic response to it, an allergic reaction is most likely. Lesions that are circumscribed, elevated, and pruritic (wheals) are a manifestation of an urticarial reaction. Therefore, the nurse should stop the antibiotic but continue administering intravenous fluids. Keeping the intravenous site in use is especially important in case an anaphylactic reaction occurs. Although cold compresses may help alleviate the itching, the child is exhibiting signs of an allergic reaction. Continuing to give the antibiotic increases the risk for a more severe reaction. Assessing the intravenous site for edema or redness would be appropriate if the nurse suspected that the intravenous site was infiltrated or the child was developing thrombophlebitis at the site. However, the child is exhibiting signs of an allergic reaction. The intravenous site is not the problem here. The child is exhibiting signs of an allergic reaction; that requires discontinuation of the antibiotic not repositioning the intravenous line. The intravenous line should be maintained in case the child has an anaphylactic reaction, which could occur if the antibiotic is continued, and needs intravenous access for resuscitation purposes. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 442 _ about (MC)
QUESTION: "The nurse would suspect that a child is receiving too little intravenous fluid replacement when the child exhibits which of the following?"
CHOICES
( X ) a.) Increasing irritability.
( X ) b.) Urine output of 26 mL for the past hour.
( O ) c.) Urine specific gravity of 1.033.
( X ) d.) An increase in blood pressure over the past 3 hours.
RATIONALE: The specific gravity of urine increases as the kidneys are forced to conserve water, a sign of dehydration. Normal specific gravity for a child would range from 1.002 to 1.030. Thus, a urine specific gravity of 1.033 is increased, suggesting too little fluid replacement. Irritability may be related to numerous factors and is not a reliable indicator of the need for more fluids. Normal minimal urine output for a child between ages 4 and 7 is 24 to 28 mL/hour. A decrease, not increase, in blood pressure would indicate that too little fluid is being infused. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 443 _ about (MC)
QUESTION: "Which of the following demonstrates the nurse's compliance with the Centers for Disease Control and Prevention guidelines concerning sterile glove use?"
CHOICES
( X ) a.) As an optional precautionary measure.
( X ) b.) When delivering care involving touching the child.
( X ) c.) Upon entering the child's room.
( O ) d.) When giving direct care to burned areas.
RATIONALE: The Centers for Disease Control and Prevention recommends that sterile gloves be worn when giving any care to a burn area. The gloves should be changed after removing soiled dressings and a new pair put on before applying new dressings. The Centers for Disease Control and Prevention recommends that sterile gloves be worn when giving any care to a burn area. The gloves should be changed after removing soiled dressings and a new pair put on before applying new dressings. The Centers for Disease Control and Prevention recommends that sterile gloves be worn when giving any care to a burn area. The gloves should be changed after removing soiled dressings and a new pair put on before applying new dressings. Gloves are not necessary when touching the child. The Centers for Disease Control and Prevention recommends that sterile gloves be worn when giving any care to a burn area. The gloves should be changed after removing soiled dressings and a new pair put on before applying new dressings. Gloves are not required to enter the child's room. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control
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--> QUESTION NUMBER _ 444 _ about (MC)
QUESTION: "The physician orders 250 mg of an antibiotic every 6 hours for a child weighing 25 kg who had infected burns. The normal dosage for this antibiotic and condition is 20 to 50 mg/kg per 24 hours. Which of the following actions would be most appropriate?"
CHOICES
( O ) a.) Carry out the order because the ordered dose is acceptable.
( X ) b.) Give the dose recommended by the pharmacy reference material.
( X ) c.) Question the order because the dose is too low.
( X ) d.) Question the order because the dose is a toxic amount.
RATIONALE: The ordered dose is 250 mg every 6 hours, which is 1,000 mg in 24 hours. The recommended dose is 20 to 50 mg times the weight of 25 kg in 24 hours, which is 500 to 1,250 mg in 24 hours. Therefore, because the ordered dose is within the recommended range, the nurse would carry out the order. The nurse cannot independently rewrite a medication order using a pharmacy reference to determine the dose. The ordered dose is 250 mg every 6 hours, which is 1,000 mg in 24 hours. The recommended dose is 20 to 50 mg times the weight of 25 kg in 24 hours, which is 500 to 1,250 mg in 24 hours. Thus, the dose ordered is within the recommended acceptable range. The ordered dose is 250 mg every 6 hours, which is 1,000 mg in 24 hours. The recommended dose is 20 to 50 mg times the weight of 25 kg in 24 hours, which is 500 to 1,250 mg in 24 hours. The dose is not a toxic amount but rather within the recommended acceptable range. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 445 _ about (MC)
QUESTION: "After having trouble breast-feeding, a 6-week-old female infant exhibits dry scaly skin and a protruding tongue. A diagnosis of congenital hypothyroidism is made. The mother asks the nurse why the child was not diagnosed with this condition at birth. Which of the following would be the nurse's best response?"
CHOICES
( X ) a.) "We had the results of the newborn screen, but you did not bring the baby in for the 2-week checkup."
( X ) b.) "Your baby had little need for thyroid hormone until she was 1 month old."
( O ) c.) "Newborns generally receive enough thyroid hormone from the mother to get by the first few weeks."
( X ) d.) "We could not reach you at home to give you the results of tests taken at birth."
RATIONALE: With congenital hypothyroidism, failure of normal development occurs during the embryonic period or when an inborn error of metabolism prevents the normal synthesis of thyroxine. Although the condition is present at birth, maternal thyroxine can pass through the placenta to the fetus, supplying the fetus and neonate sufficiently. Thus, in most neonates, the signs of hypothyroidism are commonly masked at birth. Telling the mother that she didn't bring the child in for 2 weeks implies that the mother was at fault, possibly causing the mother to become defensive. With congenital hypothyroidism, failure of normal development occurs during the embryonic period or when an inborn error of metabolism prevents the normal synthesis of thyroxine. Although the condition is present at birth, maternal thyroxine can pass through the placenta to the fetus, supplying the fetus and neonate sufficiently. Thus, in most neonates, the signs of hypothyroidism are commonly masked at birth. Telling the mother that she couldn't be reached is not therapeutic and may cause the mother to become defensive, implying that she was at fault. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 446 _ about (MC)
QUESTION: "When teaching the mother of an infant diagnosed with congenital hypothyroidism about daily oral levothyroxine sodium (Synthroid) therapy, which of the following signs and symptoms would the nurse include as possibly indicating an overdose?"
