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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 6answers

Question 1. Which of the following would be commonly assessed in early acute glomerulonephritis (AGN)?

1. Dysuria, pedal edema, decreased urinary output
2. Seizures, increased urinary output, pale-colored urine
3. Tea-colored urine, anorexia, facial puffiness
4. Vomiting, bright red urine, abdominal distention

Looking for answers(s):3
Explanation: Tea-colored urine, anorexia, and facial puffiness are characteristics of AGN. Hypertension and fatigue are also seen. Dysuria and pedal edema are not noted in AGN. Seizures rarely occur with AGN; urine is not increased or pale-colored. Bright red urine and abdominal distention are not manifestations of AGN.

Question 2. Which of the following is the earliest sign of puberty in females?

1. Adrenarche
2. Growth spurt
3. Menarche
4. Thelarche

Looking for answers(s):4
Explanation: Thelarche, the beginning of breast development, is the first sign of puberty. Adrenarche, the start of pubic hair, begins 2 to 6 months after thelarche. The growth spurt takes place after the onset of puberty. Menarche, the first menstrual period, is the hallmark of late puberty.

Question 3. A home health nurse notes excessive swallowing in a 7-year-old boy who had a tonsillectomy 1 week ago. Which of the following would be the nurse's priority intervention?

1. Administer aspirin because excessive swallowing indicates pain.
2. Administer extra fluids for dehydration.
3. Examine the child's throat for bleeding.
4. Instruct the child to spit out secretions instead of swallowing them.

Looking for answers(s):3
Explanation: The nurse should examine the child's throat because excessive swallowing 5 to 10 days postoperatively is a sign of bleeding caused by healing and tissue sloughing. Typically, the child would lessen swallowing to decrease pain. Plus, aspirin is contraindicated since it can cause bleeding due to its antiplatelet activity. A child with dehydration would have diminished saliva, not an increase in amount. Spitting places pressure on the throat and increases the likelihood of bleeding.

Question 4. Which of the following complications would the nurse least expect to develop in a child with meningitis?

1. Cerebral palsy
2. Disseminated intravascular coagulation (DIC)
3. Hydrocephalus
4. Pneumonia

Looking for answers(s):4
Explanation: Pneumonia is more likely to be a precursor of meningitis than a complication. Cerebral palsy is a long-term complication of meningitis. DIC can occur, especially with meningococcal meningitis. Hydrocephalus may occur due to obstruction of cerebrospinal fluid.

Question 5. Which of the following is exemplified by a 4-year-old sibling of a sudden infant death syndrome victim who believes that she caused her sibling's death because she wished for it?

1. Abstract thinking
2. Concrete thinking
3. Magical thinking
4. Formal operational thinking

Looking for answers(s):3
Explanation: Magical thinking is a normal cognitive process of preschoolers due to egocentrism and transductive reasoning. They believe their thoughts are all powerful. Abstract and formal operational thinking develop at about age 11 and are characterized by the ability to use abstract terms and draw logical conclusions from a set of observations. Concrete thinking develops between ages 7 and 11 when the child's thoughts become increasingly logical and coherent.

Question 6. The nurse develops a teaching plan for a mother who is concerned about her 6-month-old child awakening and crying frequently at night until comforted based on the nurse's understanding of which of the following?

1. Improper feeding
2. Maternal anxiety
3. Night terrors
4. Separation anxiety

Looking for answers(s):4
Explanation: The child is at an age where separation anxiety can become evidenced, and the child is comforted by the mother. Improper feeding would result in the child crying until satiated or evidence of other symptoms. This is not the case since the child quiets when comforted. If the mother was anxious, it is unlikely that she would be able to comfort the infant on a regular basis. It is unusual for an infant to have night terrors. These are common in preschoolers due to their active imaginations.

Question 7. Which of the following would the nurse include when developing a parental teaching plan about the characteristics of febrile seizures?

1. Are more common in schoolagers
2. Are relatively benign in nature
3. Occur as the fever peaks
4. Result in moderate neurologic problems

Looking for answers(s):2
Explanation: Febrile seizures are benign in nature. Febrile seizures are unusual after age 5. Febrile seizures do occur as the fever is rising, not when it has reached its peak. Febrile seizures rarely cause any neurologic impairment.

