Community Health Nursing Essentials

1. The mother brought her daughter to the health center. The child has head lice. The nurse anticipates that the nursing diagnosis most closely correlated with this is:

Fluid volume deficit related to vomiting

Altered body image related to alopecia

Altered comfort related to itching

Diversional activity deficit related to hospitalization

Severe itching of the scalp is the classic sign and symptom of head lice in a child. In turn, this would lead to the nursing diagnosis of “altered comfort”.

Explanation

Severe itching of the scalp is the classic sign and symptom of head lice in a child. In turn, this would lead to the nursing diagnosis of “altered comfort”.

2. A community health nurse makes a home visit to an elderly person living alone in a small house. Which of the following observation would be a great concern?

Big mirror in a wall

Scattered and unwashed dishes in the sink

Shiny floors with scattered rugs

Brightly lit rooms

It is a safety hazard to have shiny floors and scattered rugs because they can cause falls and rugs should be removed.

Explanation

It is a safety hazard to have shiny floors and scattered rugs because they can cause falls and rugs should be removed.

3. A community health nurse is caring for a group of flood victims in Marikina area. In planning for the potential needs of this group, which is the most immediate concern?

Finding affordable housing for the group

Peer support through structured groups

Setting up a 24-hour crisis center and hotline

Meeting the basic needs to ensure that adequate food, shelter and clothing are available

The question asks about the immediate concern. The ABCs of community health care are always attending to people’s basic needs of food, shelter, and clothing.

Explanation

The question asks about the immediate concern. The ABCs of community health care are always attending to people’s basic needs of food, shelter, and clothing.

4. An 8-month-old infant is admitted to the hospital due to diarrhea. The nurse caring for the client tells the mother to stay beside the infant while making assessment. Which of the following developmental milestones the infant has reached?

Has a three-word vocabulary

Interacts with other infants

Stands alone

Recognizes but is fearful of strangers

An 8-month-old infant both recognizes and is fearful of strangers. This developmental milestone is known as “stranger anxiety”.

Explanation

An 8-month-old infant both recognizes and is fearful of strangers. This developmental milestone is known as “stranger anxiety”.

5. A community health nurse makes a home visit to a child with an infectious and communicable disease. In planning care for the child, the nurse must determine that the primary goal is that the:

Child will experience mild discomfort

Child will experience only minor complications

Child will not spread the infection to others

Public health department will be notified

The primary goal is to prevent the spread of the disease to others. The child should experience no complication. Although the health department may need to be notified at some point, it is no the primary goal. It is also important to prevent discomfort as much as possible.

Explanation

The primary goal is to prevent the spread of the disease to others. The child should experience no complication. Although the health department may need to be notified at some point, it is no the primary goal. It is also important to prevent discomfort as much as possible.

6. AThe mother brought her child to the clinic for follow-up check up. The mother tells the nurse that 14 days after starting an oral iron supplement, her child’s stools are black. Which of the following is the best nursing response to the mother?

“I will notify the physician, who will probably decrease the dosage slightly”

“This is a normal side effect and means the medication is working”

“You sound quite concerned. Would you like to talk about this further?”

“I will need a specimen to check the stool for possible bleeding”

When oral iron preparations are given correctly, the stools normally turn dark green or black. Parents of children receiving this medication should be advised that this side effect indicates the medication is being absorbed and is working well.

Explanation

When oral iron preparations are given correctly, the stools normally turn dark green or black. Parents of children receiving this medication should be advised that this side effect indicates the medication is being absorbed and is working well.

7. A toddler is brought to the hospital because of severe diarrhea and vomiting. The nurse assigned to the client enters the client’s room and finds out that the client is using a soiled blanket brought in from home. The nurse attempts to remove the blanket and replace it with a new and clean blanket. The toddler refuses to give the soiled blanket. The nurse realizes that the best explanation for the toddler’s behavior is:

The toddler did not bond well with the maternal figure

The blanket is an important transitional object

The toddler is anxious about the hospital experience

The toddler is resistive to nursing interventions

The “security blanket” is an important transitional object for the toddler. It provides a feeling of comfort and safety when the maternal figure is not present or when in a new situation for which the toddler was not prepared. Virtually any object (stuffed animal, doll, book etc) can become a security blanket for the toddler.

Explanation

The “security blanket” is an important transitional object for the toddler. It provides a feeling of comfort and safety when the maternal figure is not present or when in a new situation for which the toddler was not prepared. Virtually any object (stuffed animal, doll, book etc) can become a security blanket for the toddler.

