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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 9 answers

Question 1. Which of the following should the nurse do next after noting that an 8-month-old child's posterior fontanel is slightly open?

1. Check the child's head circumference
2. Document this as a normal finding
3. Question the mother about the child's delivery
4. Schedule an x-ray of the child's head

Looking for answers(s):1
Explanation: RATIONALE: The posterior fontanel usually closes by 6 weeks to 2 months. Therefore, the nurse should measure the head circumference to determine if the child's head is larger than the established norms because hydrocephalus can cause separation of the cranium sutures. This is not a normal finding because the posterior fontanel usually closes by age 2 months. Because the child is 8 months old, the delivery history probably would not be a significant factor. An x-ray (radiologic) examination is not necessary until other data are collected.

Question 2. Which of the following nursing diagnoses would the nurse identify as the priority for a 4-month-old infant with heart failure and congenital heart disease?

1. Activity Intolerance
2. Risk for Infection
3. Impaired Mobility
4. Ineffective Health Maintenance

Looking for answers(s):1
Explanation: RATIONALE: An infant with congenital heart disease and congestive heart failure usually tires easily, leading to a priority nursing diagnosis of Activity Intolerance. Nursing care needs to focus on allowing the infant to have frequent rest periods. Infants with congenital heart disease and congestive heart failure are not necessarily at risk for more infections than other infants. Impaired Mobility usually is not a problem because an infant with congenital heart disease usually exhibits normal physical mobility. Ineffective Health Maintenance usually is not a problem because these infants still need regular and routine health check-ups.

Question 3. When developing a plan of care that includes interventions aimed at preventing complications of a low platelet count in a child with leukemia, which of the following is most appropriate?

1. Consulting with a physician about the use of a stool softener
2. Placing the child in protective isolation
3. Using heparin instead of saline to flush an intermittent IV access device
4. Eliminating raw vegetables and fruits from the child's diet

Looking for answers(s):1
Explanation: RATIONALE: A stool softener would assist in preventing damage to the rectal mucosa due to hard stool, thereby decreasing the chances of rectal bleeding. Placing the child in protective isolation would be appropriate for the child if the neutrophil count was low. The use of heparin is contraindicated in situations in which there is a possibility of increased bleeding due to low platelets. Avoiding raw vegetables or fruits would be indicated if the child's neutrophil count were low.

Question 4. The nurse teaches the parent about the normal reaction that an infant may experience 12 to 24 hours after DTaP immunization. The nurse determines that the teaching is effective when the parent asks which of the following?

1. "Will the lethargy make it harder to breast-feed?"
2. "How much acetaminophen (Tylenol) can I give for the fever?"
3. "Can you give loperamide (Imodium) to an infant?"
4. "What kind of nose spray can I use for the baby's congestion?"

Looking for answers(s):2
Explanation: RATIONALE: Mild fever is common in an infant at 12 to 24 hours after administration of a DTaP vaccine. The mother should be taught to give the infant acetaminophen for the fever. Temperature above 102 degrees F (measured rectally) should be reported to the physician. After DTaP immunization, a mild fever is common. Typically an infant with a fever is restless rather than lethargic. Diarrhea (for which loperamide [Imodium] is given in adults, not infants) is not associated with administration of the DTaP vaccine. Nasal congestion is not associated with the DTaP vaccine.

Question 5. Which of the following would indicate effective therapy in a neonate born at 38 weeks gestation and given oxygen as a treatment for cold stress?

1. Heart rate is 200 bpm at rest
2. Respiratory rate is 48 breaths/minute at rest
3. Axillary temperature is 98 c
4. Blood pressure is 56/30 mm Hg

Looking for answers(s):3
Explanation: RATIONALE: Oxygen is given to a neonate experiencing cold stress to support an increase in the metabolic rate through a complex process of increasing metabolism. Axillary temperature readings are used because the initial response to cold stress is vasoconstriction, resulting in a decreased skin temperature. A heart rate of 200 bpm is above the normal range for a neonate at rest, possibly reflecting the need for more oxygen at the cellular level. A respiratory rate of 48 breaths per minute is above the normal range for a neonate at rest, possibly reflecting the need for more oxygen at the cellular level. A blood pressure reading of 56/30 mm Hg is normal for a neonate at 38 weeks' gestation. Thus, it is not a reliable indicator of effective therapy.

Question 6. After uncomplicated abdominal surgery, which of the following would be most appropriate when determining if an alert school-aged child is ready to drink oral fluids?

1. Ask if the child wants something to drink
2. Auscultate the child's abdomen for bowel sounds
3. Determine that the child has a gag reflex
4. Palpate the epigastric area for discomfort

Looking for answers(s):2
Explanation: RATIONALE: After uncomplicated abdominal surgery, fluid intake is resumed early in the postoperative period. However, before fluids are given, the nurse needs to auscultate the child's abdomen for bowel sounds indicating the return of peristalsis and a functioning gastrointestinal tract. Fluids are withheld until bowel sounds are heard. Asking the child if he or she wants something to drink is inappropriate because medications used before and during surgery may cause thirst. Additionally, the child's degree of thirst is not an indicator for peristalsis. Determining if a gag reflex is present would be more appropriate for the child having undergone upper gastrointestinal procedures such as gastroscopy. Having a gag reflex is usually not a concern in a child who is alert and has had uncomplicated abdominal surgery. Palpating the epigastric area or abdomen for discomfort provides no information about the function of the gastrointestinal tract. Complaints of pain are likely because the client has had abdominal surgery.

Question 7. A young child who has undergone a tonsillectomy refuses to let the nurse look at the tonsillar beds to check for bleeding. To assess whether the child is bleeding from the tonsillar beds, which of the following would be most appropriate?

1. Assess capillary refill
2. Force open the mouth with a tongue blade
3. Monitor for decreased blood pressure
4. Observe for frequent swallowing

Looking for answers(s):4
Explanation: RATIONALE: By observing for frequent swallowing, the nurse can evaluate whether the child is bleeding because blood will go down the back of the throat causing the child to swallow frequently. Decreased peripheral perfusion as evidenced by assessing capillary refill may be a sign of blood loss. In children, however, it is a late sign. Forcing the mouth open with a tongue blade can result in broken teeth, tissue damage, and psychological damage. Although a drop in blood pressure is a sign of blood loss, in children it occurs late.

