Post by Nursing Board 101 on Aug 18, 2010 13:42:14 GMT -5
1. After assessing a newly admitted 5-year-old child, the nurse makes the nursing diagnosis of Parental role conflict related to child's hospitalization. Which defining characteristic would most suggest this diagnosis?
a.)Supportive child-parent interaction (speaking, listening, touching, and eye-to-eye contact
b.)Parents' active participation in child's physical or emotional care
c.)Parents' failure to use available support systems or agencies to assist in coping d.)Evidence of adaptation to parental role changes
C. RATIONALE: A failure to use available support systems or agencies is one of the defining characteristics of this diagnosis. Supportive child-parent interaction, parents' active participation in the child's care, and evidence of adaptation to parental role changes don't suggest this diagnosis.
2. An 8-year-old child enters a health care facility. During assessment, the nurse discovers that the child is experiencing the anxiety of separation from his parents. The nurse makes the nursing diagnosis of Fear related to separation from familiar environment and family. Which nursing intervention is most likely to help the child cope with fear and separation?
a.)Ask the parents not to visit the child until he has adjusted to the new environment. b.)Ask the physician to explain to the child why he needs to stay in the health care facility.
c.)Explain to the child that he must act like an adult while he's in the facility.
d.)Have the parents stay with the child and participate in his care.
D. RATIONALE: Allowing the parents to stay and participate in the child's care can provide support to the parents and the child. The other interventions won't address the client's diagnosis and may exacerbate the problem.
3. A 13 year old visits the school nurse because he's experiencing back pain, fatigue, and dyspnea. The nurse suspects that the child may have scoliosis. The nurse should first: a.)send the child home to recover.
b.)inspect the child for uneven shoulder height or uneven hip height.
c.)arrange for the child to have spinal X-rays as soon as possible.
d.)ask the child's parent to take him to a physician immediately.
B. RATIONALE: Before deciding on any specific intervention, the school nurse should perform a basic assessment for scoliosis, including inspecting for uneven shoulder or hip height. The nurse will then have more specific information to give to the parent. The parent bears responsibility for seeking further medical care for the child.
4. The nurse is caring for a child who has just been immunized. When teaching the child's parents about potential adverse effects, the nurse should instruct the parents to immediately report:
a.)pain at the injection site.
b.)generalized urticaria.
c.)mild temperature elevation.
d.)local swelling at the injection site.
B. RATIONALE: Generalized urticaria can herald the onset of a life-threatening episode and medical assistance should be sought immediately. A child may experience some pain, redness at the sight, mild temperature elevation, or localized swelling. These reactions can be treated symptomatically and aren't life-threatening.
5. The nurse is caring for a child with cystic fibrosis. The child's parents tell the nurse that they're having difficulty coping with their child's disease. Which action wouldn't be appropriate for the nurse to take?
a.)Helping the child and family obtain necessary equipment, supplies, and medication
b.)Pointing out to the parents ways in which they might have done things differently
c.)Providing referrals to local community agencies and the Cystic Fibrosis Foundation d.)Encouraging the parents to allow their child to follow as normal a childhood as possible
B. RATIONALE: The nurse should avoid being critical when talking with parents about how they have handled their child's disease or condition. The nurse can help this family by assisting them with finding appropriate financial, psychological, and social support. Providing referrals to local community agencies and the Cystic Fibrosis Foundation is also an appropriate intervention. The child should be treated as much like a normal child as possible.
6. The nurse is caring for a client who was involved in a motor vehicle accident. The client has a chest tube in place. If the chest tube is accidentally removed, the nurse should immediately:
a.)reintroduce the tube and attach it to water seal drainage.
b.)call the physician and obtain a chest tray.
c.)cover the opening with petroleum gauze.
d.)clean the wound with povidone-iodine and apply a gauze dressing.
C. RATIONALE: If a chest tube is accidentally removed, the nurse should cover the insertion site with sterile petroleum gauze. The nurse should then observe the client for respiratory distress, as tension pneumothorax may develop. If so, the nurse should remove the gauze to allow air to escape. The nurse shouldn't reintroduce the tube. Rather, the nurse should have another staff member call a physician so another tube can be introduced by the physician under sterile conditions.
7. A mist tent contains a nebulizer that creates a cool, moist environment for a child with an upper respiratory tract infection. The cool humidity helps the child breathe by:
a.)decreasing respiratory tract edema.
b.)lowering anxiety.
c.)drying secretions.
d.)increasing fluid intake.
A. RATIONALE: The mist tent decreases respiratory tract edema, which causes croup. However, the child needs to be prepared because the confinement can cause high anxiety. The tent liquefies secretions, rather than drying them and it doesn't increase the child's fluid intake.
8. An otherwise-healthy adolescent has meningitis and is receiving I.V. and oral fluids. The nurse should monitor this client's fluid intake because fluid overload may cause:
a.)cerebral edema.
b.)dehydration.
c.)heart failure.
d.)hypovolemic shock.
A. RATIONALE: Because of the inflammation of the meninges, the client is vulnerable to developing cerebral edema and increased intracranial pressure. Fluid overload won't cause dehydration. It would be unusual for an adolescent to develop heart failure unless the overhydration was extreme. Hypovolemic shock would occur with an extreme loss of fluid or blood.
9. The nurse is caring for a 16-year-old female client who isn't sexually active. The client asks if she needs a Papanicolaou (Pap) test. The nurse should reply:
a.)"Yes, you should have a Pap test after the onset of menstruation."
b.)"No, you aren't sexually active."
c.)"Yes, you're 16 years old."
d.)"No, you aren't 21 years old."
B. RATIONALE: A 16-year-old female client who isn't sexually active doesn't need a Pap test. When a client is sexually active or reaches age 18, a Pap test should be performed.
10. A teenage mother brings her 1-year-old child to the pediatrician's office for a well-baby checkup. She says that her baby can't sit alone or roll over. An appropriate response by the nurse would be:
a.)"This is very abnormal, your child must be sick."
b.)"Let's see about further developmental testing."
c.)"Don't worry, this is normal for her age."
d.)"Maybe you just haven't seen her do it."
B. RATIONALE: At age 12 months, a child should be sitting up and rolling over. Therefore, this child may have developmental problems. Options A and D aren't therapeutic and can cut off communication with the mother. Option C misleads the mother with false reassurance.
11. An emergency department nurse suspects neglect in a 3-year-old boy admitted for failure to thrive. Signs of neglect in the child would include:
a.)slapping, kicking, and punching others.
b.)poor hygiene and weight loss.
c.)loud crying and screaming.
d.)pulling hair and hitting.
B. RATIONALE: Neglect can involve failure to provide food, bed, shelter, health care, or hygiene. Slapping, kicking, punching, pulling hair, and hitting are examples of forms of physical abuse. Loud crying and screaming aren't abnormal findings in a 3-year-old child.
12. A boy, age 3, develops a fever and rash and is diagnosed with rubella. His mother has just given birth to a baby girl. Which statement by the mother best indicates that she understands the implications of rubella?
a.)"I told my husband to give my son aspirin for his fever."
b.)"I'll ask the physician about giving the baby an immunization shot."
c.)"I don't have to worry because I've had the measles."
d.)"I'll call my neighbor who is 2 months pregnant and tell her not to have contact with my son."
D. RATIONALE: Fetal defects can occur during the first trimester of pregnancy if the pregnant woman gets rubella. Aspirin shouldn't be given to young children because aspirin has been implicated in the development of Reye's syndrome. Tylenol should be used instead of aspirin. Rubella immunization isn't recommended for children until age 12 to 15 months. Measles is rubeola and won't provide immunity for rubella.
13. The nurse is caring for an adolescent client who underwent surgery for a perforated appendix. When caring for this client, the nurse should keep in mind that the main life-stage task for an adolescent is to:
a.)resolve conflict with parents.
b.)develop an identity and independence.
c.)develop trust.
d.)plan for the future.