8. The physician decided to schedule the 4-year-old client for repair of left undescended testicle. The Injection of a hormone, HCG finds it less successful for treatment. To administer a pentobarbital sodium (Nembutal) suppository preoperatively to this client, in which position should the nurse place him?

Supine with foot of bed elevated

Prone with legs abducted

Sitting with foot of bed elevated

Side-lying with upper leg flexed

The recommended position to administer rectal medications to children is side-lying with the upper leg flexed. This position allows the nurse to safely and effectively administer the medication while promoting comfort for the child.

Explanation

The recommended position to administer rectal medications to children is side-lying with the upper leg flexed. This position allows the nurse to safely and effectively administer the medication while promoting comfort for the child.

9. Which of the following technique is considered an aseptic practice during the home visit of the community health nurse?

Wrapping used dressing in a plastic bag before placing them in the nursing bag

Washing hands before removing equipment from the nursing bag

Using the client’s soap and cloth towel for hand washing

Placing the contaminated needles and syringes in a labeled container inside the nursing bag

Washing hands before removing equipment from the nursing bag is considered an aseptic practice because it helps to prevent the transfer of microorganisms from the nurse's hands to the equipment. This reduces the risk of infection for both the nurse and the client. By washing hands, the nurse can effectively remove any potential pathogens that may be present on their hands before handling the equipment, ensuring a clean and sterile environment.

Explanation

Washing hands before removing equipment from the nursing bag is considered an aseptic practice because it helps to prevent the transfer of microorganisms from the nurse's hands to the equipment. This reduces the risk of infection for both the nurse and the client. By washing hands, the nurse can effectively remove any potential pathogens that may be present on their hands before handling the equipment, ensuring a clean and sterile environment.

10. During immunization week in the health center, the parent of a 6-month-old infant asks the health nurse, “Why is our baby going to receive so many immunizations over a long time period?” The best nursing response would be:

“The number of immunizations your baby will receive shows how many pediatric communicable and infectious diseases can now be prevented.”

“You need to ask the physician”

“The number of immunizations your baby will receive is determined by your baby’s health history and age”

“It is easier on your baby to receive several immunizations rather than one at a time”

Completion for the recommended schedule of infant immunizations does not require a large number of immunizations, but it also provides protection against multiple pediatric communicable and infectious diseases.

Explanation

Completion for the recommended schedule of infant immunizations does not require a large number of immunizations, but it also provides protection against multiple pediatric communicable and infectious diseases.

11. A community nurse enters the home of the client for follow-up visit. Which of the following is the most appropriate area to place the nursing bag of the nurse when conducting a home visit?

Cushioned footstool

Bedside wood table

Kitchen countertop

Living room sofa

A wood surface provides the least chance for organisms to be present.

Explanation

A wood surface provides the least chance for organisms to be present.

12. The City health department conducted a medical mission in Barangay Marulas. Majority of the children in the Barangay Marulas were diagnosed with pinworms. The community health nurse should anticipate that the children’s chief complaint would be:

Lack of appetite

Severe itching of the scalp

Perianal itching

Severe abdominal pain

Perianal itching is the child’s chief complaint associated with the diagnosis of pinworms. The itching, in this instance, is often described as being “intense” in nature. Pinworms infestation usually occurs because the child is in the anus-to-mouth stage of development (child uses the toilet, does not wash hands, places hands and pinworm eggs in mouth). Teaching the child hand washing before eating and after using the toilet can assist in breaking the cycle.

Explanation

Perianal itching is the child’s chief complaint associated with the diagnosis of pinworms. The itching, in this instance, is often described as being “intense” in nature. Pinworms infestation usually occurs because the child is in the anus-to-mouth stage of development (child uses the toilet, does not wash hands, places hands and pinworm eggs in mouth). Teaching the child hand washing before eating and after using the toilet can assist in breaking the cycle.

13. A 9-year-old boy is admitted to the hospital. The boy is being treated with salicylates for the migratory polyarthritis accompanying the diagnosis of rheumatic fever. Which of the following activities performed by the child would give a best sign that the medication is effective?

Listening to story of his mother

Listening to the music in the radio

Playing mini piano

Watching movie in the dvd mini player

The purpose of the salicylate therapy is to relieve the pain associated with the migratory polyarthritis accompanying the rheumatic fever. Playing mini piano would require movement of the child’s joints and would provide the nurse with a means of evaluating the child’s level of pain.

