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HI there....welcome To test visual acuity, the nurse should ask the patient to cover each eye separately and read the eye chart with glasses and without, as appropriate. Fundamental of Nursing Before teaching any procedure to the patient, the nurse must first assess the patient’s willingness to learn and his current knowledge. Fundamentals of Nursing A blood pressure cuff that is too narrow can cause a falsely elevated blood pressure reading. Fundamentals of Nursing When preparing a single injection for a patient who takes regular and NPH insulin, the nurse should draw the regular insulin into the syringe first because it is clear and can be measured more accurately than the NPH insulin, which is turbid. Fundamentals of Nursing Rhonchi refers to the rumbling sounds heard on lung auscultation; they are more pronounced during expiration than during inspiration. Fundamentals of Nursing Gavage refers to forced feeding, usually through a gastric tube (a tube passed into the stomach by way of the mouth). Fundamentals of Nursing According to Maslow’s hierarchy of needs, physiologic needs (air, water, food, shelter, sex, activity, and comfort) have the highest priority. Fundamentals of Nursing Checking the identification band on a patient’s wrist is the safest and surest way to verify a patient’s identity. Fundamentals of Nursing A patient’s safety is the priority concern in developing a therapeutic environment. Fundamentals of Nursing The nurse should place the patient with a Sengstaken-Blakemore tube in semi-Fowler’s position. Fundamentals of Nursing The nurse can elicit Trousseau’s sign by occluding the brachial or radial artery; hand and finger spasms during occlusion indicate Trousseau’s sign and suggest hypocalcemia. Fundamentals of Nursing For blood transfusion in an adult, the appropriate needle size is 16 to 20G. Fundamentals of Nursing Pain that incapacities a patient and can’t be relieved by drugs is called intractable pain. Fundamentals of Nursing In an emergency, consent for treatment can be obtained by fax, telephone, or other telegraphic transmission. Fundamentals of Nursing Decibel is the unit of measurement of sound. Fundamentals of Nursing Informed consent is required for any invasive procedure. Fundamentals of Nursing A patient who can’t write his or her name to give consent for treatment must have his or her X witnessed by two persons, such as a nurse, priest, or doctor. Fundamentals of Nursing The Z-track I.M. injection technique seals medication deep into the muscle, thereby minimizing skin irritation and staining. It requires a needle that is 1’’ (2.5 cm) or longer. Fundamentals of Nursing A registered nurse (RN) should assign a licensed vocational nurse (LVN) or licensed practical nurse (LPN) to perform bedside care, such as suctioning and medication administration. Fundamentals of Nursing The therapeutic purposed of a mist tent is to increase hydration of secretions. Fundamentals of Nursing If a patient can’t void, the first nursing action should be bladder palpation to assess for bladder distention. Fundamentals of Nursing The patient who uses a cane should carry it on the unaffected side and advance it at the same time as the affected extremity. Fundamentals of Nursing To fit a supine patient for crutches, the nurse should measure from the axilla to the sole and add 2” (5 cm) to that measurement. Fundamentals of Nursing Assessment begins with the nurse’s first encounter with the patient and continues throughout the patient’s stay. The nurse obtains assessment data through the health history, physical examination, and review of diagnostic studies. Fundamentals of Nursing The appropriate needle size for an insulin injection is 25G and ⅝" (1.5 cm) long. Fundamentals of Nursing Residual urine refers to urine that remains in the bladder after voiding. The amount of residual urine normally ranges from 50 to 100 ml. Fundamentals of Nursing The five stages of the nursing process are assessment, nursing diagnosis, planning, implementation, and evaluation. Fundamentals of Nursing Planning refers to the stage of the nursing process in which the nurse assigns priorities to nursing diagnoses, defines short-term and long-term goals and expected outcomes, and establishes the nursing care plan. Fundamentals of Nursing Implementation refers to the stage of the nursing process in which the nurse puts the nursing care plan into action, delegates specific nursing interventions to members of the nursing team, and charts patient responses to nursing interventions. Fundamentals of Nursing Evaluation refers to the stage of the nursing process in which the nurse compares objective and subjective data with the outcome criteria and, if needed, modifies the nursing care plan, making the nursing process circular. Fundamentals of Nursing In the event of fire, the nurse should (1) remove the patient, (2) call the fire department, (3) attempt to contain the fire by closing the door, and (4) extinguish the fire, if it can be done safely. Fundamentals of Nursing Before administering any as need pain medication, the nurse should ask the patient to indicate the pain’s location. Fundamentals of Nursing Jehovah’s Witnesses believe that they shouldn’t receive blood components donated by other people. Fundamentals of Nursing When providing oral care for an unconscious patient, the nurse should position the patient on the side to minimize the risk of aspiration. Fundamentals of Nursing During assessment of distance vision, the patient should stand 20’ (6.1 m) from the chart. Fundamentals of Nursing The ideal room temperature for a geriatric patient or one who is extremely ill ranges form 66º to 76º F (18.8º to 24.4º C). Fundamentals of Nursing Normal room humidity ranges from 30% to 60%. Fundamentals of Nursing Hand washing is the single best method of limiting the spread of microorganisms. Hands should be washed for 10 seconds after routine contact with a patient and after gloves are removed. Fundamentals of Nursing To catheterize a female patient, the nurse should place her in the dorsal recumbent position. Fundamentals of Nursing A positive Homan’s sign may indicate thrombophlebitis. Fundamentals of Nursing Electrolytes in a solution are measured in milliequivalents per liter (mEq/L). A milliequivalent equals the number of milligrams per 100 milliliters of a solution. Fundamentals of Nursing Metabolism takes a place in two phases: anabolism (the constructive phase) and catabolism (the destructive phase). Fundamentals of Nursing The basal metabolic rate represents the amount of energy needed to maintain essential body functions. It is measured when the patient is awake and resting, hasn’t eaten for 14 to 18 hours, and is in a comfortable, warm environment. Fundamentals of Nursing Dietary fiber (roughage), which is derived from cellulose, supplies bulk, maintains adequate intestinal motility, and helps establish regular bowel habits. Fundamentals of Nursing Alcohol is metabolized primarily in the liver. Smaller amounts are metabolized by the kidneys and lungs. Fundamentals of Nursing Petechiae refers to tiny, round, purplish red spots that appear on the skin and mucous membranes as a result of intradermal or submucosal hemorrhage. Fundamentals of Nursing Purpura refers to a purple skin discoloration caused by blood extravasation. Fundamentals of Nursing Glucose-6-phosphate dehydrogenase (C6PD) deficiency is an inherited metabolic disorder characterized by red blood cells that are deficient in G6PD, a critical enzyme in aerobic glycolysis. Fundamentals of Nursing According to the standard precautions recommended by the Centers for Disease Control and Prevention, the nurse shouldn’t recap needles after use because most needle sticks result from missed needle recapping. Fundamentals of Nursing The nurse administers a drug by I.V. push by delivering the dose directly into a vein, I.V. tubing, or catheter with a needle and syringe. Fundamentals of Nursing When changing the ties on a tracheostomy tube, the nurse should leave the old ties in place until the new ones are applied. Fundamentals of Nursing A nurse should have assistance when changing the ties on a tracheostomy tube. Fundamentals of Nursing A filter is always used for blood transfusions. Fundamentals of Nursing A four-point (quad) cane is indicated when a patient needs more stability than a regular cane can provide. Fundamentals of Nursing The patient should carry a cane on the unaffected side to promote a reciprocal gait pattern and distribute weight away from the affected leg. Fundamentals of Nursing A good way to begin a patient interview is to ask “What made you seek medical help?” Fundamentals of Nursing The nurse should adhere to standard precautions for blood and body fluids when caring for all patients. Fundamentals of Nursing Potassium (K+) is the most abundant cation in intracellular fluid. Fundamentals of Nursing In the four-point gait (or alternating gait), the patient first moves the right crutch followed by the left foot and then the left crutch followed by the right foot. Fundamentals of Nursing In the three-point gait, the patient moves two crutches and the affected leg simultaneously and then moves the unaffected leg. Fundamentals of Nursing In the two-point gait, the patient moves the right leg and the left crutch simultaneously and then moves the left leg and the right crutch. Fundamentals of Nursing Vitamin B complex, the water-soluble vitamins essential for metabolism, include thiamine (B1), riboflavin (B2), niacin (B3), pyridoxine (B6), and cyanocobalamin (B12). Fundamentals of Nursing When being weighed, an adult patient should be lightly dressed and shoeless. Fundamentals of Nursing Before taking an adult’s oral temperature, the nurse should ensure that the patient hasn’t smoked or consumed hot or cold substances in the past 15 minutes. Fundamentals of Nursing The nurse shouldn’t take a rectal temperature on an adult patient if the patient has a cardiac disorder; anal lesions, or bleeding hemorrhoids or has recently undergone rectal surgery. Fundamentals of Nursing In a patient with cardiac problems, rectal temperature measurement may stimulate a vagal response, leading to vasodilation and decreased cardiac output. Fundamentals of Nursing When recording pulse amplitude and rhythm, the nurse should use these descriptive measures: +3 indicates a bounding pulse (readily palpable and forceful); +2, a normal pulse (easily palpable); +1, a thready or weak pulse (difficult to detect); and 0, an absent pulse (not detectable). Fundamentals of Nursing The intraoperative period begins when a patient is transferred to the operating room bed and ends when the patient is admitted to the postanesthesia recovery unit. Fundamentals of Nursing On the morning of surgery, the nurse should ensure that the informed consent form has been signed; that the patient hasn’t taken anything by mouth since midnight, has taken a shower with antimicrobial soap, has had mouth care (without swallowing the water, has removed common jewelry, and has received preoperative medication as prescribed; and that vital signs have taken and recorded. Artificial limbs and other prostheses are usually removed. Fundamentals of Nursing Comfort measures, such as positioning the patient, performing backrubs, and providing a restful environment, may decrease the patient’s need for analgesics or may enhance their effectiveness. Fundamentals of Nursing A drug has three names: its generic name, which is used in official publications; its trade name or brand name (such as Tylenol), which is selected by the drug company; and its chemical name, which describes the drug’s chemical composition. Fundamentals of Nursing The patient should take a liquid iron preparation through a straw to avoid staining the teeth. Fundamentals of Nursing The nurse should use the Z-track method to administer an I.M. injection of iron dextran (Imferon). Fundamentals of Nursing An organism may enter the body through the nose, mouth, rectum, urinary or reproductive tract, or skin. Fundamentals of Nursing In descending order, the levels of consciousness are alertness, lethargy, stupor, light coma, and deep coma. Fundamentals of Nursing To turn a patient by logrolling, the nurse folds the patient’s arms across the chest; extends the patient’s legs and inserts a pillow between them, if indicated; places a draw sheet under the patient; and turns the patient by slowly and gently pulling on the draw sheet. Fundamentals of Nursing The diaphragm of the stethoscope is used to hear high-pitched sounds such as breath sounds. Fundamentals of Nursing A slight blood pressure difference (5 to 10 mm Hg) between right and left arms is normal. Fundamentals of Nursing The nurse should place the blood pressure cuff 1'' (2.5 cm) above the antecubital fossa. Fundamentals of Nursing When instilling ophthalmic ointments, waste the first bed of ointment and then apply from the inner canthus to the outer canthus; twist the medication tube to detach the ointment. Fundamentals of Nursing The nurse should use a leg cuff to measure blood pressure in an obese patient. Fundamentals of Nursing If the blood pressure cuff is applied too loosely, the reading will be falsely elevated. Fundamentals of Nursing Ptosis refers to eyelid drooping. Fundamentals of Nursing A tilt table is useful for a patient with a spinal cord injury, orthostatic hypotension, or brain damage because it can move the patient gradually from a horizontal to a vertical (upright) position. Fundamentals