Question 8. Which of the following interventions would be included in the plan of care for the child with juvenile rheumatoid arthritis to reduce joint pain in the morning just after arising?

1. Having the child sleep in a sleeping bag
2. Increasing pain medication at bedtime
3. Having the child sleep with the joints flexed
4. Awakening the child once nightly to exercise the joints

Looking for answers(s):1
Explanation: RATIONALE: Sleeping in a sleeping bag keeps the joints warm, therefore more flexible. Thus, joint pain in the morning would be lessened. Increasing bedtime pain medications may help the child sleep but will not decrease early morning stiffness. The child's joints should be kept in an extended position during sleep to maintain function. Lack of sleep, such as from awakening the child at night for exercises, is a stressor that can lead to exacerbation of juvenile rheumatoid arthritis.

Question 9. A mother brings her 18-month-old child to the clinic because the child "eats ashes, crayons, and paper." Which of the following information would be most important to obtain first about this toddler?

1. Currently cutting large teeth
2. Experiencing a growth spurt
3. Experiencing changes in the home environment
4. Eating a soft, low-roughage diet

Looking for answers(s):3
Explanation: RATIONALE: It is important to determine if the child is experiencing any change in the home environment that could cause anxiety that is relieved through oral gratification. A craving to eat nonfood substances is known as pica. Nutritional deficiencies, especially iron deficiency, were once thought to cause pica but research has not substantiated this theory. The child is demonstrating a craving to eat nonfood substances, known as pica. The cutting of large teeth is an unlikely cause of pica. The child is demonstrating a craving to eat nonfood substances, known as pica. Growth spurts are considered to be an unlikely cause of pica. The child is demonstrating a craving to eat nonfood substances, known as pica. Eating a low-roughage diet is considered to be an unlikely cause of pica.

Question 10. While examining a 12-month-old child, the nurse notes that the child can stand independently but cannot walk without support. Which of the following actions would be most appropriate?

1. Ask the mother if the child uses a walker at home
2. Do nothing because this is a normal finding in a child this age
3. Initiate a consultation with a developmental specialist
4. Tell the mother that the child may have a developmental delay

Looking for answers(s):2
Explanation: RATIONALE: A child aged 12 months is expected to cruise but not necessarily walk without support. Using or not using a walker at home does not significantly affect independent walking. A developmental specialist consult is not necessary. Even if the child's development in walking is slow, this fact is not sufficient data to make the nurse suspect developmental delay. Even if the child's development in walking is slow, this fact is not sufficient data to make the nurse suspect developmental delay.

Question 11. Which of the following laboratory values would the nurse interpret as associated with cold stress in a 1-day-old preterm neonate?

1. Bilirubin level of 13 mg/dL
2. Glucose level of 15 mg/dL
3. Hematocrit of 65%
4. Hemoglobin level of 23.5 g/dL

Looking for answers(s):2
Explanation: RATIONALE: A common finding in neonates with cold stress is low serum glucose level. The normal range for this infant is 20 to 60 mg/dL. Thus, a level of 15 mg/dL suggests hypoglycemia. Bilirubin levels typically do not exceed 5 mg/dL. At 13 mg/dL, the infant would be jaundiced owing to hyperbilirubinemia. A hematocrit of 65% suggests polycythemia, not cold stress. Normally, hemoglobin is below 22 g/dL. A hemoglobin level of 23.5 mg/dL is associated with polycythemia, not cold stress.

Question 12. An 18-month-old child with acquired immunodeficiency syndrome (AIDS) is seen in the clinic for health maintenance. Which of the following vaccines would the nurse anticipate administering to this toddler?

1. Diphtheria-tetanus-acellular pertussis
2. Varicella
3. Measles, mumps, and rubella
4. Hemophilus influenza

Looking for answers(s):1
Explanation: RATIONALE: Diphtheria, acellular pertussis, and tetanus are killed vaccines and may be given to this toddler. Live virus vaccines are not routinely administered to anyone with an altered immune system because multiplication of the virus may be enhanced, causing a severe vaccine-induced illness. Varicella virus vaccine is a live virus vaccine and is not routinely administered to anyone with an altered immune system because multiplication of the virus may be enhanced, causing a severe vaccine-induced illness Measles, mumps, and rubella are live virus vaccines and are not routinely administered to anyone with an altered immune system because multiplication of the virus may be enhanced, causing a severe vaccine-induced illness. Hemophilus influenza vaccine is a live virus vaccine and is not routinely administered to anyone with an altered immune system because multiplication of the virus may be enhanced, causing a severe, vaccine-induced illness

Question 13. A 2-month-old child returns from a cardiac catheterization. The child's fontanel is flat. The diaper is dry. The respiratory rate is 20 breaths/minute and breath sounds are decreased bilaterally. The child is limp although she moves all extremities when stimulated. The dressing over the insertion site is intact, clean, and dry. The pedal pulses are palpable bilaterally and equal to the heart rate. Which of the following nursing diagnoses would be most appropriate?

1. Ineffective Tissue Perfusion related to thrombus formation
2. Deficit Fluid Volume related to inability to take in fluids
3. Risk for Injury related to disruption of vessel integrity
4. Ineffective Breathing Pattern related to sedation

Looking for answers(s):4
Explanation: RATIONALE: The defining characteristics of Ineffective Breathing Pattern include a decrease in respiratory rate and chest expansion, limpness or unresponsiveness, and changes in mental status. In this situation, sedation used during the catheterization is the most probable cause of the Ineffective Breathing Pattern. Because the child's pedal pulses are palpable, Ineffective Tissue Perfusion from a thrombus is unlikely. Because fluids are administered during the procedure, Deficit Fluid Volume is unlikely. A disruption in vessel integrity would lead to bleeding at the site and circulatory or neurologic deficit in the affected leg. The child's dressing is dry and intact and the child is able to move all extremities so Risk for Injury is an inappropriate nursing diagnosis.