B. RATIONALE: The adolescent strives for a sense of independence and identity. During this time, conflicts are heightened, not resolved. Trust begins to develop during infancy and matures along with development. Adolescents rarely finalize plans for the future; this usually happens later in adulthood.
14. What's the best advice for a nurse to give to the parents of a 2-year-old child who frequently throws temper tantrums?
a.)Move the toddler to a different setting.
b.)Allow the toddler more choices.
c.)Ignore the behavior when it happens.
d.)Give in to the toddler's demands.
C. RATIONALE: Ignore tantrum behavior because attention to the behavior can reinforce the undesirable behavior. Changing settings can increase the tantrum behavior. Allowing the toddler more choices may increase tantrum behavior if the toddler is unable to follow through with choices. The toddler should be offered only allowable and reasonable choices. It's ill-advised to give in to the toddler's demands because doing so only promotes tantrum behavior.
15. A mother tells the nurse that she wants to begin toilet training her 22-month-old child. The most important factor regarding toilet training that the nurse should stress to her is:
a.)developmental readiness of the child.
b.)consistency in approach.
c.)the mother's positive attitude.
d.)developmental level of the child's peers.
A. RATIONALE: If the child isn't developmentally ready, the child and parent will become frustrated. Consistency is important when toilet training is started. The mother's positive attitude is important when the child is determined to be ready. Developmental levels of children are individualized and comparison to peers isn't useful.
16. A mother complains to the nurse that her 4-year-old son often lies. What's the nurse's best response?
a.)Let the child know that he'll be punished for lying.
b.)Ask him why he isn't telling the truth.
c.)It's probably due to his vivid imagination and creativity.
d.)Acknowledge him by saying, "That's a pretend story."
D. RATIONALE: It's important to acknowledge the child's imagination, while also letting him know in a nice way that what he has said isn't real. Punishment isn't appropriate for a 4-year-old child using his imagination, and accusing him of lying is a negative reinforcement. The child isn't truly lying in the adult sense. Imagination and creativity need to be acknowledged.
17. A mother is playing with her infant, who is sitting securely alone on the floor of the clinic. The mother hides a toy behind her back and the infant looks for it. What age would the nurse estimate the infant to be?
a.)6 months
b.)4 months
c.)8 months
d.)10 months
D. RATIONALE: A 10-month-old child can sit alone and understands object permanence, so he would look for the hidden toy. At 4 to 6 months of age, children can't sit securely alone. At 8 months of age, children can sit securely alone but can't understand the permanence of objects.
18. The mother of a 4-year-old child tells the nurse that her child is a poor eater. What's the nurse's best recommendation for helping her increase her child's nutritional intake?
a.)Allow the child to feed herself.
b.)Use specially designed dishes for children; for example, a plate with the child's favorite cartoon character.
c.)Only serve the child's favorite foods.
d.)Allow the child to eat at a small table and chair by herself.
A. RATIONALE: The best recommendation is to allow the child to feed herself because the child's stage of development is the preschool period of initiative. Special dishes would enhance the primary recommendation. It's important to offer new foods and choices, not just serve her favorite foods. Using a small table and chair would also enhance the primary recommendation.
19. The nurse is teaching the mother of an ill child about childhood immunizations. The nurse should tell the mother that live virus vaccines shouldn't be administered to children with:
a.)diabetes.
b.)leukemia.
c.)asthma.
d.)cystic fibrosis.
B. RATIONALE: Leukemia causes immunosuppression, so inactivated rather than live viruses should be administered. Children with the other conditions listed can receive live virus vaccines because they aren't immunosuppressed.
20. A 7-year-old boy is hospitalized with cystic fibrosis. To help him manage secretions and avoid respiratory distress, the nurse should:
a.)perform chest physiotherapy every 4 hours.
b.)give pancreatic enzymes as ordered.
c.)place the child in an oxygen tent and have oxygen administered continuously. d.)serve a high-calorie diet.
A. RATIONALE: Chest physiotherapy aids in loosening secretions in the entire respiratory tract. Pancreatic enzymes aid in the absorption of necessary nutrients not in managing secretions. Oxygen therapy doesn't aid in loosening secretions and can cause carbon dioxide retention and respiratory distress in children with cystic fibrosis. A high-calorie diet is appropriate but doesn't facilitate respiratory effort.
21. The nurse is providing care to a 5-year-old client with a fractured femur whose nursing diagnosis is Imbalanced nutrition related to impaired physical mobility. Which of the following is most likely to occur with this condition?
a.)Decreased protein catabolism
b.)Increased calorie intake
c.)Increased digestive enzymes
d.)Increased carbohydrate need
D. RATIONALE: Carbohydrate need increases because healing and repair of tissue requires more carbohydrates. Increased not decreased protein catabolism is present. Decreased appetite not increased is a problem. Digestive enzymes are decreased not increased.
22. The nurse is interviewing a 16-year-old female at a clinic. It's her first visit and she says that she has been exposed to herpes by her boyfriend. Initially, with primary genital or type 2 herpes simplex, the nurse would expect the client to have:
a.)dysuria and urine retention.
b.)perineal ulcers and erosions.
c.)bilateral inguinal lymphadenopathy.
d.)burning or tingling on vulva, perineum, or vagina.
D. RATIONALE: Burning and tingling genital discomfort is the most common initial finding. This symptom will advance to vesicular lesions rupturing into ulcerations, which then dry into a crusty erosion. The client may also experience fever, headache, malaise, myalgia, regional lymphadenopathy, and dysuria.
23. A 2-year-old child is brought to the emergency department with a history of upper airway infection that has worsened over the last 2 days. The nurse suspects the child has croup. Signs of croup include a hoarse voice, inspiratory stridor, and:
a.)a barking cough.
b.)a high fever.
c.)sudden onset.
d.)dysphagia.
A. RATIONALE: Croup is an acute viral respiratory illness characterized by a barking cough. Fever is usually low-grade. Croup has a gradual onset, and dysphagia isn't a symptom.
24. A 2-year-old child is brought to the emergency department with suspected croup. The child appears frightened and cries as the nurse approaches him. The nurse needs to assess the child's breath sounds. The best way to approach the 2-year-old child is to: a.)expose the child's chest quickly and auscultate breath sounds as quickly and efficiently as possible.
b.)ask the mother to wait briefly outside until the assessment is over.
c.)tell the child the nurse is going to listen to his chest with the stethoscope.
d.)allow the child to handle the stethoscope before listening to his lungs.
D. RATIONALE: Toddlers are naturally curious about their environment and letting them handle minor equipment is distracting and helps them gain trust with the nurse. The nurse should expose only one area at a time during assessment and should approach the child slowly and unhurriedly. The caregiver should be encouraged to hold and console her child. Also, comfort the child with objects with which he's familiar. The child should be given limited choices to allow autonomy, such as "Do you want me to listen first to the front of your chest or your back?"
25. A 2-year-old child is brought to the emergency department with suspected croup. Which of the following assessment findings reflects increasing respiratory distress?
a.)Intercostal retractions
b.)Bradycardia
c.)Decreased level of consciousness
d.)Flushed skin
A. RATIONALE: Clinical manifestations of respiratory distress include tachypnea, tachycardia, restlessness, dyspnea, intercostal retractions, and cyanosis.
26. An emergency department nurse is caring for a child diagnosed with croup. The nebulizer treatment of choice for a child with croup is:
a.)albuterol (Ventolin).
b.)metaproterenol (Alupent).
c.)racepinephrine.
d.)ipratropium (Atrovent).
C. RATIONALE: Racemic epinephrine is an adrenergic used to reduce inflammation and edema of the tissue surrounding the trachea in a client with croup. Albuterol, metaproterenol, and other beta<-adrenergic drugs are used to treat asthma. Ipratropium is an anticholinergic used to treat severe asthma.