of Nursing To perform venipuncture with the least injury to the vessel, the nurse should turn the bevel upward when the vessel’s lumen is larger than the needle and turn it downward when the lumen is only slightly larger than the needle. Fundamentals of Nursing To move the patient to the edge of the bed for transfer, follow these steps: (1) Move the patient’s head and shoulders toward the edge of the bed. (2) Move the patient’s feet and legs to the edge of the bed (crescent position). (3) Place both the arms well under the patient’s hips and straighten the back while moving the patient toward the edge of the bed. Fundamentals of Nursing When being measured for crutches, a patient should wear his or her shoes. Fundamentals of Nursing The nurse should attach a restraint to a part of the bed frame that moves with the head, not to the mattress or side rails. Fundamentals of Nursing The mist in a mist tent should never become so dense that it obscures clear visualization of the patient’s respiratory pattern. Fundamentals of Nursing To administer heparin subcutaneously, the nurse should follow these steps: (1) Clean, but don’t rub, the site with alcohol. (2) Stretch the skin taut or pick up a well-defined skin fold. (3)Hold the shaft of the needle in a dart position. (4)Insert the needle into the skin at a right (90-degree) angle. (5)Firmly depress the plunger; but don’t aspirate. (6)Leave the needle in place for 10 seconds. (7)Withdraw the needle gently at the same angle it was inserted. (8)Apply pressure to the injection site with an alcohol pad. Fundamentals of Nursing For a sigmoidoscopy, the nurse should place the patient in a knee-chest or Sims’ position, depending on the doctor’s preference. Fundamentals of Nursing Maslow’s hierarchy of needs must be met in the following order: physiologic (oxygen, food, water, sex, rest, and comfort) safety and security, love and belonging, self-esteem and recognition, and self-actualization. Fundamentals of Nursing When caring for patient with a nasogastric tube, the nurse should apply a water-soluble lubricant to the nostril to prevent soreness. Fundamentals of Nursing During gastric lavage, a nasogastric tube is inserted, the stomach is flushed, and ingested substances are removed through the tube. Fundamentals of Nursing In documenting drainage on a surgical dressing, the nurse should include the size, color, and consistency of the drainage, for example, “10 mm of brown mucoid drainage noted on dressing.” Fundamentals of Nursing To elicit Babinski’s reflex, the nurse strokes the sole of the patient’s foot with a moderately sharp object, such as thumbnail. Fundamentals of Nursing In a positive Babinski’s reflex, the great toe dorsiflexes and the other toes fan out. Fundamentals of Nursing When assessing a patient for bladder distention, the nurse should check the contour of the lower abdomen for a rounded mass above the symphysis pubis. Fundamentals of Nursing The best way to prevent pressure ulcers is to reposition the bedridden patient at least every 2 hours. Fundamentals of Nursing Antiembolism stockings decompress the superficial blood vessels, thereby reducing the risk of thrombus formation. Fundamentals of Nursing The most convenient veins for venipuncture in a adult patient are the basilic and median cubital veins in the antecubital space. Fundamentals of Nursing From 2 to 3 hours before beginning a tube feeding, the nurse should aspirate the patient’s stomach contents to verify adequate gastric emptying. Fundamentals of Nursing People with type O blood are considered to be universal donors. Fundamentals of Nursing People with type AB blood are considered to be universal recipients. Fundamentals of Nursing Herts (Hz) refers to the unit of measurement of sound frequency. Fundamentals of Nursing Hearing protection is required when the sound intensity exceeds 84 dB; double hearing protection is required if it exceeds 104 dB. Fundamentals of Nursing Prothrombin, a clotting factor, is produced in the liver. Fundamentals of Nursing If a patient is menstruating when a urine sample is collected, the nurse should note this on the laboratory slip. Fundamentals of Nursing During lumbar puncture, the nurse must note the initial intracranial pressure and the cerebrospinal fluid color. Fundamentals of Nursing A patient who can’t cough to provide a sputum sample for culture may require a heated aerosol treatment to facilitate removal of a sample. Fundamentals of Nursing If eye ointment and eyedrops must be instilled in the same eye, the eyedrops should be instilled first. Fundamentals of Nursing When leaving an isolation room, the nurse should remove the gloves before the mask because fewer pathogens are on the mask. Fundamentals of Nursing Skeletal traction is applied to a bone using wire pins or tons. It is the most effective means of traction. Fundamentals of Nursing The total parenteral nutrition solution should be stored in a refrigerator and removed 30 to 60 minutes before use because delivery of a chilled solution can cause pain, hypothermia, venous spasm, and venous constriction. Fundamentals of Nursing Medication isn’t routinely injected I.M. into edematous tissue because it may not be absorbed. Fundamentals of Nursing When caring for a comatose patient, the nurse should explain each action to the patient in a normal voice. Fundamentals of Nursing When cleaning dentures, the sink should be lined with a washcloth. Fundamentals of Nursing A patient should void within 8 hours after surgery. Fundamentals of Nursing An EEG identifies normal and abnormal brain waves. Fundamentals of Nursing Stool samples for ova and parasite tests should be delivered to the laboratory without delay or refrigeration. Fundamentals of Nursing The autonomic nervous system regulates the cardiovascular and respiratory systems. Fundamentals of Nursing When providing tracheostomy care, the nurse should insert the catheter gently into the tracheostomy tube. When withdrawing the catheter, the nurse should apply intermittent suction for no more than 15 seconds and use a slight twisting motion. Fundamentals of Nursing A low-residue diet includes such as foods as roasted chicken, rice, and pasta. Fundamentals of Nursing A rectal tube should not be inserted for longer than 20 minutes; it can irritate the mucosa of the rectum and cause a loss of sphincter control. Fundamentals of Nursing A patient’s bed bath should proceed in this order: face, neck, arms, hands, chest, abdomen, back, legs, perineum. Fundamentals of Nursing When lifting and moving a patient, the nurse should use the upper leg muscles most to prevent injury. Fundamentals of Nursing Patient preparation for cholecystography includes ingestion of a contrast medium and a low-fat evening meal. Fundamentals of Nursing During occupied bed changes, the patient should be covered with a black blanket to promote warmth and prevent exposure. Fundamentals of Nursing Anticipatory grief refers to mourning that occurs for an extended time when one realizes that death is inevitable. Fundamentals of Nursing The following foods can alter stool color: beets (red), cocoa (dark red or brown), licorice (black), spinach (green), and meat protein (dark brown). Fundamentals of Nursing When preparing a patient for a skull X-ray, have the patient remove all jewelry and dentures. Fundamentals of Nursing The fight-or-flight response is a sympathetic nervous system response. Fundamentals of Nursing Bronchovesicular breath sounds in peripheral lung fields are abnormal and suggest pneumonia. Fundamentals of Nursing Wheezing refers to an abnormal, high-pitched breath sound that is accentuated on expiration. Fundamentals of Nursing Wax or a foreign body in the ear should be gently flushed out by irrigation with warm saline solution. Fundamentals of Nursing If a patient complains that his hearing aid is “not working,” the nurse should check the switch first to see if it’s turned on and then check the batteries. Fundamentals of Nursing The nurse should grade hyperactive biceps and triceps reflexes +4. Fundamentals of Nursing If two eye medications are prescribed for twice-daily instillation, they should be administered 5 minutes apart. Fundamentals of Nursing In a postoperative patient, forcing fluids helps prevent constipation. Fundamentals of Nursing The nurse must administer care in accordance with standards of care established by the American Nurses Association, state regulations, and facility policy. Fundamentals of Nursing The kilocalorie (kcal) is a unit of energy measurement that represents the amount of heat needed to raise the temperature of 1 kilogram of water 1º C. Fundamentals of Nursing As nutrients move through the body, they undergo ingestion, digestion, absorption, transport, cell metabolism, and excretion. Fundamentals of Nursing The body metabolizes alcohol at a fixed rate regardless of serum concentration. Fundamentals of Nursing In an alcoholic beverage, its proof reflects its percentage of alcohol multiplied by 2. For example, a 100-proof beverage contains 50% alcohol. Fundamentals of Nursing A living will is a witnessed document that states a patient’s desire for certain types of care and treatment, which depends on the patient’s wishes and views and quality of life. Fundamentals of Nursing The nurse should flush a peripheral heparin lock every 8 hours (if it wasn’t used during the previous 8 hours) and as needed with normal saline solution to maintain patency. Fundamentals of Nursing Quality assurance is a method of determining whether nursing actions and practices meet established standards. Fundamentals of Nursing The five rights of medication administration are the right patient, right medication, right dose, right route of administration, and the right time. Fundamentals of Nursing Outside of the hospital setting, only the sublingual and transligual forms of nitroglycerin should be used to relieve acute anginal attacks. Fundamentals of Nursing The implementation phase of the nursing process involves recording the patient’s response to the nursing plan, putting the nursing plan into action, delegating specific nursing interventions, and coordinating the patient’s activities. Fundamentals of Nursing The Patient’s Bill of Rights offers guidance and protection to patients by stating the responsibilities of the hospital and its staff toward patients and their families during hospitalization. Fundamentals of Nursing To minimize the omissions and distortion of facts, the nurse should record information as soon as it is gathered. Fundamentals of Nursing When assessing a patient’s health history, the nurse should record the current illness chronologically, beginning with the onset of the problem and continuing to the present. Fundamentals of Nursing Drug administration is a dependent activity. The nurse can administer or withhold a drug only with the doctor’s permission. Fundamentals of Nursing The nurse shouldn’t give false assurance to a patient. Fundamentals of Nursing After receiving preoperative medication, a patient isn’t competent to sign an informed consent form. Fundamentals of Nursing When lifting a patient, a nurse uses the weight of her body instead of the strength in her arms. Fundamentals of Nursing A nurse may clarify a doctor’s explanation to a patient about an operation or a procedure but must refer questions about informed consent to the doctor. Fundamentals of Nursing The nurse shouldn’t use her thumb to take a patient’s pulse rate because the thumb has a pulse of its own and may be confused with the patient’s pulse. Fundamentals of Nursing An inspiration and an expiration count as one respiration. Fundamentals of Nursing Normal respirations are known as eupnea. Fundamentals of Nursing During a blood pressure measurement, the patient should rest the arm against a surface because using muscle strength to hold up the arm may raise the blood pressure. Fundamentals of Nursing Major unalterable risk factors for coronary artery disease include heredity, sex, race, and age. Fundamentals of Nursing Inspection is the most frequently used assessment technique. Fundamentals of Nursing Family members of an elderly person in a long-term care facility should transfer some personal items (such as photographs, a favorite chair, and knickknacks) to the person’s room to provide a homey atmosphere. Fundamentals of Nursing The upper respiratory tract warms and humidifies inspired air and plays a role in taste, smell, and mastication. Fundamentals of Nursing Signs of accessory muscle use include shoulder elevation, intercostal muscle retraction, and scalene and sternocleidosmastoid muscle use during respiration. Fundamentals of Nursing When patients use axillary crutches, their palms should bear the brunt of the weight. Fundamentals of Nursing Activities of daily living include eating, bathing, dressing, grooming, toileting, and interacting socially. Fundamentals of Nursing Normal gait has two phases: the stance phase, in which the patient’s foot rests on the ground, and the swing phase, in which that patient’s foot moves forward. Fundamentals of Nursing The phases of mitosis are prophase, metaphase, anaphase, and telophase. Fundamentals of Nursing The nurse should follow standard precautions in the routine care of all patients. Fundamentals of Nursing The nurse should use the bell of the stethoscope to listen for venous hums and cardiac murmurs. Fundamentals of Nursing The nurse can assess a patient’s general knowledge by asking questions such as “Who is the president for the United