Question 14. Which of the following would the nurse most likely assess in a child who has sustained full-thickness burns?

1. Blanching to the touch
2. Excessive bleeding
3. Minimal complaints of pain
4. Blistering, moist appearance

Looking for answers(s):3
Explanation: RATIONALE: Full-thickness burns are serious injuries in which all the skin layers are destroyed. Lack of pain is characteristic of full-thickness burns. With full-thickness burns, blanching and bleeding are absent because blood supply is destroyed. With full-thickness burns, blanching and bleeding are absent because blood supply is destroyed. Blisters and moist appearance characterize partial-thickness burns.

Question 15. Which of the following would be the priority nursing diagnosis for a 4-week-old infant with a diagnosis of pyloric stenosis?

1. Constipation
2. Deficient Fluid Volume
3. Imbalanced Nutrition, less than body requirements
4. Impaired Swallowing

Looking for answers(s):2
Explanation: RATIONALE: Infants with pyloric stenosis generally have a history of spitting up, which progresses to projectile vomiting, weight loss, decrease in number of stools, and some degree of dehydration. Infants with dehydration need fluid and electrolyte replacement before surgery. A decrease in the number of stools, not constipation, is associated with pyloric stenosis. Although the infant's nutrition may be affected, a fluid volume deficit is the priority. Infants have a greater percentage of water per body weight and are at high risk for fluid imbalances. Pyloric stenosis is not associated with difficulty in swallowing.

Question 16. Immediately after the return of an 18-month-old child to his room following insertion of a ventriculoperitoneal shunt, which of the following would the nurse do first?

1. Ask the child to state his name and where he is
2. Palpate his anterior fontanel
3. Position him on the side opposite the shunt site
4. Check his pupil size and reactivity to light

Looking for answers(s):3
Explanation: RATIONALE: As soon as the child returns to his room, he needs to be positioned appropriately, in this case on the side opposite the shunt placement to avoid pressure on the operative site. Developmentally, the child at this age may or may not be able to state his name or where he is. Palpating his fontanel and checking pupils are part of the neurologic assessment that would be done once the child is positioned properly. Checking the child's pupils is part of the neurologic assessment that would be done once the child is positioned properly.

Question 17. When performing a physical assessment on an 18-month-old child, which of the following would be best?

1. Have the mother hold the toddler on her lap
2. Assess the respiratory and cardiac systems first
3. Carry out the assessment from head to toe
4. Assess motor function by having the child run and walk

Looking for answers(s):1
Explanation: RATIONALE: The best strategy for assessing a toddler is to have the parent hold the toddler. Doing so is comforting to the toddler. Assessment should begin with noninvasive assessments first while the child is quiet. Typically these include assessments of the cardiac and respiratory systems. The ears and throat are often examined last. Using a head-to-toe approach is more appropriate for an older child. For a toddler, assessment should begin with noninvasive assessments first while the child is quiet. Having a toddler run and be active may make it difficult to settle the child down after the physical exertion.

Question 18. At 3 AM, the mother of a 3-year-old child calls the emergency room nurse and reports the child has a temperature of 101.1 degreess f, a runny nose, and a barky cough that "gets going and won't stop." The mother states that she just gave the child acetaminophen (Tylenol). Which of the following should the nurse recommend next?

1. Sitting with the child in a steamy warm bathroom
2. Running a steam vaporizer near the child's bedside
3. Giving the child an over-the-counter decongestant
4. Administering aspirin in 2 hours

Looking for answers(s):1
Explanation: RATIONALE: Based on the mother's description, the child most likely is exhibiting signs and symptoms of laryngotracheal bronchitis. The mother should try to decrease the inflammation in the upper airway by exposing her child to a warm, steamy environment. The safest method is to steam up the bathroom and stay with the child. Steam vaporizers work by boiling water. Their use is to be avoided because they can cause severe burns if the child comes in close contact with the steam or if the vaporizer spills. A decongestant may assist in decreasing the rhinorrhea (runny nose) but it will not decrease the inflammation in the upper airway. Laryngotracheal bronchitis is caused by a virus. Aspirin is contraindicated in children with viral infections because this combination is implicated in Reye's syndrome.

Question 19. When developing a seminar on injury prevention to be presented to a group of parents of children from 2 to 18 years, the nurse would place the first priority on discussing the use of which of the following?

1. Child restraints in automobiles
2. Helmets for biking and skating
3. Special locks for cabinets
4. Topical bug repellent in summer

Looking for answers(s):1
Explanation: RATIONALE: Motor vehicle injuries are the leading cause of death in children older than 1 year of age. Most fatalities are related to nonuse of child restraints and seat belts. Although using helmets for biking and skating safety is important, it is not the priority. Special locks for cabinets are important in the prevention of poisoning, but this is not the priority. Topical bug repellant in summer is important for the prevention of Lyme disease. However, this is not the priority.

Question 20. The mother of a 9-month-old infant asks about adding new foods to his diet. The child is being breast-fed and takes formula and cereal when at the sitter's. Which of the following would the nurse instruct the mother to do?

1. Mix new foods with formula or breast milk
2. Mix new foods with more familiar foods
3. Offer new foods one at a time
4. Offer new foods after giving formula or breast milk

Looking for answers(s):3
Explanation: RATIONALE: Infants should be offered new foods one at a time. This gives the infant the chance to become gradually familiar with a variety of food tastes and textures and also helps identify any allergies or adverse reactions to a specific food. Mixing new foods with formula, breast milk, or other familiar foods would make it impossible to satisfactorily detect allergic or other unfavorable reactions. Mixing new foods with formula, breast milk, or other familiar foods would make it impossible to satisfactorily detect allergic or other unfavorable reactions. This practice may also cause the infant to refuse familiar foods. If a new food is offered after the infant's appetite is satisfied with formula or breast milk, the infant is not likely to eat the new food.