27. The nurse administers racemic epinephrine to a child. Ten minutes after administration, the nurse should be alert for:
a.)respiratory distress.
b.)profound tachycardia.
c.)signs of improved oxygenation.
d.)diminished cyanosis.
A. RATIONALE: A rebound effect from racemic epinephrine can occur up to 4 hours after treatment with signs of respiratory distress (tachypnea, restlessness, cyanosis). Tachycardia may initially follow treatment with racemic epinephrine as well as improvement in client status (improved oxygenation and improved color).
28. An 8-month-old male is admitted to the pediatric unit following a fall from his high chair. The child is awake, alert, and crying. The nurse should know that a brain injury is more severe in children because of:
a.)increased myelination.
b.)intracranial hypotension.
c.)cerebral hyperemia.
d.)a slightly thicker cranium.
C. RATIONALE: Cerebral hyperemia (excess blood in the brain) causes an initial increase in intracranial pressure in the head of an injured child. The brain is less myelinated in a child and more easily injured than an adult brain. Intracranial hypertension not hypotension places the child at greater risk for secondary brain injury. A child's cranium is thinner and more pliable, causing the child to receive a more severe injury.
29. The nurse is assessing an 8-month-old child for signs of neurologic deficit and increased intracranial pressure (ICP). These signs would include:
a.)a depressed fontanel.
b.)slurred speech.
c.)tachycardia.
d.)an altered level of consciousness.
D. RATIONALE: One sign of neurologic deficit in an 8-month-old child includes a decreased or altered level of consciousness. The fontanel would bulge if he had increased ICP. The child can't speak at this age, but a change in cry may be noted. Bradycardia not tachycardia is a sign of increased ICP.
30. A 12-month-old child fell down the stairs and a basilar skull fracture is suspected. The nurse should look for:
a.)cerebrospinal fluid otorrhea.
b.)deafness.
c.)raccoon eyes.
d.)Battle's sign.
A. RATIONALE: Basilar skull fracture is a fracture in any bone of the base of the skull frontal, ethmoid, sphenoid, temporal, or occipital. Otorrhea would be observed. Deafness doesn't commonly occur as a result of skull fracture. Raccoon eyes and Battle's sign occur primarily in orbital fractures.
31. A child arrives in the emergency department with a history of transient consciousness and unconsciousness. The nurse should suspect:
a.)subdural hematoma.
b.)epidural hematoma.
c.)subarachnoid hemorrhage.
d.)concussion.
B. RATIONALE: An initial loss of consciousness followed by transient consciousness leading to unconsciousness is caused by epidural hematoma. Subdural hematoma results in rapid deterioration in level of consciousness. Subarachnoid hemorrhage causes irritability rather than loss of consciousness. Concussion may result in a brief loss of consciousness.
32. A visibly upset mother carries her 2-month-old infant into the crowded emergency department. The child appears limp and lifeless. The mother screams to the nurse for help. The nurse should:
a.)take the infant from the mother and offer to help.
b.)take the infant and mother to a treatment room.
c.)call the resuscitation team and the supervisor.
d.)call security and the hospital administration.
B. RATIONALE: Taking the infant and mother into a treatment room for assessment provides privacy and a controlled environment. The mother should be allowed to remain with her child if she wishes. If she doesn't want to be present, the nurse should find a private area for her. The nurse must assess the child before calling the resuscitation team. Security isn't warranted in this situation.
33. While assessing a 2-month-old child's airway, the nurse finds that the child isn't breathing. After two unsuccessful attempts to establish an airway, the nurse should: a.)attempt rescue breaths.
b.)attempt to reposition the airway a third time.
c.)administer five back blows.
d.)attempt to ventilate with a handheld resuscitation bag.
C. RATIONALE: The child's airway is blocked despite attempts to establish it. The next step is to clear the airway with back blows and chest thrusts. Breaths can't be administered until the airway is patent. After two attempts to position the airway, the nurse can assume the airway is blocked. The nurse can't ventilate the child with a handheld resuscitation bag until the airway is patent.
34. A nurse performs cardiopulmonary resuscitation (CPR) for 1 minute on an infant without calling for assistance. In reassessing the infant after 1 minute of CPR, the nurse finds that he still isn't breathing and that he has no pulse. The nurse should then: a.)resume CPR beginning with breaths.
b.)declare her efforts futile.
c.)resume CPR beginning with chest compressions.
d.)call for assistance.
D. RATIONALE: After 1 minute of CPR, the nurse should call for assistance and then resume efforts. CPR shouldn't be stopped after it has been started unless the nurse is too exhausted to continue. A cycle usually ends with breaths, so the next beginning cycle after pulse check and summoning help would begin with chest compressions.
35. A neonate arrives at the emergency department in full cardiopulmonary arrest. Resuscitation efforts fail, and he's pronounced dead. The cause of death is sudden infant death syndrome (SIDS). Which of the following is true regarding the etiology of SIDS? a.)It occurs in suspected child abuse cases.
b.)It occurs primarily in neonates with congenital lung problems.
c.)It occurs primarily in black neonates.
d.)It occurs more commonly in neonates who sleep in the prone position.
D. RATIONALE: SIDS occurs in seemingly healthy neonates. However, more neonates who sleep in the prone position are affected. Because of the pooling of blood that occurs in the child with SIDS, child abuse is sometimes suspected. No correlation to race or lung disease exists.
36. The nurse is providing care for a mother whose child has died. The mother tells the nurse that she's angry with God for taking away her child. She has vowed never again to go to church or pray. Which nursing diagnosis is most appropriate?
a.)Ineffective coping
b.)Spiritual distress
c.)Powerlessness
d.)Ineffective denial
B. RATIONALE: The mother's expression of anger toward God is an indication of spiritual distress. Expressions of anger are a normal part of the grieving process and don't indicate ineffective coping. Although the mother may indeed be experiencing feelings of powerlessness, this isn't the most accurate diagnosis of her feelings as indicated by the assessment data. There's no evidence of denial on the mother's part.
37. A 2-year-old client is admitted to the pediatric unit with fever, seizures, and vomiting. He's awake and alert. As the nurse is putting a gown on the child, the nurse notices petechiae across the child's chest, abdomen, and back. The nurse should: a.)question the mother about the child's allergies.
b.)initiate standard precautions.
c.)evaluate the child's neurologic status.
d.)examine the child's throat and ears.
C. RATIONALE: These are signs of meningitis and the priority is to evaluate neurologic status. Petechiae aren't allergic reactions. Standard precautions should be used when there's the risk of contacting body fluids (contact precautions should be instituted for the client diagnosed with meningitis). Throat and ear examinations wouldn't be helpful in confirming a diagnosis of meningitis.
38. A nurse on the pediatric floor is caring for a toddler. The nurse should keep in mind that toddlers:
a.)express negativism.
b.)have reliable verbal responses to pain.
c.)have a good concept of danger.
d.)have little fear.
A. RATIONALE: Toddlers' increasing autonomy is commonly expressed by negativism. They're unreliable in expressing pain they respond just as strongly to painless procedures as they do to painful ones. They have little concept of danger and have common fears.
39. A 3-year-old child with Down syndrome is admitted to the pediatric unit with asthma. The child doesn't enunciate words well and holds on to furniture when he walks. The nurse should ask the mother:
a.)how long the child has been like this.
b.)if the child can walk without holding on to furniture.
c.)how the child's condition today differs from his normal condition.
d.)if the child always drools.
C. RATIONALE: Identify the chief complaint from how the child was previously behaving at home. Asking how long the child has been like this may be interpreted poorly by the caregiver. Focus on what the child can do and not on what he can't do to preserve the family's self-esteem. Focusing on negative aspects of the child's behavior is inappropriate.