States?” Fundamentals of Nursing Cold packs are applied for the first 20 to 48 hours after an injury; then heat is applied. During cold application, the pack is applied for 20 minutes and then removed for 10 to 15 minutes to prevent reflex dilation (rebound phenomenon) and frostbite injury. Fundamentals of Nursing The pons is located above the medulla and consists of white matter (sensory and motor tracts) and gray matter (reflex centers). Fundamentals of Nursing The autonomic nervous system controls the smooth muscles. Fundamentals of Nursing A correctly written patient goal expresses the desired patient behavior, criteria for measurement, time frame for achievement, and conditions under which the behavior will occur. It is developed in collaboration with the patient. Fundamentals of Nursing The optic disk is yellowish pink and circular with a distinct border. Fundamentals of Nursing A primary disability results from a pathologic process; a secondary disability, from inactivity. Nurses usually are held liable for failing to keep an accurate count of sponges and other devices during surgery. Fundamentals of Nursing The best dietary sources of vitamin B6 are liver, kidney, pork, soybeans, corn, and whole-grain cereals. Fundamentals of Nursing Iron-rich foods, such as organ meats, nuts, legumes, dried fruit, leafy vegetables, eggs, and whole gains, generally have low water content. Fundamentals of Nursing Collaboration refers to joint communication and decision making between nurses and doctors designed to meet patients’ needs by integrating the care regimens of both professions in one comprehensive approach. Fundamentals of Nursing Bradycardia refers to a heart rate of fewer than 60 beats/minute. Fundamentals of Nursing A nursing diagnosis is a statement of a patient’s actual or potential health problems that can be resolved, diminished, or otherwise changed by nursing interventions. Fundamentals of Nursing During the assessment phase of the nursing process, the nurse collects and analyzes three types of data: health history, physical examination, and laboratory and diagnostic test data. Fundamentals of Nursing The patient’s health history consists primarily of subjective data, information supplied by patient. Fundamentals of Nursing The physical examination includes objective data obtained by inspection, palpation, percussion, and auscultation. Fundamentals of Nursing When documenting patient care, the nurse should write legibly, use only standard abbreviations, and sign every entry. The nurse should never destroy or attempt to obliterate documentation or leave vacant lines. Fundamentals of Nursing Factors that affect body temperature include time of day, age, physical activity, phase of menstrual cycle, and pregnancy. Fundamentals of Nursing The most accessible and commonly used artery for measuring a patient’s pulse rate is the radial artery, which is compressed against the radius to take the pulse rate. Fundamentals of Nursing The normal pulse rate of a resting adult is 60 to 100 beats/minute. The rate is slightly faster in women than in men and much faster in children than in adults. Fundamentals of Nursing Laboratory test results are an objective form of assessment data. Fundamentals of Nursing The measurement systems most often used in clinical practice are the metric system, apothecaries’ system, and household system. Fundamentals of Nursing Before signing an informed consent, a patient should know whether other treatment options are available and should understand what will occur during the preoperative, intraoperative, and postoperative phase; the risk involved; and the possible complications. The patient also should have a general idea of the time required from surgery to recovery and should have an opportunity to ask questions. Fundamentals of Nursing A patient must sign a separate informed consent form for each procedure. Fundamentals of Nursing During percussion, the nurse uses quick, sharp tapping of the fingers or hands against body surfaces to produce sounds (that helps determine the size, shape, position, and density of underlying organs and tissues), elicit tenderness, or assess reflexes. Fundamentals of Nursing Ballottement is a form of light palpation involving gentle, repetitive bouncing of tissues against the hand and feeling their rebound. Fundamentals of Nursing A foot cradle keeps bed linen off the patient’s feet, which prevent skin irritation and breakdown, especially in a patient with peripheral vascular disease or neuropathy. Fundamentals of Nursing If the patient is a married minor, permission to perform a procedure can be obtained form the patient’s spouse. Fundamentals of Nursing Gastric lavage is the flushing of the stomach and removal of ingested substances through a nasogastric tube. It can be used to treat poisoning or drug overdose. Fundamentals of Nursing During the evaluation step of the nursing process, the nurse assesses the patient’s response to therapy. Fundamentals of Nursing Bruits commonly indicate a life- or limb-threatening vascular disease. Fundamentals of Nursing O.U. means each eye; O.D., right eye; and O.S, left eye. Fundamentals of Nursing To remove a patient’s artificial eye, the nurse depresses the lower lid. Fundamentals of Nursing The nurse should use a warm saline solution to clean an artificial eye. Fundamentals of Nursing A thready pulse is very fine and scarcely perceptible. Fundamentals of Nursing Axillary temperature usually is 1º F lower than oral temperature. Fundamentals of Nursing After suctioning a tracheostomy tube, the nurse must document the color, amount, consistency, and odor of secretions. Fundamentals of Nursing On a medication prescription, the abbreviation p.c. means that the medication should be administered after meals. Fundamentals of Nursing After bladder irrigation, the nurse should document the amount, color, and clarity of the urine and the presence of clots or sediment. Fundamentals of Nursing Laws regarding patient self-determination vary from state to state. Therefore, the nurse must be familiar with the laws of the state in which she works. Fundamentals of Nursing Gauge refers to the inside diameter of a needle. The smaller the gauge, the larger the diameter. Fundamentals of Nursing An adult normally has 32 permanent teeth. Fundamentals of Nursing After turning a patient, the nurse should document the position used, time turned, and skin assessment findings. Fundamentals of Nursing PERRLA is an abbreviation for normal pupil assessment findings: pupils equal, round, and reactive to light with accommodation. Fundamentals of Nursing When purcussing a patient’s chest for postural drainage, the nurse’s hands should be cupped. Fundamentals of Nursing When measuring a patient’s pulse, the nurse should assess the rate, rhythms, quality, and strength. Fundamentals of Nursing Before transferring a patient from a bed to a wheelchair, the nurse should push the wheelchair’s footrests to the sides and lock its wheels. Fundamentals of Nursing When assessing respirations, the nurse should document the rate, rhythm, depth, and quality. Fundamentals of Nursing For a subcutaneous injection, the nurse should use a ⅝" 25G needle. Fundamentals of Nursing The notation “AA & O x 3” indicates that the patient is awake, alert, and oriented to person (knows who he is), place (knows where he is), and time (knows the date and time). Fundamentals of Nursing Fluid intake includes all fluids taken by mouth, including foods that are liquid at room temperature, such as gelatin, custard, and ice cream; I.V. fluids; and fluids administered in feeding tubes. Fluid output includes urine, vomitus, and drainage (such as from a nasogastric tube or from a wound) as well as blood loss, diarrhea or stool, and perspiration. Fundamentals of Nursing After administering an intradermal injection, the nurse shouldn’t massage the area because massage can irritate the site and interfere with results. Fundamentals of Nursing When administering an intradermal injection, the nurse should hold the syringe almost flat against the patient’s skin (at about a 15-degree angle) with the bevel up. Fundamentals of Nursing To obtain an accurate blood pressure, the nurse should inflate the manometer 20 to 30 mm Hg above the disappearance of the radial pulse before releasing the cuff pressure. Fundamentals of Nursing The nurse should count an irregular pulse for 1 full minute. Fundamentals of Nursing A patient who is vomiting while lying down should be placed in a lateral position to prevent aspiration of vomitus. Fundamentals of Nursing Prophylaxis is disease prevention. Fundamentals of Nursing Body alignment is achieved when the body parts are in proper relation to their natural position. Fundamentals of Nursing Trust is the foundation of a nurse-patient relationship. Fundamentals of Nursing Blood pressure in the force exerted by the circulating volume of blood on arterial walls. Fundamentals of Nursing Malpractice refers to the professional’s wrongful conduct, improper discharge of duties, or failure to meet standers of care, which causes harm to another. Fundamentals of Nursing As a general rule, nurses can’t refuse a patient care assignment; however, they may refuse to participate in abortions in most states. Fundamentals of Nursing A nurse can be found negligent if a patient is injured because the nurse failed to perform a duty that a reasonable and prudent person would perform or because the nurse performed an act that a reasonable and prudent person wouldn’t perform. Fundamentals of Nursing States have enacted Good Samaritan laws to encourage professionals to provide medical assistance at the scene of an accident without fear of a lawsuit arising from such assistance. These laws don’t apply to care provided in a health care facility. Fundamentals of Nursing A doctor should sign verbal and telephone orders within the time established by institutional policy, usually within 24 hours. Fundamentals of Nursing A competent adult has the right to refuse lifesaving medical treatment; however, the individual should be fully informed of the consequences of this refusal. Fundamentals of Nursing Although a patient’s health record or chart is the health care facility’s physical property, its contents belong to the patient. Fundamentals of Nursing Before a patient’s record can be released to a third party, the patient or patient’s legal guardian must give written consent. Fundamentals of Nursing Under the Controlled Substances Act, every dose of a controlled drug dispensed by the pharmacy must be counted for, whether the dose was administered to a particular patient or discarded accidentally. Fundamentals of Nursing A nurse can’t perform duties that violate a rule or regulation established by a state licensing board even if it is authorized by a health care facility or doctor. Fundamentals of Nursing The nurse should select a private room, preferably with a door that can be closed, to minimize interruptions during a patient interview. Fundamentals of Nursing In categorizing nursing diagnosis, the nurse should address actual life-threatening problems first, followed by potentially life-threatening concerns. Fundamentals of Nursing The major components of a nursing care plan are outcome criteria (patient goals) and nursing interventions. Fundamentals of Nursing Standing orders, or protocols, establish guidelines for treating a particular disease or set of symptoms. Fundamentals of Nursing In assessing a patient’s heart, the nurse normally finds the point of maximal impulse at the fifth intercostals space near the apex. Fundamentals of Nursing The S1 sound heard on auscultation is caused by closure of the mitral and tricuspid valves. Fundamentals of Nursing To maintain package sterility, the nurse should open the wrapper’s top flap away from the body, open side flap by touching only the outer part of the wrapper, and open the final flap by grasping the turned-down corner and pulling it toward the body. Fundamentals of Nursing The nurse shouldn’t use a cotton-tipped applicator to dry a patient’s ear canal or remove wax because it may force cerumen against the tympanic membrane. Fundamentals of Nursing A patient’s identification bracelet should remain in place until the patient has been discharged from the health care facility and has left the premises. Fundamentals of Nursing The Controlled Substances Act designated five categories, or schedules, that classify controlled drugs according to their abuse liability. Fundamentals of Nursing Schedule I drugs, such as heroin, have a high abuse potential and have no currently accepted medical use in the United States. Fundamentals of Nursing Schedule II drugs, such as morphine, opium, and meperidine (Demerol), have a high abuse potential but have currently accepted medical uses. Their use may lead to physical or psychological dependence. Fundamentals of Nursing Schedule III drugs, such as paregoric and butabarbital (Butisol), have a lower abuse potential than Schedule I or II drugs. Abuse of Schedule III drugs may lead to moderate or low physical or psychological dependence, or both. Fundamentals of Nursing Schedule IV drugs, such as chloral hydrate, have a low abuse potential compared with Schedule III drugs. Fundamentals of Nursing Schedule V drugs, such as cough syrups that contain codeine, have the lowest abuse potential of the controlled substances. Fundamentals of Nursing Activities of daily living are actions that the patient must perform every day to provide self-care and interact with