Question 21. After the nurse instructs the parents of a 5-month-old infant about the purpose of the Denver Developmental Screening Test (DDST), which of the following statements by the parents about what the test measures would indicate that the teaching was effective?

1. Intelligence quotient
2. Emotional development
3. Social and physical abilities
4. Potential for future development

Looking for answers(s):3
Explanation: RATIONALE: The Denver Developmental Screening Test (DDST) measures a child's social, language, and fine and gross motor skills by testing abilities that usually occur at a given age. The DDST is not designed to measure intelligence or emotional development nor does it necessarily predict future development. The DDST is not designed to measure intelligence or emotional development nor does it necessarily predict future development. The DDST is not designed to measure intelligence or emotional development nor does it necessarily predict future development.

Question 22. Which of the following would lead the nurse to suspect that a neonate with an infection is developing septic shock?

1. Axillary temperature is 99.8 c
2. Blood pressure is 45/25 mm Hg
3. Heart rate during sleep is 205 bpm
4. Respiratory rate while awake is 32 breaths/minute

Looking for answers(s):3
Explanation: RATIONALE: A sleeping heart rate of 205 bpm is above the normal 200 bpm for this age. Increased heart rate is an early indication of ensuing septic shock. Although the temperature is slightly elevated, it is not an indication of shock. A low axillary temperature may indicate the peripheral blood supply shutdown that occurs early in shock. A blood pressure of 45/25 mm Hg is normal for a neonate. The neonate's respiratory rate is within normal limits for age.

Question 23. The mother says that the infant's physician recommends certain foods, but the infant refuses to eat them after breast-feeding. The nurse should suggest that the mother alter the feeding plan by doing which of the following?

1. Offering dessert followed by some vegetables and meat
2. Offering breast milk as long as the infant refuses to eat solid foods
3. Mixing pureed food with some breast milk in a bottle with a large-holed nipple
4. Allowing the infant to nurse for a few minutes then offering solid foods

Looking for answers(s):4
Explanation: RATIONALE: It is typical for an infant just starting on solid foods to spit them out because the infant does not know how to swallow them. Also, the infant is hungry and is accustomed to having milk to satisfy that hunger. It is generally recommended that an infant be given some milk first then offered solid foods. Offering dessert followed by vegetables and meat is inappropriate because the infant will learn to prefer the sweets first, possibly refusing intake of the vegetables and meats. Offering breast milk as long as the infant refuses solid foods is inappropriate because an infant who takes all the milk first will have no interest in the solids. Mixing pureed foods with cow's or breast milk is inappropriate because solid food should be given by a spoon. Also, using a large-holed nipple may cause the infant to choke from getting too much fluid at one time.

Question 24. The parents express concern about the condition of their premature neonate. To meet the short-term goals of decreasing the parents' fears and fostering bonding, which of the following would the nurse include in the plan of care?

1. Allowing the parents to see and touch their neonate
2. Arranging for a visit with another couple who have an ill preterm neonate
3. Encouraging the parents to participate in the neonate's care
4. Telling the parents not to worry because the neonate is doing well

Looking for answers(s):1
Explanation: RATIONALE: Permitting the parents to see and touch the neonate allows for visual searching and information gathering, one of the first steps in the bonding process. Fingertip touching also helps promote the bonding process. Seeing and touching the neonate can often help the parents feel less concerned and more comfortable. The nurse should be present to help the parents understand therapeutic measures being used for the neonate. Although support from others is important, arranging for a visit and meeting with parents of another ill neonate may only increase the parents' concerns. Although parents are generally encouraged to care for their ill children, a high-risk neonate's care involves special skills that the parents may lack. A long-term nursing goal would be to instruct the parents in such care. Telling the parents not to worry ignores their feelings and tends to cut off communication.

Question 25. After resuming feedings in an infant who has undergone a pyloroplasty, which of the following would be most appropriate?

1. Keeping the head of the bed flat with the infant lying supine
2. Offering several ounces of an oral electrolyte solution initially
3. Placing the infant in a prone position after each feeding
4. Starting feedings with 5 to 10 mL, slowly increasing amounts as tolerated

Looking for answers(s):4
Explanation: RATIONALE: The child who has undergone pyloroplasty often vomits after the first feeding because peristalsis that has been in the right-to-left direction before repair has not reverted to the normal left-to-right direction. Peristalsis reverses as a result of the tightening of the pyloric sphincter, thus not allowing stomach contents to enter the small intestine. Therefore, small feedings of 5 to 10 mL are given and slowly increased as tolerated. Because there is a chance of vomiting, it is not advisable to place an infant supine with the head of the bed flat. If the infant does vomit, aspiration of stomach contents may occur, and pneumonia may result. Small feedings of 5 to 10 mL are given initially and then slowly increased as tolerated. The use of oral electrolyte solutions is unnecessary. The child will have an abdominal incision, so a prone position would be uncomfortable.

Question 26. After teaching the parents of a 15-month-old child who has undergone cleft palate repair how to use elbow restraints, which of the following statements by the parents indicates effective teaching?

1. "We'll keep the restraints in place continuously until the doctor says it's okay to remove them."
2. "We can take off the restraints while our child is playing but we'll make sure to put them back on at night."
3. "The restraints should be taped directly to our child's arms so that they will stay in one place."
4. "We'll remove the restraints temporarily at least three times a day to check his skin then put them right back on."

Looking for answers(s):4
Explanation: RATIONALE: Elbow restraints help to keep the child from placing fingers or any other object in the mouth that would cause injury to the operative site. The restraints are worn at all times except when they are removed to check the skin. Because of the risk for skin breakdown, the restraints are removed periodically during the day to assess the child's underlying skin. It is advisable to remove only one restraint at a time while keeping hold of the child's hand on the unrestrained side. Toddlers are quick and usually want to explore the area in the mouth that the surgery has made feel different. The restraints should be in place at all times during sleep and play to prevent inadvertent injury to the operative site. Toddlers are quick and usually want to explore the area in the mouth that the surgery has made feel different. Taping the restraints directly to the skin is not advised because skin breakdown can occur when tape is reapplied to the same area over several weeks. The restraints can be fastened to clothing to keep them from slipping.