40. The nurse is caring for a toddler in respiratory arrest. The nurse will assist with endotracheal intubation and use an uncuffed tube because the:
a.)vocal cords provide a natural seal.
b.)trachea is shorter.
c.)larynx is anterior and cephalad.
d.)cricoid cartilage is the narrowest part of the larynx.
D. RATIONALE: The cricoid cartilage in the toddler is the narrowest part of larynx and provides a natural seal. This keeps the endotracheal tube in place without requiring a cuff. The vocal cords are narrower in an adult. The trachea is shorter and the larynx is anterior and cephalad, but these aren't reasons to choose an uncuffed tube.
41. The nurse is caring for a toddler with Down syndrome. To help the toddler cope with painful procedures, the nurse can:
a.)prepare the child by positive self-talk.
b.)establish a time limit to get ready for the procedure.
c.)hold and rock him and give him a security object.
d.)count and sing with the child.
C. RATIONALE: The child with Down syndrome may have difficulty coping with painful procedures and may regress during his illness. Holding, rocking, and giving the child a security object may be comforting to the child. An older child or a child without Down syndrome may benefit from positive self-talk, time limits, and diversionary tactics, such as counting and singing; but the success of these tactics depends on the child.
42. The nurse is preparing to teach a 13-year-old client with asthma to administer his own breathing treatments. Which principle should the nurse keep in mind when planning the teaching session?
a.)Adolescents can't follow detailed instructions.
b.)Adolescents are worried about appearing different from their peers. c.)Adolescents' fine motor coordination isn't sufficiently developed to administer treatments.
d.)Adolescents have a well-developed sense of self-identity.
B. RATIONALE: Adolescents have a strong need to belong, and they seek social approval from their peers. Knowing this will help the nurse construct an effective teaching plan. Adolescents can follow detailed instructions. According to Piaget, adolescents are at the formal operations stage and are capable of deductive, reflective, and hypothetical reasoning. Fine motor coordination is well developed by adolescence. According to Erikson's stages of psychosocial development, adolescence is the stage of identity versus role confusion. During this stage, the adolescent strives toward establishing a sense of identity.
43. A child, age 3, is brought to the emergency department in respiratory distress caused by acute epiglottiditis. Which clinical manifestations should the nurse expect to assess?
a.)Severe sore throat, drooling, leaning forward to breathe
b.)Low-grade fever, stridor, barking cough
c.)Pulmonary congestion, productive cough, fever
d.)Sore throat, fever, general malaise
A. RATIONALE: A child with acute epiglottiditis appears acutely ill, and clinical manifestations may include drooling (because of difficulty swallowing), severe sore throat, hoarseness, leaning forward with the neck hyperextended, high fever, and severe inspiratory stridor. A low-grade fever, stridor, and barking cough that worsens at night are suggestive of croup. Pulmonary congestion, productive cough, and fever along with nasal flaring, retractions, chest pain, dyspnea, decreased breath sounds, and crackles are indicative of pneumococcal pneumonia. A sore throat, fever, and general malaise point to viral pharyngitis.
44. When caring for a child with epiglottiditis, the nurse should first:
a.)examine his throat.
b.)prepare him for tracheotomy.
c.)administer I.V. fluids.
d.)administer antibiotics.
B. RATIONALE: Acute epiglottiditis is an emergency situation that may require tracheotomy or endotracheal intubation. Inflammation of the epiglottis can cause the airway to swell so that it can't rise and totally obstructs the airway. Never depress the tongue of a child with a tongue blade to examine the throat if signs or symptoms of epiglottiditis are present. This maneuver can cause the swollen epiglottis to completely obstruct the airway. Because the child can't swallow, I.V. fluids are necessary; however, airway concerns are a priority. After a patent airway is secured, antibiotics may be given to treat Haemophilus influenzae, a common cause of acute epiglottiditis.
45. A 4-month-old infant is brought to the pediatrician by his parents because they're concerned about his frequent respiratory infections, poor feeding habits, frequent vomiting, and colic. The physician notes that the baby has failed to gain expected weight and recommends that the baby have a sweat test performed to detect possible cystic fibrosis. To prepare the parents for the test, the nurse should explain that:
a.)the baby will need to fast before the test.
b.)a sample of blood will be necessary.
c.)a low-sodium diet is necessary for 24 hours before the test.
d.)a low-intensity, painless electrical current is applied to the skin.
D. RATIONALE: Because cystic fibrosis clients have elevated levels of sodium and chloride in their sweat, a sweat test is performed to confirm this disorder. After pilocarpine (a cholinergic medication that induces sweating) is applied to a gauze pad and placed on the arm, a low-intensity, painless electrical current is applied for several minutes. The arm is then washed off, and a filter paper is placed over the site with forceps to collect the sweat. Elevated levels of sodium and chloride are diagnostic of cystic fibrosis. No fasting is necessary before this test and no blood sample is required. A low-sodium diet isn't required before the test.
46. The nurse is taking a history from the parents of a child admitted with Reye's syndrome. Which illness would the nurse expect the parents to report their child having the previous week?
a.)Chickenpox
b.)Bacterial meningitis
c.)Strep throat
d.)Lyme disease
A. RATIONALE: Reye's syndrome commonly occurs about 1 week after a child has had a viral infection, such as chickenpox (varicella) or influenza. Children with flulike symptoms or chickenpox who receive aspirin are at increased risk for Reye's syndrome. Bacterial meningitis and strep throat are caused by bacteria and don't lead to Reye's syndrome. Lyme disease is caused by a spirochete and isn't implicated in Reye's syndrome.
47. A 4-year-old child is having a sickle cell crisis. The initial nursing intervention should be to:
a.)place ice packs on the client's painful joints.
b.)administer antibiotics.
c.)provide oral and I.V. fluids.
d.)administer folic acid supplements.
C. RATIONALE: Priority care for the child in a sickle cell crisis includes providing hydration and oxygenation to prevent more sickling. Pain relief is also a concern. However, painful joints are treated with analgesics and warm packs because cold packs may increase sickling. Antibiotics will be given to treat a sickle cell crisis if it's thought to be bacterial. Daily supplements of folic acid will help counteract anemia.
48. A nurse caring for a client who is 4 weeks pregnant should expect to collect which assessment findings?
a.)Presence of menses
b.)Uterine enlargement
c.)Breast sensitivity
d.)Fetal heart tones
C. RATIONALE: Breast sensitivity is the only sign assessed within the first 4 weeks of pregnancy. Amenorrhea is expected during this time. The other assessment findings don't occur until after the first 4 weeks of pregnancy.
49. A client is admitted to the labor and delivery department in preterm labor. To help manage preterm labor the nurse would expect to administer:
a.)ritodrine (Yutopar).
b.)bromocriptine (Parlodel).
c.)magnesium sulfate.
d.)betamethasone (Celestone).
A. RATIONALE: Ritodrine reduces frequency and intensity of uterine contractions by stimulating B<-adrenergic receptors in the uterine smooth muscle. It's the drug of choice when trying to inhibit labor. Bromocriptine, a dopamine receptor agonist and an ovulation stimulant, is used to inhibit lactation in the postpartum period. Magnesium sulfate, an anticonvulsant, is used to treat preeclampsia and eclampsia a life-threatening form of pregnancy-induced hypertension. Betamethasone, a synthetic corticosteroid, is used to stimulate fetal pulmonary surfactant (administered to the mother).