Explanation

The purpose of the salicylate therapy is to relieve the pain associated with the migratory polyarthritis accompanying the rheumatic fever. Playing mini piano would require movement of the child’s joints and would provide the nurse with a means of evaluating the child’s level of pain.

14. The nurse in the health center is making an assessment to the infant client. The nurse notes some rashes and small fluid-filled bumps in the skin. The nurse suspects that the infant has eczema. Which of the following is the most important nursing goal:

Preventing infection

Providing for adequate nutrition

Decreasing the itching

Maintaining the comfort level

Preventing infection in the infant with eczema is the nurse’s most important goal. The infant with eczema is at high risk for infection due to numerous breaks in the skin’s integrity. Intact skin is always the infant’s first line of defense against infection.

Explanation

Preventing infection in the infant with eczema is the nurse’s most important goal. The infant with eczema is at high risk for infection due to numerous breaks in the skin’s integrity. Intact skin is always the infant’s first line of defense against infection.

15. The mother brings her daughter to the health care clinic. The child was diagnosed with conjunctivitis. The nurse provides health teaching to the mother about the proper care of her daughter while at home. Which statement by the mother indicates a need for additional information?

“I do not need to be concerned about the spreading of this infection to others in my family”

“I should apply warm compresses before instilling antibiotic drops if purulent discharge is present in my daughter’s eye”

“I can use an ophthalmic analgesic ointment at nighttime if I have eye discomfort”

Conjunctivitis is highly contagious. Antibiotic drops are usually administered four times a day. When purulent discharge is present, saline eye irrigations or eye applications of warm compresses may be necessary before instilling the medication. Ophthalmic analgesic ointment or drops may be instilled, especially at bedtime, because discomfort becomes more noticeable when the eyelids are closed.

Explanation

Conjunctivitis is highly contagious. Antibiotic drops are usually administered four times a day. When purulent discharge is present, saline eye irrigations or eye applications of warm compresses may be necessary before instilling the medication. Ophthalmic analgesic ointment or drops may be instilled, especially at bedtime, because discomfort becomes more noticeable when the eyelids are closed.

16. The nurse is planning to conduct a home visit in a small community. Which of the following is the most important factor when planning the best time for a home care visit?

Purpose of the home visit

Preference of the patient’s family

Location of the patient’s home

Length of time of the visit will take

The purpose of the visit takes priority.

Explanation

The purpose of the visit takes priority.

17. The Department of Health is alarmed that almost 33 million people suffer from food poisoning every year. Salmonella enteritis is responsible for almost 4 million cases of food poisoning. One of the major goals is to promote proper food preparation. The community health nurse is tasks to conduct health teaching about the prevention of food poisoning to a group of mother everyday. The nurse can help identify signs and symptoms of specific organisms to help patients get appropriate treatment. Typical symptoms of salmonella include:

Nausea, vomiting and paralysis

Bloody diarrhea

Diarrhea and abdominal cramps

Nausea, vomiting and headache

Salmonella organisms cause lower GI symptoms

Explanation

Salmonella organisms cause lower GI symptoms

18. A mother brought her child in the health center for hepatitis B vaccination in a series. The mother informs the nurse that the child missed an appointment last month to have the third hepatitis B vaccination. Which of the following statements is the appropriate nursing response to the mother?

“I will examine the child for symptoms of hepatitis B”

“Your child will start the series again”

“Your child will get the next dose as soon as possible”

“Your child will have a hepatitis titer done to determine if immunization has taken place.”

Continuity is essential to promote active immunity and give hepatitis B lifelong prophylaxis. Optimally, the third vaccination is given 6 months after the first.

Explanation

Continuity is essential to promote active immunity and give hepatitis B lifelong prophylaxis. Optimally, the third vaccination is given 6 months after the first.

19. An 8-year-old girl is in second grade and the parents decided to enroll her to a new school. While the child is focusing on adjusting to new environment and peers, her grades suffer. The child’s father severely punishes the child and forces her daughter to study after school. The father does not allow also her daughter to play with other children. These data indicate to the nurse that this child is deprived of forming which normal phase of development?

Heterosexual relationships

A love relationship with the father

A dependency relationship with the father

Close relationship with peers

In second grade a child needs to form a close relationships with peers.

Explanation

In second grade a child needs to form a close relationships with peers.