CHOICES
( X ) a.) Anorexia.
( X ) b.) Constipation.
( O ) c.) Sweating.
( X ) d.) Sleepiness.
RATIONALE: Sweating, insomnia, rapid pulse, dyspnea, irritability, fever, and weight loss are all signs indicating levothyroxine (Synthroid) overdose. Diminished or absent appetite (anorexia) would suggest thyroid insufficiency. Constipation would suggest thyroid insufficiency. Fatigue and sleepiness would suggest thyroid insufficiency. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 447 _ about (MC)
QUESTION: "After teaching the mother about tests performed to monitor the success of the infant's treatment for congenital hypothyroidism, the nurse would determine that the teaching was effective when the mother states that the child will need frequent blood tests and regular assessment of what?"
CHOICES
( X ) a.) Blood electrolyte levels.
( X ) b.) Metabolic rate.
( X ) c.) Muscular coordination.
( O ) d.) Bone age.
RATIONALE: A child with congenital hypothyroidism who is receiving thyroid replacement therapy should be regularly assessed for blood levels of thyroxine and triiodothyronine and also undergo frequent bone age surveys to ensure optimum growth. Results of bone age surveys would demonstrate growth, indicating that the medication was adequate and effective. Electrolyte levels measure elements such as sodium, chloride, and potassium that are unrelated to medication therapy. Thus, electrolyte levels would provide no information about the effectiveness of therapy. Metabolic rate is not helpful in determining if treatment is effective. Muscular coordination is not an indicator of successful treatment for congenital hypothyroidism. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 448 _ about (MC)
QUESTION: "When developing a teaching plan for the parents of a 1 1/2-month-old infant about how to administer levothyroxine (Synthroid), which of the following would the nurse suggest as most appropriate for dissolving and mixing the medication?"
CHOICES
( X ) a.) Large amount of water.
( X ) b.) Milk or orange juice.
( O ) c.) Small amount of formula.
( X ) d.) Infant's bowl of cereal.
RATIONALE: Placing the dissolved pill in a small amount of formula would be acceptable for this infant because doing so helps to ensure that the infant will take all the medication. Mixing medications in large amounts of fluid such as water is not recommended because the infant may not take all the liquid. Thus, the parents would not know if the child received the correct dose. Mixing medication with food is also contraindicated for this infant, who would not be taking any juice yet. Mixing medications with food is also avoided for older children because food aversions can result. Mixing the medication with the infant's cereal is inappropriate because cereal should not be given to an infant younger than 4 months of age. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 449 _ about (MC)
QUESTION: "Which of the following statements by the mother of an 8-year-old child who is unconscious secondary to ketoacidosis would the nurse interpret as supportive of a diagnosis of insulin-dependent diabetes?"
CHOICES
( X ) a.) "He has become almost hyperactive in the past month."
( O ) b.) "He started to wet his bed at night for the first time in 3 years."
( X ) c.) "He seems to be gaining weight lately."
( X ) d.) "He has lost his appetite in the past 2 weeks."
RATIONALE: Bed-wetting in a previously continent child is a sign suggesting hyperglycemia. The enuresis is due to polyuria, one of the cardinal signs of insulin-dependent diabetes mellitus. Other signs include polydipsia (excessive thirst) and polyphagia (excessive hunger). Typically the child with hyperglycemia secondary to insulin-dependent diabetes is slightly lethargic. Although the child with insulin-dependent diabetes experiences excessive hunger, the child loses weight even though he or she is eating more. Another cardinal sign of insulin-dependent diabetes is polyphagia, or excessive hunger. The child eats more even though he loses weight. Excessive thirst is also a typical sign. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 450 _ about (MC)
QUESTION: "Which of the following would the nurse expect to assess in a child with ketoacidosis?"
CHOICES
( X ) a.) Slow, bounding pulse rate.
( O ) b.) Deep, rapid respirations.
( X ) c.) Diaphoretic warm skin.
( X ) d.) Elevated blood pressure.
RATIONALE: The accumulation of ketones, organic acids that readily release free hydrogen ions causing blood pH to fall, leads to ketoacidosis. To compensate, the respiratory buffering system is activated, which results in the child taking deep, rapid breaths to rid the body of excess carbon dioxide. This characteristic breathing pattern is known as Kussmaul's respirations. Typically with ketoacidosis, the pulse rate would be more rapid and weak due to dehydration and loss of electrolytes. Typically with ketoacidosis, the skin will be dry due to dehydration. With ketoacidosis, hypotension results from the contracted blood volume secondary to dehydration. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 451 _ about (MC)
QUESTION: "When preparing to give a child with insulin-dependent diabetes his dose of regular and NPH humulin insulin, which of the following actions would be most appropriate? "
CHOICES
( X ) a.) Taking the premixed insulin out of the refrigerator, then withdrawing the amount into one syringe.
( X ) b.) Using two syringes, one for each type of insulin, and giving two injections.
( X ) c.) Withdrawing the NPH insulin first, then withdrawing the regular insulin into one syringe.
( O ) d.) Withdrawing the regular insulin first, then withdrawing the NPH insulin into one syringe.
RATIONALE: Using only one syringe is recommended for the client taking regular insulin along with an intermediate- or long-acting insulin. Additionally, insulin types, such as protamine zinc, globin zinc, and NPH, contain an additional modifying protein that slows absorption. Therefore, a vial of insulin that does not contain the protein (ie, regular insulin) should never be contaminated with insulin that does have the added protein. Premixing is rarely recommended because NPH does not remain stable for extended periods when mixed with regular insulin . Using two syringes is not recommended because the insulin types can be mixed. Also, using two syringes is more expensive. Insulin types, such as protamine zinc, globin zinc, and NPH, contain an additional modifying protein that slows absorption. A vial of insulin that does not contain the protein (ie, regular insulin) should never be contaminated with insulin that does have the added protein. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 452 _ about (MC)
QUESTION: "A child diagnosed with insulin-dependent diabetes mellitus is attending a camp for diabetic children. He gives himself regular and Lente insulin at 8:00 AM. The nurse would plan to observe him for signs and symptoms of hypoglycemia resulting from the effects of the Lente insulin between which of the following times?"