Question 8. To test a schoolager's sense of conservation, which of the following would the nurse do?

1. Give the child a group of numbered blocks and have him arrange them according to some ordinal scale.
2. Give the child a mixture of stamps, wrappers, and shells and have him group them according to some classification system.
3. Show the child two equal-length pencils side by side, then move them out of alignment to see if he realizes they are still the same length.
4. State a situation to the child, then have him anticipate the consequences and rethink the action in a different direction.

Looking for answers(s):3
Explanation: Conservation refers to the child's realization the certain properties remain the same even when their outward appearance has changed. Having a child arrange numbered blocks according to an ordinal scale would test the child's ability to serialize. The ability to group objects according to the attributes they have in common would test the child's ability to classify. The ability to think through an action sequence, anticipate the consequence and, if needed, return to the beginning and rethink the action in a different direction would test the child's ability to reverse.

Question 9. Which of the following statements, if voiced by the parents of a female child receiving co-trimoxazole (Bactrim) for a urinary tract infection (UTI), would indicate the need for additional teaching?

1. "We'll call the physician immediately if a rash occurs."
2. "We'll continue to give her the medication until it is finished."
3. "We'll make arrangements to have her white blood cell (WBC) count checked routinely."
4. "We'll try to make sure that she doesn't go outside in the sun."

Looking for answers(s):3
Explanation: Routine WBC counts are not necessary when co-trimoxazole is given for a UTI. Monitoring for leukopenia is only done for children receiving long-term therapy such as those infected with human immunodeficiency virus receiving the drug for Pneumocystis carinii. This medication may cause toxic epidermal necrolysis as a possible effect. Therefore, rashes should be reported immediately. Co-trimoxazole, as with most antibiotics, should be continued until the supply is finished to prevent recurrence. Co-trimoxazole is associated with photosensitivity. Therefore, exposure to the sun should be avoided.

Question 10. At which of the following ages would a child typically experience the most age-related psychological stress from a hypospadias repair?

1. 2 years
2. 4 years
3. 6 years
4. 8 years

Looking for answers(s):2
Explanation: The child around age 4 would experience the most psychological stress from a hypospadias repair because preschoolers are in the genital stage and have castration anxiety, further heightened by genital surgery. 2-year-olds would have no more stress with their surgery than they would with other comparable surgery. Schoolagers, while being embarrassed, would not experience the most age-related stress for this type of surgery.

Question 11. A nurse finds a 3-year-old boy simulating sexual intercourse with some dolls. The nurse should recognize this as which of the following?

1. A sign of possible sexual abuse
2. A symptom of developmental delay
3. Normal curiosity during play
4. The child's inexperience with doll play

Looking for answers(s):1
Explanation: Although preschoolers engage in curiosity play, they are not normally familiar with the act of sexual intercourse unless they have witnessed or experienced it. Therefore, sexual abuse should be suspected. Even though some children with developmental delays may exhibit difficulty with doll play, all children at this age should be unfamiliar with the act of sexual intercourse. This is not normal curiosity of this age group. Therefore, sexual abuse should be suspected. Inexperience with doll play would not promote acting out of sexual simulations in preschool children.

Question 12. Which of the following assessments would be least likely to create a suspicion of Munchausen Syndrome by Proxy (MSP) in an infant admitted for persistent diarrhea?

1. Parent totally refuses to leave the hospital
2. Parent who gives history inconsistent with findings
3. Parent who is over-friendly to staff
4. Parent with little knowledge of child's illness

Looking for answers(s):4
Explanation: Parents involved in MSP tend to be knowledgeable about their child's illness, procedures, and treatments. Although many parents find it difficult to leave their sick children, refusing to leave the hospital and giving extreme attention to the child are considered warning signs of MSP. A history that is inconsistent with clinical findings is a key warning sign of MSP and other forms of child abuse. Parental need for attention may be one of the underlying factors of MSP and over-friendliness to the staff is one of the warning signs.

Question 13. When planning the care for children with primary enuresis, the nurse bases the plan on the knowledge of which of the following?