20. The community nurse is conducting a health teaching in the group of married women. When teaching a woman about fertility awareness, the nurse should emphasize that the basal body temperature:

Should be recorded each morning before any activity

Is the average temperature taken each morning

Can be done with a mercury thermometer but not a digital one

Has a lower degree of accuracy in predicting ovulation than the cervical mucus test

The basal body temperature (BBT) is the lowest body temperature of a healthy person that is taken immediately after waking and before getting out of bed. The BBT usually varies from 36.2 – 36.3 degree Celsius during menses and for about 5-7 days afterward. About the time of ovulation, a slight drop approximately 0.05 degree Celsius in temperature may be seen; after ovulation, in concert with the increasing progesterone levels of the early luteal phase, the BBT rises 0.2-0.4 degree Celsius. This elevation remains until 2-3 days before menstruation, or if pregnancy has occurred.

Explanation

The basal body temperature (BBT) is the lowest body temperature of a healthy person that is taken immediately after waking and before getting out of bed. The BBT usually varies from 36.2 – 36.3 degree Celsius during menses and for about 5-7 days afterward. About the time of ovulation, a slight drop approximately 0.05 degree Celsius in temperature may be seen; after ovulation, in concert with the increasing progesterone levels of the early luteal phase, the BBT rises 0.2-0.4 degree Celsius. This elevation remains until 2-3 days before menstruation, or if pregnancy has occurred.

21. The student nurse is assigned to take the vital signs of the clients in the pediatric ward. The student nurse reports to the staff nurse that the parent of a toddler who is 2 days postoperative after a cleft palate repair has given the toddler a pacifier. What would be the best immediate action of the nurse?

Notify the pediatrician of this finding

Reassure the student that this is an acceptable action on the parent’s part

Discuss this action with the parents

Ask the student nurse to remove the pacifier from the toddler’s mouth

Nothing must be placed in the mouth of a toddler who just undergone a cleft palate repair until the suture line has completely healed. It is the nurse’s responsibility to inform the parent of the client. Spoon, forks, straws, and tongue blades are other unacceptable items to place in the mouth of a toddler who just undergone cleft palate repair. The general principle of care is that nothing should enter the mouth until the suture line has completely healed.

Explanation

Nothing must be placed in the mouth of a toddler who just undergone a cleft palate repair until the suture line has completely healed. It is the nurse’s responsibility to inform the parent of the client. Spoon, forks, straws, and tongue blades are other unacceptable items to place in the mouth of a toddler who just undergone cleft palate repair. The general principle of care is that nothing should enter the mouth until the suture line has completely healed.

22. The nurse is caring to a 24-month-old child diagnosed with congenital heart defect. The physician prescribed digoxin (Lanoxin) to the client. Before the administration of the drug, the nurse checks the apical pulse rate to be 110 beats per minute and regular. What would be the next nursing action?

Check the other vital signs and level of consciousness

Withhold the digoxin and notify the physician

Give the digoxin as prescribed

Check the apical and radial simultaneously, and if they are the same, give the digoxin.

For a 12month-old child, 110 apical pulse rate is normal and therefore it is safe to give the digoxin. A toddler’s normal pulse rate is slightly lower than an infant’s (120).

Explanation

For a 12month-old child, 110 apical pulse rate is normal and therefore it is safe to give the digoxin. A toddler’s normal pulse rate is slightly lower than an infant’s (120).

23. A mother who gave birth to her second daughter is so concerned about her 2-year old daughter. She tells the nurse, “I am afraid that my 2-year-old daughter may not accept her newly born sister”. It is appropriate to the nurse to response that:

The older daughter not have interaction with the baby at the hospital, because she may harm her new sibling

The mother spend time alone with her older daughter when the baby is sleeping

The introduction of a baby into a family with one or more children challenges parent to promote acceptance of the baby by siblings. The parent’s attitudes toward the arrival of the baby can set the stage for the other children’s reaction. Spending time with the older siblings alone will also reassure them of their place in the family, even though the older children will have to eventually assume new positions within the family hierarchy.

Explanation

The introduction of a baby into a family with one or more children challenges parent to promote acceptance of the baby by siblings. The parent’s attitudes toward the arrival of the baby can set the stage for the other children’s reaction. Spending time with the older siblings alone will also reassure them of their place in the family, even though the older children will have to eventually assume new positions within the family hierarchy.

24. The community nurse is providing an instruction to the clients in the health center about the use of diaphragm for family planning. To evaluate the understanding of the woman, the nurse asks her to demonstrate the use of the diaphragm. Which of following statement indicates a need for further health teaching?