CHOICES
( X ) a.) 8:30 PM and 10:30 PM.
( X ) b.) 10:00 AM and noon.
( X ) c.) Noon and 2:00 PM.
( O ) d.) 2:00 PM and 4:00 PM.
RATIONALE: The action of an intermediate-acting insulin such as Lente begins 2 to 4 hours after injection and peaks 6 to 8 hours after injection. The child is most at risk for hypoglycemia at the times when the insulin would peak, in this case between 2 PM and 4 PM. The action of an intermediate-acting insulin such as Lente begins 2 to 4 hours after injection and peaks 6 to 8 hours after injection. The child is most at risk for hypoglycemia at the times the insulin would peak, in this case between 2 PM and 4 PM. The action of an intermediate-acting insulin such as Lente begins 2 to 4 hours after injection and peaks 6 to 8 hours after injection. The child is most at risk for hypoglycemia at the times the insulin would peak, in this case between 2 PM and 4 PM. The action of an intermediate-acting insulin such as Lente begins 2 to 4 hours after injection and peaks 6 to 8 hours after injection. The child is most at risk for hypoglycemia at the times the insulin would peak, in this case between 2 PM and 4 PM. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 453 _ about (MC)
QUESTION: "While attending an arts and craft session at a diabetic camp, a child with insulin-dependent diabetes begins to behave strangely. Which of the following would the nurse do first?"
CHOICES
( O ) a.) Give the child a form of easily digested simple sugar to prevent further complications.
( X ) b.) Ask the child if he took his insulin this morning to determine if he is ketoacidotic.
( X ) c.) Call the child's physician and parents before taking any action.
( X ) d.) Have the child run around the camp track to improve insulin use.
RATIONALE: Assessing a child with hypoglycemia can be difficult. The only sign may be a change in behavior. Because hypoglycemia is a life-threatening condition, the nurse must assume that the child is hypoglycemic and proceed by giving the child a form a easily digested simple sugar, such as a piece of hard candy. If the child is hyperglycemic, an increase in blood glucose level at this point would not be lethal. Immediate action is warranted because hypoglycemia is a life-threatening condition. Asking the child if he took his insulin this morning wastes valuable time. The nurse must assume that the child is hypoglycemic and proceed by giving the child a form a easily digested simple sugar. Even if the child is hyperglycemic, an increase in blood glucose level at this point would not be lethal. However, continued hypoglycemia could be. Immediate action is warranted because hypoglycemia is a life-threatening condition. There is no time to confer with a physician or the child's parents. Exercise increases the efficiency of insulin and would only aggravate a hypoglycemic reaction. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 454 _ about (MC)
QUESTION: "The mother of a newly diagnosed diabetic child is being taught the principles of the diabetic diet. Which of the following statements by the mother indicates effective teaching?"
CHOICES
( X ) a.) "By spreading the calories throughout the day in small frequent meals, the risk of hyperglycemia is eliminated."
( X ) b.) "Most children find it difficult to eat all the calories required on their diets in three main meals."
( O ) c.) "Snacks are used to keep blood glucose at acceptable levels during times when the insulin level peaks."
( X ) d.) "Snacks are used to offset the desire for sweets and to keep the meals smaller so he can eat better."
RATIONALE: Snacks are included in the diabetic diet to offset periods of peak insulin action. Because of the lack of pancreatic functioning, the child does not receive differing amounts of insulin in response to the glucose level in the bloodstream. The child with diabetes mellitus is given insulin at specific times; dietary intake must be matched to the insulin peaks and troughs. The risk of hyperglycemia is not eliminated through regular snacks, although spreading the calories throughout the day may help the child achieve a more steady blood glucose level. Snacks are not used to decrease the amount of food eaten at meals. Snacks are not used to offset hunger for sweets. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 455 _ about (MC)
QUESTION: "While planning interventions with the nurse that will allow the diabetic child to participate in an early morning tennis program at school, the mother offers several interventions. Which of the following would the nurse recommend eliminating?"
CHOICES
( X ) a.) Injecting the morning insulin dose in an area away from major muscles used in playing tennis.
( X ) b.) Having the child eat more calories for breakfast on tennis days.
( X ) c.) Having the child carry a source of quickly absorbed carbohydrate to the program.
( O ) d.) Teaching the other children in the class the signs and symptoms of hyperglycemia.
RATIONALE: It is not necessary that the other children be able to identify hyperglycemia in this child. Hyperglycemia is not life-threatening, but hypoglycemia can be. The other children can be taught signs and symptoms of hypoglycemia and how to treat the condition. Insulin uptake from the subcutaneous tissue is increased when the circulation in the area is increased. This occurs around large muscle groups used in strenuous exercise. The child should eat something before participating in a strenuous activity, because exercise increases both the efficiency of insulin and the amount of energy required by the body. In this case, increasing caloric intake at breakfast will offset the increased need for energy and increased insulin efficiency. An easily absorbed carbohydrate should be available in case the child experiences hypoglycemia. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 456 _ about (MC)
QUESTION: "The nurse offers to meet with the mother and the child's teacher before school to discuss the teacher's responsibilities in relation to the 9-year-old child's diabetes. Which of the following would the nurse expect to discuss in this meeting?"
CHOICES
( X ) a.) How to give an insulin injection.
( X ) b.) How to perform a glucometer test.
( O ) c.) Signs and symptoms of hypoglycemia.
( X ) d.) The American Diabetic Association (ADA) diet.
RATIONALE: Because an insulin reaction can be life threatening and may occur while the child is in school, the nurse and mother should discuss hypoglycemia's seriousness and evaluation in the child with the child's teachers. The teachers also need to know what measures to take if an insulin reaction occurs. There is no reason why a teacher would need to be able to give an insulin injection. If the child needs to take insulin during school hours, the school nurse would be responsible for monitoring this aspect. The child should be responsible for insulin injections, diet, and testing blood glucose levels. The child should be responsible for insulin injections, diet, and testing blood glucose levels. Additional help could be obtained from the school nurse. The teacher does not need to understand the ADA diet plan because the child should assume this responsibility. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 457 _ about (MC)
QUESTION: "A child brought to the hospital with ketoacidosis is to receive regular insulin via an intravenous infusion. Which of the following intravenous solutions would the nurse expect the physician to order initially?"