Question 27. Which of the following methods for checking placement of a gavage feeding catheter would be most appropriate after introducing the catheter into the neonate's stomach?

1. Aspirating stomach contents through the catheter with a syringe
2. Auscultating clear breath sounds after instilling a small amount of air into the catheter
3. Aspirating water back into a syringe after introducing it into the catheter
4. Flushing the catheter with a small amount of water

Looking for answers(s):1
Explanation: RATIONALE: The method most often recommended to determine whether or not the gavage catheter is in the stomach is to aspirate stomach contents with a syringe. The presence of stomach contents indicates that the catheter is in the stomach. Any stomach contents obtained should be reintroduced into the stomach to prevent loss of electrolytes. Water introduced into the catheter before placement is confirmed may end up in the lungs. Air introduced into the catheter can be auscultated as a "whoosh" in the stomach area, not as clear breath sounds. No water should be used to confirm placement because water introduced into the catheter before placement is confirmed may end up in the lungs. No water should be used to confirm placement because water introduced into the catheter before placement is confirmed may end up in the lungs.

Question 28. On observing a parent propping a bottle for a 2-month-old child in the waiting room, the nurse explains the dangers of this to the parent. Which of the following statements indicates that the parent has understood the nurse's teaching?

1. "I didn't know it would cause my baby to gain too much weight."
2. "I can see how it might cause choking, but how does it cause dental caries?"
3. "So, because I prop the bottle, I might have trouble weaning the child?"
4. "I will stop propping the bottle so my child will sleep through the night."

Looking for answers(s):2
Explanation: RATIONALE: Many mothers prop a bottle of formula or fruit juice for their infants at bedtime. The infant then awakens periodically to take more formula or juice, constantly bathing the teeth with high-carbohydrate liquid that predisposes the infant to dental caries. Choking is also a risk because of the fluids dripping from the hole in the nipple if the child falls asleep while the nipple is still in the mouth. Propping a bottle does not necessarily lead to obesity, abnormally prolonged use of a bottle, or nighttime feedings. Propping a bottle does not necessarily lead to obesity, abnormally prolonged use of a bottle, or nighttime feedings. Propping a bottle does not necessarily lead to obesity, abnormally prolonged use of a bottle, or nighttime feedings.

Question 29. A preschool client immobilized in a spica cast complains of having trouble breathing after meals. Which of the following actions would be best?

1. Encourage the client to drink more between meals
2. Teach the child pursed-lip breathing
3. Give the client a laxative after meals
4. Offer the client small feedings several times a day

Looking for answers(s):4
Explanation: RATIONALE: A hip spica cast extends up over the abdomen. Because the abdomen is in a fixed space, abdominal distention secondary to eating pushes the abdominal contents against the diaphragm resulting in decreased chest expansion and subsequent possible respiratory distress. Because the client's complaints are associated with meals, offering small frequent meals provides nutritional support while minimizing distention. Encouraging increased drinking would increase the abdominal distention thus increasing the child's respiratory distress. With a hip spica cast, the child's complaints are due to decreased chest expansion from the abdomen pushing up against the diaphragm. Pursed lip breathing would be effective in preventing air trapping not decreased chest expansion. With a hip spica cast, the child's complaints are due to decreased chest expansion from the abdomen pushing up against the diaphragm. Administering a laxative with meals would be ineffective in relieving the decreased chest expansion.

Question 30. When determining the effectiveness of teaching a child's mother about sickle cell disease, which of the following statements by the mother indicates the need for additional teaching?

1. "I've started to give him some extra fluids with and between meals."
2. "I'm concerned about how the hospital staff will manage his pain."
3. "He's going to be playing on a soccer team when he's feeling better."
4. "I've told the child's father that both he and I are carriers of the disease."

Looking for answers(s):3
Explanation: RATIONALE: Physical and emotional stress can precipitate a sickle cell crisis. Physical exercise such as running involved in soccer would increase the child's risk for a crisis. Thus, the mother needs additional instructions about this area. Providing extra fluids with and in between meals is appropriate because it is important for the child with sickle cell disease to keep well-hydrated. In addition, these children often have nephrosis related to sickle cell disease and have difficulty conserving fluids. Therefore, they need up to 150% of normal fluid intake. Pain control is an issue in sickle cell crisis. The mother is showing concern for her child by asking how pain will be managed. Sickle cell disease is an autosomal recessive disease. For the child to have the disease, both parents must carry the recessive gene.

Question 31. After the nurse has taught the parents of a 5-year-old boy who has leukemia how to talk with their child about death and dying, which of the following would indicate that the parents have age-appropriate expectations about their child's reaction to his impending death?

1. "He is too young to understand what is happening to him."
2. "He might think he can cause his death because he has misbehaved."
3. "He will accept his death as caused by his disease."
4. "He will understand how much his siblings will miss him."

Looking for answers(s):2
Explanation: RATIONALE: A 5-year-old child is in the preoperational stage of cognitive development and thinks of death as temporary. Also, for a child this age, thinking about behavior often is believed to be magical; thus, the child may think that his behavior can cause death. Generally, children under 3 years of age are unable to differentiate death from temporary separation and are unable to understand what is happening. Logical thinking, evidenced by accepting death due to his disease, would occur during Piaget's stage of concrete operations between ages 6 and 12 years. Although a 5-year-old child will be able to understand that he will be missed, he lacks the cognitive development to understand the extent of how much his siblings will miss him.

Question 32. When preparing to conduct prenatal and parenting classes for a group of parents, the clinic's nursing staff will be providing childcare for the parents' children who range in age from 13 months to 6 years. The clinic has a playroom. Which of the following activities would be most appropriate to include?