1. An underlying urological abnormality is common.
2. The child has had difficulty with toilet training.
3. The disorder is benign and self-limiting.
4. There is an underlying psychological disorder.

Looking for answers(s):3
Explanation: Primary enuresis is benign and self-limiting. The age at which children attain dryness is varied. There is rarely an underlying urological abnormality in primary enuresis. However, it may be present in secondary enuresis. Toilet training problems are not usually associated with primary enuresis. An old belief about primary enuresis was that the disorder was due to an underlying psychological disorder. However, this may be the underlying problem in secondary enuresis.

Question 14. A 2-year-old being treated for nephrotic syndrome develops a temperature of 99.8°F and a slight cough. Which of the following should the nurse do?

1. Assess the child for signs of a respiratory infection.
2. Encourage fluids to decrease fever.
3. Give the child a lozenge for sore throat.
4. Increase activity to prevent pneumonia.

Looking for answers(s):1
Explanation: Infection is a major concern in children with nephrotic syndrome, especially since such signs as high fever can be masked by steroids used to treat the disorder. Increased fluids are not allowed in a child who already has fluid overload. Lozenges should never be given due to the risk of aspiration. Children with nephrotic syndrome require bed rest, so increased activity should be avoided.

Question 15. The nurse prepares to administer acetaminophen 200 mg as ordered for fever for a child who weighs 44 lb. What is the maximum safe dose for this child if acetaminophen should be given at 10 to 15 mg/kg per dose?

1. 200
2. 320
3. 300
4. 230

Looking for answers(s):3
Explanation: The child weighs 44 lb, which equals 20 kg (44 divided by 2.2). The maximum dose is 15 mg/kg, which equals 300 mg (15 × 20).

Question 16. When reviewing the laboratory results of a child with a possible urinary tract infection, which of the following collection method results indicates an infection when the colony count is more than 1,000 colonies/ml of a single organism?

1. Catheterized specimen
2. Clean catch specimen
3. Routine specimen
4. Suprapubic tap specimen

Looking for answers(s):4
Explanation: Due to the accuracy of the suprapubic tap specimen, the colony count only needs to be greater than 1,000 colonies/ml. For a catheterized specimen, the colony count needs to be greater than 10,000 colonies/ml for the diagnosis of infection. For a clean catch specimen, the colony count must be greater than 100,000 colonies/ml for diagnosis of an infection. Routine specimen collection is always unreliable for infection detection because the genital area is inadequately cleaned and the specimen cup is usually not sterile.

Question 17. Which of the following preventive measures should the nurse include in the teaching plan for a female child to prevent urinary tract infections?

1. Avoid tight jeans.
2. Empty bladder every 5 to 6 hours.
3. Use nylon underwear.
4. Wipe self back to front.

Looking for answers(s):1
Explanation: Because tight jeans decrease air circulation and thus increase organism growth, they should be avoided. The bladder should be emptied every 3 to 4 hours to prevent stasis. Nylon underwear decreases air circulation and thus increases organism growth. Cotton underwear should be used. The child should wipe herself front to back to prevent fecal contamination of the urinary meatus.

Question 18. Which of the following would the nurse do first when a child has a sudden and unexpected seizure?

1. Clear the area of hazards to prevent harm.
2. Place a tongue blade in the child's mouth to prevent aspiration.
3. Restrain the child to prevent injury.
4. Shake the child to ascertain level of consciousness (LOC).

Looking for answers(s):1
Explanation: Because the child may injure himself, especially during the clonic phase of the seizure, the nurse should clear the area of hazards to prevent injury. Placing a tongue blade in the mouth to prevent aspiration can cause severe injury to the mouth. To prevent aspiration if the child vomits, turn the child to the side. Restraining should be avoided because it can cause injury. Shaking the child to ascertain LOC is inappropriate because it will cause harm to the child. The child's LOC, which will be altered during the seizure, should be assessed after the seizure.

Question 19. Which of the following complications would the nurse least expect to develop in a child with meningitis?

1. Cerebral palsy
2. Disseminated intravascular coagulation (DIC)
3. Hydrocephalus
4. Pneumonia

Looking for answers(s):4
Explanation: Pneumonia is more likely to be a precursor of meningitis than a complication. Cerebral palsy is a long-term complication of meningitis. DIC can occur, especially with meningococcal meningitis. Hydrocephalus may occur due to obstruction of cerebrospinal fluid.