“I should check the diaphragm carefully for holes every time I use it.”

“The diaphragm must be left in place for at least 6 hours after intercourse.”

“I really need to use the diaphragm and jelly most during the middle of my menstrual cycle

“I may need a different size diaphragm if I gain or lose more than 20 pounds”

The woman must understand that, although the “fertile” period is approximately midcycle, hormonal variations do occur and can result in early or late ovulations. To be effective, the diaphragm should be inserted before every intercourse.

Explanation

The woman must understand that, although the “fertile” period is approximately midcycle, hormonal variations do occur and can result in early or late ovulations. To be effective, the diaphragm should be inserted before every intercourse.

25. The community health nurse is conducting a health teaching about nutrition to a group of pregnant women who are anemic and are lactose intolerant. Which of the following foods should the nurse especially encourage during the third trimester?

Cheese, yogurt, and fish for protein and calcium needs plus prenatal vitamins and iron supplements

Prenatal iron and calcium supplements plus a regular adult diet

Red beans, green leafy vegetables, and fish for iron and calcium needs plus prenatal vitamins and iron supplements

Red meat, milk and eggs for iron and calcium needs plus prenatal vitamins and iron supplements

This is appropriate foods that are high in iron and calcium but would not affect lactose intolerance.

Explanation

This is appropriate foods that are high in iron and calcium but would not affect lactose intolerance.

26. MThe nurse is providing a health teaching to the mother of an 8-year-old child with cystic fibrosis. Which of the following statement if made by the mother would indicate to the nurse the need for further teaching about the medication regimen of the child?

“My child might need an extra capsule if the meal is high in fat”

“I’ll give the enzyme capsule before every snack”

“I’ll give the enzyme capsule before every meal”

“My child hates to take pills, so I’ll mix the capsule into a cup of hot chocolate

The pancreatic capsules contain pancreatic enzyme that should be administered in a cold, not a hot, medium (example: chilled applesauce versus hot chocolate) to maintain the medication’s integrity.

Explanation

The pancreatic capsules contain pancreatic enzyme that should be administered in a cold, not a hot, medium (example: chilled applesauce versus hot chocolate) to maintain the medication’s integrity.

27. The nurse in the health center is providing immunization to the children. The nurse is carefully assessing the condition of the children before giving the vaccines. Which of the following would the nurse note to withhold the infant’s scheduled immunizations?

A dry cough

A skin rash

A low-grade fever

A runny nose

A skin rash could indicate a concurrent infectious disease process in the infant. The scheduled immunizations should be withheld until the status of the infant’s health can be determined. Fevers above 38.5 degrees Celsius, alteration in skin integrity, and infectious-appearing secretions are indications to withhold immunizations.

Explanation

A skin rash could indicate a concurrent infectious disease process in the infant. The scheduled immunizations should be withheld until the status of the infant’s health can be determined. Fevers above 38.5 degrees Celsius, alteration in skin integrity, and infectious-appearing secretions are indications to withhold immunizations.

28. The nurse has knowledge about the developmental task of the child. In caring a 3-year-old-client, the nurse knows that the suited developmental task of this child is to:

Learn to play with other children

Able to trust others

Express all needs through speaking

Explore and manipulate the environment

Toddlers need to meet the developmental milestone of autonomy versus shame and doubt. In order to accomplish this, the toddler must be able to explore and manipulate the environment.

Explanation

Toddlers need to meet the developmental milestone of autonomy versus shame and doubt. In order to accomplish this, the toddler must be able to explore and manipulate the environment.

29. A nurse is providing safety instructions to the parents of the 11-month-old child. Which of the following will the nurse includes in the instructions?

Plugging all electrical outlets in the house

Installing a gate at the top and bottom of any stairs in the home

Purchasing an infant car seat as soon as possible

Begin to teach the child not to place small objects in the mouth

An 11-month-old child stands alone and can walk holding onto people or objects. Therefore the installation of a gate at the top and bottom of any stairs in the house is crucial for the child’s safety.

Explanation

An 11-month-old child stands alone and can walk holding onto people or objects. Therefore the installation of a gate at the top and bottom of any stairs in the house is crucial for the child’s safety.

30. The health nurse is conducting health teaching about “safe” sex to a group of high school students. Which of the following statement about the use of condoms should the nurse avoid making?