1. Free play with adult supervision
2. A group sing-along
3. Drawing and painting projects
4. Viewing cartoon videos

Looking for answers(s):1
Explanation: RATIONALE: Planning any single activity that will appeal to children from ages 13 months to 6 years is next to impossible because of the developmental differences found in such a wide age group. It would be best to allow these children to participate in free play with adult supervision. A group sing-along would be appropriate for preschoolers and school-aged children. However, toddlers have short attention spans and would most likely find it difficult to participate in a group activity, such as a sing-along, for long. Although drawing and painting projects would be appropriate for preschoolers and school-aged children, toddlers have a tendency to put objects into their mouths. Therefore, drawing and painting projects would be inappropriate for this age group. Viewing cartoon videos would be inappropriate for young toddlers, who typically have short attention spans. Additionally, young toddlers may not understand the videos.

Question 33. When completing an assessment of a healthy adolescent client, which of the following would be most appropriate?

1. Obtain a detailed account of the adolescent's prenatal and early developmental history
2. Discuss sexual preferences and behaviors with the parents present for legal reasons
3. Discuss the client's smoking with parents present in the room
4. Assess the adolescent in private; gather additional information from the parents

Looking for answers(s):4
Explanation: RATIONALE: When assessing an adolescent, it is appropriate to first obtain information from the adolescent in private then interview the parents for additional information. Doing so helps to promote independence and responsibility for self-care. Obtaining prenatal and early developmental history information is usually not important for a healthy adolescent. In addition, this information typically would have already been obtained at an earlier age. No legal reason would prohibit the nurse from discussing sexuality with the adolescent without the parents present. Discussing smoking with the parents present in the room is inappropriate. If the adolescent smokes, the parents may be unaware and the adolescent would lose trust in the nurse. When assessing an adolescent, it is appropriate to first obtain information from the adolescent in private then interview the parents for additional information. Doing so helps to promote independence and responsibility for self care.

Question 34. When discussing a 7-month-old infant's motor skill development with the mother, the nurse should explain that by age 7 months, an infant most likely will be able to do which of the following?

1. Walk with one hand held
2. Eat successfully with a spoon
3. Stand while holding onto furniture
4. Sit alone using the hands for support

Looking for answers(s):4
Explanation: RATIONALE: By age 6 months, an infant can sit alone, leaning forward on the hands for support. The ability to sit follows progressive head control and straightening of the back. By 12 months, an infant can walk with one hand held. At about 18 months, an infant can eat successfully with a spoon. At 11 months, an infant can stand and walk while holding onto furniture.

Question 35. When planning a screening clinic for scoliosis, the nurse would anticipate targeting which of the following groups?

1. Preadolescents at the beginning of a growth spurt
2. Toddlers who have diets low in calcium and vitamin D
3. Preschoolers who are entering kindergarten
4. Infants whose mothers have had no prenatal care

Looking for answers(s):1
Explanation: RATIONALE: Preadolescents are at greatest risk for scoliosis because of the growth associated with this age group. Incidence is higher in girls than boys and increases during periods of rapid growth.

A toddler with a diet low in vitamin D and calcium is prone to develop rickets.

The risk for scoliosis is greatest during adolescence, not for preschoolers. However, prior to entering school, preschoolers are required to have their immunizations up-to-date.

No relationship exists between poor prenatal care and scoliosis.

Question 36. When assessing a 6-month-old child with a large ventricular septal defect, the nurse notices that the child has gained 5 pounds in 1 month. The mother reports that the child has not been wetting many diapers in the last week, although the child is taking the prescribed amounts of formula. "I think it is because he seems to sweat so much." Auscultation of the lung fields reveals fine crackles in the bases. The child's digoxin level is 1 mg/mL. Which of the following nursing diagnoses would be most appropriate?

1. Imbalanced Nutrition: More Than Body Requirements
2. Excess Fluid Volume
3. Risk for Injury
4. Urinary Retention

Looking for answers(s):2
Explanation: RATIONALE: The child is exhibiting characteristics of fluid volume excess related to heart failure. These include decreased output, diaphoresis, weight gain, and crackles. The heart failure is related to left to right shunting that occurs when the child has a large ventral septal defect. No evidence is presented to indicate that altered nutrition is the problem. In fact the mother reports that the child is taking the prescribed amounts of formula. The weight gain is due to the fluid overload. The child's digoxin level is within normal limits. Additionally, there is no evidence to suggest any risk for injury. Although the child's output is decreased, the weight gain is related to fluid overload systemically, not urinary retention.

Question 37. Assessment of a child with rheumatic fever reveals chorea. Which of the following would the nurse consider to be most important?

1. Explain to the child and family that the chorea will disappear over time
2. Institute measures to keep the child in a warm environment
3. Perform neurologic checks every 4 hours until the chorea subsides
4. Promote ambulation by giving aspirin every 4 hours

Looking for answers(s):1
Explanation: RATIONALE: Because the clumsiness and uncontrolled actions can be upsetting to both the child and family, they need to understand that chorea associated with rheumatic fever is not permanent. Measures to keep the child in a warm environment are unnecessary because the child's cardiac workload will increase as the child attempts to remain cool. Neurologic assessments every 4 hours are not necessary because chorea is self-limiting and nonprogressive. Because the child has cardiac involvement, ambulation is contraindicated to minimize the increased oxygen demands on the heart. Aspirin is used primarily as an anti-inflammatory drug and secondarily for pain relief.

Question 38. The mother of a 15-month-old child who is coughing and having trouble breathing telephones the clinic to ask advice because she suspects that her child has croup. Which of the following instructions would be most appropriate?

1. Administer acetaminophen (Tylenol) every 4 hours
2. Take the child into the bathroom and run the hot water
3. Give over-the-counter cough syrup every 6 hours
4. Get the child to take as much fluid as possible

Looking for answers(s):2
Explanation: RATIONALE: For the child with croup who is coughing and having difficulty breathing, the child should be taken into the shower where hot water is running to make the bathroom steamy. Steam helps to loosen secretion and relieve some of the respiratory distress. Giving acetaminophen is helpful but will not ease difficult breathing. Giving over-the-counter cough syrup is inappropriate because the underlying problem is airway inflammation and subsequent mucus accumulation and bronchoconstriction. Getting the child to take as much fluid as possible is important but it will not be effective in easing difficult breathing.