Question 20. When evaluating the effectiveness of client teaching for an adolescent with mild mental retardation, which of the following would indicate the need for further teaching?

1. Adequate performance of activities of daily living (ADLs)
2. Avoidance of sexual discussions
3. Demonstration of practical skills
4. Dressing like peers

Looking for answers(s):2
Explanation: Avoiding sexual discussions indicates more teaching is needed because as many of half of youngsters with mental retardation have engaged in sexual intercourse and many are sexually abused. Therefore, open discussions about sex and sexuality are encouraged. An adolescent with mild mental retardation should be capable of performing ADLs and able to perform practical skills, eventually attaining vocational skills. Adolescents with mild mental retardation should be encouraged to dress like their peers to promote integration.

Question 21. Which of the following would be most beneficial when caring for an infant with Nonorganic Failure to Thrive (NOFTT)?

1. Alternating staff for each feeding for variety
2. Changing routines when the child refuses feedings
3. Gradually introducing new foods to the child's diet
4. Stimulating the child with play during feedings

Looking for answers(s):3
Explanation: Because many children with NOFTT have been exclusively bottle-fed, they need time to adjust to new foods. Thus, new foods should be introduced gradually. Consistent staffing is necessary to allow nurses to learn the child's cues and to respond appropriately and consistently. Consistent persistence is one of the most important aspects of care and helps to extinguish negative behaviors. Many children with NOFTT are very distractible, and their attention is easily diverted. Stimulating the child during feeding would make the feeding more difficult.

Question 22. Which of the following dietary measures would the nurse expect to institute for the child with acute glomerulonephritis (AGN)?

1. Decreased calcium
2. Decreased sodium
3. Increased nitrogen
4. Increased protein

Looking for answers(s):2
Explanation: Mild sodium restrictions may be needed to control mild edema and hypertension associated with AGN. Calcium intake is not increased or decreased in AGN. There is no additional need for intake of foods high in nitrogen. Protein does not need to be increased in the child with AGN.

Question 23. Which of the following is a primary prevention strategy for mental retardation?

1. Infant stimulation programs
2. Neonate screening
3. Prenatal diagnosis
4. Rubella vaccine

Looking for answers(s):4
Explanation: The rubella vaccine is a primary prevention strategy, designed to preclude the occurrence of a condition (rubella) that causes mental retardation. Early intervention programs are tertiary prevention strategies, designed to minimize long-term consequences of diagnosis conditions. Neonate screening and prenatal diagnosis are secondary prevention strategies, designed to identify the condition early and institute treatment to avert cerebral damage.

Question 24. The infant of a 13-year-old runaway mother is not held, fed, or changed consistently. This child is likely to develop a sense of which of the following?

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

Looking for answers(s):4
Explanation: Infants who do not have their needs met consistently and efficiently may develop a sense of mistrust. Doubt develops when toddlers are made to feel unimportant and self-conscious. Guilt develops when preschoolers are made to feel that their actions or feelings are bad. Inferiority develops when schoolagers are made to believe they cannot live up to the standards of others.

Question 25. When monitoring the urine of a child with acute glomerulonephritis, which of the following values would be the most important to monitor?

1. Blood
2. pH
3. Protein
4. Specific gravity

Looking for answers(s):1
Explanation: Blood in the urine is the most important because this evaluates the disease progress. Although urine pH is also monitored, this value is not the most important one. Although protein urine levels and urine specific gravity are also monitored, they are not the most important values.

teaching age-related sources of stress to a group of parents and teachers, which of the following is a source of stress for 6-year-olds?

1. Infrequent interaction with peers
2. Interruption of sense of decorum
3. Own criticalness of performance
4. Sitting still for long periods

Looking for answers(s):4
Explanation: Most 6-year-olds are unable to stay still for long periods and therefore perceive this as stressful. Decreased peer interaction does not become stressful until age 8. It is usually 9-year-olds who become stressed when their sense of decorum is interrupted. Although all school-age children are critical of themselves, it is not usually stressful until between ages 10 and 12.

