Maternal and Child Health Nursing (Nurs320)

1. The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn after the first bowel movement. The mother expresses concern because the large amount of thick, sticky stool is very dark green, almost black. She asks the nurse if something is wrong. The nurse should respond to this mother's concern by:

Telling the mother not to worry because all breastfed babies have this type of stool

Asking the mother what she ate for her last meal

Suggesting to the mother that she ask her pediatrician to explain normal newborn stooling patterns to her

The majority of healthy term infants pass meconium during the first 12 to 24 hours after birth. Meconium is composed of amniotic fluid, intestinal secretions, shed mucosal cells, and possibly blood, resulting in the dark green to black color.

Explanation

The majority of healthy term infants pass meconium during the first 12 to 24 hours after birth. Meconium is composed of amniotic fluid, intestinal secretions, shed mucosal cells, and possibly blood, resulting in the dark green to black color.

2. An appropriate nursing intervention when caring for a child with pneumonia is which of the following?

Avoid placing child on affected side.

Monitor respiratory status frequently.

Place in Trendelenburg position.

Administer antitussive agents around the clock.

2. The child's respiratory rate, status, oxygenation, general disposition, and level of activity are frequently monitored.
1. Lying on the affected side may promote comfort by splinting the chest and reducing pleural rubbing. The child should be positioned with the unaffected side up to promote maximum expansion.
3. Children should be placed in a semierect position or position of comfort.
4. Antitussives are usually not indicated.

Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: Implementation

Explanation

2. The child's respiratory rate, status, oxygenation, general disposition, and level of activity are frequently monitored.
1. Lying on the affected side may promote comfort by splinting the chest and reducing pleural rubbing. The child should be positioned with the unaffected side up to promote maximum expansion.
3. Children should be placed in a semierect position or position of comfort.
4. Antitussives are usually not indicated.

Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: Implementation

3. An expectant father confides in the nurse that his pregnant wife, 10 weeks of gestation, is driving him crazy. "One minute she seems happy, and the next minute she is crying over nothing at all. Is there something wrong with her?" The nurse's best response is:

"This is normal behavior and should begin to subside by the second trimester."

"She may be having difficulty adjusting to pregnancy; I will refer her to a counselor I know."

"You seem impatient with her. Perhaps this is precipitating her behavior."

This is the most appropriate response because it gives an explanation and a time frame for when the mood swings may stop.

Explanation

This is the most appropriate response because it gives an explanation and a time frame for when the mood swings may stop.

4. The nurse is caring for a child who has just died. The parents ask to be left alone so that they can rock their child one more time. The nurse should do which of the following?

Grant their request.

Assess why they think this is necessary.

Discourage this because it will only prolong their grief.

Kindly explain that they need to say good-bye to their child now and leave.

1. The parents should be allowed to remain with their child after the death. The nurse can remove all the tubes and equipment and offer the parents the option of preparing the body.
2. The parents should be allowed to remain with their child after the death. This is an important part of the grieving process and should be allowed if the parents desire. It is important for the nurse to ascertain whether the family has any special needs.
3. The parents should be allowed to remain with their child after the death. This is an important part of the grieving process and should be allowed if the parents desire. It is important for the nurse to ascertain whether the family has any special needs.
4. The parents should be allowed to remain with their child after the death. This is an important part of the grieving process and should be allowed if the parents desire. It is important for the nurse to ascertain whether the family has any special needs.

Level of cognitive ability: Analysis
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: Implementation

Explanation

1. The parents should be allowed to remain with their child after the death. The nurse can remove all the tubes and equipment and offer the parents the option of preparing the body.
2. The parents should be allowed to remain with their child after the death. This is an important part of the grieving process and should be allowed if the parents desire. It is important for the nurse to ascertain whether the family has any special needs.
3. The parents should be allowed to remain with their child after the death. This is an important part of the grieving process and should be allowed if the parents desire. It is important for the nurse to ascertain whether the family has any special needs.
4. The parents should be allowed to remain with their child after the death. This is an important part of the grieving process and should be allowed if the parents desire. It is important for the nurse to ascertain whether the family has any special needs.

Level of cognitive ability: Analysis
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: Implementation

5. A woman who is 14 weeks pregnant tells the nurse that she always had a glass of wine with dinner before she became pregnant. She has abstained during her first trimester and would like to know if it is safe for her to have a drink with dinner now. The nurse tells her:

"Because you're in your second trimester, there's no problem with having one drink with dinner."

"One drink every night is too much. One drink three times a week should be fine."

"Because you're in your second trimester, you can drink as much as you like."

A safe level of alcohol consumption during pregnancy has not yet been established. Although the consumption of occasional alcoholic beverages may not be harmful to the mother or her developing fetus, complete abstinence is strongly advised.

Explanation

A safe level of alcohol consumption during pregnancy has not yet been established. Although the consumption of occasional alcoholic beverages may not be harmful to the mother or her developing fetus, complete abstinence is strongly advised.

6. Nurses, certified nurse-midwives, and other advanced practice nurses have the knowledge and expertise to assist women in making informed choices regarding contraception. A multidisciplinary approach should ensure that the woman's social, cultural, and interpersonal needs are met. Which action should the nurse take first when meeting with a new client to discuss contraception?

Obtain data about the frequency of coitus.

Determine the woman's level of knowledge about contraception and commitment to any particular method.

Assess the woman's willingness to touch her genitals and cervical mucus

Evaluate the woman's contraceptive life plan.

This is the primary step of this nursing assessment and necessary before completing the process and moving on to a nursing diagnosis. Once the client's level of knowledge is determined, the nurse can interact with the woman to compare options, reliability, cost, comfort level, protection from sexually transmitted infections (STIs), and a partner’s willingness to participate.

Explanation

This is the primary step of this nursing assessment and necessary before completing the process and moving on to a nursing diagnosis. Once the client's level of knowledge is determined, the nurse can interact with the woman to compare options, reliability, cost, comfort level, protection from sexually transmitted infections (STIs), and a partner’s willingness to participate.

7. Nursing interventions to promote coping among the siblings of a child with special needs include which of the following?

Explain to the siblings that embarrassment is unhealthy.

Encourage the parents not to expect siblings to help them care for the child with special needs.

Provide information to the siblings about the child’s condition only as requested.

4. The presence of a child with special needs in a family will change the family dynamic. Siblings may be asked to take on additional responsibilities to help the parents to care for the child. The parents should show gratitude, such as an increase in allowance, special privileges, and verbal praise.
1. Embarrassment may be associated with having a sibling with a chronic illness or disability. Parents must be able to respond in an appropriate manner.
2. The parents may need assistance with the care of the child. Most siblings are positive about the extra responsibilities.
3. The siblings need to be informed about the child's condition before a nonfamily member does so. The parents do not want the siblings to fantasize about what is wrong with the child.

Level of cognitive ability: Analysis
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: Implementation

Explanation

4. The presence of a child with special needs in a family will change the family dynamic. Siblings may be asked to take on additional responsibilities to help the parents to care for the child. The parents should show gratitude, such as an increase in allowance, special privileges, and verbal praise.
1. Embarrassment may be associated with having a sibling with a chronic illness or disability. Parents must be able to respond in an appropriate manner.
2. The parents may need assistance with the care of the child. Most siblings are positive about the extra responsibilities.
3. The siblings need to be informed about the child's condition before a nonfamily member does so. The parents do not want the siblings to fantasize about what is wrong with the child.

Level of cognitive ability: Analysis
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: Implementation

8. The nurse is providing support to a family who is experiencing anticipatory grief related to their child's imminent death. Which of the following is an appropriate nursing intervention?

Be available to family.

Attempt to “lighten the mood.”

Suggest activities to cheer up the family.

Discourage crying until actual time of death.

1. One of the most important nursing interventions around the time of death is the availability of the nurse for the family.
2. Attempting to "lighten the mood" or suggesting activities to cheer up the family would be highly inappropriate. The parents are in engaged in the grieving process.
3. Attempting to "lighten the mood" or suggesting activities to cheer up the family would be highly inappropriate. The parents are in engaged in the grieving process.
4. The parents should be encouraged to express their feelings appropriately.

Level of cognitive ability: Application
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: Implementation

Explanation

1. One of the most important nursing interventions around the time of death is the availability of the nurse for the family.
2. Attempting to "lighten the mood" or suggesting activities to cheer up the family would be highly inappropriate. The parents are in engaged in the grieving process.
3. Attempting to "lighten the mood" or suggesting activities to cheer up the family would be highly inappropriate. The parents are in engaged in the grieving process.
4. The parents should be encouraged to express their feelings appropriately.

Level of cognitive ability: Application
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: Implementation

9. The school nurse is caring for a child with hemophilia who fell on his arm during recess. Which of the following supportive measures should the nurse do until factor replacement therapy can be instituted?

Apply warm, moist compresses.

Apply tourniquet for at least 5 minutes.

Elevate arm above the level of the heart.

Begin passive range of motion unless pain is severe.

3. The initial response should include elevation.
1. Cold should be applied to the arm. This will aid in vasoconstriction.
2. Pressure is effective in small areas, but would not work for an extremity.
4. Passive range of motion is not recommended. The child can perform active range of motion after the bleeding episode has resolved.

Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: Implementation

Explanation

3. The initial response should include elevation.
1. Cold should be applied to the arm. This will aid in vasoconstriction.
2. Pressure is effective in small areas, but would not work for an extremity.
4. Passive range of motion is not recommended. The child can perform active range of motion after the bleeding episode has resolved.

Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: Implementation

10. Which of the following self-report pain rating scales can be used in children as young as 3 years of age?

Poker Chip Tool

Visual Analog Scale

FACES Pain Rating Scale

Word-Graphic Rating Scale

1. The Poker Chip Tool has been validated for children age 4 years who have been determined to have the cognitive ability to identify the larger of 2 numbers.
2. The Visual Analog Scale can be used for children over 4 years of age, but is most appropriate for ages 7 and older.
3. The FACES Pain Rating Scale is for children as young as 3 years of age.
4. The Word-Graphic Rating Scale uses descriptive words and is recommended for children age 4-17 years.

Level of cognitive ability: Comprehension
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: Assessment

Explanation

1. The Poker Chip Tool has been validated for children age 4 years who have been determined to have the cognitive ability to identify the larger of 2 numbers.
2. The Visual Analog Scale can be used for children over 4 years of age, but is most appropriate for ages 7 and older.
3. The FACES Pain Rating Scale is for children as young as 3 years of age.
4. The Word-Graphic Rating Scale uses descriptive words and is recommended for children age 4-17 years.

Level of cognitive ability: Comprehension
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: Assessment

11. A pregnant woman at 10 weeks of gestation jogs three or four times per week. She is concerned about the effect of exercise on the fetus. The nurse should inform her:

"You don't need to modify your exercising any time during your pregnancy."

"Stop exercising, because it will harm the fetus."

"You may find that you need to modify your exercise to walking later in your pregnancy, around the seventh month."

"Jogging is too hard on your joints; switch to walking now."

Typically, running should be replaced with walking around the seventh month of pregnancy.

Explanation

Typically, running should be replaced with walking around the seventh month of pregnancy.

12. Which of the following is an important nursing consideration in the care of a child with celiac disease?

Refer to a nutritionist for detailed dietary instructions and education.

Help child and family understand that diet restrictions are usually only temporary.

Teach proper hand washing and Standard Precautions to prevent disease transmission.

Suggest ways to cope more effectively with stress to minimize symptoms.