50. The nurse is caring for a client with mild active bleeding from placenta previa. Which assessment factor indicates that an emergency cesarean section may be necessary? a.)Increased maternal blood pressure of 150/90 mm Hg
b.)Decreased amount of vaginal bleeding
c.)Fetal heart rate of 80 beats/minute
d.)Maternal heart rate of 65 beats/minute
C. RATIONALE: A drop in fetal heart rate signals fetal distress and may indicate the need for a cesarean section to prevent neonatal death. Maternal blood pressure, pulse rate, respiratory rate, intake and output, and description of vaginal bleeding are all important assessment factors; however, changes in these factors don't always necessitate delivery.
a.)Supportive child-parent interaction (speaking, listening, touching, and eye-to-eye contact
b.)Parents' active participation in child's physical or emotional care
c.)Parents' failure to use available support systems or agencies to assist in coping d.)Evidence of adaptation to parental role changes
C. RATIONALE: A failure to use available support systems or agencies is one of the defining characteristics of this diagnosis. Supportive child-parent interaction, parents' active participation in the child's care, and evidence of adaptation to parental role changes don't suggest this diagnosis.
2. An 8-year-old child enters a health care facility. During assessment, the nurse discovers that the child is experiencing the anxiety of separation from his parents. The nurse makes the nursing diagnosis of Fear related to separation from familiar environment and family. Which nursing intervention is most likely to help the child cope with fear and separation?
a.)Ask the parents not to visit the child until he has adjusted to the new environment. b.)Ask the physician to explain to the child why he needs to stay in the health care facility.
c.)Explain to the child that he must act like an adult while he's in the facility.
d.)Have the parents stay with the child and participate in his care.
D. RATIONALE: Allowing the parents to stay and participate in the child's care can provide support to the parents and the child. The other interventions won't address the client's diagnosis and may exacerbate the problem.
3. A 13 year old visits the school nurse because he's experiencing back pain, fatigue, and dyspnea. The nurse suspects that the child may have scoliosis. The nurse should first: a.)send the child home to recover.
b.)inspect the child for uneven shoulder height or uneven hip height.
c.)arrange for the child to have spinal X-rays as soon as possible.
d.)ask the child's parent to take him to a physician immediately.
B. RATIONALE: Before deciding on any specific intervention, the school nurse should perform a basic assessment for scoliosis, including inspecting for uneven shoulder or hip height. The nurse will then have more specific information to give to the parent. The parent bears responsibility for seeking further medical care for the child.
4. The nurse is caring for a child who has just been immunized. When teaching the child's parents about potential adverse effects, the nurse should instruct the parents to immediately report:
a.)pain at the injection site.
b.)generalized urticaria.
c.)mild temperature elevation.
d.)local swelling at the injection site.
B. RATIONALE: Generalized urticaria can herald the onset of a life-threatening episode and medical assistance should be sought immediately. A child may experience some pain, redness at the sight, mild temperature elevation, or localized swelling. These reactions can be treated symptomatically and aren't life-threatening.
5. The nurse is caring for a child with cystic fibrosis. The child's parents tell the nurse that they're having difficulty coping with their child's disease. Which action wouldn't be appropriate for the nurse to take?
a.)Helping the child and family obtain necessary equipment, supplies, and medication
b.)Pointing out to the parents ways in which they might have done things differently
c.)Providing referrals to local community agencies and the Cystic Fibrosis Foundation d.)Encouraging the parents to allow their child to follow as normal a childhood as possible
B. RATIONALE: The nurse should avoid being critical when talking with parents about how they have handled their child's disease or condition. The nurse can help this family by assisting them with finding appropriate financial, psychological, and social support. Providing referrals to local community agencies and the Cystic Fibrosis Foundation is also an appropriate intervention. The child should be treated as much like a normal child as possible.
6. The nurse is caring for a client who was involved in a motor vehicle accident. The client has a chest tube in place. If the chest tube is accidentally removed, the nurse should immediately:
a.)reintroduce the tube and attach it to water seal drainage.
b.)call the physician and obtain a chest tray.
c.)cover the opening with petroleum gauze.
d.)clean the wound with povidone-iodine and apply a gauze dressing.
C. RATIONALE: If a chest tube is accidentally removed, the nurse should cover the insertion site with sterile petroleum gauze. The nurse should then observe the client for respiratory distress, as tension pneumothorax may develop. If so, the nurse should remove the gauze to allow air to escape. The nurse shouldn't reintroduce the tube. Rather, the nurse should have another staff member call a physician so another tube can be introduced by the physician under sterile conditions.
7. A mist tent contains a nebulizer that creates a cool, moist environment for a child with an upper respiratory tract infection. The cool humidity helps the child breathe by:
a.)decreasing respiratory tract edema.
b.)lowering anxiety.
c.)drying secretions.
d.)increasing fluid intake.
A. RATIONALE: The mist tent decreases respiratory tract edema, which causes croup. However, the child needs to be prepared because the confinement can cause high anxiety. The tent liquefies secretions, rather than drying them and it doesn't increase the child's fluid intake.
8. An otherwise-healthy adolescent has meningitis and is receiving I.V. and oral fluids. The nurse should monitor this client's fluid intake because fluid overload may cause:
a.)cerebral edema.
b.)dehydration.
c.)heart failure.
d.)hypovolemic shock.
A. RATIONALE: Because of the inflammation of the meninges, the client is vulnerable to developing cerebral edema and increased intracranial pressure. Fluid overload won't cause dehydration. It would be unusual for an adolescent to develop heart failure unless the overhydration was extreme. Hypovolemic shock would occur with an extreme loss of fluid or blood.
9. The nurse is caring for a 16-year-old female client who isn't sexually active. The client asks if she needs a Papanicolaou (Pap) test. The nurse should reply:
a.)"Yes, you should have a Pap test after the onset of menstruation."
b.)"No, you aren't sexually active."
c.)"Yes, you're 16 years old."
d.)"No, you aren't 21 years old."
B. RATIONALE: A 16-year-old female client who isn't sexually active doesn't need a Pap test. When a client is sexually active or reaches age 18, a Pap test should be performed.
10. A teenage mother brings her 1-year-old child to the pediatrician's office for a well-baby checkup. She says that her baby can't sit alone or roll over. An appropriate response by the nurse would be:
a.)"This is very abnormal, your child must be sick."
b.)"Let's see about further developmental testing."
c.)"Don't worry, this is normal for her age."
d.)"Maybe you just haven't seen her do it."
B. RATIONALE: At age 12 months, a child should be sitting up and rolling over. Therefore, this child may have developmental problems. Options A and D aren't therapeutic and can cut off communication with the mother. Option C misleads the mother with false reassurance.
11. An emergency department nurse suspects neglect in a 3-year-old boy admitted for failure to thrive. Signs of neglect in the child would include:
a.)slapping, kicking, and punching others.
b.)poor hygiene and weight loss.
c.)loud crying and screaming.
d.)pulling hair and hitting.
B. RATIONALE: Neglect can involve failure to provide food, bed, shelter, health care, or hygiene. Slapping, kicking, punching, pulling hair, and hitting are examples of forms of physical abuse. Loud crying and screaming aren't abnormal findings in a 3-year-old child.
12. A boy, age 3, develops a fever and rash and is diagnosed with rubella. His mother has just given birth to a baby girl. Which statement by the mother best indicates that she understands the implications of rubella?
a.)"I told my husband to give my son aspirin for his fever."
b.)"I'll ask the physician about giving the baby an immunization shot."
c.)"I don't have to worry because I've had the measles."
d.)"I'll call my neighbor who is 2 months pregnant and tell her not to have contact with my son."
D. RATIONALE: Fetal defects can occur during the first trimester of pregnancy if the pregnant woman gets rubella. Aspirin shouldn't be given to young children because aspirin has been implicated in the development of Reye's syndrome. Tylenol should be used instead of aspirin. Rubella immunization isn't recommended for children until age 12 to 15 months. Measles is rubeola and won't provide immunity for rubella.
13. The nurse is caring for an adolescent client who underwent surgery for a perforated appendix. When caring for this client, the nurse should keep in mind that the main life-stage task for an adolescent is to:
a.)resolve conflict with parents.
b.)develop an identity and independence.
c.)develop trust.
d.)plan for the future.