Question 27.
The nurse is caring for a child who has Kawasaki Disease (KD). Which of the following nursing interventions are appropriate? Select all that apply:

1. Administer prescribed prophylactic anticonvulsant medication.
2. Encourage fluids to maintain adequate kidney function.
3. Provide mouth care using lubricated ointment.
4. Use passive range of motion (ROM) if arthritis develops.
5. Assess for signs of heart failure.
3 4 5

Explanation: Manifestations of KD include cracked lips and pharyngitis that require mouth care. Some children develop arthritis, necessitating passive ROM. Heart failure may develop secondary to cardiac sequelae, warranting monitoring, rest and, possibly, fluid restriction. Seizures are not typically part of the disorder.

Question 28. In evaluating a 10-year-old's psychosocial development, the nurse notes that the child is within normal for age. Therefore, the child has attained a sense of which of the following?

1. Autonomy
2. Identity
3. Industry
4. Initiative

Looking for answers(s):3
Explanation: The schoolager should attain a sense of industry to successfully complete the psychosocial crisis of the school-age period. A sense of autonomy is achieved during toddlerhood. A sense of identity is attained during adolescence. A sense of initiative is a normal attainment of preschoolers.

Question 29. The nurse understands that the incidence of Reye's syndrome has decreased because of the association with which of the following?

1. Administration of immune toxoid
2. Decreased administration of aspirin for viral infections
3. Earlier identification of the disorder
4. Improved diagnostic testing for the disorder

Looking for answers(s):2
Explanation: The decrease in the administration of aspirin for viral disorders, such as chickenpox and influenza, is credited for the decrease in the incidence of Reye's syndrome. There is no type of immunization for Reye's syndrome. Early diagnosis indicates the presence of the disease, and therefore has no bearing on decreased incidence. Improved diagnostic testing indicates presence of the disorder and has no bearing on increased incidence.

Question 30. Which of the following would the nurse expect a 21-year-old with an IQ of 30 to be able to do?

1. Conform to daily routines.
2. Demonstrate social skills.
3. Perform simple tasks.
4. Travel alone to familiar places.

Looking for answers(s):1
Explanation: People with IQs between 20 and 40 are usually capable of conforming to daily routines and repetitive activities. An IQ of 50, mild retardation, is usually necessary for social skills. Performance of simple tasks is usually in the realm of people with an IQ of at least 35, signifying moderate mental retardation. The ability to travel alone to familiar places usually requires an IQ of 35 or more.

Question 31. Which of the following are true about pediatric pain management? Select all that apply:

1. Acute pain can lead to depression.
2. Young children have difficulty expressing their pain.
3. Pain scales can be effective for children.
4. I.M. pain therapy is preferable and effective.
5. The pain threshold is the maximum level of tolerance for pain.
2 3

Explanation: Young children have limited vocabularies, making it difficult for them to express their pain. Adolescents may be stoic, fearing being labeled a "cry-baby." Pain scales, such as the "Oucher," are effective tools for assessing children's pain. Chronic pain can lead to depression; the threshold is the point at which pain is felt; and I.M. injections cause fear, making other routes more preferable.

Question 32. Which of the following would the nurse identify as the primary outcome when planning nursing care for a child with mental retardation?

1. The child will demonstrate self-care measures.
2. The child will demonstrate vocational skills.
3. The child will develop communication skills.
4. The child will obtain optimum development.
Looking for answers(s):4
Explanation: RATIONALE: Despite the level of disability, the primary outcome for all children with mental retardation is to achieve an optimum level of development. Not all children with mental retardation will be able to perform self-care measures; abilities depend on the level of retardation. Vocational skills are usually only achievable by those with mild mental retardation. Children with profound retardation have only primitive speech.

Question 33. Which of the following organisms would the nurse suspect as the most likely cause of bronchiolitis?

1. Haemophilus influenzae
2. Mycoplasma pneumoniae
3. Parainfluenza virus
4. Respiratory syncytial virus (RSV)

Looking for answers(s):4
Explanation: RSV, which can be easily transmitted by direct contact, causes most cases of bronchiolitis. Different strains of H. influenzae cause such problems as otitis media, meningitis, and epiglottiditis. M. pneumoniae primarily causes bronchitis and pneumonia. Parainfluenza virus, while a possible cause of bronchiolitis, is not the primary organism. Typically, this organism is associated with laryngotracheobronchitis.