CHOICES
( X ) a.) 2.5% dextrose.
( X ) b.) 5% dextrose.
( X ) c.) 0.45% saline.
( O ) d.) 0.9% saline.
RATIONALE: A client in ketoacidosis receives normal saline as a solution because it is isotonic and does not contain glucose. The client receives this solution until the blood glucose level approaches the normal range. The rate, or units given per hour, is based on the child's weight. A child in ketoacidosis has elevated blood glucose levels. A 2.5% dextrose is not used because its glucose content would only serve to further elevate the child's glucose levels. A child in ketoacidosis has elevated blood glucose levels. A 5% dextrose solution is not used because its glucose content would only serve to further elevate the child's glucose levels. A 0.45% saline solution would not be used. Physicians typically order a 0.9% saline solution because it is isotonic and more nearly matches the concentration of a child's blood. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 458 _ about (MC)
QUESTION: "Which of the following would be most appropriate when responding to a mother who asks how to manage her child's morning hyperglycemia? "
CHOICES
( X ) a.) Tell the mother that this is normal and to continue with the ordered doses.
( O ) b.) Ask the mother what her child's blood glucose levels have been for the last few days.
( X ) c.) Inform the mother that this is unusual and the child needs to be seen in the emergency room now.
( X ) d.) Question the mother if her child has been avoiding sweets.
RATIONALE: Management of children with early morning hyperglycemia depends on whether the hyperglycemia is due to insulin-waning, a progressive rise in blood glucose throughout the day, or rebound hyperglycemia (Somogyi effect; an increase in blood sugar glucose at bedtime, a drop at about 2:00 AM, then a rebound rise early in the morning). Information about the child's blood glucose levels would provide clues to determine which event is occurring. Telling the mother that this is normal is inappropriate. Management of children with early morning hyperglycemia depends on whether the hyperglycemia is due to insulin-waning, a progressive rise in blood glucose throughout the day, or rebound hyperglycemia (Somogyi effect; an increase in blood sugar glucose at bedtime, a drop at about 2:00 AM, then a rebound rise early in the morning). Information about the child's blood glucose levels would provide clues to determine which event is occurring. Early morning hyperglycemia is not unusual nor is it an emergency situation. Management of children with early morning hyperglycemia depends on whether the hyperglycemia is due to insulin-waning, a progressive rise in blood glucose throughout the day, or rebound hyperglycemia (Somogyi effect; an increase in blood sugar glucose at bedtime, a drop at about 2:00 AM, then a rebound rise early in the morning). Information about the child's blood glucose levels would provide clues to determine which event is occurring. Although questioning the mother to gain more information is appropriate, asking her specifically about avoiding sweets may imply the mother is at fault for not monitoring the child's intake closely. Additionally, carbohydrates, not sweets, are implicated in diabetes. Management of children with early morning hyperglycemia depends on whether the hyperglycemia is due to insulin-waning, a progressive rise in blood glucose throughout the day, or rebound hyperglycemia (Somogyi effect; an increase in blood sugar glucose at bedtime, a drop at about 2:00 AM, then a rebound rise early in the morning). Information about the child's blood glucose levels would provide clues to determine which event is occurring. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 459 _ about (MC)
QUESTION: "The mother of a 10-year-old girl with diabetes asks the nurse's advice about whether or not her child, who has always been compliant with treatment, should be allowed to go trick-or-treating on Halloween with several friends. Which of the following would be the nurse's best response?"
CHOICES
( X ) a.) "No, it would be a life-threatening emergency if she eats sweets."
( X ) b.) "You must go with her and watch her so she doesn't eat any sweets."
( X ) c.) "Yes, just give her a little extra insulin before she goes."
( O ) d.) "Yes, she needs to be with friends and do the things other children do."
RATIONALE: The nurse should advise the mother to allow the child to go trick-or-treating. Children need to be treated like their peers. Sheltering them from all temptation does not allow them the opportunity to develop coping strategies for dealing with the restraints made necessary by their disease. Eating sweets can result in hyperglycemia. Although not desired, hyperglycemia is not life-threatening in this context. Trust between the parent and child is essential in managing this disease. Telling the mother that she must go with her child and watch her would not promote trust. It would not be advisable to give extra insulin because this action could result in severe hypoglycemia, especially if this usually compliant child remains faithful to the treatment regimen. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 460 _ about (MC)
QUESTION: "When developing the teaching plan for an adolescent with insulin-dependent diabetes, which of the following would the nurse expect to include about the relationship among exercise, diet, and insulin?"
CHOICES
( X ) a.) "Before running, inject your insulin into the leg muscle for quicker absorption.
( O ) b.) "If your blood glucose is 240 mg/dL or above, do not run."
( X ) c.) "You will need to take extra insulin before you go running."
( X ) d.) "Do not eat your snack before running because you'll get a stomachache.
RATIONALE: Strenous exercise, such as running, should be avoided if the adolescent's blood glucose level is 240 mg/dL or above. When insulin levels are not adequate, the cells cannot receive glucose even though the blood glucose level is high. With low insulin levels, glucagons acts to increase hepatic glucose production thus raising the blood glucose level, which cannot be used at the muscle site. Vigorous muscle contraction increases local blood flow and absorption of insulin injected into that area, placing the adolescent at risk for hypoglycemia. This action should be avoided. Because exercise decreases blood glucose levels, snacks would be given before strenuous exercise to prevent hypoglycemia. Taking extra insulin and the effects of exercise place the adolescent at high risk for hypoglycemia. Snacks are used before strenuous exercise to prevent hypoglycemia. If the adolescent cannot tolerate the extra needed food, insulin dosage may be reduced but only on the advice of the physician. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 461 _ about (MC)
QUESTION: "Which of the following is appropriate to include in a teaching plan for a 9-year-old child who has had diabetes for several years?"
CHOICES
( X ) a.) Beginning recognition of symptoms of hypoglycemia.
( X ) b.) Measurement of insulin accurately in the syringe.
( O ) c.) Beginning ability to give own injections with adult supervision.
( X ) d.) Assumption of responsibility for self-care.
