Fundamentals Of Nursing NCLEX Quiz 28

1. While preparing to discharge an 8-month-old infant who is recovering from gastroenteritis and dehydration. the nurse teaches the parents about their infant's dietary and fluid requirements. The nurse should include which other topic in the teaching session?

Nursery schools

Toilet Training

Safety guidelines

Preparation for surgery

The nurse always should reinforce safety guidelines when teaching parents how to care for their child. By giving anticipatory guidance the nurse can help prevent many accidental injuries. For parents of a 9-month-old infant. it is too early to discuss nursery schools or toilet training. Because surgery is not used gastroenteritis. this topic is inappropriate.

Explanation

The nurse always should reinforce safety guidelines when teaching parents how to care for their child. By giving anticipatory guidance the nurse can help prevent many accidental injuries. For parents of a 9-month-old infant. it is too early to discuss nursery schools or toilet training. Because surgery is not used gastroenteritis. this topic is inappropriate.

2. The mother of Gian. a preschooler with spina bifida tells the nurse that her daughter sneezes and gets a rash when playing with brightly colored balloons. and that she recently had an allergic reaction after eating kiwifruit and bananas. The nurse would suspect that the child may have an allergy to:

Bananas

Latex

Kiwifruit

Color dyes

Children with spina bifida often develop an allergy to latex and shouldn’t be exposed to it. If a child is sensitive to bananas. kiwifruit. and chestnuts. then she’s likely to be allergic to latex. Some children are allergic to dyes in foods and other products but dyes aren’t a factor in a latex allergy.

Explanation

Children with spina bifida often develop an allergy to latex and shouldn’t be exposed to it. If a child is sensitive to bananas. kiwifruit. and chestnuts. then she’s likely to be allergic to latex. Some children are allergic to dyes in foods and other products but dyes aren’t a factor in a latex allergy.

3. Patrick. a healthy adolescent has meningitis and is receiving I.V. and oral fluids. The nurse should monitor this client's fluid intake because fluid overload may cause:

Cerebral edema

Dehydration

Heart failure

Hypovolemic shock

Because of the inflammation of the meninges. the client is vulnerable to developing cerebral edema and increased intracranial pressure. Fluid overload won’t cause dehydration. It would be unusual for an adolescent to develop heart failure unless the overhydration is extreme. Hypovolemic shock would occur with an extreme loss of fluid of blood.

Explanation

Because of the inflammation of the meninges. the client is vulnerable to developing cerebral edema and increased intracranial pressure. Fluid overload won’t cause dehydration. It would be unusual for an adolescent to develop heart failure unless the overhydration is extreme. Hypovolemic shock would occur with an extreme loss of fluid of blood.

4. A parent brings a toddler. age 19 months. to the clinic for a regular check-up. When palpating the toddler's fontanels. what should the nurse expects to find?

Closed anterior fontanel and open posterior fontanel

Open anterior and fontanel and closed posterior fontanel

Closed anterior and posterior fontanels

Open anterior and posterior fontanels

By age 18 months. the anterior and posterior fontanels should be closed. The diamond-shaped anterior fontanel normally closes between ages 9 and 18 months. The triangular posterior fontanel normally closes between ages 2 and 3 months.

Explanation

By age 18 months. the anterior and posterior fontanels should be closed. The diamond-shaped anterior fontanel normally closes between ages 9 and 18 months. The triangular posterior fontanel normally closes between ages 2 and 3 months.

5. An infant is hospitalized for treatment of nonorganic failure to thrive. Which nursing action is most appropriate for this infant?

Encouraging the infant to hold a bottle

Keeping the infant on bed rest to conserve energy

Rotating caregivers to provide more stimulation

Maintaining a consistent. structured environment

The nurse caring for an infant with nonorganic failure to thrive should maintain a consistent. structured environment that provides interaction with the infant to promote growth and development. Encouraging the infant to hold a bottle would reinforce an uncaring feeding environment. The infant should receive social stimulation rather than be confined to bed rest. The number of caregivers should be minimized to promote consistency of care.