Question 34. Which of the following is not a common signal that a child is ready for toilet training?

1. Ability to stay dry for 4 hours
2. >Expression of willingness to please parents
3. Regular bowel movements
4. Skills to indicate urge to go to the bathroom

Looking for answers(s):1
Explanation: The child only needs to stay dry for 2 hours to be ready for toilet training. A 4-hour bladder capacity for children of toilet-training age is unrealistic. The child must want to please the parent before following the "rules." The child must have regular bowel movements to "time" when to place the child on the potty as bowel training usually takes place before bladder. The child must be able to verbally or nonverbally indicate that he has to go to the bathroom.

Question 35.
Which of the following assessments would be noted in children with Minimal Change Nephrotic Syndrome (MCNS)?

1. Foul-smelling urine, frequency, dysuria
2. High blood pressure, hematuria, facial edema
3. Malaise, flank pain, high fever
4. Proteinuria, marked edema, slightly decreased blood pressure

Looking for answers(s):4
Explanation: Proteinuria, marked edema, and slightly decreased blood pressure are manifestations of MCNS. Foul-smelling urine, frequency, and dysuria are symptoms of a lower urinary tract infection (UTI). High blood pressure, hematuria, and facial edema are manifestations of acute glomerulonephritis. Malaise, flank pain, and high fever are manifestations of an upper UTI.

Question 36. Which of the following would be included in the care plan for a child receiving oral phenytoin (Dilantin) for seizures?

1. Encouraging fluids
2. Giving rigorous oral hygiene
3. Monitoring blood pressure every 4 hours
4. Providing meticulous skin care

Looking for answers(s):2
Explanation: Phenytoin causes gingival hyperplasia, which can be minimized with rigorous oral hygiene. There is no specific need to encourage fluids with phenytoin. However, it should be administered with or after meals, to prevent GI irritation, and followed by a full glass of water to prevent direct contact of the drug with mucosa. There is no need to closely monitor blood pressure because hypotension is an adverse effect of I.V. administration only. Even though phenytoin may cause rashes, meticulous skin care is not a primary nursing concern. receiving oral phenytoin (Dilantin) for seizures?

Question 37. A 16-year-old who is diagnosed with depression suddenly cheers up and gives her cherished teddy bear to her favorite nurse. Which of the following is the priority for the nurse at this time?

1. Assess the adolescent for possible suicidal ideation.
2. Give the bear back and discuss transitional objects.
3. Praise her mood change and her passage from childhood.
4. Tell her mother to call for a psychiatric referral.

Looking for answers(s):1
Explanation: This adolescent is exhibiting two warning signs for suicidal ideation: sudden cheerfulness in a depressed individual and the giving away of cherished objects. The nurse needs to assess the adolescent for further suicidal ideation. Giving the bear back and discussing transitional objects distract from the issue at hand and are not appropriate actions. The sudden mood change and the giving away of a cherished object are not indicative of a mood improvement or a passage from childhood, but are signs of suicidal ideation; thus, should be assessed, not praised. Because the adolescent is exhibiting two warning signs of suicidal ideation, suggesting a psychiatric referral without assessment could be disastrous.

Question 38. The mother of a 7-year-old with acute glomerulonephritis (AGN) states that she is worried that her child will end up needing dialysis for the rest of his life. On which of the following would the nurse base the response to this mother?

1. Most children have relapses but do not need dialysis.
2. Most children have renal failure and need dialysis.
3. Most children only need temporary dialysis.
4. Most children return to normal functioning.

Looking for answers(s):4
Explanation: Most children who develop AGN do return to normal functioning. Only a few children with AGN have relapses. Chronic renal disease is rare. Renal failure rarely occurs in children with AGN. Use of dialysis is rare in children with AGN because renal failure is rare.

Question 39. A mother asks why her daughter needs further evaluation after having two urinary tract infections (UTIs). The nurse bases her explanation on the understanding that which of the following is commonly associated with UTIs?