1. The main consideration is helping the child adhere to dietary management. Considerable time is spent in explaining to the child and parents the disease process, the specific role of gluten in aggravating the condition, and those foods that must be restricted. Referral to a nutritionist would help in this process.
2. The most severe symptoms usually occur in early childhood and adult life. Dietary avoidance of gluten should be lifelong.
3. Celiac disease is not transmissible.
4. Celiac disease is not stress related.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Teaching/Learning

Explanation

1. The main consideration is helping the child adhere to dietary management. Considerable time is spent in explaining to the child and parents the disease process, the specific role of gluten in aggravating the condition, and those foods that must be restricted. Referral to a nutritionist would help in this process.
2. The most severe symptoms usually occur in early childhood and adult life. Dietary avoidance of gluten should be lifelong.
3. Celiac disease is not transmissible.
4. Celiac disease is not stress related.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Teaching/Learning

13. A woman taking an oral contraceptive pill (OCP) as her birth control method of choice should notify her health care provider immediately if she notes:

Breast tenderness and swelling

Weight gain

Swelling and pain in one of her legs

Mood swings

Leg pain and swelling (edema) may indicate thrombophlebitis and should be reported immediately.

Explanation

Leg pain and swelling (edema) may indicate thrombophlebitis and should be reported immediately.

14. The nurse should recognize that when a child develops diabetic ketoacidosis, this is which of the following?

Expected outcome

Best treated at home

Life-threatening situation

Best treated at practitioner’s office or clinic

3. Diabetic ketoacidosis is the state of complete insulin deficiency. It is a medical emergency that must be diagnosed and treated. The child is usually admitted to an intensive care unit for assessment, insulin administration, and fluid and electrolyte replacement.
1. Diabetic ketoacidosis is a medical emergency needing prompt assessment and intervention, usually in an intensive care environment.
2. Diabetic ketoacidosis is a medical emergency needing prompt assessment and intervention, usually in an intensive care environment.
4. Diabetic ketoacidosis is a medical emergency needing prompt assessment and intervention, usually in an intensive care environment.

Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Teaching/Learning; Nursing Process: Evaluation

Explanation

3. Diabetic ketoacidosis is the state of complete insulin deficiency. It is a medical emergency that must be diagnosed and treated. The child is usually admitted to an intensive care unit for assessment, insulin administration, and fluid and electrolyte replacement.
1. Diabetic ketoacidosis is a medical emergency needing prompt assessment and intervention, usually in an intensive care environment.
2. Diabetic ketoacidosis is a medical emergency needing prompt assessment and intervention, usually in an intensive care environment.
4. Diabetic ketoacidosis is a medical emergency needing prompt assessment and intervention, usually in an intensive care environment.

Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Teaching/Learning; Nursing Process: Evaluation

15. One of the goals for children with asthma is to prevent respiratory tract infection. This is because respiratory tract infection does which of the following?

Increases sensitivity to allergens

Causes exercise-induced asthma

Lessens effectiveness of medications

Can trigger an episode or aggravate asthmatic state

4. Viral respiratory tract infections can exacerbate asthma, especially in young children, whose airways are mechanically smaller and more reactive than those of older children.
1. Respiratory tract infections do not affect sensitivity to allergens.
2. Exercise precipitates exercise-induced asthma.
3. The respiratory tract infection does not lessen the effectiveness of the medications.

Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: Implementation

Explanation

4. Viral respiratory tract infections can exacerbate asthma, especially in young children, whose airways are mechanically smaller and more reactive than those of older children.
1. Respiratory tract infections do not affect sensitivity to allergens.
2. Exercise precipitates exercise-induced asthma.
3. The respiratory tract infection does not lessen the effectiveness of the medications.

Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: Implementation

16. An important nursing consideration when caring for a child with sickle cell anemia is which of the following?

Refer parents and child for genetic counseling.

Teach parents and child how to recognize signs and symptoms of crises.

Help the child and family adjust to a short-term disease.

Observe for complications of multiple blood transfusions.

2. Parents need specific instructions on the need to watch for changes in the child's condition, including adequate hydration, and environmental concerns.
1. Genetic counseling is important, but teaching care of the child is a priority.
3. Sickle cell anemia is a long-term, chronic illness.
4. Multiple blood transfusions are an option for some children with sickle cell disease. The priority for all children with this condition is properly preparing the parents to care for them.

Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Teaching/Learning

Explanation

2. Parents need specific instructions on the need to watch for changes in the child's condition, including adequate hydration, and environmental concerns.
1. Genetic counseling is important, but teaching care of the child is a priority.
3. Sickle cell anemia is a long-term, chronic illness.
4. Multiple blood transfusions are an option for some children with sickle cell disease. The priority for all children with this condition is properly preparing the parents to care for them.

Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Teaching/Learning

17. An adolescent girl dies in the emergency department after a car accident. Her family arrives at the hospital shortly after death. They request to see her body. Because she is disfigured from the accident, the most appropriate nursing action is which of the following?

Contact a clergyperson to discuss this problem with them.

Explain that their daughter is disfigured and it would be best not to see her.

Encourage them to wait for viewing until the funeral home has prepared her body.

Inform them of what to expect and then let them see their daughter.

4. Prepare the family before viewing by telling them what to expect. Include bodily changes from the accident, tubes, and cold skin.
1. The parents can be asked if they would like a clergyperson present. Requesting to see their daughter is not a problem.
2. Encouraging the parents to delay or to not see their daughter are not appropriate interventions. The parents should be accompanied by a staff member with bereavement training.
3. Encouraging the parents to delay or to not see their daughter are not appropriate interventions. The parents should be accompanied by a staff member with bereavement training.

Level of cognitive ability: Analysis
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: Implementation

Explanation

4. Prepare the family before viewing by telling them what to expect. Include bodily changes from the accident, tubes, and cold skin.
1. The parents can be asked if they would like a clergyperson present. Requesting to see their daughter is not a problem.
2. Encouraging the parents to delay or to not see their daughter are not appropriate interventions. The parents should be accompanied by a staff member with bereavement training.
3. Encouraging the parents to delay or to not see their daughter are not appropriate interventions. The parents should be accompanied by a staff member with bereavement training.

Level of cognitive ability: Analysis
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: Implementation

18. The nurse suspects a child is having an adverse reaction to a blood transfusion. The first action by the nurse should be which of the following?

Notify physician.

Take vital signs and blood pressure and compare them with baseline.

Dilute infusing blood with equal amounts of normal saline.

Stop transfusion and maintain a patent intravenous line with normal saline and new tubing.

4. Stopping the transfusion and maintaining a patent intravenous line with normal saline and new tubing is the priority nursing action. If an adverse reaction is occurring, it is essential to minimize the amount of blood that is infused.
1. Notifying a physician and taking vital signs and blood pressure should be performed after the blood transfusion is stopped and infusion of normal saline has begun.
2. Notifying a physician and taking vital signs and blood pressure should be performed after the blood transfusion is stopped and infusion of normal saline has begun.
3. Blood should not be diluted; it should be returned to the blood bank if an adverse reaction has occurred.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Pharmacologic and Parenteral Therapy
Integrated process: Nursing Process: Implementation

Explanation

4. Stopping the transfusion and maintaining a patent intravenous line with normal saline and new tubing is the priority nursing action. If an adverse reaction is occurring, it is essential to minimize the amount of blood that is infused.
1. Notifying a physician and taking vital signs and blood pressure should be performed after the blood transfusion is stopped and infusion of normal saline has begun.
2. Notifying a physician and taking vital signs and blood pressure should be performed after the blood transfusion is stopped and infusion of normal saline has begun.
3. Blood should not be diluted; it should be returned to the blood bank if an adverse reaction has occurred.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Pharmacologic and Parenteral Therapy
Integrated process: Nursing Process: Implementation

19. You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase IV fluid, and perform a vaginal exam. The cervix has not changed. Five minutes have passed, and the FHR remains in the 80s. What additional nursing measures should you take?

Call for help.

Insert a Foley catheter.

Start oxytocin (Pitocin).

Notify the primary health care provider immediately.

To relieve an FHR deceleration the nurse can reposition the mother, increase IV fluid, and provide oxygen. Also if oxytocin is infusing, it should be discontinued. If the FHR does not resolve, the primary health care provider should be notified immediately.

Explanation

To relieve an FHR deceleration the nurse can reposition the mother, increase IV fluid, and provide oxygen. Also if oxytocin is infusing, it should be discontinued. If the FHR does not resolve, the primary health care provider should be notified immediately.

20. Which of the following is the definition that best describes children with special health care needs?

Having a loss or abnormality of structure or function

Having a condition or barrier imposed by society, the environment, or one’s self

4. Being at increased risk for a chronic physical, behavioral, developmental, or emotional condition and also requiring health and related services of a type or amount beyond those required by children in general is the definition of children with special health care needs used by the federal Maternal and Child Health Bureau.
1. Having a loss or abnormality of structure or function is the definition of impairment.
2. Having a condition or barrier imposed by society, the environment, or one's self is the definition of handicap.
3. Having a condition that interferes with daily function for more than 3 months a year, causes hospitalization of more than 1 month a year, or is likely to do either of these is the definition of chronic illness.

Level of cognitive ability: Knowledge
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: Planning

Explanation

4. Being at increased risk for a chronic physical, behavioral, developmental, or emotional condition and also requiring health and related services of a type or amount beyond those required by children in general is the definition of children with special health care needs used by the federal Maternal and Child Health Bureau.
1. Having a loss or abnormality of structure or function is the definition of impairment.
2. Having a condition or barrier imposed by society, the environment, or one's self is the definition of handicap.
3. Having a condition that interferes with daily function for more than 3 months a year, causes hospitalization of more than 1 month a year, or is likely to do either of these is the definition of chronic illness.

Level of cognitive ability: Knowledge
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: Planning

21. The clinical manifestations of nephrotic syndrome include which of the following?

Hematuria, bacteriuria, weight gain

Gross hematuria, albuminuria, fever

Hypertension, weight loss, proteinuria

Proteinuria, hypoalbuminemia, edema

4. Edema, proteinuria, hypoalbuminemia, and hypercholesterolemia are the clinical manifestations of nephrotic syndrome in children.
1. Bacteriuria is not a diagnostic criterion for nephrotic syndrome.
2. Fever is not associated with nephrotic syndrome.
3. Weight gain occurs secondary to the edema.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Assessment

Explanation

4. Edema, proteinuria, hypoalbuminemia, and hypercholesterolemia are the clinical manifestations of nephrotic syndrome in children.
1. Bacteriuria is not a diagnostic criterion for nephrotic syndrome.
2. Fever is not associated with nephrotic syndrome.
3. Weight gain occurs secondary to the edema.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Assessment

22. Which of the following urine tests of renal function is used to estimate glomerular filtration?

PH

Creatinine

Osmolality

Protein level

2. The most useful clinical estimation of glomerular filtration is the clearance of creatinine. The production and secretion of creatinine remain relatively constant from day to day, and its appearance in the urine is determined by the serum level.
1. The pH is a measure of alkalinity, not glomerular filtration.
3. Osmolality is a measure of concentration.
4. Presence of protein is indicative of abnormal glomerular permeability.

Level of cognitive ability: Knowledge
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Assessment

Explanation

2. The most useful clinical estimation of glomerular filtration is the clearance of creatinine. The production and secretion of creatinine remain relatively constant from day to day, and its appearance in the urine is determined by the serum level.
1. The pH is a measure of alkalinity, not glomerular filtration.
3. Osmolality is a measure of concentration.
4. Presence of protein is indicative of abnormal glomerular permeability.

Level of cognitive ability: Knowledge
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Assessment

23. The father of a 9-year-old child with several physical disabilities tells the nurse that his son concentrates on what he can, rather than cannot, do and is as independent as possible. The nurse's best interpretation of this is which of the following?

The father is experiencing denial.

The father is expressing his own views.

Child is using an adaptive coping style.

Child is using a maladaptive coping style.

3. The father is describing a well-adapted child who has learned to accept physical limitations. These children function well at home, at school, and with peers. Their understanding of their disorder allows them to accept their limitations, assume responsibility for care, and assist in treatment and rehabilitation.
1. The father is describing his child's behavior. He is not denying the child's limitations.
2. The father is describing his child's behavior, not his own views.
4. The father is describing a well-adapted child who has learned to accept physical limitations. This is descriptive of an adaptive coping style.