Question 39. The mother of an infant with a congenital heart defect involving decreased pulmonary blood flow tells the nurse that her child has not been gaining weight even with an increased-calorie formula. The mother states that the infant starts out with a good suck but tires and quits after 2 ounces. The infant is receiving oxygen through a nasal cannula as necessary and is on digoxin therapy. Which of the following should the nurse suggest to the mother?

1. Cut a large hole in the nipple
2. Feed the infant every 2 hours
3. Have the infant tested for digoxin toxicity
4. Increase the oxygen for feedings

Looking for answers(s):4
Explanation: RATIONALE: All children use energy to ingest and digest nutrients. The body needs oxygen to use the calories taken in to provide energy. Usually the caloric intake outweighs the energy needed to obtain the nutrients. A child with a congenital heart defect involving decreased pulmonary blood flow that circulates unoxygenated blood to the tissues may need extra oxygen support during times of high energy consumption such as feeding. Without this extra support, the child may become tired. If the child's suck is good, then enlarging the hole in the nipple will give the child too much volume with each suck and may cause the child to choke. Feeding the infant every 2 hours will tire the infant, possibly leading to the ingestion of fewer calories with the next feeding. Tiring during feedings is not a symptom of digoxin toxicity, although lack of appetite may be.
Question 40. The mother of an 8-year-old child with a fluid restriction of 1000 mL/day is staying with the child in the room. Which of the following would be most appropriate for the nurse to include in the child's plan of care?

1. Discussing the fluid restriction with the mother and child, allowing them to decide how to allocate the fluids over the 24 hours
2. Explaining to the mother that hospital personnel will assume the responsibility for providing fluids to the child.
3. Letting the child drink fluid until the limit is reached and then allowing the child to drink no more fluids
4. Telling the mother exactly how much fluid the child can have each hour, showing her examples of the amount

Looking for answers(s):1
Explanation: RATIONALE: Planning the child's fluid restriction with the mother and child is most appropriate because the mother and child would best know the child's usual pattern of fluid intake. Doing so also provides the mother with a feeling of some control over her child's situation and helps to promote compliance. Anyone, not just hospital personnel, can provide the child with fluids. However, a strict record of the child's intake must be kept to ensure adherence to the restriction. It is not advisable to allow a client on fluid restriction to drink all the allotted fluid at once. This may result in many thirsty hours for the client. The nurse also should remind the mother to count fluids used when the child takes any medications. Telling the mother exactly how much fluid the child can have each hour restricts the extent of the mother's and child's participation in care. Additionally, doing so ignores the child's usual needs, such as the usual pattern of fluid intake, possibly interfering with adherence to the fluid restriction.

Question 41. A mother asks the nurse when she should wean her 4-month-old infant from breast-feeding and begin using a cup. Which of the following would the nurse explain as the best indication of the infant's readiness to be weaned?

1. Taking solid foods well
2. Sleeping through the night
3. Shortening the nursing time
4. Eating on a regular schedule

Looking for answers(s):3
Explanation: RATIONALE: Readiness for weaning is an individual matter but is usually indicated when an infant begins to decrease the time spent nursing. The infant is then showing independence and will soon be ready to take a cup and learn a new skill. The infant ready for weaning may also demonstrate an ability to take solid foods well, sleep through the night, and eat on a regular schedule. These behaviors though are not necessarily the best evidence of readiness for weaning. The infant ready for weaning may also demonstrate an ability to take solid foods well, sleep through the night, and eat on a regular schedule. These behaviors though are not necessarily the best evidence of readiness for weaning. The infant ready for weaning may also demonstrate an ability to take solid foods well, sleep through the night, and eat on a regular schedule. These behaviors though are not necessarily the best evidence of readiness for weaning.

Question 42. A 10-day-old neonate brought to the clinic by the parents is lethargic and tachypneic with a heart rate of 200 bpm. Which of the following would be the nurse's primary focus initially?

1. Temperature pattern over the last few days
2. Number of wet diapers in the past 24 hours
3. Pupillary response now and 30 minutes later
4. Sleep patterns over the past week

Looking for answers(s):2
Explanation: RATIONALE: The neonate is exhibiting signs and symptoms of a possible infection that place her or him at risk for sepsis due to an immature immunologic response. In addition, a neonate's kidneys are immature so they cannot conserve water as necessary, making dehydration a rapid process in an ill neonate. Thus, the nurse's primary focus is to determine the neonate's hydration status by assessing the number of wet diapers in the past 24 hours. Sepsis can result in shock. Other important assessment data would include skin turgor, mucous membrane status, and status of the fontanel. (A sunken fontanel indicates dehydration.) A neonate with sepsis would exhibit a normal or lower than normal temperature. A neonate has an immature immune system and does not manifest signs and symptoms of illness as an older infant would. Pupillary response would be assessed if meningitis or another neurologic infection were suspected. When a neonate develops sepsis, sleep patterns change. Typically, the neonate sleeps more than usual and is commonly irritable when awake.

Question 43. The physician orders eye patching for a child with strabismus. Which of the following statements by the child's mother would indicate the need for additional teaching about this treatment?

1. "You see, his problem eye is patched."
2. "I keep the patch on even when he fusses."
3. "I have to watch him when he walks because he is clumsy."
4. "I take the patch off at night when he goes to bed."

Looking for answers(s):1
Explanation: RATIONALE: When an eye patch is used to correct strabismus, the normal eye is patched. That forces the child to use the abnormal, or "lazy," eye, thereby increasing that eye's muscle strength. Keeping the patch on during the child's waking hours, even when he's irritable or fussy, is appropriate to ensure effective treatment. Patching one eye interferes with depth perception and can cause the child to be clumsy at first. The patch can be removed at night while the child sleeps.

Question 44. A mother of an ill child is concerned because the child "isn't eating well." Which of the following strategies devised by the mother to help increase the child's intake should the nurse advise against using?