Explanation

The nurse caring for an infant with nonorganic failure to thrive should maintain a consistent. structured environment that provides interaction with the infant to promote growth and development. Encouraging the infant to hold a bottle would reinforce an uncaring feeding environment. The infant should receive social stimulation rather than be confined to bed rest. The number of caregivers should be minimized to promote consistency of care.

6. After the nurse provides dietary restrictions to the parents of a child with celiac disease. which statement by the parents indicates effective teaching?

“Well follow these instructions until our child’s symptoms disappear.”

“Our child must maintain these dietary restrictions until adulthood.”

“Our child must maintain these dietary restrictions lifelong.”

“We’ll follow these instructions until our child has completely grown and developed.”

A patient with celiac disease must maintain dietary restrictions lifelong to avoid recurrence of clinical manifestations of the disease. The other options are incorrect because signs and symptoms will reappear if the patient eats prohibited foods.

Explanation

A patient with celiac disease must maintain dietary restrictions lifelong to avoid recurrence of clinical manifestations of the disease. The other options are incorrect because signs and symptoms will reappear if the patient eats prohibited foods.

7. The parents of a child. age 6. who will begin school in the fall ask the nurse for anticipatory guidance. The nurse should explain that a child of this age:

Still depends on the parents

Rebels against scheduled activities

Is highly sensitive to criticism

Loves to tattle

In a 6-year-old child. a precarious sense of self causes overreaction to criticism and a sense of inferiority. By age 6. most children no longer depend on the parents for daily tasks and love the routine of a schedule. Tattling is more common at age 4 to 5. by age 6. the child wants to make friends and be a friend.

Explanation

In a 6-year-old child. a precarious sense of self causes overreaction to criticism and a sense of inferiority. By age 6. most children no longer depend on the parents for daily tasks and love the routine of a schedule. Tattling is more common at age 4 to 5. by age 6. the child wants to make friends and be a friend.

8. When caring for an 11-month-old infant with dehydration and metabolic acidosis. the nurse expects to see which of the following?

A reduced white blood cell count

A decreased platelet count

Shallow respirations

Tachypnea

The body compensates for metabolic acidosis via the respiratory system. which tries to eliminate the buffered acids by increasing alveolar ventilation through deep. rapid respirations. altered white blood cell or platelet counts are not specific signs of metabolic imbalance.

Explanation

The body compensates for metabolic acidosis via the respiratory system. which tries to eliminate the buffered acids by increasing alveolar ventilation through deep. rapid respirations. altered white blood cell or platelet counts are not specific signs of metabolic imbalance.

9. Nurse Betina should begin screening for lead poisoning when a child reaches which age?

6 months

12 months

18 months

24 months

The nurse should start screening a child for lead poisoning at age 18 months and perform repeat screening at age 24. 30. and 36 months. High-risk infants. such as premature infants and formula-fed infants not receiving iron supplementation. should be screened for iron-deficiency anemia at 6 months. Regular dental visits should begin at age 24 months.

Explanation

The nurse should start screening a child for lead poisoning at age 18 months and perform repeat screening at age 24. 30. and 36 months. High-risk infants. such as premature infants and formula-fed infants not receiving iron supplementation. should be screened for iron-deficiency anemia at 6 months. Regular dental visits should begin at age 24 months.

10. Cristina. a mother of a 4-year-old child tells the nurse that her child is a very poor eater. What's the nurse's best recommendation for helping the mother increase her child's nutritional intake?

Allow the child to feed herself

Use specially designed dishes for children – for example. a plate with the child’s favorite cartoon character

Only serve the child’s favorite foods

Allow the child to eat at a small table and chair by herself

The best recommendation is to allow the child to feed herself because the child’s stage of development is the preschool period of initiative. Special dishes would enhance the primary recommendation. The child should be offered new foods and choices. not just served her favorite foods. Using a small table and chair would also enhance the primary recommendation.

Explanation

The best recommendation is to allow the child to feed herself because the child’s stage of development is the preschool period of initiative. Special dishes would enhance the primary recommendation. The child should be offered new foods and choices. not just served her favorite foods. Using a small table and chair would also enhance the primary recommendation.