Level of cognitive ability: Application
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: Assessment

Explanation

3. The father is describing a well-adapted child who has learned to accept physical limitations. These children function well at home, at school, and with peers. Their understanding of their disorder allows them to accept their limitations, assume responsibility for care, and assist in treatment and rehabilitation.
1. The father is describing his child's behavior. He is not denying the child's limitations.
2. The father is describing his child's behavior, not his own views.
4. The father is describing a well-adapted child who has learned to accept physical limitations. This is descriptive of an adaptive coping style.

Level of cognitive ability: Application
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: Assessment

24. The nurse caring for a pregnant woman knows that her health teaching regarding fetal circulation has been effective when the woman reports that she has been sleeping:

In a side-lying position

On her back with a pillow under her knees

With the head of the bed elevated

On her abdomen

Optimal circulation is achieved when the woman is lying at rest on her side. Decreased uterine circulation may lead to intrauterine growth restriction. Previously it was believed that the left lateral position promoted maternal cardiac output, thereby enhancing blood flow to the fetus. However, it is now known that either side-lying position enhances uteroplacental blood flow.

Explanation

Optimal circulation is achieved when the woman is lying at rest on her side. Decreased uterine circulation may lead to intrauterine growth restriction. Previously it was believed that the left lateral position promoted maternal cardiac output, thereby enhancing blood flow to the fetus. However, it is now known that either side-lying position enhances uteroplacental blood flow.

25. The nurse is caring for a child dying from cancer. Parents ask how they will know that the child is approaching death. The nurse's answer should include which of the following?

Rapid pulse

Change in respiratory pattern

Sensation of cold although body feels hot

Loss of hearing followed by loss of other senses

2. The respiratory pattern will become slower and shallower with periodic deep sighs, followed by Cheyne-Stokes respirations and the "death rattle."
1. The pulse rate will slow.
3. The child may have sensations of heat, while the body feels cool.
4. Hearing is the last sense to fail.

Level of cognitive ability: Comprehension
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Teaching/Learning

Explanation

2. The respiratory pattern will become slower and shallower with periodic deep sighs, followed by Cheyne-Stokes respirations and the "death rattle."
1. The pulse rate will slow.
3. The child may have sensations of heat, while the body feels cool.
4. Hearing is the last sense to fail.

Level of cognitive ability: Comprehension
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Teaching/Learning

26. Which of the following interventions will foster a sense of independence in a toddler with disabilities?

Help parents learn special care needs of their child.

Help parents provide safe opportunities to explore the environment at home and in the hospital.

Expose child to pleasurable experiences as much as possible.

Avoid separation from family during hospitalization.

2. Within the constraints of the disability, parents should provide safe opportunities for exploration that foster independence at home and in the hospital.
1. Helping parents learn special care needs of their child and avoiding separation from family during hospitalization are part of family-centered care. They do not necessarily foster autonomy.
3. Exposing the child to pleasurable experiences, especially sensory ones, is a supportive intervention. It does not support autonomy.
4. Helping parents learn special care needs of their child and avoiding separation from family during hospitalization are part of family-centered care. They do not necessarily foster autonomy.

Level of cognitive ability: Analysis
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: Planning

Explanation

2. Within the constraints of the disability, parents should provide safe opportunities for exploration that foster independence at home and in the hospital.
1. Helping parents learn special care needs of their child and avoiding separation from family during hospitalization are part of family-centered care. They do not necessarily foster autonomy.
3. Exposing the child to pleasurable experiences, especially sensory ones, is a supportive intervention. It does not support autonomy.
4. Helping parents learn special care needs of their child and avoiding separation from family during hospitalization are part of family-centered care. They do not necessarily foster autonomy.

Level of cognitive ability: Analysis
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: Planning

27. Which of the following is the primary clinical manifestation of acute renal failure?

Oliguria

Hematuria

Proteinuria

Bacteriuria

1. Oliguria is the primary clinical symptom of acute renal failure. Generally, urinary output is less than 1 ml/kg/hr.
2. Hematuria, proteinuria, and bacteriuria may be present in renal disease, but they are not the primary manifestations of acute renal failure.
3. Hematuria, proteinuria, and bacteriuria may be present in renal disease, but they are not the primary manifestations of acute renal failure.
4. Hematuria, proteinuria, and bacteriuria may be present in renal disease, but they are not the primary manifestations of acute renal failure.

Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Teaching/Learning; Nursing Process: Planning

Explanation

1. Oliguria is the primary clinical symptom of acute renal failure. Generally, urinary output is less than 1 ml/kg/hr.
2. Hematuria, proteinuria, and bacteriuria may be present in renal disease, but they are not the primary manifestations of acute renal failure.
3. Hematuria, proteinuria, and bacteriuria may be present in renal disease, but they are not the primary manifestations of acute renal failure.
4. Hematuria, proteinuria, and bacteriuria may be present in renal disease, but they are not the primary manifestations of acute renal failure.

Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Teaching/Learning; Nursing Process: Planning

28. A 13-year-old girl is brought to the clinic with the complaint of insomnia and hyperactivity. Other symptoms include gradual weight loss despite a good appetite; warm, flushed, and moist skin; and unusually fine hair. These manifestations are most suggestive of which of the following?

Hypothyroidism

Hyperthyroidism

Hypoparathyroidism

Hyperparathyroidism

2. These symptoms are suggestive of hyperthyroidism. Other symptoms include academic difficulties resulting from a short attention span and inability to sit still, unexplained fatigue and sleeplessness, and difficulty with fine motor skills.
1. Hypothyroidism is seen with decelerated growth from chronic deprivation of thyroid hormone. Other manifestations are myxedematous skin changes (dry skin, puffiness around the eyes, sparse hair), constipation, sleepiness, and mental decline.
3. Early manifestations of hypoparathyroidism may be anxiety and mental depression, followed by paresthesia and evidence of heightened neuromuscular excitability.
4. Hyperparathyroidism results in hypercalcemia, which can be manifested by a change in behavior, gastrointestinal symptoms, and cardiac irregularities.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Assessment

Explanation

2. These symptoms are suggestive of hyperthyroidism. Other symptoms include academic difficulties resulting from a short attention span and inability to sit still, unexplained fatigue and sleeplessness, and difficulty with fine motor skills.
1. Hypothyroidism is seen with decelerated growth from chronic deprivation of thyroid hormone. Other manifestations are myxedematous skin changes (dry skin, puffiness around the eyes, sparse hair), constipation, sleepiness, and mental decline.
3. Early manifestations of hypoparathyroidism may be anxiety and mental depression, followed by paresthesia and evidence of heightened neuromuscular excitability.
4. Hyperparathyroidism results in hypercalcemia, which can be manifested by a change in behavior, gastrointestinal symptoms, and cardiac irregularities.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Assessment

29. Which of the following best describes the 4-year-old child's concept of death?

Death is temporary.

Death is permanent.

Death is inevitable at some age.

Death is personified in various forms.

1. Preschool-age children view death as a type of departure. It is temporary and reversible.
2. The older school-age child recognizes the permanence and inevitability of death.
3. The older school-age child recognizes the permanence and inevitability of death.
4. The young school-age child personifies death as the devil, God, or a bogeyman.

Level of cognitive ability: Comprehension
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Documentation and Communication

Explanation

1. Preschool-age children view death as a type of departure. It is temporary and reversible.
2. The older school-age child recognizes the permanence and inevitability of death.
3. The older school-age child recognizes the permanence and inevitability of death.
4. The young school-age child personifies death as the devil, God, or a bogeyman.

Level of cognitive ability: Comprehension
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Documentation and Communication

30. When teaching self-care prevention of genital tract infections, the nurse should instruct the woman to:

Increase dietary sugar and avoid yogurt

Limit time spent in damp exercise clothes and limit exposure to bath salts or bubble bath

Choose underwear or hosiery with a nylon crotch

Douche frequently

Clinical observations and research have suggested that tight-fitting clothing and underwear or pantyhose made of nonabsorbent materials create an environment in which a vaginal fungus can grow. Bathing in bath salts or bubble bath may further irritate sensitive genital tissue.

Explanation

Clinical observations and research have suggested that tight-fitting clothing and underwear or pantyhose made of nonabsorbent materials create an environment in which a vaginal fungus can grow. Bathing in bath salts or bubble bath may further irritate sensitive genital tissue.

31. A school-age child with cancer is beginning to feel better now that the necessary medical procedures and treatments are not so traumatic. The child has also become very uncooperative with the parents. The nurse should explain that:

The child is denying the seriousness of the illness.

This is a common reaction and a way to express anger.

More discipline is needed to deal with the uncooperativeness.

Permissiveness is needed as child copes with a life-threatening illness.

2. Children of this age-group are likely to exhibit fears through verbal uncooperativeness. It is the child's attempt to have some control over what is happening.
1. The child recognizes the seriousness of the illness and is attempting to exercise control.
3. Stricter discipline will not help with the child's behavior. It is necessary to allow the child to communicate feelings and provide outlets for aggression.
4. The child needs to have the support of the family and health care team. Structure is necessary with opportunities for communication and control when feasible.

Level of cognitive ability: Comprehension
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Documentation and Communication

Explanation

2. Children of this age-group are likely to exhibit fears through verbal uncooperativeness. It is the child's attempt to have some control over what is happening.
1. The child recognizes the seriousness of the illness and is attempting to exercise control.
3. Stricter discipline will not help with the child's behavior. It is necessary to allow the child to communicate feelings and provide outlets for aggression.
4. The child needs to have the support of the family and health care team. Structure is necessary with opportunities for communication and control when feasible.

Level of cognitive ability: Comprehension
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Documentation and Communication

32. An essential component of counseling women regarding safe sex practices includes discussion regarding avoiding the exchange of body fluids. The physical barrier promoted for the prevention of sexually transmitted infections (STIs) and human immunodeficiency virus (HIV) is the condom. Nurses can help motivate clients to use condoms by initiating a discussion related to a number of aspects of condom use. The most important of these is:

Strategies to enhance condom use

Choice of colors and special features

Leaving the decision up to the male partner

Places to safely carry condoms

When the nurse opens discussion on safe sex practices, this gives the woman permission to clear up any concerns or misapprehensions she may have regarding condom use. The nurse can also suggest ways that the woman can enhance her condom negotiation and communications skills. These include role-playing, rehearsal, cultural barriers, and situations that put the client at risk.

Explanation

When the nurse opens discussion on safe sex practices, this gives the woman permission to clear up any concerns or misapprehensions she may have regarding condom use. The nurse can also suggest ways that the woman can enhance her condom negotiation and communications skills. These include role-playing, rehearsal, cultural barriers, and situations that put the client at risk.

33. Which of the following is the primary clinical manifestation of diabetes insipidus?

Oliguria

Glycosuria

Nausea, vomiting

Polyuria, polydipsia

4. Diabetes insipidus results from the hyposecretion of antidiuretic hormone. Since insufficient amounts are produced, excessive amounts of urine are produced. When allowed access to fluids, the child maintains balance with an almost insatiable thirst.
1. Oliguria is diminished urinary output. Children with diabetes insipidus have increased urinary output.
2. Glycosuria is not a manifestation of diabetes insipidus. It may be a manifestation of diabetes mellitus.
3. Nausea and vomiting are not manifestations of diabetes insipidus. They can occur with oversecretion of antidiuretic hormone.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Assessment

Explanation

4. Diabetes insipidus results from the hyposecretion of antidiuretic hormone. Since insufficient amounts are produced, excessive amounts of urine are produced. When allowed access to fluids, the child maintains balance with an almost insatiable thirst.
1. Oliguria is diminished urinary output. Children with diabetes insipidus have increased urinary output.
2. Glycosuria is not a manifestation of diabetes insipidus. It may be a manifestation of diabetes mellitus.
3. Nausea and vomiting are not manifestations of diabetes insipidus. They can occur with oversecretion of antidiuretic hormone.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Assessment

34. The nurse is talking with the parent of a child newly diagnosed with a chronic illness. The parent is upset and tearful. The nurse asks, "When something is worrying you, what do you do?" This should be interpreted as which of the following?