B. RATIONALE: The adolescent strives for a sense of independence and identity. During this time, conflicts are heightened, not resolved. Trust begins to develop during infancy and matures along with development. Adolescents rarely finalize plans for the future; this usually happens later in adulthood.
14. What's the best advice for a nurse to give to the parents of a 2-year-old child who frequently throws temper tantrums?
a.)Move the toddler to a different setting.
b.)Allow the toddler more choices.
c.)Ignore the behavior when it happens.
d.)Give in to the toddler's demands.
C. RATIONALE: Ignore tantrum behavior because attention to the behavior can reinforce the undesirable behavior. Changing settings can increase the tantrum behavior. Allowing the toddler more choices may increase tantrum behavior if the toddler is unable to follow through with choices. The toddler should be offered only allowable and reasonable choices. It's ill-advised to give in to the toddler's demands because doing so only promotes tantrum behavior.
15. A mother tells the nurse that she wants to begin toilet training her 22-month-old child. The most important factor regarding toilet training that the nurse should stress to her is:
a.)developmental readiness of the child.
b.)consistency in approach.
c.)the mother's positive attitude.
d.)developmental level of the child's peers.
A. RATIONALE: If the child isn't developmentally ready, the child and parent will become frustrated. Consistency is important when toilet training is started. The mother's positive attitude is important when the child is determined to be ready. Developmental levels of children are individualized and comparison to peers isn't useful.
16. A mother complains to the nurse that her 4-year-old son often lies. What's the nurse's best response?
a.)Let the child know that he'll be punished for lying.
b.)Ask him why he isn't telling the truth.
c.)It's probably due to his vivid imagination and creativity.
d.)Acknowledge him by saying, "That's a pretend story."
D. RATIONALE: It's important to acknowledge the child's imagination, while also letting him know in a nice way that what he has said isn't real. Punishment isn't appropriate for a 4-year-old child using his imagination, and accusing him of lying is a negative reinforcement. The child isn't truly lying in the adult sense. Imagination and creativity need to be acknowledged.
17. A mother is playing with her infant, who is sitting securely alone on the floor of the clinic. The mother hides a toy behind her back and the infant looks for it. What age would the nurse estimate the infant to be?
a.)6 months
b.)4 months
c.)8 months
d.)10 months
D. RATIONALE: A 10-month-old child can sit alone and understands object permanence, so he would look for the hidden toy. At 4 to 6 months of age, children can't sit securely alone. At 8 months of age, children can sit securely alone but can't understand the permanence of objects.
18. The mother of a 4-year-old child tells the nurse that her child is a poor eater. What's the nurse's best recommendation for helping her increase her child's nutritional intake?
a.)Allow the child to feed herself.
b.)Use specially designed dishes for children; for example, a plate with the child's favorite cartoon character.
c.)Only serve the child's favorite foods.
d.)Allow the child to eat at a small table and chair by herself.
A. RATIONALE: The best recommendation is to allow the child to feed herself because the child's stage of development is the preschool period of initiative. Special dishes would enhance the primary recommendation. It's important to offer new foods and choices, not just serve her favorite foods. Using a small table and chair would also enhance the primary recommendation.
19. The nurse is teaching the mother of an ill child about childhood immunizations. The nurse should tell the mother that live virus vaccines shouldn't be administered to children with:
a.)diabetes.
b.)leukemia.
c.)asthma.
d.)cystic fibrosis.
B. RATIONALE: Leukemia causes immunosuppression, so inactivated rather than live viruses should be administered. Children with the other conditions listed can receive live virus vaccines because they aren't immunosuppressed.
20. A 7-year-old boy is hospitalized with cystic fibrosis. To help him manage secretions and avoid respiratory distress, the nurse should:
a.)perform chest physiotherapy every 4 hours.
b.)give pancreatic enzymes as ordered.
c.)place the child in an oxygen tent and have oxygen administered continuously. d.)serve a high-calorie diet.
A. RATIONALE: Chest physiotherapy aids in loosening secretions in the entire respiratory tract. Pancreatic enzymes aid in the absorption of necessary nutrients not in managing secretions. Oxygen therapy doesn't aid in loosening secretions and can cause carbon dioxide retention and respiratory distress in children with cystic fibrosis. A high-calorie diet is appropriate but doesn't facilitate respiratory effort.
21. The nurse is providing care to a 5-year-old client with a fractured femur whose nursing diagnosis is Imbalanced nutrition related to impaired physical mobility. Which of the following is most likely to occur with this condition?
a.)Decreased protein catabolism
b.)Increased calorie intake
c.)Increased digestive enzymes
d.)Increased carbohydrate need
D. RATIONALE: Carbohydrate need increases because healing and repair of tissue requires more carbohydrates. Increased not decreased protein catabolism is present. Decreased appetite not increased is a problem. Digestive enzymes are decreased not increased.
22. The nurse is interviewing a 16-year-old female at a clinic. It's her first visit and she says that she has been exposed to herpes by her boyfriend. Initially, with primary genital or type 2 herpes simplex, the nurse would expect the client to have:
a.)dysuria and urine retention.
b.)perineal ulcers and erosions.
c.)bilateral inguinal lymphadenopathy.
d.)burning or tingling on vulva, perineum, or vagina.
D. RATIONALE: Burning and tingling genital discomfort is the most common initial finding. This symptom will advance to vesicular lesions rupturing into ulcerations, which then dry into a crusty erosion. The client may also experience fever, headache, malaise, myalgia, regional lymphadenopathy, and dysuria.
23. A 2-year-old child is brought to the emergency department with a history of upper airway infection that has worsened over the last 2 days. The nurse suspects the child has croup. Signs of croup include a hoarse voice, inspiratory stridor, and:
a.)a barking cough.
b.)a high fever.
c.)sudden onset.
d.)dysphagia.
A. RATIONALE: Croup is an acute viral respiratory illness characterized by a barking cough. Fever is usually low-grade. Croup has a gradual onset, and dysphagia isn't a symptom.
24. A 2-year-old child is brought to the emergency department with suspected croup. The child appears frightened and cries as the nurse approaches him. The nurse needs to assess the child's breath sounds. The best way to approach the 2-year-old child is to: a.)expose the child's chest quickly and auscultate breath sounds as quickly and efficiently as possible.
b.)ask the mother to wait briefly outside until the assessment is over.
c.)tell the child the nurse is going to listen to his chest with the stethoscope.
d.)allow the child to handle the stethoscope before listening to his lungs.
D. RATIONALE: Toddlers are naturally curious about their environment and letting them handle minor equipment is distracting and helps them gain trust with the nurse. The nurse should expose only one area at a time during assessment and should approach the child slowly and unhurriedly. The caregiver should be encouraged to hold and console her child. Also, comfort the child with objects with which he's familiar. The child should be given limited choices to allow autonomy, such as "Do you want me to listen first to the front of your chest or your back?"
25. A 2-year-old child is brought to the emergency department with suspected croup. Which of the following assessment findings reflects increasing respiratory distress?
a.)Intercostal retractions
b.)Bradycardia
c.)Decreased level of consciousness
d.)Flushed skin
A. RATIONALE: Clinical manifestations of respiratory distress include tachypnea, tachycardia, restlessness, dyspnea, intercostal retractions, and cyanosis.
26. An emergency department nurse is caring for a child diagnosed with croup. The nebulizer treatment of choice for a child with croup is:
a.)albuterol (Ventolin).
b.)metaproterenol (Alupent).
c.)racepinephrine.
d.)ipratropium (Atrovent).
C. RATIONALE: Racemic epinephrine is an adrenergic used to reduce inflammation and edema of the tissue surrounding the trachea in a client with croup. Albuterol, metaproterenol, and other beta<-adrenergic drugs are used to treat asthma. Ipratropium is an anticholinergic used to treat severe asthma.