RATIONALE: Eight- to 10-year-old children are developmentally ready to begin to give their own injections with adult supervision. Their fine motor skills are developed enough to accomplish this skill. Beginning to recognize symptoms of hypoglycemia is appropriate for 4- to 6-year-old children because of their beginning ability to verbalize how they feel. Measuring insulin accurately in a syringe is more appropriate for 10- to 12-year-old children who have better fine motor skills. Because of the complexity of disease management, assuming responsibility for self-care is appropriate for an older adolescent. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 462 _ about (MC)
QUESTION: "Which of the following statements made by a mother of a 3-year-old child with unexplained injuries would the nurse determine as supportive of suspicions about abuse?"
CHOICES
( X ) a.) "A good friend and I go shopping at least weekly."
( O ) b.) "I'm disappointed that my child can't tie his shoes."
( X ) c.) "My mother helps me with the children."
( X ) d.) "My child helps dress himself."
RATIONALE: Parents who are abusive typically lack knowledge of the child's development and needs. A child at age 3 can help dress himself but would not be expected to tie his shoes. Abusive parents usually lack social support from family and friends. Abusive parents usually lack social support from family and friends. Parents who are abusive typically lack knowledge of the child's development and needs. A child at age 3 can help dress himself and would demonstrate the mother's understanding about the child's development. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 463 _ about (MC)
QUESTION: "When the nurse asks a child suspected of being physically abused how his shoulder was hurt, he replies, "It was my fault. I was bad." Which of the following would be the nurse's best response?"
CHOICES
( O ) a.) "Perhaps it wasn't your fault. Can we talk about what happened?"
( X ) b.) "Tell me what you did that made your father hurt you."
( X ) c.) "We'll make you better and we won't let your father do this to you again."
( X ) d.) "You'll have to behave better so this won't happen again."
RATIONALE: Encouraging the abused child to talk about or play out events surrounding the "accident" can help the child and also provide assessment data. An abused child may feel self-blame. Even if the parent is accused of abuse, the child may still accept responsibility for the act. Asking the child to tell what he did to cause the abuse is inappropriate because it implies that the child is at fault and the problem. Telling the child that the nurse won't let the father hurt the child again is a promise that the nurse cannot keep. The nurse should never make promises that cannot be kept. The child is not at fault and the child's behavior did not cause the abuse. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 464 _ about (MC)
QUESTION: "An abused child is admitted to the hospital, and the nurse is aware that a court appearance may be necessary. To plan for this eventuality, which of the following would be the priority?"
CHOICES
( X ) a.) Remembering the parents' and child's behavior when the child was admitted.
( O ) b.) Documenting physical findings and behaviors observed during the child's admission.
( X ) c.) Formulating subjective opinions about the cause of any injuries.
( X ) d.) Preparing answers to questions that may be asked by the attorneys.
RATIONALE: When dealing with child abuse, the priority is accurate and complete documentation of physical findings and observed behaviors on the client's record. Court proceedings usually occur sometime after the nurse's involvement with the child and family, and memories fade. Thus, careful documentation of the facts, not hearsay or subjective opinion, is essential. Because court proceedings usually occur sometime after the nurse's involvement with the child and family, remembering may be difficult because memories fade. Objective data, not subjective opinions, are key. Preparing answers to questions that may be asked by the attorneys is not a priority for the nurse when the child is admitted. This may become appropriate later. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care
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--> QUESTION NUMBER _ 465 _ about (MC)
QUESTION: "A nurse is approached by an adolescent who has been admitted to the hospital for headaches. She confides that she is being sexually abused by a family friend. Which of the following would be the nurse's best initial response?"
CHOICES
( X ) a.) "Can you tell me what happened?"
( O ) b.) "I believe you; you were right to tell me."
( X ) c.) "Have you told your mother and father about this?"
( X ) d.) "Who else have you told about this?"
RATIONALE: Regardless of the child's age, a child who reports abuse must be believed because confiding this information is frightening and takes courage. Establishing trust is essential. The nurse should start with neutral questions then later ask the child for an account of the event. Often the child who has tried to tell the parents about the abuse has not been believed or has been rejected. Or the child may be afraid to tell the parents. Initially the adolescent must be reassured for reporting the abuse. Asking about which other persons the adolescent may have told is inappropriate and can destroy any trust that has developed to this point. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 466 _ about (MC)
QUESTION: "A nurse caring for a 15-month-old girl suspects that she has been sexually abused. Which of the following would guide the nurse to the decision to report the abuse?"
CHOICES
( X ) a.) The parents need to be notified before suspected abuse can be reported.
( X ) b.) Physicians are primarily responsible for reporting suspected abuse.
( X ) c.) A nurse can be sued when reporting abuse on suspicions only.
( O ) d.) A nurse who suspects child abuse is legally required to report the suspicions.
RATIONALE: All states have mandatory reporting laws relating to child abuse and neglect. A nurse or other health care professional who fails to report suspected abuse may be charged with a misdemeanor. Reporting the incident is the first step required by law. Parents do not need to be notified first. Anyone who suspects child abuse is obligated to report it. Nurses who report suspected child abuse have immunity from being sued. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care
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--> QUESTION NUMBER _ 614 _ about (MC)
QUESTION: "A 2-year-old child is brought to the emergency room with a broken arm. Which of the following findings would lead the nurse to suspect child abuse?"
CHOICES
( X ) a.) The child has bruises on the forearms.
( X ) b.) The child's clothes are dirty, torn, and obviously "hand-me-downs."
( O ) c.) The child's father alters the story of the injury each time he tells it.
( X ) d.) The child's mother did not come to the hospital with the child.
RATIONALE: The nurse should suspect child abuse when the child's caregiver changes the story of the injury each time it is told. A child who is still learning to walk and run often will have bruises on the forearms and shins; bruises on the upper arms and thighs are suspicious. Children often become dirty and tear clothes when they play. A parent may not be able to come to the hospital with the child for many reasons, such as care of other children, illness, or lack of transportation. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 617 _ about (MC)
QUESTION: "A 9-month-old, well-nourished boy who lives with his extensive extended family tests positive for tuberculosis. Which of the following is a risk factor for tuberculosis in this client?"
CHOICES
( X ) a.) Male sex.
( X ) b.) The infant is in the 95th percentile for height and weight.