Verbal cue to stop crying

Part of assessing parent’s coping skills

Inappropriate, because parent is so upset

Diverting the present crisis to similar situations with which parent has dealt

2. Assessments of coping skills are important data for the nurse to obtain. This question will provide information about the marital relationship (does the parent speak to the spouse?), alternate support systems, and ability to communicate. By assessing these areas, the nurse can facilitate the identification and use of community resources as needed.
1. Emotional support is necessary. The nurse should acknowledge with body and facial language how difficult the diagnosis is for the parents. Tissues should be available.
3. Assessment of coping skills is an important part of assessment information.
4. The nurse is obtaining information to help support the parent through the diagnosis.

Level of cognitive ability: Analysis
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: Assessment

Explanation

2. Assessments of coping skills are important data for the nurse to obtain. This question will provide information about the marital relationship (does the parent speak to the spouse?), alternate support systems, and ability to communicate. By assessing these areas, the nurse can facilitate the identification and use of community resources as needed.
1. Emotional support is necessary. The nurse should acknowledge with body and facial language how difficult the diagnosis is for the parents. Tissues should be available.
3. Assessment of coping skills is an important part of assessment information.
4. The nurse is obtaining information to help support the parent through the diagnosis.

Level of cognitive ability: Analysis
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: Assessment

35. Pyloric stenosis can best be described as which of the following?

Dilation of pylorus

Hypertrophy of pyloric muscle

Hypotonicity of pyloric muscle

Reduction of tone in the pyloric muscle

2. Hypertrophic pyloric stenosis occurs when the circumferential muscle of the pyloric sphincter becomes thickened, resulting in elongation and narrowing of the pyloric channel.
1. Dilation of pylorus, hypotonicity of pyloric muscle, and reduction of tone in the pyloric muscle are not the definition of pyloric stenosis.
3. Dilation of pylorus, hypotonicity of pyloric muscle, and reduction of tone in the pyloric muscle are not the definition of pyloric stenosis.
4. Dilation of pylorus, hypotonicity of pyloric muscle, and reduction of tone in the pyloric muscle are not the definition of pyloric stenosis.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: Assessment

Explanation

2. Hypertrophic pyloric stenosis occurs when the circumferential muscle of the pyloric sphincter becomes thickened, resulting in elongation and narrowing of the pyloric channel.
1. Dilation of pylorus, hypotonicity of pyloric muscle, and reduction of tone in the pyloric muscle are not the definition of pyloric stenosis.
3. Dilation of pylorus, hypotonicity of pyloric muscle, and reduction of tone in the pyloric muscle are not the definition of pyloric stenosis.
4. Dilation of pylorus, hypotonicity of pyloric muscle, and reduction of tone in the pyloric muscle are not the definition of pyloric stenosis.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: Assessment

36. A woman is 8 months pregnant. She tells the nurse that she knows her baby listens to her, but her husband thinks she is imagining things. Which response by the nurse is most appropriate?

"Many women imagine what their baby is like."

"A baby in utero does respond to the mother's voice."

"You'll need to ask the doctor if the baby can hear yet."

"Thinking that your baby hears will help you bond with the baby."

Fetuses respond to sound by 24 weeks. The fetus can be soothed by the sound of the mother's voice.

Explanation

Fetuses respond to sound by 24 weeks. The fetus can be soothed by the sound of the mother's voice.

37. When planning care for a 4-month-old child admitted with respiratory distress caused by respiratory syncytial virus (RSV) and bronchiolitis, it is essential to include which of the following?

Give antibiotics.

Ensure adequate hydration.

Administer cough syrup.

Feed 4 oz of formula every 4 hours.

2. When respiratory distress is present, hydration is an essential consideration. Usually infants cannot take fluids by the oral route because of the difficulty breathing. Intravenous fluid administration may be necessary.
1. RSV is a virus. Antibiotics are not beneficial.
3. Cough syrup is not routinely used in RSV.
4. Although fluid and calories are important, the infant with respiratory distress is usually unable to drink this amount of fluid.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Pharmacologic and Parenteral Therapy
Integrated process: Nursing Process: Planning

Explanation

2. When respiratory distress is present, hydration is an essential consideration. Usually infants cannot take fluids by the oral route because of the difficulty breathing. Intravenous fluid administration may be necessary.
1. RSV is a virus. Antibiotics are not beneficial.
3. Cough syrup is not routinely used in RSV.
4. Although fluid and calories are important, the infant with respiratory distress is usually unable to drink this amount of fluid.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Pharmacologic and Parenteral Therapy
Integrated process: Nursing Process: Planning

38. A woman in active labor receives an opioid agonist analgesic. Which medication relieves severe, persistent, or recurrent pain, creates a sense of well-being, overcomes inhibitory factors, and may even relax the cervix but should be used cautiously in women with cardiac disease?

Meperidine (Demerol)

Promethazine (Phenergan)

Butorphanol tartrate (Stadol)

Nalbuphine (Nubain)

Meperidine is the most commonly used opioid agonist analgesic for women in labor throughout the world. It overcomes inhibitory factors in labor and may even relax the cervix. Because tachycardia is a possible adverse reaction, meperidine is used cautiously in women with cardiac disease.

Explanation

Meperidine is the most commonly used opioid agonist analgesic for women in labor throughout the world. It overcomes inhibitory factors in labor and may even relax the cervix. Because tachycardia is a possible adverse reaction, meperidine is used cautiously in women with cardiac disease.

39. Parents tell the nurse that their 7-year-old daughter wants to see her brother's body and attend the funeral. Which of the following should the nurse do?

Encourage child to attend funeral but not see the body.

Refer the child to someone who can assess her readiness for these experiences.

Suggest that instead of these experiences the child visit the grave site after the services are over.

Explain that her parents or another significant person should provide support during these experiences.

4. For children of this age and older, attendance at funerals is both useful and meaningful. It helps the child acknowledge the death, honor the deceased, and receive comfort and support from a parent or significant person.
1. If an open coffin is used for the funeral, the child should be prepared for how her brother will look.
2. The child is asking to attend. Children who participate in the funeral planning and attend the services have higher self-esteem than those who are excluded.
3. The child is asking to attend. Children who participate in the funeral planning and attend the services have higher self-esteem than those who are excluded.

Level of cognitive ability: Analysis
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: Implementation

Explanation

4. For children of this age and older, attendance at funerals is both useful and meaningful. It helps the child acknowledge the death, honor the deceased, and receive comfort and support from a parent or significant person.
1. If an open coffin is used for the funeral, the child should be prepared for how her brother will look.
2. The child is asking to attend. Children who participate in the funeral planning and attend the services have higher self-esteem than those who are excluded.
3. The child is asking to attend. Children who participate in the funeral planning and attend the services have higher self-esteem than those who are excluded.

Level of cognitive ability: Analysis
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: Implementation

40. In providing nourishment for a child with cystic fibrosis (CF), which of the following factors should the nurse keep in mind?

Fats and proteins must be greatly curtailed.

Diet should be high in calories and protein.

Most fruits and vegetables are not well tolerated.

Diet should be high in easily digested carbohydrates and fats.

2. Children with CF require a well-balanced, high-protein, high-calorie diet because of impaired intestinal absorption.
1. Fats and proteins are a necessary part of a well-balanced diet.
3. A well-balanced diet containing fruits and vegetables is important.
4. Enzyme supplementation helps digest foods; other modifications are not necessary.

Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: Implementation

Explanation

2. Children with CF require a well-balanced, high-protein, high-calorie diet because of impaired intestinal absorption.
1. Fats and proteins are a necessary part of a well-balanced diet.
3. A well-balanced diet containing fruits and vegetables is important.
4. Enzyme supplementation helps digest foods; other modifications are not necessary.

Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: Implementation

41. The nurse is caring for a child hospitalized with acute adrenocortical insufficiency. Because of the sudden, severe nature of the disease the family needs a great deal of emotional support. The most appropriate nursing action is which of the following?

Prepare family for impending death.

Prepare the family for each procedure.

Prepare family for long-term consequences of paralysis.

Reassure family that flaccid paralysis is not problematic.

2. By preparing the family for each procedure, the nurse is showing sensitivity to the family's emotional needs.
1. Acute adrenocortical insufficiency is a reversible condition when associated with adrenocortical insufficiency.
3. Acute adrenocortical insufficiency is a reversible condition when associated with adrenocortical insufficiency.
4. Flaccid paralysis is problematic if not reversible.

Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Teaching/Learning

Explanation

2. By preparing the family for each procedure, the nurse is showing sensitivity to the family's emotional needs.
1. Acute adrenocortical insufficiency is a reversible condition when associated with adrenocortical insufficiency.
3. Acute adrenocortical insufficiency is a reversible condition when associated with adrenocortical insufficiency.
4. Flaccid paralysis is problematic if not reversible.

Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Teaching/Learning

42. Which of the following types of croup is always considered a medical emergency?

Laryngitis

Epiglottitis

Spasmodic croup

Laryngotracheobronchitis

2. Epiglottitis is always a medical emergency needing antibiotics and airway support for treatment.
1. Laryngitis is a common viral illness in older children and adolescents, with hoarseness and upper respiratory tract infection symptoms.
3. Spasmodic croup is treated with humidity.
4. Laryngotracheobronchitis may progress to a medical emergency in some children.

Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: Planning

Explanation

2. Epiglottitis is always a medical emergency needing antibiotics and airway support for treatment.
1. Laryngitis is a common viral illness in older children and adolescents, with hoarseness and upper respiratory tract infection symptoms.
3. Spasmodic croup is treated with humidity.
4. Laryngotracheobronchitis may progress to a medical emergency in some children.

Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: Planning

43. During a health history interview, a woman tells the nurse that her husband physically abuses her. The nurse's first response should be to:

Advise the woman of mandatory state reporting laws pertaining to abuse and confidentiality

Reassure the woman that the abuse is not her fault

Give the woman referrals to local agencies and shelters where she can obtain help

Formulate an escape plan for the woman that she can use the next time her husband abuses her

Many states have mandatory reporting laws for health care providers. It is important to inform the woman that you may need to report this. Nurses should be knowledgeable about the reporting requirements of the state in which they practice.

Explanation

Many states have mandatory reporting laws for health care providers. It is important to inform the woman that you may need to report this. Nurses should be knowledgeable about the reporting requirements of the state in which they practice.

44. A 5-year-old has patient-controlled analgesia (PCA) for pain management following abdominal surgery. Your explanation to the parents should include:

The child will be pain free.

Only the child is allowed to push the button for a bolus.

The pump allows for a continuous basal rate and delivers a constant amount of medication to control pain.

There is a high risk of overdose so monitoring is done every 15 minutes.

3. The PCA prescription can be set for a basal rate for a continued infusion of pain medication to prevent pain from returning during sleep and when patient cannot control the infusion.
1. Although the goal of PCA is to have effective pain relief, a pain-free state may not be possible. With a child of 5, the parents and nurse must assess the child to ensure that adequate medication is being given.
2. A child of 5 may not be able to understand the concept of pushing a button. Evidence suggests that effective analgesia can be obtained with the parents and nurse giving boluses as necessary.
4. The prescription for the PCA includes how much medication can be given in a defined period. Monitoring every 1 to 2 hours for patient response is sufficient.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Teaching/Learning

Explanation

3. The PCA prescription can be set for a basal rate for a continued infusion of pain medication to prevent pain from returning during sleep and when patient cannot control the infusion.
1. Although the goal of PCA is to have effective pain relief, a pain-free state may not be possible. With a child of 5, the parents and nurse must assess the child to ensure that adequate medication is being given.
2. A child of 5 may not be able to understand the concept of pushing a button. Evidence suggests that effective analgesia can be obtained with the parents and nurse giving boluses as necessary.
4. The prescription for the PCA includes how much medication can be given in a defined period. Monitoring every 1 to 2 hours for patient response is sufficient.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Teaching/Learning

45. The nurse is caring postoperatively for an 8-year-old child with multiple fractures and other trauma resulting from a motor vehicle injury. The child is experiencing severe pain. Which of the following is an important consideration in managing the child's pain?

Give only an opioid analgesic at this time.