1. Allowing the child to choose his meals from an acceptable list of foods
2. Letting the child substitute items on his tray for other nutritious foods
3. Asking the child to say why he is not eating
4. Telling the child he must eat or else he will not get better

Looking for answers(s):4
Explanation: RATIONALE: Although nutrition plays a large part in the healing process, it is not advisable to tell a child that he will not get better if he does or does not do a particular activity. Not only is this dishonest, it also makes the child believe that his own actions are causing the illness. Allowing children choices often helps them feel in control. They also will be more likely to eat foods they have chosen. Letting the child substitute items on his tray for other nutritious foods is another way to allow the child to make choices, thus helping him to feel in control. It is important to find out the reason the child is not eating. Clients refuse to eat for multiple reasons, and interventions should be devised taking into consideration the reason for the child's refusal.

Question 45. Initial nursing interventions for a child admitted to the hospital with a diagnosis of meningitis due to H. influenzae should include which of the following?

1. Keeping the child well hydrated
2. Maintaining a quiet, cool environment
3. Keeping the child positioned flat in the bed
4. Placing the child on airborne precautions

Looking for answers(s):2
Explanation: RATIONALE: The child with meningitis should be kept in a quiet, cool environment to minimize stimulation, thus helping to decrease intracranial pressure. The child's hydration status requires a careful balance. Any fluid deficit should be corrected. Then the child should be kept on low fluid maintenance to prevent cerebral edema. To decrease intracranial pressure and facilitate venous return, the child should be positioned with the head of the bed elevated and the head midline. A child with meningitis does not need to be placed on airborne precautions. Rather, the treatment is droplet precautions because meningitis caused by H. influenzae is transmitted via contact with the conjunctivae or mucous membranes of the nose or mouth of a susceptible person via sneezing, coughing, or talking.

Question 46. A 23-month-old child pulled a pan of hot water off the stove and spilled it onto her chest and arms. Her mother was right there when it happened. Which of the following should the mother have done immediately?

1. Apply ice directly to the burned areas
2. Place the child in the bathtub of cool water
3. Apply antibiotic ointment to the burned areas
4. Call the neighbor to come over and help her

Looking for answers(s):2
Explanation: RATIONALE: The emergency treatment of both minor and major burns includes stopping the burning process by immersing the burned area in cool, but not cold, water. Thus, the mother should place the child in a bathtub of cool water. Applying ice directly to the burned area is inappropriate at this time because more tissue damage can result. Antibiotic ointment should not be applied to the burned area at this time because the burning process must be stopped first. Calling a neighbor for help is appropriate after she has placed then removed her child from the bathtub.

Question 47. Parents ask for advice about handling their 2-year-old's negativism. Which of the following would be the best recommendation?

1. Ignore this behavior because it is a stage the child is going through
2. Set realistic limits for the child, then be sure to stick to them
3. Encourage the grandmother to visit frequently to relieve them
4. Punish the child for misbehaving or violating set, strict limits

Looking for answers(s):2
Explanation: RATIONALE: A characteristic of 2-year-olds is negativism, a response to their developing autonomy. Setting realistic limits is important so that the toddler learns what behavior is and is not acceptable. Ignoring the behavior may lead the child to believe that there are no limits. As a result, the child does not learn appropriate behavior. Having the grandmother visit will give the parents a break, but setting limits is more important to the child's development. Limits need to be realistic to ensure that the child learns appropriate behavior. Limits that are too strict are inappropriate, interfering with learning appropriate behavior.

Question 48. When preparing to give a neonate the first feeding by nipple, for which of the following reasons would the nurse anticipate using a 5 mL feeding of sterile water first?

1. Ascertain the patency of the neonate's esophagus
2. Determine if the neonate can retain the feeding
3. Ensure that the neonate has the energy to take oral feedings
4. Ensure that the mother will be able to feed the neonate

Looking for answers(s):1
Explanation: RATIONALE: Small amounts of sterile water are given to a neonate first to ascertain if the esophagus is patent and to prevent the aspiration of formula if it is not. Assessment of the neonate's ability to retain feedings requires additional time and collection of additional information. Determining if the neonate has the energy to take oral feedings requires additional assessment time and data. More information about the mother is needed. For example, the nurse should watch the mother actually feeding the neonate to determine her ability.

Question 49. Which of the following would the nurse include in the plan of care for a child with a fracture in skeletal traction to prevent osteomyelitis?

1. Encouraging the child to eat nutritious foods
2. Administering prophylactic antibiotics as ordered
3. Maintaining the child in reverse isolation
4. Protecting the child from visitors with colds

Looking for answers(s):1
Explanation: RATIONALE: The best prevention strategy for osteomyelitis, a bacterial infection of the bone, is to maintain skin integrity and promote good nutrition. Encouraging the intake of nutritional foods is essential to ensure bone repair and healing, thereby minimizing the risk of infection. Unless the child already has a bacterial infection, antibiotics are not administered prophylactically when skeletal traction is used. Maintaining reverse isolation is not necessary for this child and could lead to social isolation. Protecting the child from visitors with colds is inappropriate because colds are caused by viruses while osteomyelitis is caused by bacteria invading bone tissue. Additionally, restricting visitors could lead to social isolation.

Question 50. A nurse working in a neonatal intensive care unit is developing infection control policies. Which of the following policies would the nurse expect to include as the single most effective means of preventing the spread of infection?

1. Having everyone coming in contact with neonates perform frequent hand and arm washing.
2. Keeping each neonate in an isolation incubator that is opened as infrequently as possible
3. Maintaining a ventilation system in the unit that provides for continuous clean-air exchange
4. Requiring everyone who comes in contact with neonates to wear gowns and masks

Looking for answers(s):1
Explanation: RATIONALE: Authorities agree that the single most effective way to control the spread of infection is to have personnel perform frequent arm and hand washings. Although using isolation incubators may be beneficial, it is not the most effective means of infection control. Although ventilation systems with clean-air exchanges may be beneficial, they are not the most effective means of infection control. Wearing gowns and masks is helpful but not the most effective means of infection control
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