( X ) c.) His mother did not receive prenatal care until the second trimester of her pregnancy.
( O ) d.) Age.
RATIONALE: Infants are more susceptible to tuberculosis because of a diminished resistance to infection due to an immature immune system. In later childhood and adolescence, morbidity and mortality are higher in females than males. A higher than average weight and height would indicate that the child has had good nutrition. Poor nutrition is a risk factor for tuberculosis. Prenatal care is unrelated to tuberculosis. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 620 _ about (MC)
QUESTION: "A preschool-aged child who is hospitalized with gastroenteritis has been NPO. The physician has written an order to advance the diet as tolerated. The first feeding the nurse should offer the child is:"
CHOICES
( O ) a.) Cooked cereal.
( X ) b.) Ice cream shake.
( X ) c.) Clear lemon carbonated beverage.
( X ) d.) Toast.
RATIONALE: A child with gastroenteritis should start to receive soft foods first after resting the bowel and rehydration. Cooked cereals, vegetables, and meats are recommended. Milk-based foods are not recommended because a child with gastroenteritis may become lactose-intolerant for a period after the acute illness. A child with gastroenteritis should start to receive soft foods first after resting the bowel and rehydration. Cooked cereals, vegetables, and meats are recommended. A child with gastroenteritis should start to receive soft foods first after resting the bowel and rehydration. Cooked cereals, vegetables, and meats are recommended. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 626 _ about (MC)
QUESTION: "An infant admitted to the hospital with acute rotaviral infection is having frequent diarrheal stools. On assessment, the nurse notes 40 to 60 bowel sounds per minute. The child has poor skin turgor, and the mucous membranes are dry. The nurse would make a nursing diagnosis of Deficient Fluid Volume related to:"
CHOICES
( X ) a.) Decreased gastric emptying.
( X ) b.) Insufficient antidiuretic hormone.
( X ) c.) Inability to metabolize nutrients.
( O ) d.) Increased gastrointestinal motility.
RATIONALE: Rotavirus is a type of viral infection that affects the gastrointestinal tract. It causes diarrhea which results in fluid loss. This type of infection can be very serious in infants who, because of their immature kidneys, cannot adjust to fluid loss as readily as adults. Acute diarrheal infection results in increased gastric emptying. Insufficient production of antidiuretic hormone is not a consequence of acute diarrheal infection. Acute diarrheal infection results in malabsorption, not an inability to metabolize nutrients that are absorbed. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 631 _ about (MC)
QUESTION: "The nurse preparing to give a child an intramuscular injection chooses to give the injection into the gluteal muscle. The site is acceptable because the child:"
CHOICES
( O ) a.) Has been walking for 1 year.
( X ) b.) Has small deltoid muscles.
( X ) c.) Is older than 2 years.
( X ) d.) Weighs more than 25 pounds.
RATIONALE: Muscle mass determines whether or not a muscle can be safely used as an injection site. The gluteal muscle enlarges in response to use in walking. After the child has been walking for a year, it should be safe to use the gluteus maximus for injections. Small deltoid muscles are not appropriate for injections. Age has only a minor influence on muscle mass. Weight has only a minor influence on muscle mass. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 632 _ about (MC)
QUESTION: "An infant who has undergone surgery for bilateral clubfoot returns from the operating room with bilateral casts. After noting that the infant's toes are slightly cool and edematous, the nurse should first:"
CHOICES
( X ) a.) Cut the casts.
( O ) b.) Elevate the legs on pillows.
( X ) c.) Notify the surgeon.
( X ) d.) Place warm packs on the child's feet.
RATIONALE: The nurse's first action here is to elevate the part that is edematous. Decreasing the edema by promoting venous return may help improve circulation and warm the toes. The nurse should follow up after a short time to evaluate if the intervention is effective. The toes may also be cool because plaster casts are wet and cool. There are no data, such as decreased pulses or altered skin color, to support cutting the casts. There is no reason to notify the surgeon at this time because this condition is expected. A warm pack would be contraindicated at this point; it would serve to increase circulation and the potential for edema, and to further decrease venous return. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 637 _ about (MC)
QUESTION: "A nurse observes a family in the waiting room of a well-child clinic. Which of the following behaviors would be considered to be an example of social affective play?"
CHOICES
( X ) a.) The 8-year-old child is taking turns playing a hand-held video game with another child he met in the waiting room.
( X ) b.) The 4-year-old child is listening to the mother's chest with a stethoscope.
( O ) c.) The infant makes happy noises in response to her father speaking to her.
( X ) d.) The 2-year-old child is sitting in her mother's lap hugging a teddy bear.
RATIONALE: Social affective play occurs when infants take pleasure in relationships with people. The 8-year-old child is participating in interactive play. The 4-year-old child is participating in symbolic or pretend play. The 2-year-old child is exhibiting unoccupied behavior. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 641 _ about (MC)
QUESTION: "The clinic nurse is instructing a group of parents about emergency treatment for accidental poisoning and injury. The nurse would need to do further teaching if one of the mothers states, "I should:"
CHOICES
( X ) a.) Flush my child's eye with room temperature tap water for 15 to 20 minutes if a caustic material gets into it."
( X ) b.) Save the emesis if my child vomits."
( O ) c.) Call the poison control center if there are any symptoms."
( X ) d.) Give 2 to 5 teaspoons of clear fluids after administering ipecac."
RATIONALE: Many poisons require immediate attention but do not cause immediate symptoms. Eyes should be flushed for 15 to 20 minutes with saline or room temperature tap water. Emesis should be saved for analysis, especially if the type or amount of poison ingested is not clear. Ipecac should be followed by 10 to 20 mL of clear liquids. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control
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--> QUESTION NUMBER _ 643 _ about (MC)
QUESTION: "To help promote independence in the area of feeding for a school-aged child in skeletal traction, the nurse would help the child choose which of the following meals?"
CHOICES
( X ) a.) Carrot sticks, celery with cream cheese, roast beef and gravy, peas, gelatin, and milk in a cup.
( X ) b.) Chicken noodle soup with crackers, grilled cheese sandwich, cole slaw, and chocolate milk in a carton.
( O ) c.) Chicken nuggets with sauce, carrot sticks, French-fried potatoes, ice cream sandwich, and milk in a carton.