Increase the dosage of analgesic until the child is adequately sedated.

Plan a preventive schedule of pain medication around the clock.

Give the child a clock and explain when she or he can have pain medications.

3. For severe postoperative pain, a preventive around-the-clock schedule is necessary to prevent decreased plasma levels of medications.
1. The opioid analgesic will help for the present, but it is not an effective strategy.
2. Increasing the dosage requires an order. The nurse should give the drug on a regular schedule and evaluate the effectiveness.
4. This strategy is counterproductive. It focuses the child's attention on how long he or she will need to wait for pain relief.

Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Planning

Explanation

3. For severe postoperative pain, a preventive around-the-clock schedule is necessary to prevent decreased plasma levels of medications.
1. The opioid analgesic will help for the present, but it is not an effective strategy.
2. Increasing the dosage requires an order. The nurse should give the drug on a regular schedule and evaluate the effectiveness.
4. This strategy is counterproductive. It focuses the child's attention on how long he or she will need to wait for pain relief.

Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Planning

46. A school-age child recently diagnosed with type 1 diabetes mellitus asks the nurse if he can still play soccer, play baseball, and swim. The nurse's response should be based on knowledge that:

Exercise is contraindicated.

The level of activity depends on the type of insulin required.

Exercise is not restricted unless indicated by other health conditions.

Soccer and baseball are too strenuous, but swimming is acceptable.

3. Exercise is encouraged for children with diabetes because it lowers blood glucose levels. Insulin and meal requirements require careful monitoring to ensure that the child has sufficient energy for exercise.
1. Exercise is highly encouraged. The decrease in blood glucose can be accommodated by having snacks available.
2. The level of activity is not dependent on the type of insulin used. Long- and short-acting insulin both may be used to compensate for the effects of training and sporting events.
4. Sports are encouraged to help regulate the insulin, and food should be adjusted according to the amount of exercise. The child needs to be cautioned to monitor responses to the exercises.

Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Teaching/Learning

Explanation

3. Exercise is encouraged for children with diabetes because it lowers blood glucose levels. Insulin and meal requirements require careful monitoring to ensure that the child has sufficient energy for exercise.
1. Exercise is highly encouraged. The decrease in blood glucose can be accommodated by having snacks available.
2. The level of activity is not dependent on the type of insulin used. Long- and short-acting insulin both may be used to compensate for the effects of training and sporting events.
4. Sports are encouraged to help regulate the insulin, and food should be adjusted according to the amount of exercise. The child needs to be cautioned to monitor responses to the exercises.

Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Teaching/Learning

47. Which of the following statements best describes Cushing syndrome?

It is caused by excessive production of cortisol.

Treatment involves replacement of cortisol.

The major clinical features are exophthalmia and pigmentary changes.

Diagnosis is suspected with findings of hypotension, hyperkalemia, and polyuria.

1. Cushing syndrome is a description of the clinical manifestations caused by too much circulating cortisol. In children this is caused by a tumor or excessive and prolonged steroid therapy.
2. The treatment is reduction of circulating cortisol. If the cause is a pituitary tumor, surgery is indicated.
3. Exophthalmia is a manifestation of hyperthyroidism, not Cushing syndrome.
4. Hypertension and hypokalemia are expected findings.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Assessment

Explanation

1. Cushing syndrome is a description of the clinical manifestations caused by too much circulating cortisol. In children this is caused by a tumor or excessive and prolonged steroid therapy.
2. The treatment is reduction of circulating cortisol. If the cause is a pituitary tumor, surgery is indicated.
3. Exophthalmia is a manifestation of hyperthyroidism, not Cushing syndrome.
4. Hypertension and hypokalemia are expected findings.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Assessment

48. Which of the following heart defects causes hypoxemia and cyanosis because desaturated venous blood is entering the systemic circulation?

Coarctation of the aorta

Atrial septal defect

Patent ductus arteriosus

Tetralogy of Fallot

4. Tetralogy of Fallot is a cardiac defect that has a mixed blood circulation.
1. Coarctation of the aorta is an obstructive defect. There is no mixing of oxygenated and unoxygenated blood.
2. Atrial septal defect and patent ductus arteriosus have increased flow of blood to the pulmonary system. The pressure gradient allows for oxygenated blood to return to the lungs.
3. Atrial septal defect and patent ductus arteriosus have increased flow of blood to the pulmonary system. The pressure gradient allows for oxygenated blood to return to the lungs.

Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: Planning

Explanation

4. Tetralogy of Fallot is a cardiac defect that has a mixed blood circulation.
1. Coarctation of the aorta is an obstructive defect. There is no mixing of oxygenated and unoxygenated blood.
2. Atrial septal defect and patent ductus arteriosus have increased flow of blood to the pulmonary system. The pressure gradient allows for oxygenated blood to return to the lungs.
3. Atrial septal defect and patent ductus arteriosus have increased flow of blood to the pulmonary system. The pressure gradient allows for oxygenated blood to return to the lungs.

Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: Planning

49. The nurse is talking with the parents of a child who died 6 months ago. They sometimes still "hear" the child's voice and have trouble sleeping. They describe feeling empty and depressed. The nurse should recognize which of the following?

These are normal grief responses.

The pain of the loss is usually less by this time.

These grief responses are more typical of the early stages of grief.

This grieving is essential until the pain is gone and the child is gradually forgotten.

1. Hearing the child, troubles sleeping, feeling empty and depressed are normal grief responses. The grief response is lengthy.
2. The resolution of grief may take years, with an intensification of grief during the early years.
3. The resolution of grief may take years, with an intensification of grief during the early years.
4. The child will never be forgotten by the parents.

Level of cognitive ability: Comprehension
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: Assessment

Explanation

1. Hearing the child, troubles sleeping, feeling empty and depressed are normal grief responses. The grief response is lengthy.
2. The resolution of grief may take years, with an intensification of grief during the early years.
3. The resolution of grief may take years, with an intensification of grief during the early years.
4. The child will never be forgotten by the parents.

Level of cognitive ability: Comprehension
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: Assessment

50. In understanding and guiding a woman through her acceptance of pregnancy, a maternity nurse should be aware that:

Nonacceptance of the pregnancy very often equates to rejection of the child

Ambivalent feelings during pregnancy usually are seen only in emotionally immature or very young mothers

Mood swings are natural and are likely to affect every woman to some degree.

Explanation

Mood swings are natural and are likely to affect every woman to some degree.

51. A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure is to use:

Counterpressure against the sacrum

Pant-blow (breaths and puffs) breathing techniques

Effleurage

Biofeedback

Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back.

Explanation

Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back.

52. Women with severe and persistent mental illness are likely to be more vulnerable to being involved in controlling and/or violent relationships. However, many women develop mental health problems as a result of long-term abuse. The psychologic consequences of continued abuse do not include:

Substance abuse

Posttraumatic stress disorder (PTSD)

Eating disorders

Bipolar disorder

Bipolar disorder is a specific illness (also known as manic depressive disorder) not related to abuse.

Explanation

Bipolar disorder is a specific illness (also known as manic depressive disorder) not related to abuse.

53. A child who has been receiving morphine intravenously will now start receiving it orally. The nurse should anticipate that to achieve equianalgesia (equal analgesic effect), the oral dose will be which of the following?

Same as the intravenous dose

Greater than the intravenous dose

One half of the intravenous dose

One fourth of the intravenous dose

2. Oral morphine undergoes significant metabolism from the first-pass effect. For this reason, a higher oral dose is necessary to achieve the same effect as parenteral morphine.
1. The same dose given orally will provide less pain relief.
3. A larger dose must be given to achieve an equianalgesic effect.
4. A larger dose must be given to achieve an equianalgesic effect.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Planning

Explanation

2. Oral morphine undergoes significant metabolism from the first-pass effect. For this reason, a higher oral dose is necessary to achieve the same effect as parenteral morphine.
1. The same dose given orally will provide less pain relief.
3. A larger dose must be given to achieve an equianalgesic effect.
4. A larger dose must be given to achieve an equianalgesic effect.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Planning

54. Nurses can advise their clients that all are signs that precede labor except:

A return of urinary frequency as a result of increased bladder pressure

Persistent low backache from relaxed pelvic joints

Stronger and more frequent uterine (Braxton Hicks) contractions

A decline in energy, as the body stores up for labor

A surge of energy is a phenomenon that is common in the days preceding labor.

Explanation

A surge of energy is a phenomenon that is common in the days preceding labor.

55. Nursing considerations related to the administration of chemotherapeutic drugs include which of the following?

Anaphylaxis cannot occur, since the drugs are considered toxic to normal cells.

Infiltration will not occur unless superficial veins are used for the intravenous infusion.

Many chemotherapeutic agents are vesicants that can cause severe cellular damage if drug infiltrates.

Good hand washing is essential when handling chemotherapeutic drugs, but gloves are not necessary.

3. Chemotherapeutic agents can be extremely damaging to cells. Nurses experienced with the administration of vesicant drugs should be responsible for giving these drugs and be prepared to treat extravasations if necessary.
1. Anaphylaxis is a possibility with some chemotherapeutic and immunologic agents.
2. Infiltration and extravasations are always a risk, especially with peripheral veins.
4. Gloves are worn to protect the nurse when handling the drugs, and the hands should be thoroughly washed afterward.

Explanation

3. Chemotherapeutic agents can be extremely damaging to cells. Nurses experienced with the administration of vesicant drugs should be responsible for giving these drugs and be prepared to treat extravasations if necessary.
1. Anaphylaxis is a possibility with some chemotherapeutic and immunologic agents.
2. Infiltration and extravasations are always a risk, especially with peripheral veins.
4. Gloves are worn to protect the nurse when handling the drugs, and the hands should be thoroughly washed afterward.

56. The parents of a child hospitalized with sickle cell anemia tell the nurse that they are concerned about narcotic analgesics causing addiction. The nurse should explain which of the following concerning narcotic analgesics?

They are often ordered but not usually needed.

When they are medically indicated, children rarely become addicted.

They are given as a last resort because of the threat of addiction.

They are used only if other measures, such as ice packs, are ineffective.

2. Pain is the most common and debilitating symptom experienced by patients with sickle cell disease.
1. The chronic nature of this pain can greatly affect the child's development. A multidisciplinary approach is best for its management.
3. Patient-controlled analgesia or continuous intravenous administration is usually effective.
4. Pharmacologic intervention is necessary for the pain of sickle cell crisis.

Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Pharmacologic and Parenteral Therapy
Integrated process: Teaching/Learning

Explanation

2. Pain is the most common and debilitating symptom experienced by patients with sickle cell disease.
1. The chronic nature of this pain can greatly affect the child's development. A multidisciplinary approach is best for its management.
3. Patient-controlled analgesia or continuous intravenous administration is usually effective.
4. Pharmacologic intervention is necessary for the pain of sickle cell crisis.

Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Pharmacologic and Parenteral Therapy
Integrated process: Teaching/Learning

57. A maternity nurse should be aware of which fact about the amniotic fluid?

It serves as a source of oral fluid and as a repository for waste from the fetus.

The volume remains about the same throughout the term of a healthy pregnancy.

A volume of less than 300 ml is associated with gastrointestinal malformations.

A volume of more than 2 L is associated with fetal renal abnormalities.

Amniotic fluid also cushions the fetus and helps maintain a constant body temperature.

Explanation

Amniotic fluid also cushions the fetus and helps maintain a constant body temperature.

58. Which of the following is the most consistent and commonly used indicator of pain in infants?

Increased respirations

Increased heart rate

Thrashing of arms and legs

Facial expression of discomfort

4. Facial expression has consistently been validated as an indicator of pain in infants. Behavioral pain measures are most reliable for sharp procedural pain in infants.
1. Increased heart rate and respirations are indicative of a generalized and complex response to stress. They are not specific for pain in infants.
2. Increased heart rate and respirations are indicative of a generalized and complex response to stress. They are not specific for pain in infants.
3. Thrashing of arms and legs is a reliable indicator in young children, not infants.