1. Acute glomerulonephritis (AGN)
2. Nephrotic syndrome
3. Pyelonephritis
4. Vesicoureteral reflux (VUR)

Looking for answers(s):4
Explanation: VUR is commonly associated as a precursor and as a result of UTIs. AGN is usually associated with streptococcal infections. There is no association between nephrotic syndrome and UTIs. Pyelonephritis is a UTI.

Question 40. Which of the following is the first step in assessing suicidality?

1. Accessibility
2. Lethality
3. Proximity
4. Specificity

Looking for answers(s):4
Explanation: The first step in assessing suicidality is specificity, that is, to ask adolescents if they feel suicidal and, if so, what is their plan? Accessibility is the third stage and involves determining the ability of the means of suicide. Even though the method is important, it is first necessary to assess whether or not the adolescent is actually considering suicide. Lethality assessment is the second stage and involves determining the lethality of the methods available to them, such as guns, carbon monoxide, and pills. Proximity is the fourth stage of suicide assessment and involves assessing whether they have determined a time to commit suicide and when it will be.

Question 41. When performing a neonate examination, a nurse suspects mild hypospadias. Which of the following demonstrates the nurse's understanding about the rationale for reporting this finding as soon as possible?

1. Circumcision should be postponed.
2. Infection must be prevented.
3. It requires immediate repair.
4. Undescended testes may be present.

Looking for answers(s):1
Explanation: Circumcision should be postponed because the foreskin is usually used in the repair of hypospadias (meatal opening on the ventral aspect of the penis). Infection is not a primary concern in hypospadias. Immediate repair is not required; hypospadias is usually repaired between ages 6 and 18 months. Even though other abnormalities such as undescended testes are possible, this is not the reasoning for early reporting.

Question 42. When a nurse is caring for a child who is receiving ribavirin (Virazole), the nurse plans interventions based on the knowledge of which of the following?

1. Contact precautions are discontinued during administration.
2. Pregnant nurses should not care directly for the infant.
3. Ribavirin is given via nebulizer four times per day.
4. Ribavirin is used for any infant with respiratory syncytial virus (RSV) bronchiolitis.

Looking for answers(s):2
Explanation: Pregnant nurses should be advised to not care directly for an infant who is receiving ribavirin since it has produced teratogenic effects on laboratory rodents. Contact precautions should remain in effect during treatment, usually 3 to 5 days. Ribavirin is given via small-particle aerosol generator into an oxyhood, tent, or mask. Ribavirin is used only for children who are at high risk for complications caused by other conditions, such as heart disease, and for children who are severely ill or who will progress from mild to severe illness.


Question 43. Which of the following reflects the child's level of moral development when a 2 1/2-year-old child states that the nurse is "a bad girl" after she administers an I.M. injection?

1. Conventional/"law and order"
2. Conventional/interpersonal concordance
3. Preconventional/naive instrumentation
4. Preconventional/punishment-obedience

Looking for answers(s):4
Explanation: Children between ages 1 and 3 are at the Preconventional/punishment-obedience stage and determine the goodness or badness of an action in terms of its consequences. Children ages 8 to 12 are at the Conventional/"law and order" stage and believe that obeying the rules and maintaining law and order is the correct behavior. Children ages 6 to 8 are at the Conventional/interpersonal concordance stage and view behavior that meets with approval and pleases or helps others as good. Conformity to the norm is good and one earns approval by being nice. Children between ages 3 and 6 are at the Preconventional/naive instrumentation stage and believe that the right behavior consists of that which satisfies the child's own needs.

Question 44. Based on the nurse's knowledge of the organism primarily responsible for causing urinary tract infections (UTIs) in children, which of the following would be included in a teaching plan on prevention?

1. Escherichia coli
2. Klebsiella
3. Mycoplasma
4. Proteus

Looking for answers(s):1
Explanation: E. coli is responsible for about 80% of all childhood UTIs, many of which can be related to "improper" wiping in female children. Klebsiella and Proteus are not the most common causative organisms associated with UTIs. Mycoplasma is more commonly associated with respiratory infections, not UTIs.