“Condoms should be used because they can prevent infection and because they may prevent pregnancy”

“Condoms should be used even if you have recently tested negative for HIV”

“Condoms should be used every time you have sex because condoms prevent all forms of sexually transmitted diseases”

Condoms do not prevent ALL forms of sexually transmitted diseases.

Explanation

Condoms do not prevent ALL forms of sexually transmitted diseases.

31. The physician prescribed gentamicin (Garamycin) to a child who is also receiving chemotherapy. Before administering the drug, the nurse should check the results of the child’s:

CBC and platelet count

Auditory tests

Renal Function tests

Abdominal and chest x-rays

Both gentamicin and chemotherapeutic agents can cause renal impairment and acute renal failure; thus baseline renal function must be evaluated before initiating either medication.

Explanation

Both gentamicin and chemotherapeutic agents can cause renal impairment and acute renal failure; thus baseline renal function must be evaluated before initiating either medication.

32. Which of the following clients is at high risk for developmental problem?

A toddler with acute Glomerulonephritis on antihypertensive and antibiotics

A 5-year-old with asthma on cromolyn sodium

A preschooler with tonsillitis

A 2 1/2 –year old boy with cystic fibrosis

It is the developmental task of an 18-month-old toddler to explore and learn about the environment. The respiratory complications associated with cystic fibrosis (which are present in almost all children with cystic fibrosis) could prevent this development task from occurring.

Explanation

It is the developmental task of an 18-month-old toddler to explore and learn about the environment. The respiratory complications associated with cystic fibrosis (which are present in almost all children with cystic fibrosis) could prevent this development task from occurring.

33. An 8-year-old boy with asthma is brought to the clinic for check up. The mother asks the nurse if the treatment given to her son is effective. What would be the appropriate response of the nurse?

I will review first the child’s height on a growth chart to know if the treatment is working

I will review first the child’s weight on a growth chart to know if the treatment is working

Reviewing the number of prescription refills the child has required over the last 6 months would be the best indicator of how well controlled and thus how effective the child’s asthma treatment is. Breakthrough wheezing, shortness of breath, and upper respiratory infections would require that the child take additional medication. This would be reflected in the number of prescription refills.

Explanation

Reviewing the number of prescription refills the child has required over the last 6 months would be the best indicator of how well controlled and thus how effective the child’s asthma treatment is. Breakthrough wheezing, shortness of breath, and upper respiratory infections would require that the child take additional medication. This would be reflected in the number of prescription refills.

34. A 14 day-old infant with a cyanotic heart defects and mild congestive heart failure is brought to the emergency department. During assessment, the nurse checks the apical pulse rate of the infant. The apical pulse rate is 130 beats per minute. Which of the following is the appropriate nursing action?

Retake the apical pulse in 15 minutes

Retake the apical pulse in 30 minutes

Notify the pediatrician immediately

Administer the medication as scheduled

The normal heart rate of an infant is 120-160 beats per minute.

Explanation

The normal heart rate of an infant is 120-160 beats per minute.

35. A 5-year-old boy client is scheduled for hernia surgery. The nurse is preparing to do preoperative teaching with the child. The nurse should knows that the 5-year-old would:

Expect a simple yet logical explanation regarding the surgery

Asks many questions regarding the condition and the procedure

Worry over the impending surgery

Be uninterested in the upcoming surgery

A 5-year-old is highly concerned with body integrity. The preschool-age child normally asks many questions and in a situation such as this, could be expected to ask even more.

Explanation

A 5-year-old is highly concerned with body integrity. The preschool-age child normally asks many questions and in a situation such as this, could be expected to ask even more.

36. Which of the following is the suited size of the needle would the nurse select to administer the IM injection to a preschool child?

18 G, 1-1/2 inch

25 G, 5/8 inch

21 G, 1 inch

18 G, 1inch

In selecting the correct needle to administer an IM injection to a preschooler, the nurse should always look at the child and use judgment in evaluating muscle mass and amount of subcutaneous fat. In this case, in the absence of further data, the nurse would be most correct in selecting a needle gauge and length appropriate for the “average’ preschool child. A medium-gauge needle (21G) that is 1 inch long would be most appropriate.

Explanation

In selecting the correct needle to administer an IM injection to a preschooler, the nurse should always look at the child and use judgment in evaluating muscle mass and amount of subcutaneous fat. In this case, in the absence of further data, the nurse would be most correct in selecting a needle gauge and length appropriate for the “average’ preschool child. A medium-gauge needle (21G) that is 1 inch long would be most appropriate.