society. Fundamentals of Nursing Testing of the six cardinal fields of gaze evaluates the function of all extraocular muscles and cranial nerves III, IV, and VI. Fundamentals of Nursing The six types of heart murmurs are graded from 1 to 6. A grade 6 heart murmur can be heard with stethoscope slightly raised from the chest. Fundamentals of Nursing The most important goal to include in a care plan is the patient’s goal. Fundamentals of Nursing Fruits are high in fiber and low in protein and should be omitted from a low-residue diet. Fundamentals of Nursing The nurse should use an objective scale to assess and quantify pain because postoperative pain varies greatly among individuals. Fundamentals of Nursing Postmortem care includes cleaning and preparing the deceased patient for family viewing, arranging transportation to the morgue or funeral home, and determining the disposition of belongings. Fundamentals of Nursing The nurse should provide honest answers to the patient’s questions. Fundamentals of Nursing Milk shouldn’t be included in a clear liquid diet. Fundamentals of Nursing Consistency in nursing personnel is paramount when caring for a child, and infant, or a confused patient. Fundamentals of Nursing The hypothalamus secretes vasopressin and oxytocin, which are stored in the pituitary gland. Fundamentals of Nursing The three membranes that enclose that brain and spinal cord are the dura mater, pia mater, and arachnoid. Fundamentals of Nursing A nasogastric tube is used to remove fluid and gas from the small intestine preoperatively or postoperatively. Fundamentals of Nursing Psychologists, physical therapists, and chiropractors aren’t authorized to write prescriptions for medication. Fundamentals of Nursing The area around a stoma should be cleaned with mild soap and water. Fundamentals of Nursing Vegetables have a high fiber content. Fundamentals of Nursing The nurse should use a tuberculin syringe to administer an S.C. injection of less than 1 ml. Fundamentals of Nursing For adults, S.C. injections require a 25G 1" needle; for infants, children, elderly, or very thin patients, they require a 25G to 27G ½" needle. Fundamentals of Nursing Before administering medication, the nurse should identify the patient by checking the identification band and asking the patient to state his name. Fundamentals of Nursing To clean the skin before an injection, the nurse should use a sterile alcohol swab and wipe from the center of the site outward in a circular motion. Fundamentals of Nursing The nurse always should inject heparin deep into S.C. tissue at a 90-degree angle (perpendicular to the skin) to prevent skin irritation. Fundamentals of Nursing If blood is aspirated into the syringe before an I.M. injection, the nurse should withdraw the needle, prepare another syringe, and repeat the procedure. Fundamentals of Nursing The nurse shouldn’t cut the patient’s hair without written consent from the patient or an appropriate relative. Fundamentals of Nursing If bleeding occurs after an injection, the nurse should apply pressure until the bleeding stops; if bruising occurs, the nurse should monitor the site for an enlarging hematoma. Fundamentals of Nursing When providing hair and scalp care, the nurse should begin combing at the end of the hair and work toward the head. Fundamentals of Nursing Frequency of patient hair care depends on the length and texture of the hair, duration of hospitalization, and patient’s condition. Fundamentals of Nursing Proper hearing aid function requires careful handling during insertion and removal, regular cleaning of the ear piece to prevent wax buildup, and prompt replacement of dead batteries. Fundamentals of Nursing The hearing aid marked with a blue dot is for the left ear; the one with the red dot is for the right ear. Fundamentals of Nursing A hearing aid shouldn’t be exposed to heat or humidity and shouldn’t be immersed in water. Fundamentals of Nursing The nurse should instruct a patient not to use hair spray while wearing a hearing aid. Fundamentals of Nursing The five branches of pharmacology are pharmacokinetics, pharmacodynamics, pharmacotherapeutics, toxicology, and pharmacognosy. Fundamentals of Nursing The nurse should remove heel protectors every 8 hours to inspect the foot for signs of skin breakdown. Fundamentals of Nursing The purpose of heat application is to promote vasodilation, which reduces pain caused by inflammation. Fundamentals of Nursing A sutured surgical incision is an example of healing by first intention (healing directly, without granulation). Fundamentals of Nursing Healing by secondary intention (healing by granulation) is closure of the wound by the granulation tissue filling the defect and allowing reepithelialization to occur, beginning at the wound edges and continuing to the center, until the entire wound is covered. Fundamentals of Nursing Keloid formation is an abnormality in healing characterized by overgrowth of scar tissue at the wound site. Fundamentals of Nursing The nurse should administer procaine penicillin by deep I.M. injection in the upper outer portion of the buttocks in the adult or in the midlateral thigh in the child. The nurse shouldn’t massage the injection site. Fundamentals of Nursing The ascending colostomy drains fluid feces; the descending colostomy drains solid fecal matter. Fundamentals of Nursing A folded towel (called a scrotal bridge) can provide scrotal support for the patient with scrotal edema caused by vasectomy, epididymitis, or orchitis. Fundamentals of Nursing When giving an injection to the patient with a bleeding disorder, the nurse should use a small-gauge needle and apply pressure to the site for 5 minutes after the injection. Fundamentals of Nursing Platelets are the smallest and most fragile formed element of the blood and are essential for coagulation. Fundamentals of Nursing To insert a nasogastric tube, the nurse should first instruct the patient to tilt the head back slightly and then insert the tube. When the tube is felt curving at the pharynx, the nurse should tell the patient to tilt the head forward to close the trachea and open the esophagus by swallowing. (Sips of water can facilitate this action.) Fundamentals of Nursing According to families whose loved ones are in intensive care units, their four most important needs are to have questions answered honestly, to be assured that the best possible car is being provided, to know the prognosis, and to feel there is hope. Fundamentals of Nursing A double-bind communication when the verbal message contradicts the nonverbal message and the receiver is unsure of which message to respond to. Fundamentals of Nursing A nonjudgmental attitude displayed by the nurse demonstrates that she neither approves nor disapproves of the patient. Fundamentals of Nursing Target symptoms are those that the patient and others find most distressing. Fundamentals of Nursing Advise the patient to take aspirin on an empty stomach with a full glass of water and to avoid foods with acid such as coffee, citrus fruits, and cola. Fundamentals of Nursing For every patient problem, there is a nursing diagnosis; for every nursing diagnosis, there is a goal; and for every goal, there are interventions designed to make the goal a reality. The keys to answering examination questions correctly are identifying the problem presented, formulating a goal for that specific problem, and then selecting the intervention from the choices provided that will enable the patient to reach that goal. Fundamentals of Nursing Fidelity means loyalty and can be shown as a commitment to the profession of nursing and to the patient. Fundamentals of Nursing Giving an I.M. injection against the patient’s will and without legal authority is battery. Fundamentals of Nursing An example of a third-party payor is an insurance company. Fundamentals of Nursing On-call medication should be given within 5 minutes of receipt of the call. Fundamentals of Nursing Generally, the best method to determine the cultural or spiritual needs of the patient is to ask him. Fundamentals of Nursing An incident report shouldn’t be made part of the patient’s record but is an in-house document for the purpose of correcting the problem. Fundamentals of Nursing Critical pathways are a multidisciplinary guideline for patient care. Fundamentals of Nursing When prioritizing nursing diagnoses, use this hierarchy: (1) problems associated with airway, (2) those concerning breathing, and (3) those related to circulation. Fundamentals of Nursing The two nursing diagnoses with the highest priority that the nurse can assign are Ineffective airway clearance and Ineffective breathing pattern. Fundamentals of Nursing A subjective sign that a sitz bath has been effective is that patient expresses a decrease in pain or discomfort. Fundamentals of Nursing For the nursing diagnosis Diversional activity deficit to be valid, the patient must make the statement that he’s “bored, there is nothing to do” or words to that effect. Fundamentals of Nursing The most appropriate nursing diagnosis for an individual who doesn’t speak English is Communication, impaired, related to inability to speak dominant language (English). Fundamentals of Nursing The family of the patient who has been diagnosed as hearing impaired should be instructed to face the individual when they speak to him. Fundamentals of Nursing Up to age 3, the pinna should be pulled down and back to straighten the eustachian tube before instilling medication. Fundamentals of Nursing When administering eyedrops, the nurse should waste the first drop and instill the medication in the lower conjunctival sac to prevent injury to the cornea. Fundamentals of Nursing When administering eye ointment, the nurse should waste the first bead of medication and then apply the medication from the inner to the outer canthus. Fundamentals of Nursing When removing gloves and mask, the gloves, which most likely contain pathogens and are soiled, should be removed first. Fundamentals of Nursing Crutches should placed 6" (15 cm) in front of the patient and 6" to the side to assume a tripod position. Fundamentals of Nursing Listening is the most effective communication technique. Fundamentals of Nursing Process recording is a method of evaluating one’s communication effectiveness. Fundamentals of Nursing When feeding the elderly, limit high-carbohydrate foods because of the risk of glucose intolerance. Fundamentals of Nursing Passive range of motion maintains joint mobility whereas resistive exercises increase muscle mass. Fundamentals of Nursing Isometric exercises are performed on an extremity in a cast. Fundamentals of Nursing A back rub is an example of the gate-control theory of pain. Fundamentals of Nursing Anything below the waist is considered unsterile, a sterile field becomes unsterile when it comes in contact with nay unsterile item, a sterile field must be continuously monitored, and the 1" (2.5 cm) border around a sterile field is considered unsterile. Fundamentals of Nursing A “shift to the left” is evident when there is an increase in immature cells (bands) in the blood to fight an infection. Fundamentals of Nursing A “shift to the right” is evident when there is an increase in mature cells in the blood as seen in advanced liver diseases and pernicious anemia. Fundamentals of Nursing Before administering preoperative medication, make sure that an informed consent form has been signed and attached to the patient’s record. Fundamentals of Nursing The nurse should spend no more than 30 minutes per 8-hour shift in providing care to the patient with a radiation implant. Fundamentals of Nursing The nurse should stand near the patient’s shoulders for cervical implants and at the foot of the bed for head and neck implants. Fundamentals of Nursing The nurse should never be assigned to care for more than one patient with radiation implants. Fundamentals of Nursing Long-handled forceps and a lead-lined container should be in the room of the patient who has a radiation implant. Fundamentals of Nursing Generally, patients who have the same infection and are in strict isolation can share the same room. Fundamentals of Nursing Diseases requiring strict isolation include chickenpox, diphtheria, and viral hemorrhagic fever such as Marburg virus disease. Fundamentals of Nursing For the patient abiding by Jewish custom, milk and meat shouldn’t be served in the same meal. Fundamentals of Nursing Whether the patient can perform a procedure (psychomotor domain of learning) is a better indicator of the effectiveness of patient teaching than whether the patient can simply state the steps of the procedure (cognitive domain of learning). Fundamentals of Nursing Developmental stages according to Erik Erikson are trust versus mistrust (birth to 18 months), autonomy versus shame and doubt (18 months to 3 years), initiative versus guilt (3 to 5 years), industry versus inferiority (5 to 12 years), identity versus identity diffusion (12 to 18 years), intimacy versus isolation (18 to 25 years), generativity versus stagnation (25 to 60 years), and ego integrity versus despair (older than 60 years). Fundamentals of Nursing Face the hearing impaired patient when communicating with him. Fundamentals of Nursing A proper nursing intervention for the spouse of the patient who has suffered a serious incapacitating disease is to assist him in mobilizing a support system. Fundamentals of Nursing Hyperpyrexia refers to extreme elevation in temperature above 106º F (41.1º C). Fundamentals of Nursing