27. The nurse administers racemic epinephrine to a child. Ten minutes after administration, the nurse should be alert for:
a.)respiratory distress.
b.)profound tachycardia.
c.)signs of improved oxygenation.
d.)diminished cyanosis.
A. RATIONALE: A rebound effect from racemic epinephrine can occur up to 4 hours after treatment with signs of respiratory distress (tachypnea, restlessness, cyanosis). Tachycardia may initially follow treatment with racemic epinephrine as well as improvement in client status (improved oxygenation and improved color).
28. An 8-month-old male is admitted to the pediatric unit following a fall from his high chair. The child is awake, alert, and crying. The nurse should know that a brain injury is more severe in children because of:
a.)increased myelination.
b.)intracranial hypotension.
c.)cerebral hyperemia.
d.)a slightly thicker cranium.
C. RATIONALE: Cerebral hyperemia (excess blood in the brain) causes an initial increase in intracranial pressure in the head of an injured child. The brain is less myelinated in a child and more easily injured than an adult brain. Intracranial hypertension not hypotension places the child at greater risk for secondary brain injury. A child's cranium is thinner and more pliable, causing the child to receive a more severe injury.
29. The nurse is assessing an 8-month-old child for signs of neurologic deficit and increased intracranial pressure (ICP). These signs would include:
a.)a depressed fontanel.
b.)slurred speech.
c.)tachycardia.
d.)an altered level of consciousness.
D. RATIONALE: One sign of neurologic deficit in an 8-month-old child includes a decreased or altered level of consciousness. The fontanel would bulge if he had increased ICP. The child can't speak at this age, but a change in cry may be noted. Bradycardia not tachycardia is a sign of increased ICP.
30. A 12-month-old child fell down the stairs and a basilar skull fracture is suspected. The nurse should look for:
a.)cerebrospinal fluid otorrhea.
b.)deafness.
c.)raccoon eyes.
d.)Battle's sign.
A. RATIONALE: Basilar skull fracture is a fracture in any bone of the base of the skull frontal, ethmoid, sphenoid, temporal, or occipital. Otorrhea would be observed. Deafness doesn't commonly occur as a result of skull fracture. Raccoon eyes and Battle's sign occur primarily in orbital fractures.
31. A child arrives in the emergency department with a history of transient consciousness and unconsciousness. The nurse should suspect:
a.)subdural hematoma.
b.)epidural hematoma.
c.)subarachnoid hemorrhage.
d.)concussion.
B. RATIONALE: An initial loss of consciousness followed by transient consciousness leading to unconsciousness is caused by epidural hematoma. Subdural hematoma results in rapid deterioration in level of consciousness. Subarachnoid hemorrhage causes irritability rather than loss of consciousness. Concussion may result in a brief loss of consciousness.
32. A visibly upset mother carries her 2-month-old infant into the crowded emergency department. The child appears limp and lifeless. The mother screams to the nurse for help. The nurse should:
a.)take the infant from the mother and offer to help.
b.)take the infant and mother to a treatment room.
c.)call the resuscitation team and the supervisor.
d.)call security and the hospital administration.
B. RATIONALE: Taking the infant and mother into a treatment room for assessment provides privacy and a controlled environment. The mother should be allowed to remain with her child if she wishes. If she doesn't want to be present, the nurse should find a private area for her. The nurse must assess the child before calling the resuscitation team. Security isn't warranted in this situation.
33. While assessing a 2-month-old child's airway, the nurse finds that the child isn't breathing. After two unsuccessful attempts to establish an airway, the nurse should: a.)attempt rescue breaths.
b.)attempt to reposition the airway a third time.
c.)administer five back blows.
d.)attempt to ventilate with a handheld resuscitation bag.
C. RATIONALE: The child's airway is blocked despite attempts to establish it. The next step is to clear the airway with back blows and chest thrusts. Breaths can't be administered until the airway is patent. After two attempts to position the airway, the nurse can assume the airway is blocked. The nurse can't ventilate the child with a handheld resuscitation bag until the airway is patent.
34. A nurse performs cardiopulmonary resuscitation (CPR) for 1 minute on an infant without calling for assistance. In reassessing the infant after 1 minute of CPR, the nurse finds that he still isn't breathing and that he has no pulse. The nurse should then: a.)resume CPR beginning with breaths.
b.)declare her efforts futile.
c.)resume CPR beginning with chest compressions.
d.)call for assistance.
D. RATIONALE: After 1 minute of CPR, the nurse should call for assistance and then resume efforts. CPR shouldn't be stopped after it has been started unless the nurse is too exhausted to continue. A cycle usually ends with breaths, so the next beginning cycle after pulse check and summoning help would begin with chest compressions.
35. A neonate arrives at the emergency department in full cardiopulmonary arrest. Resuscitation efforts fail, and he's pronounced dead. The cause of death is sudden infant death syndrome (SIDS). Which of the following is true regarding the etiology of SIDS? a.)It occurs in suspected child abuse cases.
b.)It occurs primarily in neonates with congenital lung problems.
c.)It occurs primarily in black neonates.
d.)It occurs more commonly in neonates who sleep in the prone position.
D. RATIONALE: SIDS occurs in seemingly healthy neonates. However, more neonates who sleep in the prone position are affected. Because of the pooling of blood that occurs in the child with SIDS, child abuse is sometimes suspected. No correlation to race or lung disease exists.
36. The nurse is providing care for a mother whose child has died. The mother tells the nurse that she's angry with God for taking away her child. She has vowed never again to go to church or pray. Which nursing diagnosis is most appropriate?
a.)Ineffective coping
b.)Spiritual distress
c.)Powerlessness
d.)Ineffective denial
B. RATIONALE: The mother's expression of anger toward God is an indication of spiritual distress. Expressions of anger are a normal part of the grieving process and don't indicate ineffective coping. Although the mother may indeed be experiencing feelings of powerlessness, this isn't the most accurate diagnosis of her feelings as indicated by the assessment data. There's no evidence of denial on the mother's part.
37. A 2-year-old client is admitted to the pediatric unit with fever, seizures, and vomiting. He's awake and alert. As the nurse is putting a gown on the child, the nurse notices petechiae across the child's chest, abdomen, and back. The nurse should: a.)question the mother about the child's allergies.
b.)initiate standard precautions.
c.)evaluate the child's neurologic status.
d.)examine the child's throat and ears.
C. RATIONALE: These are signs of meningitis and the priority is to evaluate neurologic status. Petechiae aren't allergic reactions. Standard precautions should be used when there's the risk of contacting body fluids (contact precautions should be instituted for the client diagnosed with meningitis). Throat and ear examinations wouldn't be helpful in confirming a diagnosis of meningitis.
38. A nurse on the pediatric floor is caring for a toddler. The nurse should keep in mind that toddlers:
a.)express negativism.
b.)have reliable verbal responses to pain.
c.)have a good concept of danger.
d.)have little fear.
A. RATIONALE: Toddlers' increasing autonomy is commonly expressed by negativism. They're unreliable in expressing pain they respond just as strongly to painless procedures as they do to painful ones. They have little concept of danger and have common fears.
39. A 3-year-old child with Down syndrome is admitted to the pediatric unit with asthma. The child doesn't enunciate words well and holds on to furniture when he walks. The nurse should ask the mother:
a.)how long the child has been like this.
b.)if the child can walk without holding on to furniture.
c.)how the child's condition today differs from his normal condition.
d.)if the child always drools.
C. RATIONALE: Identify the chief complaint from how the child was previously behaving at home. Asking how long the child has been like this may be interpreted poorly by the caregiver. Focus on what the child can do and not on what he can't do to preserve the family's self-esteem. Focusing on negative aspects of the child's behavior is inappropriate.
40. The nurse is caring for a toddler in respiratory arrest. The nurse will assist with endotracheal intubation and use an uncuffed tube because the:
a.)vocal cords provide a natural seal.
b.)trachea is shorter.
c.)larynx is anterior and cephalad.
d.)cricoid cartilage is the narrowest part of the larynx.