37. The nurse is providing health teaching about the breastfeeding and family planning to the client who gave birth to a healthy baby girl. Which of the following statement would alert the nurse that the client needs further teaching?

“I understand that the hormones for breastfeeding may affect when my periods come”

“Breastfeeding causes my womb to tighten and bleed less after birth”

“I may not have periods while I am breastfeeding, so I don’t need family planning”

“I can get pregnant as early as one month after my baby was born”

It is common misconception that breastfeeding may prevent pregnancy.

Explanation

It is common misconception that breastfeeding may prevent pregnancy.

38. The nurse assigned in the health center is counseling a 30-year-old client requesting oral contraceptives. The client tells the nurse that she has an active yeast infection that has recurred several times in the past year. Which statement by the nurse is inaccurate concerning health promotion actions to prevent recurring yeast infection?

“During treatment for yeast, avoid vaginal intercourse for one week”

“Wear loose-fitting cotton underwear”

“Avoid eating large amounts of sugar or sugar-bingeing”

“Douche once a day with a mild vinegar and water solution”

Frequent douching interferes with the natural protective barriers in the vagina that resist yeast infection and should be avoided.

Explanation

Frequent douching interferes with the natural protective barriers in the vagina that resist yeast infection and should be avoided.

39. A woman with active tuberculosis (TB) and has visited the health center for regular therapy for five months wants to become pregnant. The nurse knows that further information is necessary when the woman states:

“Spontaneous abortion may occur in one out of five women who are infected”

“Pulmonary TB may jeopardize my pregnancy”

“I can get pregnant after I have been free of TB for 6 months”

Intervention is needed when the woman thinks that she needs to wait only 6 months after being free of TB before she can get pregnant. She needs to wait 1.5-2years after she is declared to be free of TB before she should attempt pregnancy.

Explanation

Intervention is needed when the woman thinks that she needs to wait only 6 months after being free of TB before she can get pregnant. She needs to wait 1.5-2years after she is declared to be free of TB before she should attempt pregnancy.

40. The mother brings a child to the health care clinic because of severe headache and vomiting. During the assessment of the health care nurse, the temperature of the child is 40 degree Celsius, and the nurse notes the presence of nuchal rigidity. The nurse is suspecting that the child might be suffering from bacterial meningitis. The nurse continues to assess the child for the presence of Kernig’s sign. Which finding would indicate the presence of this sign?

Flexion of the hips when the neck is flexed from a lying position

Calf pain when the foot is dorsiflexed

Inability of the child to extend the legs fully when lying supine

Pain when the chin is pulled down to the chest

Kernig’s sign is the inability of the child to extend the legs fully when lying supine. This sign is frequently present in bacterial meningitis. Nuchal rigidity is also present in bacterial meningitis and occurs when pain prevents the child from touching the chin to the chest.

Explanation

Kernig’s sign is the inability of the child to extend the legs fully when lying supine. This sign is frequently present in bacterial meningitis. Nuchal rigidity is also present in bacterial meningitis and occurs when pain prevents the child from touching the chin to the chest.

41. The nurse is caring to a child client who is receiving tetracycline. The nurse is aware that in taking this medication, it is very important to:

Administer the drug between meals

Monitor the child’s hearing

Give the drug through a straw

Keep the child out of the sunlight

Tetracycline may cause a phototoxic reaction.

Explanation

Tetracycline may cause a phototoxic reaction.

42. A 2-year-old client with cystic fibrosis is confined to bed and is not allowed to go to the playroom. Which of the following is an appropriate toy would the nurse select for the child:

Puzzle

Musical automobile

Arranging stickers in the album

Pounding board and hammer

The autonomous toddler would be frustrated by being confined to be. The pounding board and hammer is developmentally appropriate and an excellent way for the toddler to release frustration.

Explanation

The autonomous toddler would be frustrated by being confined to be. The pounding board and hammer is developmentally appropriate and an excellent way for the toddler to release frustration.

43. An 8-year-old client with cystic fibrosis is admitted to the hospital and will undergo a chest physiotherapy treatment. The therapy should be properly coordinated by the nurse with the respiratory therapy department so that treatments occur during:

After meals

Between meals

After medication

Around the child’s play schedule

Chest physiotherapy treatments are scheduled between meals to prevent aspiration of stomach contents, because the child is placed in a variety of positions during the treatment process.

Explanation

Chest physiotherapy treatments are scheduled between meals to prevent aspiration of stomach contents, because the child is placed in a variety of positions during the treatment process.