Pediatric Drill 5answers

Question 1. For which of the following would the nurse monitor when caring for a child who is receiving vincristine (Oncovin)?

1. Cardiac abnormalities
2. Foot drop
3. Hemorrhagic cystitis
4. Moon face

Looking for answers(s):2
Explanation: Because vincristine is neurotoxic, the nurse must monitor for neurologic impairment such as foot drop. The most common chemotherapeutic agent associated with causing cardiac abnormalities is doxorubicin (Adriamycin). The chemotherapeutic agent most likely to cause hemorrhagic cystitis is cyclophosphamide (Cytoxan). Pharmacologic agents most commonly associated with moon face are corticosteroids.

Question 2. Which of the following is the primary nursing goal when caring for the child with erythema subitum (roseola)?

1. Experience of minimal discomfort
2. Maintenance of normal body temperature
3. Maintenance of skin integrity
4. Minimization of long-term complications

Looking for answers(s):2
Explanation: Children with roseola have persistent high fevers, which last for 3 to 4 days. Thus, the goal is to maintain normal body temperature. The rash in roseola is a discrete rose-pink macular rash, which disappears in 1 to 2 days and is not pruritic. Complications of roseola include encephalitis (rare) and recurrent febrile seizures, which can be avoided by maintaining a normal body temperature.

Question 3. The nurse institutes proper infection control precautions for a 1-year-old brought to the emergency department with coryza, conjunctivitis, and small red, blue-white centered spots on her buccal mucosa because the nurse suspects which of the following?

1. Fifth disease
2. Roseola
3. Rubella
4. Rubeola

Looking for answers(s):4
Explanation: Coryza, conjunctivitis, and small red, blue-white centered spots on the client's buccal mucosa (Koplik spots) are indicative of rubeola (measles). A 1-year-old child has yet to be immunized since the vaccine is given at age 15 months. Fifth disease (erythema infectiosum) presents with a "slap-faced" appearance followed by a macular rash chiefly on the extremities. Roseola (exanthema subitum) presents as a high fever for 3 to 4 days, followed by a macular rash when the fever breaks. Rubella (German measles) does not present with Koplik spots (the oral lesions), even though there is usually coryza and conjunctivitis.

Question 4. Which of the following would be the nurse's least concern for a child requiring prolonged immobilization?