Level of cognitive ability: Comprehension
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: Assessment

Correct Answer(s): D

Explanation

4. Facial expression has consistently been validated as an indicator of pain in infants. Behavioral pain measures are most reliable for sharp procedural pain in infants.
1. Increased heart rate and respirations are indicative of a generalized and complex response to stress. They are not specific for pain in infants.
2. Increased heart rate and respirations are indicative of a generalized and complex response to stress. They are not specific for pain in infants.
3. Thrashing of arms and legs is a reliable indicator in young children, not infants.

Level of cognitive ability: Comprehension
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: Assessment

Correct Answer(s): D

59. A school-age child with cancer is being prepared for a procedure. The child says, "I have had one of these. They hurt." The nurse's response should be based on knowledge that children:

Often lie about experiencing pain.

Tolerate pain better than adults.

Become accustomed to painful procedures.

Commonly experience treatment-related moderate to severe pain when they have cancer.

4. Pain is reported by approximately 84% of children with cancer. Of these, most report it as moderate to severe, and half report the pain as highly distressing.
1. There are no data to support that children misrepresent pain experiences.
2. Pain tolerance is a complex phenomenon that is not based on age.
3. Children do not become accustomed to painful procedures.

Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Implementation

Explanation

4. Pain is reported by approximately 84% of children with cancer. Of these, most report it as moderate to severe, and half report the pain as highly distressing.
1. There are no data to support that children misrepresent pain experiences.
2. Pain tolerance is a complex phenomenon that is not based on age.
3. Children do not become accustomed to painful procedures.

Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Implementation

60. Asthma is now classified into four categories: mild intermittent, mild persistent, moderate persistent, and severe persistent. Clinical features used to determine these categories include all of the following except:

Lung function.

Associated allergies.

Frequency of symptoms.

Frequency and severity of exacerbations.

2. Associated allergies are not part of the classification system used in the Guidelines for the Diagnosis and Management of Asthma
1. The clinical features that are assessed in the classification system are frequency of daytime and nighttime symptoms, frequency and severity of exacerbations, and lung function.
3. The clinical features that are assessed in the classification system are frequency of daytime and nighttime symptoms, frequency and severity of exacerbations, and lung function.
4. The clinical features that are assessed in the classification system are frequency of daytime and nighttime symptoms, frequency and severity of exacerbations, and lung function.

Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: Implementation

Explanation

2. Associated allergies are not part of the classification system used in the Guidelines for the Diagnosis and Management of Asthma
1. The clinical features that are assessed in the classification system are frequency of daytime and nighttime symptoms, frequency and severity of exacerbations, and lung function.
3. The clinical features that are assessed in the classification system are frequency of daytime and nighttime symptoms, frequency and severity of exacerbations, and lung function.
4. The clinical features that are assessed in the classification system are frequency of daytime and nighttime symptoms, frequency and severity of exacerbations, and lung function.

Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: Implementation

61. An infant with short-bowel syndrome will be discharged home on total parenteral nutrition (TPN) and gastrostomy feedings. Nursing care should include which of the following?

Prepare family for impending death.

Teach family how to calculate caloric needs.

Ensure that family can identify signs of central venous catheter infections.

Secure TPN and gastrostomy tubing under diaper to lessen risk of dislodgment.

3. During TPN therapy care must be taken to minimize the risk of complications related to the central venous access device, such as catheter infections, occlusions, or accidental removal. This is an important part of family teaching.
1. The prognosis for patients with short-bowel syndrome depends in part on the length of residual small intestine. It has improved with advances in TPN.
2. Although parents need to be taught about nutritional needs, the caloric needs and prescribed TPN and rate are the responsibility of the health care team.
4. The tubes should not be placed under the diapers because of the risk of infection.

Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Pharmacologic and Parenteral Therapy
Integrated process: Teaching/Learning

Explanation

3. During TPN therapy care must be taken to minimize the risk of complications related to the central venous access device, such as catheter infections, occlusions, or accidental removal. This is an important part of family teaching.
1. The prognosis for patients with short-bowel syndrome depends in part on the length of residual small intestine. It has improved with advances in TPN.
2. Although parents need to be taught about nutritional needs, the caloric needs and prescribed TPN and rate are the responsibility of the health care team.
4. The tubes should not be placed under the diapers because of the risk of infection.

Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Pharmacologic and Parenteral Therapy
Integrated process: Teaching/Learning

62. A woman inquires about herbal alternative methods for improving fertility. Which statement by the nurse is the most appropriate when instructing the woman in which herbal preparations to avoid while trying to conceive?

"You should avoid nettle leaf, dong quai, and vitamin E while you are trying to get pregnant."

"You may want to avoid licorice root, lavender, fennel, sage, and thyme while you are trying to conceive."

"You should not take anything with vitamin E, calcium, or magnesium. They will make you infertile."

"Herbs have no bearing on fertility."

Herbs that a woman should avoid while trying to conceive include licorice root, yarrow, wormwood, ephedra, fennel, goldenseal, lavender, juniper, flaxseed, pennyroyal, passionflower, wild cherry, cascara, sage, thyme, and periwinkle.

Explanation

Herbs that a woman should avoid while trying to conceive include licorice root, yarrow, wormwood, ephedra, fennel, goldenseal, lavender, juniper, flaxseed, pennyroyal, passionflower, wild cherry, cascara, sage, thyme, and periwinkle.

63. The most common signs and symptoms of leukemia related to bone marrow involvement are which of the following?

Petechiae, fever, fatigue

Headache, papilledema, irritability

Muscle wasting, weight loss, fatigue

Decreased intracranial pressure, psychosis, confusion

1. Signs of infiltration of the bone marrow are petechiae from lowered platelet count, fever related to infection from the depressed number of effective leukocytes, and fatigue from the anemia.
2. Headache, papilledema, irritability, muscle wasting, weight loss, fatigue, decreased intracranial pressure, psychosis, and confusion are not signs of bone marrow involvement.
3. Headache, papilledema, irritability, muscle wasting, weight loss, fatigue, decreased intracranial pressure, psychosis, and confusion are not signs of bone marrow involvement.
4. Headache, papilledema, irritability, muscle wasting, weight loss, fatigue, decreased intracranial pressure, psychosis, and confusion are not signs of bone marrow involvement.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: Assessment

Explanation

1. Signs of infiltration of the bone marrow are petechiae from lowered platelet count, fever related to infection from the depressed number of effective leukocytes, and fatigue from the anemia.
2. Headache, papilledema, irritability, muscle wasting, weight loss, fatigue, decreased intracranial pressure, psychosis, and confusion are not signs of bone marrow involvement.
3. Headache, papilledema, irritability, muscle wasting, weight loss, fatigue, decreased intracranial pressure, psychosis, and confusion are not signs of bone marrow involvement.
4. Headache, papilledema, irritability, muscle wasting, weight loss, fatigue, decreased intracranial pressure, psychosis, and confusion are not signs of bone marrow involvement.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: Assessment

64. A woman gave birth to a 7-lb, 3-oz boy 2 hours ago. The nurse determines that the woman's bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious consequence likely to occur from bladder distention is:

Urinary tract infection

Excessive uterine bleeding

A ruptured bladder

Bladder wall atony

Excessive bleeding can occur immediately after birth if the bladder becomes distended because it pushes the uterus up and to the side and prevents it from contracting firmly.

Explanation

Excessive bleeding can occur immediately after birth if the bladder becomes distended because it pushes the uterus up and to the side and prevents it from contracting firmly.

65. Nurses can help their clients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate?

Latent: mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours

Active: moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6 hours

Lull: no contractions; dilation stable; duration of 20 to 60 minutes

Transition: very strong but irregular contractions; 8 to 10 cm dilation; duration of 1 to 2 hours

The active phase is characterized by moderate, regular contractions; 4 to 7 cm dilation; and a duration of 3 to 6 hours.

Explanation

The active phase is characterized by moderate, regular contractions; 4 to 7 cm dilation; and a duration of 3 to 6 hours.

66. Therapeutic management of most children with Hirschsprung disease is primarily which of the following?

Daily enemas

Low-fiber diet

Permanent colostomy

Removal of affected piece of bowel

4. Most children with Hirschsprung disease require surgical rather than medical management. Surgery is done to remove the aganglionic portion of the bowel, relieve obstruction, and restore normal bowel motility and function of the internal anal sphincter.
1. Preoperative management may include enemas and low-fiber, high-calorie, high-protein diet, until the child is physically ready for surgery.
2. Preoperative management may include enemas and low-fiber, high-calorie, high-protein diet, until the child is physically ready for surgery.
3. The colostomy that is created in Hirschsprung disease is usually temporary.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Implementation

Explanation

4. Most children with Hirschsprung disease require surgical rather than medical management. Surgery is done to remove the aganglionic portion of the bowel, relieve obstruction, and restore normal bowel motility and function of the internal anal sphincter.
1. Preoperative management may include enemas and low-fiber, high-calorie, high-protein diet, until the child is physically ready for surgery.
2. Preoperative management may include enemas and low-fiber, high-calorie, high-protein diet, until the child is physically ready for surgery.
3. The colostomy that is created in Hirschsprung disease is usually temporary.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Implementation

67. Nursing interventions for the child after a cardiac catheterization would include which of the following?

Allow ambulation as tolerated.

Monitor vital signs every 2 hours.

Assess the affected extremity for temperature and color.

Check pulses above the catheterization site for equality and symmetry.

3. The involved extremity is carefully assessed for signs of complications. Pulses below the catheterization site are monitored for equality and symmetry. Temperature and color are also monitored.
1. The child is maintained on bed rest or in parent's lap for 4 to 6 hours after the procedure.
2. Initially, vital signs are taken every 15 minutes.
4. Pulses are checked distal to the catheterization site.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: Assessment

Explanation

3. The involved extremity is carefully assessed for signs of complications. Pulses below the catheterization site are monitored for equality and symmetry. Temperature and color are also monitored.
1. The child is maintained on bed rest or in parent's lap for 4 to 6 hours after the procedure.
2. Initially, vital signs are taken every 15 minutes.
4. Pulses are checked distal to the catheterization site.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: Assessment

68. Which of the following should the nurse include when discussing a child's precocious puberty with the parents?

The child is not yet fertile.

Heterosexual interest is usually advanced.

Dress and activities should be appropriate to chronologic age.

Appearance of secondary sexual characteristics does not proceed in the usual order.

3. Because of the early sexual maturation of the child, both family and child require extensive teaching. Included in this is the information that the child should be engaged in activities according to chronologic age.
1. Functioning sperm or ova may be produced, thereby making the child fertile at an early age.
2. Heterosexual interest is usually appropriate to chronologic age.
4. Development of the secondary sexual characteristics proceeds in the usual order.

Level of cognitive ability: Analysis
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Teaching/Learning

Explanation

3. Because of the early sexual maturation of the child, both family and child require extensive teaching. Included in this is the information that the child should be engaged in activities according to chronologic age.
1. Functioning sperm or ova may be produced, thereby making the child fertile at an early age.
2. Heterosexual interest is usually appropriate to chronologic age.
4. Development of the secondary sexual characteristics proceeds in the usual order.

Level of cognitive ability: Analysis
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Teaching/Learning

69. A significant, common side effect that occurs with opioid administration is:

Euphoria.

Diuresis.

Constipation.

Allergic reactions.

3. Constipation is one of the most common side effects of opioid administration. Preventive strategies should be implemented to minimize this problem.
1. Sedation is a more common result.
2. Urinary retention, not diuresis, may occur with opiates.
4. Rarely, some individuals may have pruritus.

Level of cognitive ability: Knowledge
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Planning

Explanation

3. Constipation is one of the most common side effects of opioid administration. Preventive strategies should be implemented to minimize this problem.
1. Sedation is a more common result.
2. Urinary retention, not diuresis, may occur with opiates.
4. Rarely, some individuals may have pruritus.

Level of cognitive ability: Knowledge
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Planning

70. A woman who is 32 weeks pregnant is informed by the nurse that a danger sign of pregnancy could be:

Constipation

Alteration in the pattern of fetal movement

Heart palpitations

Edema in the ankles and feet at the end of the day

An alteration in the pattern or amount of fetal movement may indicate fetal jeopardy.