( X ) d.) Spaghetti and meat sauce, cherry cobbler, and apple juice in a can.
RATIONALE: To promote self-feeding, the nurse should provide the child with foods that can be eaten with the fingers or that do not spill easily. Gravies and small round vegetables can easily spill from a spoon or fork when the child is eating in an unfamiliar position. Fluids should be provided in containers with straws to prevent spills. Soups can easily spill from a spoon when the child is eating in an unfamiliar position. Spaghetti can be very difficult for the child to eat. Fluids should be provided in containers with straws to prevent spillage. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 660 _ about (MC)
QUESTION: "A nurse is performing a Denver Developmental Screening Test (Denver II) on a 4-year-old. The nurse determines that the test has resulted in a caution score when there are:"
CHOICES
( O ) a.) Failed or refused items intersected by the age line between the 25th and 75th percentiles.
( X ) b.) A large number of refusals to the right of the age line.
( X ) c.) More failures than passes along the age line.
( X ) d.) Passed or failed items intersected by the age line in the 25th and 75th percentiles.
RATIONALE: A caution score is given when there are failed or refused items intersected by the age line between the 25th and 75th percentiles. Failed items need to be considered in relation to where the age line crosses the item box. Large numbers of refusals result in an untestable score. A caution score is given when there are failed or refused items intersected by the age line between the 25th and 75th percentiles. Failed items need to be considered in relation to where the age line crosses the item box. Large numbers of refusals result in an untestable score. A caution score is given when there are failed or refused items intersected by the age line between the 25th and 75th percentiles. Failed items need to be considered in relation to where the age line crosses the item box. Large numbers of refusals result in an untestable score. A caution score is given when there are failed or refused items intersected by the age line between the 25th and 75th percentiles. Failed items need to be considered in relation to where the age line crosses the item box. Large numbers of refusals result in an untestable score. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 664 _ about (MC)
QUESTION: "After completing teaching about sickle cell disease to a mother, the nurse would be concerned if the mother states:"
CHOICES
( O ) a.) "I know she does not have as much pain as she acts like she has."
( X ) b.) "I need to stop at the health food store to pick up medicines that my child will need."
( X ) c.) "When my child runs a high fever, I will need to call the physician."
( X ) d.) "I will be sure to give her a lot of fluids when she gets sick."
RATIONALE: Crises cause pain, which needs to be treated with pain medication. The mother doesn't believe her child nor does she understand the teaching. Homeopathic treatment can be appropriate as long as the child is not placed in any danger and accepted medical therapy is also followed. Calling the physician when the child has a high fever would be appropriate in this situation. Hemodilution is an important aspect of sickle cell crisis prevention. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 673 _ about (MC)
QUESTION: "An 8-year-old child with severe cerebral palsy is underweight and undersized for his age. He is being fed a diet of pureed foods and liquids through a syringe. An appropriate nursing diagnosis for this child would be Imbalanced Nutrition: Less Than Body Requirements related to:"
CHOICES
( X ) a.) Increased metabolism.
( X ) b.) Inability to metabolize fats.
( O ) c.) Impaired oral motor control.
( X ) d.) Increased intracranial pressure.
RATIONALE: A child with severe cerebral palsy often has a lack of oral motor control that interferes with tongue control, chewing, and swallowing. This is the reason that this child is being fed pureed foods and fluids. Lack of tongue control often causes the child to push the food back out of the mouth while trying to chew and swallow. A child with cerebral palsy has a nonprogressive central nervous system insult. Cerebral palsy does not affect the client's metabolism. This child should be able to absorb and metabolize ingested nutrients. Cerebral palsy does not affect the client's metabolism of fats. Ongoing, increased intracranial pressure is not related to cerebral palsy. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 674 _ about (MC)
QUESTION: "A school-aged child has her broken arm in a cast. Her parents are ready to take her home from the emergency room. Discharge teaching should consist of telling the parents that which of the following would indicate she needed to be brought back to the emergency room?"
CHOICES
( O ) a.) Her fingers become pale and she complains of numbness.
( X ) b.) The plaster cast does not dry in 4 hours.
( X ) c.) The cast feels too heavy and it's hard for her to move her arm.
( X ) d.) Her pain is not better 30 minutes after taking acetaminophen.
RATIONALE: New complaints of tingling and pale fingers would indicate a serious problem that needs immediate attention. The plaster cast will take longer than 4 hours to dry. The cast will feel heavy. Acetaminophen may not be a strong enough medication to relieve the pain. It also may take 45 minutes before she has any pain relief, particularly if she has just eaten. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 675 _ about (MC)
QUESTION: "A community health nurse has taught a parent in the clinic about the ages that children receive immunizations and the reason why certain immunizations are given at different times. The nurse would judge the teaching as successful when she overhears this parent tell another parent:"
CHOICES
( O ) a.) "My 6-month-old child will have to wait for the MMR (measles, mumps, and rubella) vaccine."
( X ) b.) "My child has a cold and will have to wait 2 weeks to receive immunizations."
( X ) c.) "Children must wait 4 months between MMR and the polio vaccines."
( X ) d.) "Children receive their MMR vaccine then have to wait 1 month for the tuberculin skin test."
RATIONALE: Research studies have shown that complete immunity for the MMR vaccine is not achieved until the child is 12 months of age. Therefore, the normal healthy child should not receive it before that time. An upper respiratory tract infection is not a reason to withhold immunizations in children. There is no 4-month waiting period between MMR and polio vaccines. The tuberculin skin test (purified protein derivative [PPD]) can be administered at the same time as the MMR. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 678 _ about (MC)
QUESTION: "An 8-year-old child is sent home by the school nurse with pediculosis. The child's father speaks with the nurse and is obviously upset and embarrassed. Which of the following statements by the father would indicate to the nurse that he understands how his child got pediculosis?"
CHOICES
( X ) a.) "I brush her hair twice a day."
( O ) b.) "Could this result from sharing batting helmets at T-ball practice?"
( X ) c.) "I make sure she shampoos her hair daily."
( X ) d.) "We always use a dandruff-control shampoo."