Question 45. Which of the following nursing diagnoses would be least likely associated with Minimal Change Nephrotic Syndrome (MCNS)?

1. Fatigue
2. Deficient fluid volume
3. Risk for impaired skin integrity
4. Risk for infection

Looking for answers(s):2
Explanation: With MCNS, the child has excess fluid volume related to fluid accumulation in tissues and third spaces. The child with MCNS typically is fatigued, especially with the cumbersome bulk of the edema. Marked edema associated with MCNS places the child at risk for impaired skin integrity. The child with MCNS is at risk for infection due to protein loss, edema, and being immunosuppressed from high dose steroids.

Question 46. The nurse instructs the mother of an 8-year-old with group A beta-hemolytic streptococcal tonsillitis to take his prescribed penicillin for 10 days, primarily to prevent which of the following?

1. Acute poststreptococcal glomerulonephritis
2. Juvenile rheumatoid arthritis
3. Rheumatic fever
4. Subacute bacterial endocarditis

Looking for answers(s):3
Explanation: Proper treatment of streptococcal tonsillitis does prevent the occurrence of rheumatic fever. There is no guarantee that the administration of antibiotics in the treatment of streptococcal tonsillitis will prevent acute poststreptococcal glomerulonephritis. There is no relationship between juvenile rheumatoid arthritis and hemolytic streptococcal infections. Most cases of subacute bacterial endocarditis occur in children with heart defects who did not receive proper antibiotic prophylaxis for dental procedures.

Question 47. Which of the following behaviors would be a cause of concern for a 5-year-old child whose pet hamster just died?

1. Acting sad and tearful
2. Sleeplessness and loss of appetite
3. Trying to dig it up from its grave
4. Wanting to buy the dead animal food

Looking for answers(s):2
Explanation: Sleeplessness and loss of appetite are not common reactions to loss and may be signs of clinical depression in a preschooler. Sadness and tearfulness are common reactions to loss, especially in a small child. Trying to dig the hamster up from its grave is a typical behavior toward death in a preschooler who views death as reversible. Preschoolers have a limited understanding of death and may attribute behaviors to the dead such as eating.


Question 48. Which of the following infection control precautions should the nurse initiate when a child is admitted for possible meningococcal meningitis?

1. Airborne precautions
2. Contact precautions
3. Droplet precautions
4. Neutropenic precautions

Looking for answers(s):3
Explanation: Droplet precautions are instituted when meningococcal meningitis is known or suspected and maintained for 24 hours following the start of antibiotic therapy. Airborne precautions are used for infections transmitted by small airborne droplet nuclei or dust particles containing the infectious agent, such as measles or pulmonary tuberculosis. Contact precautions are instituted when there is a risk for skin-to-skin contact, such as with large draining abscesses and varicella. Neutropenic precautions are used when the client's neutrophil count, part of the white blood cell differential, drops below 500/mm

Question 49. When managing an abused child, the nurse should be aware that this child is most likely to do which of the following?

1. Compensate by doing well in school.
2. Develop aggressive behavior toward other children.
3. Develop overly strong peer attachments.
4. Seek assistance from teachers.

Looking for answers(s):2
Explanation: Because abused children see violence as an expected way of coping with life, they tend to develop aggressive behaviors toward other children. Many abused children fail to do well in school and are unable to compensate for their abused status. Many abused children have difficulty in establishing relationships, and those that are formed are usually superficial. Even though many abused children use attention-seeking behaviors toward their teachers, they are usually not seeking assistance, just attention.

Question 50. A mother is concerned because her 16-month-old child is not walking yet. Which of the following would be the home health nurse's best response?

1. "Give him more time; children grow at their own pace."
2. "Refer this to your primary care physician."
3. "Try using high-topped shoes to support his ankles."
4. "Use a walker; it will help to strengthen his legs."

Looking for answers(s):2
Explanation: Children should be walking by age 15 months, regardless of their own pacing. The child may have a neuromuscular or developmental deficiency and should be evaluated. High-topped shoes do not improve walking by supporting ankles. Children walk best when barefoot. However, shoes provide safety by preventing injury to feet. Walkers do not assist children in walking in any fashion, and they are dangerous because many children topple down stairs in them.
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