Explanation

An alteration in the pattern or amount of fetal movement may indicate fetal jeopardy.

71. After change of shift report the nurse assumes care of a multiparous client in labor. The woman is complaining of pain that radiates to her abdominal wall, lower back, buttocks, and down her thighs. Before implementing a plan of care, the nurse should understand that this type of pain is:

Visceral

Referred

Somatic

Afterpain

As labor progresses the woman often experiences referred pain. This occurs when pain that originates in the uterus radiates to the abdominal wall, the lumbosacral area of the back, the gluteal area, and thighs. The woman usually has pain only during a contraction and is free from pain between contractions.

Explanation

As labor progresses the woman often experiences referred pain. This occurs when pain that originates in the uterus radiates to the abdominal wall, the lumbosacral area of the back, the gluteal area, and thighs. The woman usually has pain only during a contraction and is free from pain between contractions.

72. A woman in the active phase of the first stage of labor is using a shallow pattern of breathing, which is about twice the normal adult breathing rate. She starts to complain about feeling lightheaded and dizzy and states that her fingers are tingling. The nurse should:

Notify the woman's physician

Tell the woman to slow the pace of her breathing

Administer oxygen via a mask or nasal cannula

Help her breathe into a paper bag

This woman is experiencing the side effects of hyperventilation, which include the symptoms of lightheadedness, dizziness, tingling of the fingers, or circumoral numbness. Having the woman breathe into a paper bag held tightly around her mouth and nose may eliminate respiratory alkalosis. The woman can also breathe into her cupped hands if no paper bag is available.

Explanation

This woman is experiencing the side effects of hyperventilation, which include the symptoms of lightheadedness, dizziness, tingling of the fingers, or circumoral numbness. Having the woman breathe into a paper bag held tightly around her mouth and nose may eliminate respiratory alkalosis. The woman can also breathe into her cupped hands if no paper bag is available.

73. Which of the following is an early sign of heart failure that the nurse should recognize?

Tachypnea

Bradycardia

Inability to sweat

Increased urinary output

1. Tachypnea is one of the early signs that should be identified. Tachycardia at rest, dyspnea, retractions, and activity intolerance are other physical signs and symptoms.
2. Tachycardia, not bradycardia, is one of the symptoms suggestive of congestive heart failure.
3. The child may be diaphoretic.
4. Urinary output usually will be decreased.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: Assessment

Explanation

1. Tachypnea is one of the early signs that should be identified. Tachycardia at rest, dyspnea, retractions, and activity intolerance are other physical signs and symptoms.
2. Tachycardia, not bradycardia, is one of the symptoms suggestive of congestive heart failure.
3. The child may be diaphoretic.
4. Urinary output usually will be decreased.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: Assessment

74. A woman was treated recently for toxic shock syndrome (TSS). She has intercourse occasionally and uses over-the-counter protection. Based on her history, what contraceptive method should she and her partner avoid?

Cervical cap

Condom

Vaginal film

Vaginal sheath

Women with a history of TSS should not use a cervical cap.

Explanation

Women with a history of TSS should not use a cervical cap.

75. What is an appropriate nursing intervention when caring for an infant with an upper respiratory tract infection and elevated temperature?

Give tepid water baths to reduce fever.

Encourage food intake to maintain caloric needs.

Have child wear heavy clothing to prevent chilling.

Give small amounts of favorite fluids frequently to prevent dehydration.

4. Preventing dehydration by small, frequent feedings is an important intervention in the febrile child.
1. Tepid water baths may induce shivering, which raises temperature.
2. Food should not be forced; it may result in the child vomiting.
3. The febrile child should be dressed in light, loose clothing.

Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: Intervention

Explanation

4. Preventing dehydration by small, frequent feedings is an important intervention in the febrile child.
1. Tepid water baths may induce shivering, which raises temperature.
2. Food should not be forced; it may result in the child vomiting.
3. The febrile child should be dressed in light, loose clothing.

Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: Intervention

76. The nurse is caring for a boy with probable intussusception. He had diarrhea before admission, but while waiting for a barium enema, he passes a normal brown stool. The most appropriate nursing action is which of the following?

Notify physician.

Measure abdominal girth.

Auscultate for bowel sounds.

Take vital signs, including blood pressure.

1. Passage of a normal brown stool indicates that the intussusception has reduced itself. This is immediately reported to the practitioner, who may choose to alter the diagnostic and therapeutic care plan.
2. The first action would be to report the normal stool to the practitioner.
3. The first action would be to report the normal stool to the practitioner.
4. The first action would be to report the normal stool to the practitioner.

Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: Implementation

Explanation

1. Passage of a normal brown stool indicates that the intussusception has reduced itself. This is immediately reported to the practitioner, who may choose to alter the diagnostic and therapeutic care plan.
2. The first action would be to report the normal stool to the practitioner.
3. The first action would be to report the normal stool to the practitioner.
4. The first action would be to report the normal stool to the practitioner.

Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: Implementation

77. The Centers for Disease Control and Prevention (CDC)-recommended medication for the treatment of chlamydia is:

Doxycycline

Podofilox

Acyclovir

Penicillin

Doxycycline is effective for treating chlamydia; however, it should be avoided if a woman is pregnant.

Explanation

Doxycycline is effective for treating chlamydia; however, it should be avoided if a woman is pregnant.

78. Which of the following pediatric oncologic emergencies is caused by the rapid release of intracellular metabolites during the initial treatment of some cancers?

Hyperleukocytosis

Overwhelming infection

Acute tumor lysis syndrome

Superior vena cava syndrome

3. Acute tumor lysis syndrome is caused by the rapid release of intracellular metabolites during the initial treatment of malignancies.
1. Hyperleukocytosis, a white blood cell count greater than 100,000/mm3, can be present at diagnosis. It is not a result of the treatment.
2. Infection may occur from bone marrow suppression that results from many chemotherapeutic agents.
4. Superior vena cava syndrome can occur from compression of the mediastinal structures by Hodgkin disease and non-Hodgkin lymphoma.

Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Implementation

Explanation

3. Acute tumor lysis syndrome is caused by the rapid release of intracellular metabolites during the initial treatment of malignancies.
1. Hyperleukocytosis, a white blood cell count greater than 100,000/mm3, can be present at diagnosis. It is not a result of the treatment.
2. Infection may occur from bone marrow suppression that results from many chemotherapeutic agents.
4. Superior vena cava syndrome can occur from compression of the mediastinal structures by Hodgkin disease and non-Hodgkin lymphoma.

Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Implementation

79. A woman at 35 weeks of gestation has had an amniocentesis. The results reveal that surface-active phospholipids are present in the amniotic fluid. The nurse is aware that this finding indicates:

The fetus is at risk for Down syndrome

The woman is at high risk for developing preterm labor

Lung maturity

Meconium is present in the amniotic fluid

The detection of the presence of pulmonary surfactants, surface-active phospholipids, in amniotic fluid has been used to determine fetal lung maturity, or the ability of the lungs to function after birth. This occurs at approximately 35 weeks of gestation.

Explanation

The detection of the presence of pulmonary surfactants, surface-active phospholipids, in amniotic fluid has been used to determine fetal lung maturity, or the ability of the lungs to function after birth. This occurs at approximately 35 weeks of gestation.

80. Which of the following is characterized by a chronic inflammatory process that may involve any part of the gastrointestinal (GI) tract, from mouth to anus?

Crohn disease

Ulcerative colitis

Meckel diverticulum

Irritable bowel syndrome

1. The chronic inflammatory process of Crohn disease involves any part of the GI tract from the mouth to the anus, but most often affects the terminal ileum.
2. Ulcerative colitis, Meckel diverticulum, and irritable bowel syndrome do not affect the entire GI tract.
3. Ulcerative colitis, Meckel diverticulum, and irritable bowel syndrome do not affect the entire GI tract.
4. Ulcerative colitis, Meckel diverticulum, and irritable bowel syndrome do not affect the entire GI tract.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Implementation

Explanation

1. The chronic inflammatory process of Crohn disease involves any part of the GI tract from the mouth to the anus, but most often affects the terminal ileum.
2. Ulcerative colitis, Meckel diverticulum, and irritable bowel syndrome do not affect the entire GI tract.
3. Ulcerative colitis, Meckel diverticulum, and irritable bowel syndrome do not affect the entire GI tract.
4. Ulcerative colitis, Meckel diverticulum, and irritable bowel syndrome do not affect the entire GI tract.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Implementation

81. With regard to the condition and reconditioning of the urinary system after childbirth, nurses should be aware that:

Kidney function returns to normal a few days after birth

Diastasis recti abdominis is a common condition that alters the voiding reflex

With adequate emptying of the bladder, bladder tone usually is restored 2 to 3 weeks after childbirth

Excess fluid loss through other means occurs as well.

Explanation

Excess fluid loss through other means occurs as well.

82. Which of the following best describes the cause of most cases of acute glomerulonephritis?

Renal vascular anomalies

Antecedent streptococcal infection

Results from a urinary tract infection

Structural anomalies of genitourinary tract

2. Most cases are postinfectious and have been associated with pneumococcal, streptococcal, and viral infections.
1. Renal vascular anomalies are not associated with acute glomerulonephritis.
3. Urinary tract infections and structural anomalies can result in progressive renal injury, not acute glomerulonephritis.
4. Urinary tract infections and structural anomalies can result in progressive renal injury, not acute glomerulonephritis.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Assessment

Explanation

2. Most cases are postinfectious and have been associated with pneumococcal, streptococcal, and viral infections.
1. Renal vascular anomalies are not associated with acute glomerulonephritis.
3. Urinary tract infections and structural anomalies can result in progressive renal injury, not acute glomerulonephritis.
4. Urinary tract infections and structural anomalies can result in progressive renal injury, not acute glomerulonephritis.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Assessment

83. The nurse comes into the room of a child who was just diagnosed with a chronic disability. The child's parents begin to yell at the nurse about a variety of concerns. Which of the following is the nurse's best response?

“What is really wrong?”

“Being angry is only natural.”

“Yelling at me will not change things.”

“I will come back when you settle down.”

2. Parental anger after the diagnosis of a child with a chronic disability is a common response. One of the most common targets for parental anger is members of the staff. The nurse should recognize the common response of anger to the diagnosis and allow the family to ventilate.
1. Responding with "What is really wrong?" "Yelling at me will not change things" or "I will come back when you settle down" will place the parents on the defensive and not facilitate communication.
3. Responding with "What is really wrong?" "Yelling at me will not change things" or "I will come back when you settle down" will place the parents on the defensive and not facilitate communication.
4. Responding with "What is really wrong?" "Yelling at me will not change things" or "I will come back when you settle down" will place the parents on the defensive and not facilitate communication.

Level of cognitive ability: Comprehension
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Communication and Documentation

Explanation

2. Parental anger after the diagnosis of a child with a chronic disability is a common response. One of the most common targets for parental anger is members of the staff. The nurse should recognize the common response of anger to the diagnosis and allow the family to ventilate.
1. Responding with "What is really wrong?" "Yelling at me will not change things" or "I will come back when you settle down" will place the parents on the defensive and not facilitate communication.
3. Responding with "What is really wrong?" "Yelling at me will not change things" or "I will come back when you settle down" will place the parents on the defensive and not facilitate communication.
4. Responding with "What is really wrong?" "Yelling at me will not change things" or "I will come back when you settle down" will place the parents on the defensive and not facilitate communication.

Level of cognitive ability: Comprehension
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Communication and Documentation

84. Semen analysis is a common diagnostic procedure related to infertility. In instructing a male client regarding this test, the nurse would tell him to:

Ejaculate into a sterile container

Obtain the specimen after a period of abstinence from ejaculation of 2 to 5 days

Transport specimen with container packed in ice

Ensure that the specimen arrives at the laboratory within 30 minutes of ejaculation

An ejaculated sample should be obtained after a period of abstinence to get the best results.