D. RATIONALE: The cricoid cartilage in the toddler is the narrowest part of larynx and provides a natural seal. This keeps the endotracheal tube in place without requiring a cuff. The vocal cords are narrower in an adult. The trachea is shorter and the larynx is anterior and cephalad, but these aren't reasons to choose an uncuffed tube.
41. The nurse is caring for a toddler with Down syndrome. To help the toddler cope with painful procedures, the nurse can:
a.)prepare the child by positive self-talk.
b.)establish a time limit to get ready for the procedure.
c.)hold and rock him and give him a security object.
d.)count and sing with the child.
C. RATIONALE: The child with Down syndrome may have difficulty coping with painful procedures and may regress during his illness. Holding, rocking, and giving the child a security object may be comforting to the child. An older child or a child without Down syndrome may benefit from positive self-talk, time limits, and diversionary tactics, such as counting and singing; but the success of these tactics depends on the child.
42. The nurse is preparing to teach a 13-year-old client with asthma to administer his own breathing treatments. Which principle should the nurse keep in mind when planning the teaching session?
a.)Adolescents can't follow detailed instructions.
b.)Adolescents are worried about appearing different from their peers. c.)Adolescents' fine motor coordination isn't sufficiently developed to administer treatments.
d.)Adolescents have a well-developed sense of self-identity.
B. RATIONALE: Adolescents have a strong need to belong, and they seek social approval from their peers. Knowing this will help the nurse construct an effective teaching plan. Adolescents can follow detailed instructions. According to Piaget, adolescents are at the formal operations stage and are capable of deductive, reflective, and hypothetical reasoning. Fine motor coordination is well developed by adolescence. According to Erikson's stages of psychosocial development, adolescence is the stage of identity versus role confusion. During this stage, the adolescent strives toward establishing a sense of identity.
43. A child, age 3, is brought to the emergency department in respiratory distress caused by acute epiglottiditis. Which clinical manifestations should the nurse expect to assess?
a.)Severe sore throat, drooling, leaning forward to breathe
b.)Low-grade fever, stridor, barking cough
c.)Pulmonary congestion, productive cough, fever
d.)Sore throat, fever, general malaise
A. RATIONALE: A child with acute epiglottiditis appears acutely ill, and clinical manifestations may include drooling (because of difficulty swallowing), severe sore throat, hoarseness, leaning forward with the neck hyperextended, high fever, and severe inspiratory stridor. A low-grade fever, stridor, and barking cough that worsens at night are suggestive of croup. Pulmonary congestion, productive cough, and fever along with nasal flaring, retractions, chest pain, dyspnea, decreased breath sounds, and crackles are indicative of pneumococcal pneumonia. A sore throat, fever, and general malaise point to viral pharyngitis.
44. When caring for a child with epiglottiditis, the nurse should first:
a.)examine his throat.
b.)prepare him for tracheotomy.
c.)administer I.V. fluids.
d.)administer antibiotics.
B. RATIONALE: Acute epiglottiditis is an emergency situation that may require tracheotomy or endotracheal intubation. Inflammation of the epiglottis can cause the airway to swell so that it can't rise and totally obstructs the airway. Never depress the tongue of a child with a tongue blade to examine the throat if signs or symptoms of epiglottiditis are present. This maneuver can cause the swollen epiglottis to completely obstruct the airway. Because the child can't swallow, I.V. fluids are necessary; however, airway concerns are a priority. After a patent airway is secured, antibiotics may be given to treat Haemophilus influenzae, a common cause of acute epiglottiditis.
45. A 4-month-old infant is brought to the pediatrician by his parents because they're concerned about his frequent respiratory infections, poor feeding habits, frequent vomiting, and colic. The physician notes that the baby has failed to gain expected weight and recommends that the baby have a sweat test performed to detect possible cystic fibrosis. To prepare the parents for the test, the nurse should explain that:
a.)the baby will need to fast before the test.
b.)a sample of blood will be necessary.
c.)a low-sodium diet is necessary for 24 hours before the test.
d.)a low-intensity, painless electrical current is applied to the skin.
D. RATIONALE: Because cystic fibrosis clients have elevated levels of sodium and chloride in their sweat, a sweat test is performed to confirm this disorder. After pilocarpine (a cholinergic medication that induces sweating) is applied to a gauze pad and placed on the arm, a low-intensity, painless electrical current is applied for several minutes. The arm is then washed off, and a filter paper is placed over the site with forceps to collect the sweat. Elevated levels of sodium and chloride are diagnostic of cystic fibrosis. No fasting is necessary before this test and no blood sample is required. A low-sodium diet isn't required before the test.
46. The nurse is taking a history from the parents of a child admitted with Reye's syndrome. Which illness would the nurse expect the parents to report their child having the previous week?
a.)Chickenpox
b.)Bacterial meningitis
c.)Strep throat
d.)Lyme disease
A. RATIONALE: Reye's syndrome commonly occurs about 1 week after a child has had a viral infection, such as chickenpox (varicella) or influenza. Children with flulike symptoms or chickenpox who receive aspirin are at increased risk for Reye's syndrome. Bacterial meningitis and strep throat are caused by bacteria and don't lead to Reye's syndrome. Lyme disease is caused by a spirochete and isn't implicated in Reye's syndrome.
47. A 4-year-old child is having a sickle cell crisis. The initial nursing intervention should be to:
a.)place ice packs on the client's painful joints.
b.)administer antibiotics.
c.)provide oral and I.V. fluids.
d.)administer folic acid supplements.
C. RATIONALE: Priority care for the child in a sickle cell crisis includes providing hydration and oxygenation to prevent more sickling. Pain relief is also a concern. However, painful joints are treated with analgesics and warm packs because cold packs may increase sickling. Antibiotics will be given to treat a sickle cell crisis if it's thought to be bacterial. Daily supplements of folic acid will help counteract anemia.
48. A nurse caring for a client who is 4 weeks pregnant should expect to collect which assessment findings?
a.)Presence of menses
b.)Uterine enlargement
c.)Breast sensitivity
d.)Fetal heart tones
C. RATIONALE: Breast sensitivity is the only sign assessed within the first 4 weeks of pregnancy. Amenorrhea is expected during this time. The other assessment findings don't occur until after the first 4 weeks of pregnancy.
49. A client is admitted to the labor and delivery department in preterm labor. To help manage preterm labor the nurse would expect to administer:
a.)ritodrine (Yutopar).
b.)bromocriptine (Parlodel).
c.)magnesium sulfate.
d.)betamethasone (Celestone).
A. RATIONALE: Ritodrine reduces frequency and intensity of uterine contractions by stimulating B<-adrenergic receptors in the uterine smooth muscle. It's the drug of choice when trying to inhibit labor. Bromocriptine, a dopamine receptor agonist and an ovulation stimulant, is used to inhibit lactation in the postpartum period. Magnesium sulfate, an anticonvulsant, is used to treat preeclampsia and eclampsia a life-threatening form of pregnancy-induced hypertension. Betamethasone, a synthetic corticosteroid, is used to stimulate fetal pulmonary surfactant (administered to the mother).
50. The nurse is caring for a client with mild active bleeding from placenta previa. Which assessment factor indicates that an emergency cesarean section may be necessary? a.)Increased maternal blood pressure of 150/90 mm Hg
b.)Decreased amount of vaginal bleeding
c.)Fetal heart rate of 80 beats/minute
d.)Maternal heart rate of 65 beats/minute
C. RATIONALE: A drop in fetal heart rate signals fetal distress and may indicate the need for a cesarean section to prevent neonatal death. Maternal blood pressure, pulse rate, respiratory rate, intake and output, and description of vaginal bleeding are all important assessment factors; however, changes in these factors don't always necessitate delivery.