1. Decreased catabolic activity related to muscle atrophy
2. Decreased movement of secretions from the tracheobronchial tree
3. Dependent edema related to decreased venous return
4. Hypercalcemia due to bone demineralization

Looking for answers(s):1
Explanation: Immobility results in increased catabolic activity related to muscle atrophy, resulting in negative nitrogen balance. Immobility may lead to decreased movement of secretions from the tracheobronchial tree, placing the child at risk for pneumonia. Immobility may lead to dependent edema from decreased venous return. Edematous tissue is more prone to infection. Immobility leads to hypercalcemia from bone demineralization, which may result in the formation of renal calculi.

Question 5. Which of the following is characteristic of Duchenne muscular dystrophy?

1. Death between ages 15 and 25
2. Early weakness of the shoulder muscles
3. Intervals without disease progression
4. Onset in the first year of life

Looking for answers(s):1
Explanation: Unfortunately, the prognosis for Duchenne muscular dystrophy is poor, with most children dying between ages 15 and 25. Weakness of pelvic and shoulder muscles is seen in limb-girdle muscular dystrophy. Duchenne muscular dystrophy is a progressive disorder without remissions. Onset is usually between ages 1 and 3.

Question 6. Which of the following would the nurse expect to find in a child with hypopituitarism?

1. Delay evident in first year
2. Delayed primary tooth eruption
3. Skeletal proportions normal for age

Looking for answers(s):3
Explanation: Skeletal proportions are normal for age in children with hypopituitarism. Children with hypopituitarism usually have normal growth parameters in the first year. Primary teeth usually appear at the expected age. Height may be more retardant than weight because many of these children can become obese due to nutritional reasons.

Question 7. When caring for a child with mumps, which of the following complications would the home health nurse expect as least likely to occur?

1. Arthritis
2. Bronchiolitis
3. Encephalitis
4. Orchitis

Looking for answers(s):2
Explanation: Bronchiolitis is not a complication of mumps. However, it can be a complication of measles. Arthritis, encephalitis, and orchitis can be complications of mumps.

Question 8. Which of the following assessment findings would be exhibited in a child with Cushing syndrome?

1. Decreased appetite and paleness
2. Decreased blood pressure and acidosis
3. Hypoglycemia and skin thickening
4. Increased susceptibility to infection and virilization

Looking for answers(s):4
Explanation: Assessment findings associated with Cushing syndrome include increased susceptibility to infection, which develops from decreased production and circulating levels of antibodies by lysis of fixed plasma cells and lymphocytes. In Cushing syndrome, the child typically exhibits an increase in appetite. Because of capillary visibility and polycythemia, the skin increases in color. Typically, with Cushing syndrome, blood pressure increases from sodium and water retention (hypervolemia), and alkalosis develops from increased excretion of potassium and hydrogen ions. Hyperglycemia develops secondary to increased gluconeogenesis by the liver and decreased rate of glucose utilization by the cells.

Question 9. Which of the following interventions would be included in the care plan to prevent the most serious shunt complication?

1. Checking for inflammation at operative site and shunt tracts
2. Observing behavior, blood pressure, and pulse
3. Positioning carefully, flat on operative side
4. Providing meticulous skin care

Looking for answers(s):1
Explanation: Because infection is the greatest hazard of the postoperative period, monitoring the site and shunt tracts for inflammation assists in noting infections early. Increased intracranial pressure, indicated by increased blood pressure, decreased pulse, and behavioral changes, is not the greatest concern postoperatively. The child should be positioned carefully on the unoperative side to prevent pressure on the shunt valve. Skin breakdown is not a primary postoperative problem.

Question 10. Upon admission of a 4-year-old child to rule out leukemia, the parents ask the nurse when they will know the diagnosis. The nurse's response is based on the knowledge that the results of which of the following confirms leukemia?

1. Bone marrow aspiration
2. Complete blood count
3. Lumbar puncture
4. Peripheral blood smear

Looking for answers(s):1
Explanation: A bone marrow aspiration or biopsy confirms the diagnosis and type of leukemia based on an examination of the actual cells. Although a CBC may suggest leukemia (such as normal, elevated, or decreased white blood cell count with immature cells, decreased red blood cell count, and decreased platelet count), it does not confirm the diagnosis. A lumbar puncture is performed to rule out spread of leukemia cells to the central nervous system once the diagnosis has been established. Even though the peripheral blood smear is used to note immature blood cells, it is not the definitive diagnostic test.

Question 11. Which of the following manifestations would the nurse include in the teaching plan for a mother who is concerned that her 15-year-old daughter may have acquired hypothyroidism because the girl's grandmother had it?

1. Constipation, dry skin, sparse hair
2. Diarrhea, weight loss, and short stature
3. Lethargy, mental retardation, growth failure
4. Urine retention, coarse hair, cold hands

Looking for answers(s):1
Explanation: Acquired hypothyroidism represents a deficiency in the secretion of thyroid hormone. This results in manifestations such as myxedematous skin changes (dry skin, sparse hair, periorbital puffiness), constipation, sleeplessness, and mental decline. Diarrhea and weight loss are manifestations of hyperthyroidism. Manifestations of acquired hypothyroidism may include lethargy; however, mental retardation and growth retardation are unlikely at this age. Manifestations of acquired hypothyroidism do not usually include urine retention, although coarse hair and cold hands may occur.

Question 12. Which of the following would be inappropriate to assist a child with cerebral palsy in performing his activities of daily living (ADLs)?

1. Allowing for frequent rest periods
2. Decreasing calories to prevent weight gain
3. Encouraging activity with signs of fatigue
4. Praising the child for his accomplishments

Looking for answers(s):2
Explanation: The child needs increased calories to meet the energy demands of increased muscle activity and to provide strength for performing ADLs. The nurse should allow for rest periods to prevent fatigue and increase strength needed to perform ADLs. The child will not be able to perform because he is tired. The child should be praised for his accomplishments to promote self-esteem and to further his desire to perform ADLs.

Question 13. Which of the following client statements indicates that a 15-year-old with alopecia secondary to chemotherapy requires more teaching?

1. "I think I'll use a scarf so I can look better."
2. "If I need chemo again, my hair won't fall out as bad."
3. "I'll wear a cap or bandana in the sun."
4. "My hair will start to regrow in 1 year."

Looking for answers(s):4
Explanation: When receiving chemotherapy, hair usually starts to regrow in 3 to 6 months, not 1 year. Adolescents are encouraged to use scarves and wigs to improve their appearance and body image. Alopecia is usually less severe with a second treatment of chemotherapy. The client should use protection in the sun since natural protection is lost.

Question 14. When evaluating the effectiveness of the preoperative teaching plan with the parents of children diagnosed with Wilms' tumor, which of the following would indicate to the nurse that the parents require further teaching?

1. Asking about the child's blood pressure
2. Encouraging the child to discuss fears
3. Frequently palpating the child's abdomen
4. Stating that they will discuss alopecia after surgery

Looking for answers(s):3
Explanation: For a child with Wilms' tumor, frequent abdominal palpation must be avoided because palpation of the mass may cause dissemination of cancer cells to adjacent and distant sites. Asking about the child's blood pressure is appropriate because some children with Wilms' tumor experience hypertension, probably caused by the tumor secreting excess renin. Typically, the child will be anxious due to hospitalization, impending surgery, and the child's level of understanding about the diagnosis and reaction to sensing his parents' apprehension. Discussing alopecia after surgery is appropriate because radiotherapy and chemotherapy, which are usually done immediately after surgery, result in alopecia.

Question 15.
Which of the following agents would the nurse suspect as the probable cause of mood swings in a child with leukemia?

1. Allopurinol
2. Granulocyt colony-stimulating factor
3. L-asparaginase
4. Steroids

Looking for answers(s):4
Explanation: One of the many effects associated with the use of steroids is mood swings. Allopurinol is typically associated with rash, nausea and vomiting, renal failure, and bone marrow depression, not mood swings. Adverse effects of granulocyte colony-stimulating factor include bone pain, fever, rash, and malaise, but not mood swings. L-asparaginase may cause allergic reactions, fever, nausea and vomiting, anorexia, and liver toxicity, but not mood swings.

Question 16. A mother is upset because her 8-year-old daughter developed a right breast mass. She asks the nurse what she should do. The nurse bases her response on knowing that the breast mass is most likely due to which of the following?

1. Gynecomastia
2. Precocious pseudo puberty
3. Precocious thelarche
4. The onset of puberty

Looking for answers(s):4
Explanation: The onset of puberty may start as early as age 8, with development possibly beginning unilaterally. Gynecomastia is the development of breast tissue in males. Precocious pseudo puberty is a precocity that develops with no early secretion of gonadotropin. Precocious thelarche occurs before the onset of the pubertal period, which can start as young as age 8.

Question 17. When evaluating the effectiveness of teaching about exchange diets for an adolescent with diabetes mellitus, which of the following fast food choices, when stated by the client, indicates understanding about using the least amount of exchange equivalents?

1. A taco
2. Cheeseburger
3. Roast beef sandwich
4. Three slices of pizza

Looking for answers(s):1
Explanation: A fast-food taco uses 1 meat, 1 bread, and 1 fat. A fast-food cheeseburger uses 3 meats, 2 1/2 breads, and 2 1/2 fats. A fast-food roast beef sandwich uses 2 1/2 meats and 2 breads. Three slices of fast-food pizza uses 2 meats, 3 1/2 breads, 1/2 fat, and 2 vegetables.

Question 18. Which of the following maternal deficiencies is associated with the development of neural tube defects (NTDs)?

1. Amino acid
2. Ascorbic acid
3. Folic acid
4. Valproic acid

Looking for answers(s):3
Explanation: Deficiency of the vitamin folic acid has been associated with NTDs. There is no relationship between the amino acids and NTDs. There is no relationship between ascorbic acid (vitamin C) deficiency and NTDs. Valproic acid is the generic name for the drug Depakene, an antiseizure medication.

Question 19. When assessing children for early signs of increased intracranial pressure (ICP), the nurse monitors the child for which of the following?