Explanation

An ejaculated sample should be obtained after a period of abstinence to get the best results.

85. Nursing care of the infant and child with heart failure would include which of the following?

Force fluids appropriate to age.

Monitor respirations during active periods.

Organize activities to allow for uninterrupted sleep.

Give larger feedings less often to conserve energy.

3. The child needs to be well rested before feeding. The child's needs should be met as quickly as possible to minimize crying. The nurse must organize care to minimize the child's energy expenditure.
1. The child who has heart failure has an excess of fluid.
2. Monitoring vital signs is appropriate, but minimizing energy expenditure is a priority.
4. The child often cannot tolerate larger feedings.

Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: Evaluation

Explanation

3. The child needs to be well rested before feeding. The child's needs should be met as quickly as possible to minimize crying. The nurse must organize care to minimize the child's energy expenditure.
1. The child who has heart failure has an excess of fluid.
2. Monitoring vital signs is appropriate, but minimizing energy expenditure is a priority.
4. The child often cannot tolerate larger feedings.

Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: Evaluation

86. Nurses should be aware that infertility:

Is perceived differently by women and men

Has a relatively stable prevalence among the overall population and throughout a womens potential reproductive years

Is more likely the result of a physical flaw in the woman than in her male partner

Is the same thing as sterility

Women tend to be more stressed about infertility tests and to place more importance on having children.

Explanation

Women tend to be more stressed about infertility tests and to place more importance on having children.

87. A proton pump inhibitor (PPI) is ordered for an infant with gastroesophageal reflux. The nurse should include in the drug teaching that:

The drug should be given 30 minutes before bedtime.

Three times a day dosing has maximum effect.

The drug can be stopped once symptoms have resolved.

Several days may pass before full effect is reached.

4. PPIs require several days to achieve the maximum effect.
1. Optimum administration time is 30 minutes before breakfast. This allows for peak plasma levels at mealtime.
2. Once daily dosing is usually recommended.
3. Continued administration is necessary to maintain effect.

Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Pharmacologic and Parenteral Therapy
Integrated process: Teaching/Learning

Explanation

4. PPIs require several days to achieve the maximum effect.
1. Optimum administration time is 30 minutes before breakfast. This allows for peak plasma levels at mealtime.
2. Once daily dosing is usually recommended.
3. Continued administration is necessary to maintain effect.

Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Pharmacologic and Parenteral Therapy
Integrated process: Teaching/Learning

88. With regard to primary and secondary powers, the maternity nurse should understand that:

Primary powers are responsible for effacement and dilation of the cervix

The primary powers are responsible for dilation and effacement; secondary powers are concerned with expulsion of the fetus.

Explanation

The primary powers are responsible for dilation and effacement; secondary powers are concerned with expulsion of the fetus.

89. With regard to the father's acceptance of the pregnancy and preparation for childbirth, the maternity nurse should know that:

The father goes through three phases of acceptance of his own

Typically men remain ambivalent about fatherhood right up to the birth of their child

A father typically goes through three phases of acceptance: accepting the biologic fact, adjusting to the reality, and focusing on his role.

Explanation

A father typically goes through three phases of acceptance: accepting the biologic fact, adjusting to the reality, and focusing on his role.

90. The breasts of a bottle-feeding woman are engorged. The nurse should instruct her to:

Wear a snug, supportive bra

Allow warm water to soothe the breasts during a shower

Express milk from breasts occasionally to relieve discomfort

Place absorbent pads with plastic liners into her bra to absorb leakage

A snug, supportive bra limits milk production and reduces discomfort by supporting the tender breasts and limiting their movement. Ice packs, fresh cabbage leaves, and mild analgesics may also relieve discomfort.

Explanation

A snug, supportive bra limits milk production and reduces discomfort by supporting the tender breasts and limiting their movement. Ice packs, fresh cabbage leaves, and mild analgesics may also relieve discomfort.

91. With regard to breathing techniques during labor, maternity nurses should be aware that:

By the time labor has begun, it is too late for instruction in breathing and relaxation

Controlled breathing techniques are most difficult near the end of the second stage of labor

The patterned-paced breathing technique can help prevent hyperventilation

First-stage techniques promote relaxation of abdominal muscles, thereby increasing the size of the abdominal cavity.

Explanation

First-stage techniques promote relaxation of abdominal muscles, thereby increasing the size of the abdominal cavity.

92. The nurse knows that the second stage of labor, the descent phase, has begun when:

The amniotic membranes rupture

The cervix cannot be felt during a vaginal examination

The woman experiences a strong urge to bear down

The presenting part is below the ischial spines

During the descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down.

Explanation

During the descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down.

93. A married couple is discussing male and female sterilization with the nurse. Which statement is most appropriate for the nurse to make?

"Male and female sterilization methods are 100% effective."

"A vasectomy may have a slight effect on sexual performance."

"Tubal ligation can be easily reversed if you change your mind in the future."

"Major complications after sterilization are rare."

Sterilization procedures can be safely done on an outpatient basis. Complications are uncommon and usually not serious.

Explanation

Sterilization procedures can be safely done on an outpatient basis. Complications are uncommon and usually not serious.

94. Which of the following statements best describes hypopituitarism?

Skeletal proportions are normal for age.

Weight is usually more retarded than height.

Growth is normal during the first 3 years of life.

Most of these children have subnormal intelligence.

1. Skeletal proportions are normal for age, but these children appear young for their age.
2. Growth in height is usually more delayed than in weight.
3. Growth is normal for the first year of age, and then they follow a slowed growth curve.
4. Most of the children have normal intelligence. Often they are considered precocious because their educational ability seems to exceed their size. Emotional problems are not uncommon because of the small stature.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Assessment

Explanation

1. Skeletal proportions are normal for age, but these children appear young for their age.
2. Growth in height is usually more delayed than in weight.
3. Growth is normal for the first year of age, and then they follow a slowed growth curve.
4. Most of the children have normal intelligence. Often they are considered precocious because their educational ability seems to exceed their size. Emotional problems are not uncommon because of the small stature.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Assessment

95. With regard to emergency contraception pills, nurses should be aware that:

The pills must be taken no later than 48 hours after unprotected intercourse or birth control mishap

The pills protect the woman against pregnancy even if she engages in unprotected intercourse in the days after treatment

Emergency contraception has no medical contraindications

A backup method of birth control is also a good idea for beginners.

Explanation

A backup method of birth control is also a good idea for beginners.

96. The parent of a 10-year-old child with diabetes asks the nurse why home blood glucose monitoring is being recommended. The nurse should base the explanation on which of the following?

It is an easier method of testing.

Parents are better able to manage the diabetes.

Children have a greater sense of control over the diabetes.

Fewer visits to the primary care provider will be necessary.

3. Blood glucose monitoring affords the child a greater sense of control. The immediate feedback allows for regulation of insulin doses.
1. Home blood glucose monitoring provides a more accurate assessment of control than urine testing.
2. Although parents are involved in the management, a 10-year-old child should be taking responsibility for testing.
4. The same number of visits will be necessary, but the blood glucose monitoring will enable better control.

Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Teaching/Learning

Explanation

3. Blood glucose monitoring affords the child a greater sense of control. The immediate feedback allows for regulation of insulin doses.
1. Home blood glucose monitoring provides a more accurate assessment of control than urine testing.
2. Although parents are involved in the management, a 10-year-old child should be taking responsibility for testing.
4. The same number of visits will be necessary, but the blood glucose monitoring will enable better control.

Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Teaching/Learning

97. Physiologic measurements in children's pain assessment are:

Not useful as the sole indicator for pain.

The best indicator of pain in children of all ages.

Of most value when children also report having pain.

Essential to determine whether a child is telling the truth about pain.

1. Physiologic manifestations of pain may vary considerably, not providing a consistent measure of pain. Heart rate may increase or decrease. The same signs that may suggest fear, anxiety, or anger also indicate pain. In chronic pain, the body adapts, and these signs decrease or stabilize.
2. Physiologic measurements are of limited value and must be viewed in the context of a pain rating scale, behavioral assessment, and parental report.
3. Physiologic measurements are of limited value and must be viewed in the context of a pain rating scale, behavioral assessment, and parental report.
4. When the child reports pain on an appropriate pain scale, the appropriate interventions should be used.

Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Assessment

Explanation

1. Physiologic manifestations of pain may vary considerably, not providing a consistent measure of pain. Heart rate may increase or decrease. The same signs that may suggest fear, anxiety, or anger also indicate pain. In chronic pain, the body adapts, and these signs decrease or stabilize.
2. Physiologic measurements are of limited value and must be viewed in the context of a pain rating scale, behavioral assessment, and parental report.
3. Physiologic measurements are of limited value and must be viewed in the context of a pain rating scale, behavioral assessment, and parental report.
4. When the child reports pain on an appropriate pain scale, the appropriate interventions should be used.

Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Assessment

98. Therapeutic management of nephrotic syndrome includes which of the following?

Corticosteroids

Long-term diuretics

Antihypertensive agents

Fluid and salt restrictions

1. Most children with nephrotic syndrome respond to corticosteroids, making this group the drug of choice. Corticosteroid therapy is begun as soon as the diagnosis has been determined.
2. Children with nephrotic syndrome usually do not respond to diuretics. Furosemide, in combination with metolazone, is useful for severe edema.
3. Antihypertensive agents are not indicated in the management.
4. Fluids are rarely restricted. The child is placed on a no-added-salt diet.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Assessment

Explanation

1. Most children with nephrotic syndrome respond to corticosteroids, making this group the drug of choice. Corticosteroid therapy is begun as soon as the diagnosis has been determined.
2. Children with nephrotic syndrome usually do not respond to diuretics. Furosemide, in combination with metolazone, is useful for severe edema.
3. Antihypertensive agents are not indicated in the management.
4. Fluids are rarely restricted. The child is placed on a no-added-salt diet.

Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: Assessment

99. Although remarkable developments have occurred in reproductive medicine, assisted reproductive therapies are associated with a number of legal and ethical issues. Nurses can provide accurate information about the risks and benefits of treatment alternatives so couples can make informed decisions about their choice of treatment. Which issue would not need to be addressed by an infertile couple before treatment?

Risk of multiple gestation

Whether or how to disclose the facts of conception to offspring

Freezing embryos for later use

Financial ability to cover the cost of treatment

Although the method of payment is important, obtaining this information is not the nurse’s responsibility. It is also of note that 14 states have mandated some form of insurance to assist couples with coverage for infertility.

Explanation

Although the method of payment is important, obtaining this information is not the nurse’s responsibility. It is also of note that 14 states have mandated some form of insurance to assist couples with coverage for infertility.

100. An 8-year-old child will soon be able to return to school after an injury that resulted in several severe, chronic disabilities. Which of the following is the most appropriate action by the school nurse?

Recommend the parents attend school at first to prevent teasing.

Request to visit the school.

Refer the child to a school where the children have similar chronic disabilities.

2. Attendance at school is an important part of normalization. The nurse should ask for permission to visit the school to observe the child's behaviors with classmates and teachers.
1. A visit by the parents can be helpful, but unless the classmates are prepared for the changes, it alone will not prevent teasing.
3. The child's school experience should be normalized as much as possible. Children need the opportunity to interact with healthy peers, as well as to engage in activities with groups or clubs composed of similarly affected persons.
4. Children with special needs are encouraged to maintain and reestablish relationships with peers and to participate according to their capabilities.

Level of cognitive ability: Application
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: Implementation

Explanation

2. Attendance at school is an important part of normalization. The nurse should ask for permission to visit the school to observe the child's behaviors with classmates and teachers.
1. A visit by the parents can be helpful, but unless the classmates are prepared for the changes, it alone will not prevent teasing.
3. The child's school experience should be normalized as much as possible. Children need the opportunity to interact with healthy peers, as well as to engage in activities with groups or clubs composed of similarly affected persons.
4. Children with special needs are encouraged to maintain and reestablish relationships with peers and to participate according to their capabilities.

Level of cognitive ability: Application
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: Implementation