44. The community health nurse implemented a new program about effective breast cancer screening technique for the female personnel of the health department of Valenzuela. Which of the following technique should the nurse consider to be of the lowest priority?

Yearly breast exam by a trained professional

Detailed health history to identify women at risk

Screening mammogram every year for women over age 50

Screening mammogram every 1-2 years for women over age of 40.

Because of the high incidence of breast cancer, all women are considered to be at risk regardless of health history.

Explanation

Because of the high incidence of breast cancer, all women are considered to be at risk regardless of health history.

45. The client visits the clinic for prenatal check-up. While waiting for the physician, the nurse decided to conduct health teaching to the client. The nurse informed the client that primigravida mother should go to the hospital when which patter is evident?

Contractions are 2-3 minutes apart, lasting 90 seconds, and membranes have ruptured

Contractions are 5-10 minutes apart, lasting 30 seconds, and are felt as strong menstrual cramps

Contractions are 3-5 minutes apart, accompanied by rectal pressure and bloody show

Contractions are 5 minutes apart, lasting 60 seconds, and increasing in intensity

Although instructions vary among birth centers, primigravidas should seek care when regular contractions are felt about 5 minutes apart, becoming longer and stronger.

Explanation

Although instructions vary among birth centers, primigravidas should seek care when regular contractions are felt about 5 minutes apart, becoming longer and stronger.

46. The parent of a 16-year-old boy tells the nurse that his son is driving a motorbike very fast and with one hand. “It is making me crazy!” What would be the best explanation of the nurse to the behavior of the boy?

The adolescent might have an unconscious death wish

The adolescent feels indestructible

The adolescent lacks life experience to realize how dangerous the behavior is

The adolescent has found a way to act out hostility toward the parent

Adolescents do feel indestructible, and this is reflected in many risk-taking behaviors.

Explanation

Adolescents do feel indestructible, and this is reflected in many risk-taking behaviors.

47. Which of the following would be the best divesionary activity for the nurse to select for a 2 weeks hospitalized 3-year-old girl?

Crayons and coloring books

Doll

Xylophone toy

Puzzles

The best diversion for a hospitalized child aged 2-3 years old would be anything that makes noise or makes a mess; xylophone which certainly makes noise or music would be the best choice.

Explanation

The best diversion for a hospitalized child aged 2-3 years old would be anything that makes noise or makes a mess; xylophone which certainly makes noise or music would be the best choice.

48. The nine-year-old client is admitted in the hospital for almost 1 week and is on bed rest. The child complains of being bored and it seems tiresome to stay on bed and doing nothing. What activity selected by the nurse would the child most likely find stimulating?

Watching a video

Putting together a puzzle

Assembling handouts with the nurse for an upcoming staff development meeting

Listening to a compact disc

A 9-year-old enjoys working and feeling a sense of accomplishment. The school-age child also enjoys “showing off,” and doing something with the nurse on the pediatric unit would allow this. This activity also provides the school-age child a needed opportunity to interact with others in the absence of school and personal friends.

Explanation

A 9-year-old enjoys working and feeling a sense of accomplishment. The school-age child also enjoys “showing off,” and doing something with the nurse on the pediatric unit would allow this. This activity also provides the school-age child a needed opportunity to interact with others in the absence of school and personal friends.

49. A nurse is planning a home visit program to a new mother who is 2 weeks postpartum and breastfeeding, the nurse includes in her health teaching about the resumption of fertility, contraception and sexual activity. Which of the following statement indicates that the mother has understood the teaching?

“Because breastfeeding speeds the healing process after birth, I can have sex right away and not worry about infection”

“After birth, you have to have a period before you can get pregnant again’

Prolactin suppresses estrogen, which is needed to stimulate vaginal lubrication during arousal.

Explanation

Prolactin suppresses estrogen, which is needed to stimulate vaginal lubrication during arousal.

50. The department of health is promoting the breastfeeding program to all newly mothers. The nurse is formulating a plan of care to a woman who gave birth to a baby girl. The nursing care plan for a breast-feeding mother takes into account that breast-feeding is contraindicated when the woman:

Is pregnant

Has genital herpes infection

Develops mastitis

Has inverted nipples

Pregnancy is one contraindication to breast-feeding. Milk secretion is inhibited and the baby’s sucking may stimulate uterine contractions.

Explanation

Pregnancy is one contraindication to breast-feeding. Milk secretion is inhibited and the baby’s sucking may stimulate uterine contractions.