1. Altered pupil reactivity
2. Decreased level of consciousness (LOC)
3. Early morning headache
4. Papilledema

Looking for answers(s):3
Explanation: Headache, especially in the early morning, is an early sign of increased ICP in the child. Altered pupil reactivity, decreased LOC, and papilledema are later signs of increased ICP.

Question 20. Which of the following actions would be most appropriate when caring for a child with leukemia who has a platelet count of 20,000/mm?

1. Discouraging nose-blowing
2. Increasing iron-rich foods in the diet
3. Instituting strict isolation
4. Medicating for pain every 4 hours

Looking for answers(s):1
Explanation: The child with a very low platelet count (normal platelet count after the neonate period—150,000 to 400,000 mm) is at risk for bleeding. Because epistaxis is common, especially after nose-blowing, the child is discouraged from blowing his nose. Iron-rich foods are not useful for low platelet counts. However, they are helpful for the associated anemia. Infection control precautions are heightened for low white blood cell counts, not platelet counts and, even then, strict isolation usually is not warranted. Pain medication will not help a lowered platelet count. Aspirin is contraindicated because of its antiplatelet properties.

Question 21. The mother of a child with scarlet fever demonstrates the need for more teaching when she states which of the following?

1. "I can give my child gargles and lozenges for sore throat."
2. "I will administer the full 10-day course of penicillin."
3. "I'll give the child a soft diet of small, frequent meals."
4. "I'll keep the child in isolation until the rash disappears."

Looking for answers(s):4
Explanation: The child only needs isolation for 24 hours following the initiation of antibiotic therapy. Gargles and lozenges are useful in soothing the child's sore throat. Scarlet fever results from an infection with group A beta-hemolytic streptococci and thus requires a full course of antibiotics to prevent the occurrence of rheumatic fever. A soft diet with small, frequent meals will assist the child who may have mild stomach upset.

Question 22. When planning nursing care, which of the following childhood illnesses does not require antibiotics?

1. Diphtheria
2. Pertussis
3. Poliomyelitis
4. Scarlet fever

Looking for answers(s):3
Explanation: Because poliomyelitis is viral in origin, antibiotics typically are not required. However, antibiotics may be used to prevent secondary infection. Diphtheria, a bacterial infection, requires an antibiotic due to its severity. Pertussis, a bacterial infection, requires an antibiotic due to its severity, especially in neonates and small infants. Scarlet fever, a bacterial infection, requires an antibiotic to prevent subsequent rheumatic fever.

Question 23. For a child with which of the following would the nurse question an order for a lumbar puncture?

1. Encephalitis
2. Increased intracranial pressure (ICP)
3. Leukemia
4. Meningitis

Looking for answers(s):2
Explanation: Lumbar punctures are contraindicated in children with increased ICP because the change in spinal fluid pressure may result in herniation. Lumbar puncture is used in the diagnosis of encephalitis. Lumbar puncture is performed to check for leukemic cells in the cerebrospinal fluid. Lumbar puncture is needed to confirm the diagnosis of meningitis.

Question 24. Which of the following would be inappropriate for a child in a Boston or Thoraco-Lumbo-Sacral Orthosis?

1. Brace removal every 2 hours for skin care
2. Compliance with brace use
3. Maintenance of positive body image
4. Maintenance of skin integrity

Looking for answers(s):1
Explanation: The brace must remain in place at all times except for 1 hour out of the day. Compliance is a significant problem due to the uncomfortable and unattractive nature of the brace. The awkwardness of the brace causes some interference with body image and self-esteem. Skin integrity should be monitored after the brace is removed.

Question 25. Which of the following is the most appropriate response to the mother of a child with varicella who asks how long her child will be contagious?

1. "For 3 to 4 days after the very first lesions begin to appear."
2. "For a total of 10 to 21 days."
3. "From the appearance of cold symptoms until when the lesions are crusted."
4. "Starting from the time when there are lesions present."

Looking for answers(s):3
Explanation: Varicella (chickenpox) is contagious from the prodromal period (onset of coryza) to the complete crusting of the lesions. The incubation period of varicella ranges from 10 to 21 days, not the period of communicability.

Question 26. When planning the postoperative care of an infant with hydrocephalus, which of the following would the nurse expect as the most common type of shunt used?

1. Ventricular bypass
2. Ventriculoatrial (VA)
3. Ventriculoperitoneal (VP)
4. Ventriculopleural

Looking for answers(s):3
Explanation: A VP shunt allows for excess tubing, minimizing the number of revisions needed as the child grows. Thus, it is the most common type of shunt used. A ventricular bypass into intracranial channels may be used in older children with noncommunicating hydrocephalus caused by adequate stenosis or posterior fossa masses. A VA shunt is reserved for older children because it requires lengthening. A ventriculopleural shunt is sometimes used in children over age 5.

Question 27. When assessing a 4-year-old child with a brain tumor, which of the following preoperative assessments would the nurse consider least important?

1. Behavior
2. Cranial enlargement
3. Headaches
4. Projectile vomiting

Looking for answers(s):2
Explanation: Cranial enlargement, possibly significant in a much younger child, is unlikely in a child such as a 4-year-old whose fontanelles and sutures have closed. Behavioral changes are highly significant because they are early signs of increased intracranial pressure (ICP) in children. Headaches are early signs of increased ICP in children. Projectile vomiting, especially in the early morning, is a key sign of increased ICP in children.

Question 28. When assessing an infant with developmental dysplasia of the hip (DDH), the nurse would most likely note which of the following?

1. Positive Ortolani's sign
2. Positive Trendelenburg sign
3. Shortening of unaffected limb
4. Symmetry of the gluteal folds

Looking for answers(s):1
Explanation: A positive Ortolani's sign is a manifestation of DDH. A click would be felt and heard when the leg was externally rotated and flexed. A positive Trendelenburg sign would be noted in an older child with DDH, not an infant. The nurse would note shortening of the affected limb. The nurse would notice asymmetry of the gluteal and thigh folds.

Question 29. After teaching a group of parents about cancer and associated cardinal signs and symptoms, which of the following signs and symptoms, if stated by the group, would indicate to the nurse that the group needs more teaching?

1. Localized pain
2. Sudden vision changes
3. Unexplained bleeding
4. Unusual mass or swelling

Looking for answers(s):3
Explanation: Unexplained bleeding is the answer because, although bleeding is a cardinal sign in adults, it is not a cardinal sign in children. Persistent localized pain may be the initial sign in bone tumors. Sudden vision changes are a cardinal sign, possibly indicating solid tumors of the eye. An unusual mass or swelling, especially in the abdomen, may indicate cancer in children.

Question 30. For which of the following should the nurse be alert when a 3-year-old child with sickle cell anemia develops erythema infectiosum?

1. Chest pain and fever
2. Increased arthralgia
3. Neurologic impairment
4. Profound anemia

Looking for answers(s):4
Explanation: Erythema infectiosum may cause aplastic crisis in children with hemolytic diseases. Chest pain and fever are signs of chest syndrome in sickle cell anemia. There is no indication that erythema infectiosum causes increased arthralgia in children with sickle cell anemia. However, a self-limiting arthritis may occur in all children with erythema infectiosum. There is no indication that erythema infectiosum causes neurologic impairment in any children.

Question 31. Which of the following parental statements indicates the need for additional teaching about human growth hormone (HGH)?

1. "Our child will reach adult height, but slower than his peers."
2. "The best time to administer the medication would be at bedtime."
3. "This medication is expensive to buy."
4. "We'll administer the medication with food, but we won't give it with milk."

Looking for answers(s):4
Explanation: HGH is administered by injection only. Therefore, parental statements about giving it with food are inappropriate. When diagnosed and treated early, children will attain their adult height, but more slowly than their peers. Bedtime administration is suggested because of the pituitary release of growth hormone during the first 45 to 90 minutes of sleep. The medication is expensive, costing between $20,000 and $30,000 per year.


Question 32. Which of the following would the nurse be sure to include in the teaching plan as the most common cause of Cushing syndrome in children?

1. Adrenal hyperplasia
2. Adrenocortical neoplasm
3. Extra pituitary lesion
4. Use of large amounts of corticosteroids

Looking for answers(s):4
Explanation: Cushing syndrome in children is usually iatrogenic and the direct result of administration of large amounts of corticosteroids. Although the other options are also causes of Cushing syndrome, they are not the most common cause.

Question 33. Which of the following clinical assessments would be included when caring for an infant with hydrocephalus?

1. Ataxia
2. Increased head circumference
3. Papilledema
4. Vomiting

Looking for answers(s):2
Explanation: Ventricular enlargement causes increased head circumference due to the presence of the fontanelles and sutures that allow for this expansion. Ataxia, papilledema, and vomiting are usually seen in older children who exhibit classic signs of increased intracranial pressure because their fontanelles are closed.

Question 34. Which of the following should the school nurse do first when a child with diabetes mellitus becomes unresponsive during recess?

1. Administer 3 to 6 ounces of orange juice.
2. Administer glucagon as prescribed.
3. Give the child milk and peanut butter crackers.
4. Immediately transport the child by car to the hospital.

Looking for answers(s):2
Explanation: The appropriate emergency treatment for a child with diabetes mellitus who is most likely experiencing severe hypoglycemia is the administration of glucagon as prescribed to allow release of stored glycogen from the liver. It takes about 15 to 20 minutes to restore the glucose level. Oral fluids should never be administered to an unconscious child due to the risk of aspiration. Commercial glucose gel, honey, or cake frosting may be rubbed on the unconscious child's gums if proper treatment is unavailable. Also, the administration of a high carbohydrate food, such as orange juice, is used for the treatment of hypoglycemia. Also, the administration of simple carbohydrates, followed by a larger snack, is used for treatment of moderate hypoglycemia. If transport to the hospital is required, the nurse must call 911 and contact the parents.