RATIONALE: Pediculosis, or head lice, is commonly spread by the sharing of headwear, combs, and brushes. The adult lice can also travel from one person to another if contact is close. The adult lice lay eggs, or nits. These nits are "glued" to the hair and cannot be removed unless treated with special shampoo formulated for just this purpose. The hair is then combed with a fine-toothed comb to remove the nits. Because head lice spread so easily, a child is usually kept out of school until he or she is treated and found to be free of nits. Hairbrushing will not prevent pediculosis. Cleanliness does not prevent the acquisition of pediculosis. Dandruff shampoos will not protect the child from head lice. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 680 _ about (MC)
QUESTION: "A 4-year-old child with hemophilia is brought to the pediatrician's office with spontaneous soft tissue bleeding of the right knee. Immediately on the child's arrival, the nurse would plan to:"
CHOICES
( X ) a.) Administer aspirin for discomfort.
( X ) b.) Immobilize the knee in a dependent position.
( O ) c.) Elevate the right knee.
( X ) d.) Do a type and cross-match for platelets.
RATIONALE: The goal is to decrease the bleeding. This can be aided by decreasing circulation to the area. Elevating the part and applying cold decreases circulation to the area. The child will also receive cryoprecipitate. Aspirin is contraindicated for clients who have bleeding disorders because it increases capillary fragility. The dependent position will increase bleeding and swelling. Lack of clotting factors, not lack of platelets, is the problem in children with hemophilia.
NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 685 _ about (MC)
QUESTION: "The nurse caring for a child with leukemia should place priority on:"
CHOICES
( X ) a.) Preventing injury.
( X ) b.) Monitoring the child's platelet count.
( O ) c.) Monitoring the child's temperature.
( X ) d.) Encouraging increased fluid intake.
RATIONALE: The most common cause of death in children with leukemia is infection. The child should be monitored for any signs of infection, including temperature. Preventing injury is a concern because of the bleeding that can result. Bleeding, although a common problem, is not the most common cause of death. Increasing fluids is necessary when a fever is present. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 687 _ about (MC)
QUESTION: "A 6-month-old infant is brought to the clinic with a high fever and cold symptoms. She is pulling at her left ear. She is scheduled to receive her 6-month immunizations. The mother asks the nurse if she will receive them. The nurse's best response would be:"
CHOICES
( X ) a.) "She will receive just one of the immunizations."
( O ) b.) "She can have them when she is returned to have her ear rechecked."
( X ) c.) "She will receive her DaTP, Hib, and hepatitis today."
( X ) d.) "She will receive only two of the immunizations today."
RATIONALE: Generally, immunizations are not given to a child with a severe febrile illness. Once the child is well, then normal immunizations can be given. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 692 _ about (MC)
QUESTION: "For a child receiving steroids in therapeutic doses over a long period, the nurse should:"
CHOICES
( O ) a.) Monitor the child's serum glucose level.
( X ) b.) Decrease the child's ingestion of potassium-rich foods.
( X ) c.) Give the drug on an empty stomach.
( X ) d.) Monitor the child's temperature to assess for infection.
RATIONALE: Steroid use tends to elevate glucose levels. The child should be monitored for increases. Potassium intake should be increased. The drug should be taken with food or milk to reduce gastrointestinal upset. Because steroids suppress the inflammatory response, temperature measurement is not an effective assessment tool for identifying infections. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 693 _ about (MC)
QUESTION: "A father calls the clinic saying his child has chickenpox. The father asks how to care for the lesions. The nurse would advise that the child:"
CHOICES
( X ) a.) Soak in a hot tub for 30 minutes three times a day.
( O ) b.) Take an antihistamine and use calamine lotion on the lesions.
( X ) c.) Take acetaminophen and use an antibiotic ointment on the lesions.
( X ) d.) Remove lesions' crusts as they form.
RATIONALE: Use of an antihistamine and calamine lotion are recommended to help decrease the itching. The child can have a bath in cool water but soaking will dry out the skin. Use of oatmeal baths helps decrease itching. Acetaminophen would be used only if the child has a fever. Antibiotic ointment may be used if lesions are infected. Only remove loose crusts that rub and irritate the child. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 695 _ about (MC)
QUESTION: "A child with appendicitis is being readied for surgery. Which of the following would be the nurse's first action?"
CHOICES
( X ) a.) Administer an enema.
( X ) b.) Insert a nasogastric tube.
( O ) c.) Obtain vital signs.
( X ) d.) Administer antibiotics.
RATIONALE: Any child going to surgery needs a current set of vital signs documented on the chart. Enemas are not administered because they increase gastric motility and may cause the appendix to rupture. Nasogastric tubes are usually inserted after the child is under anesthesia. Antibiotics are not routinely administered preoperatively. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 696 _ about (MC)
QUESTION: "Two adolescents come to the school nurse's office to talk about their friend. They are concerned because he seems to be using several different drugs. One of the adolescents asks how he would be able to tell if his friend was using cocaine. The nurse replies that his:"
CHOICES
( X ) a.) Eyes would be red and bloodshot.
( O ) b.) Pupils would be large.
( X ) c.) Pupils would be constricted to pinpoints.
( X ) d.) Eyes would look tired.
RATIONALE: Cocaine use causes pupils to dilate. Marijuana causes eyes to be red and appear bloodshot. Heroin causes pupils to be pinpoints. Having tired-looking eyes would not necessarily be caused by drug use. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 699 _ about (MC)
QUESTION: "The nurse should plan to include which of the following interventions in the plan of care for a child admitted to the hospital with a medical diagnosis of febrile seizure?"
CHOICES
( X ) a.) Keep the child supine.
( X ) b.) Place the child in droplet isolation precautions and restrict visitors.
( O ) c.) Keep the room temperature low and bedclothes to a minimum.
( X ) d.) Place a padded tongue blade at the bedside.
RATIONALE: One nursing goal for clients with febrile seizures is to maintain temperature at a level low enough to prevent recurrence of seizures. Decreasing the environmental temperature and removing excess clothing and blankets will help decrease the client's temperature. There is no reason to keep the child supine; a side-lying position would be acceptable and help decrease intracranial pressure. A febrile seizure, though, results from abnormal electrical activity in the brain due to elevated body temperature. Droplet isolation precautions are not necessary unless the child has a condition that warrants such an isolation. Using tongue blades to separate the teeth in the upper jaw from the lower jaw in an attempt to prevent the child from biting the tongue has proved to be ineffective and may result in broken teeth. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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