Question 35. Which of the following foods would be inappropriate for a 6-year-old in a full body cast?

1. Apple juice
2. Cereal
3. Hamburger
4. Milk shakes

Looking for answers(s):4
Explanation: Milk is high in calcium and could lead to formation of renal calculi in children who are immobilized. Juices, such as apple juice, are acid ash foods and are encouraged for children who are immobilized. Cereals and meats, also acid ash foods, are encouraged for children who are immobilized. Meats are also high in protein, which help in the correction of the negative nitrogen balance.

Question 36. To provide effective client teaching, the nurse is aware that idiopathic hypopituitarism is usually related to which of the following?

1. Constitutional growth delay
2. Familial short stature
3. Growth hormone (GH) deficiency
4. Psychosocial dwarfism

Looking for answers(s):3
Explanation: Idiopathic hypopituitarism is usually related to GH deficiency, inhibiting somatic growth in body cells. Constitutional growth delay is a term used for those children with delayed growth behind their peers who typically reach adult height. Familial short stature is a term used for healthy children who have ancestors with heights in the low percentiles. Psychosocial dwarfism is a psychologically induced state of growth delay.

Question 37. When caring for children who have received bone marrow transplants, the nurse is aware that graft-versus-host disease (GVHD) least commonly occurs with which of the following?

1. Allogenic
2. Autologous
3. Human leukocyte antigen (HLA) system complex
4. Syngeneic

Looking for answers(s):2
Explanation: Autologous transplantations use the client's own marrow, collected from disease-free tissue, and therefore is the least likely to result in GVHD. Allogenic transplantations involve the matching of a histocompatible donor, usually a sibling, with the client, and may result in GVHD. HLA system complexes are the histocompatibility antigens that are present on the cell membrane of almost all body cells used for tissue matching. Syngeneic transplantations use marrow from an identical twin and still may result in GVHD.

Question 38. Which of the following systems is least likely associated with the development of complications in the long-term follow-up of childhood cancer survivors?

1. Endocrine
2. Reproductive
3. Respiratory
4. Skeletal

Looking for answers(s):3
Explanation: Although respiratory complications may occur, the respiratory system is not one of the four systems that have complications unique to children. Radiation therapy administered to children may affect growth hormone and cause delayed or stunted growth. Radiation therapy and the use of alkylating agents cause decreased fertility and sterility. Irradiation to bones and cartilage causes defects and possible osteoporosis.

Question 39. Which of the following might a parent notice in a child with early retinoblastoma

1. Blindness
2. Inflamed conjuctiva
3. Protruding eyes
4. White appearing in the lens

Looking for answers(s):4
Explanation: A whitish appearance (cat's eye reflex or leukokoria) is symptomatic of retinoblastoma. The coloring is due to the visualization of the tumor as the light momentarily falls on the mass. Blindness is a late sign of retinoblastoma. An inflamed conjunctiva is seen in various forms of conjunctivitis, not retinoblastoma. Protruding eyes are seen in children with hyperthyroidism or goiter.

Question 40. The mother of a 4-year-old admitted with a fractured femur states, "He ran into a door and his bones break easy because he has that real common kind of brittle bone disease." Which of the following assessments would help the nurse to confirm the mother's statement?

1. Blue sclera
2. Different staged bruises
3. Lack of tooth development
4. Marked limb deformity

Looking for answers(s):1
Explanation: The "real common type of brittle bone disease" in children is type I osteogenesis imperfecta. Another sign of this disorder is blue sclera. Different staged bruising is usually indicative of child abuse, especially with a history that does not match the severity of the injury. Although absence of tooth development may be noted in severe cases of osteogenesis imperfecta, it is uncommon in the most typical form. Although marked limb deformity may be noted in severe cases of osteogenesis imperfecta, it is uncommon in the most typical form. Marked limb deformity may also indicate other disorders.

Question 41. Which of the following parental statements indicates the need for additional teaching about the use of long-acting desmopressin acetate (DDAVP)?

1. "The drug should last for 48 to 72 hours."
2. "We might see breakthrough urination in the evening."
3. "We should watch for headaches and nausea."
4. "We will administer it intranasally through a flexible tube."

Looking for answers(s):1
Explanation: The parents need more teaching about the duration of action of long-acting DDAVP, which lasts 8 to 20 hours. Injectable vasopressin lasts from 48 to 72 hours. Even breakthrough urination is usually allowed to prevent over-medication. Possible effects of DDAVP include headaches, nausea, and nasal irritation. DDAVP is administered intranasally through a flexible tube.

Question 42. The parents of a child who has been newly diagnosed with cerebral palsy question the nurse about the child's prognosis. The nurse bases her response on knowing which of the following?

1. Cerebral palsy is nonprogressive with variable outcomes.
2. The child will become progressively worse.
3. The condition improves gradually with stimulation.
4. The illness progression is variable, but results in predicted patient outcomes.

Looking for answers(s):1
Explanation: Cerebral palsy is nonprogressive. However, there is usually no way to predict the outcome at the time of diagnosis. Many children appear to have worsened because their disability becomes more obvious with age. Stimulation has no effect on the outcome of the disorder.

Question 43. Which of the following denotes the primary reason for teaching testicular self-examination of males ages 13 to 14 who are at least at Tanner's stage III of development?

1. Testicular cancer is most common in males ages 15 to 34.
2. They will become more comfortable with their own sexuality.
3. They will become more familiar with their own anatomy.
4. They will develop a health promotion habit important in later life.

Looking for answers(s):1
Explanation: Testicular cancer, although not common in general, is the most common cancer in males ages 15 to 34. Even though it can be a beneficial way to get the client to discuss sexual issues and become familiar with his own anatomy, these are not the primary reasons for teaching testicular self-examination. Testicular self-examination should be taught for use at this age.

Question 44. Which of the following would be an early sign of insulin-dependent diabetes mellitus (IDDM) in children?

1. Abdominal discomfort and nausea
2. Marked increase in fluid intake
3. Recurrent Candida infections
4. Sudden onset of bedwetting

Looking for answers(s):3
Explanation: Recurrent vaginal and urinary infections, especially those caused by Candida, are commonly early signs of IDDM in children and adolescents. Abdominal discomfort and nausea are vague nonspecific signs and occur somewhat later in the disease process. A marked increase in thirst and increased fluid intake are somewhat later signs of IDDM. The sudden onset of bedwetting is a somewhat later sign associated with IDDM.

Question 45. Which of the following conditions is most commonly associated with ethical and moral issues regarding life support withdrawal and organ donation?

1. Anencephaly
2. Encephalocele
3. Meningocele
4. Microcephaly

Looking for answers(s):1
Explanation: Anencephaly, a congenital disorder where both cerebral hemispheres are absent, is incompatible with life. Therefore, the nurse is usually challenged with ethical and moral issues regarding life support withdrawal and organ donation. Encephalocele, herniation of the brain and meninges through a skull defect, is usually successfully treated. Meningocele, herniation of the meninges through a spinal defect, is usually successfully treated. Ethical and moral issues regarding life support and organ donation issues are not commonly encountered with microcephaly (small brain).

Question 46. Which of the following would be least likely to occur when providing routine postoperative care for an infant with myelomeningocele?

1. Cognitive delays
2. Head circumference increase
3. Latex allergy
4. Urine retention

Looking for answers(s):1
Explanation: Cognitive delays are not readily apparent postoperatively and, thus, would be least likely to occur. Hydrocephalus may develop and can be monitored for by noting head enlargement. Children with spina bifida are prone to latex allergies. Swelling around the operative site may cause urine retention.

Question 47. Which of the following is an early warning sign of cerebral palsy?

1. Failure to sit without support at age 5 months
2. Failure to smile by age 3 months
3. Poor head control at age 2 months
4. Pushing food out of mouth with tongue at age 3 months

Looking for answers(s):2
Explanation: A social smile should be evident by age 2 months. Lack of it indicates problems, including cerebral palsy. Children do not usually sit without support until age 8 months. Basic head control is not expected until age 3 months. The tongue thrust usually persists until age 4 months.

Question 48. Which of the following would be the most appropriate mouth care for a 2-year-old with stomatitis?

1. Hydrogen peroxide
2. Lemon and glycerin swabs
3. Plain water
4. Viscouse lidocaine

Looking for answers(s):3
Explanation: Because the child cannot swish and spit and is most likely to swallow mouthwash or other substances, plain tap water is the best choice. Hydrogen peroxide and lemon and glycerin swabs have a drying effect on the mucosa and should not be used. Also, lemon is irritating to mouth sores and may lead to tooth decay. Viscous lidocaine may suppress the gag reflex in a young child, increasing the risk of aspiration.



Question 49. Which of the following psychosocial stressors is likely to be imposed upon an immobilized 2-year-old?

1. Guilt
2. Inferiority
3. Mistrust
4. Shame

Looking for answers(s):4
Explanation: Immobilization impedes autonomy in toddlers, leading to feelings of shame and doubt unless intervention occurs. Immobilization impedes initiative in preschoolers, leading to feelings of guilt without intervention. Immobilization impedes industry in schoolagers, leading to feelings of inferiority without intervention. Immobilization impedes trust in infants, leading to feelings of mistrust without intervention.

Question 50. In addition to the usual postoperative care, immediate postoperative care of the adolescent who had a Luque repair of scoliosis includes which of the following?

1. Administering nonopioids for pain
2. Assessing for neurologic integrity
3. Encouraging frequent voiding
4. Logrolling every 2 hours

Looking for answers(s):2
Explanation: With this type of surgical repair, there is a danger of spinal nerve damage. The pain from scoliosis surgery is severe. The client should receive opioids around the clock until the pain can be controlled with nonopioids. Postoperatively, the client will have an indwelling catheter in place. Immediately following a Luque repair, the client must lie flat for 12 hours before logrolling.
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