Fundamentals Of Nursing NCLEX Quiz 36

1. The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source of fluids for an infant until about 12 months of age?

Formula or breastmilk

Dilute nonfat dry milk

Warmed fruit juice

Fluoridated tap water

Formula or breast milk are the perfect food and source of nutrients and liquids up to 1 year of age.

Explanation

Formula or breast milk are the perfect food and source of nutrients and liquids up to 1 year of age.

2. While the nurse is administering medications to a client. the client states "I do not want to take that medicine today." Which of the following responses by the nurse would be best?

“That’s OK. its alright to skip your medication now and then.”

“I will have to call your doctor and report this.”

“Is there a reason why you don’t want to take your medicine?”

“Do you understand the consequences of refusing your prescribed treatment?”

When a new problem is identified. it is important for the nurse to collect accurate assessment data. This is crucial to ensure that client needs are adequately identified in order to select the best nursing care approaches. The nurse should try to discover the reason for the refusal which may be that the client has developed untoward side effects.

Explanation

When a new problem is identified. it is important for the nurse to collect accurate assessment data. This is crucial to ensure that client needs are adequately identified in order to select the best nursing care approaches. The nurse should try to discover the reason for the refusal which may be that the client has developed untoward side effects.

3. Which action by the mother of a preschooler would indicate a disturbed family interaction?

Tells her child that if he does not sit down and shut up she will leave him there.

Explains that the injection will burn like a bee sting.

Tells her child that the injection can be given while he’s in her lap

Reassures child that it is acceptable to cry.

Threatening a child with abandonment will destroy the child’s trust in his family.

Explanation

Threatening a child with abandonment will destroy the child’s trust in his family.

4. The nurse is assessing a 4 month-old infant. Which motor skill would the nurse anticipate finding?

Hold a rattle

Bang two blocks

Drink from a cup

Wave “bye-bye”

The age at which a baby will develop the skill of grasping a toy with help is 4 to 6 months.

Explanation

The age at which a baby will develop the skill of grasping a toy with help is 4 to 6 months.

5. During the history. which information from a 21-year-old client would indicate a risk for development of testicular cancer?

Genital Herpes

Hydrocele

Measles

Undescended testicle

Undescended testicles make the client high risk for testicular cancer. Mumps. inguinal hernia in childhood. orchitis. and testicular cancer in the contralateral testis are other predisposing factors.

Explanation

Undescended testicles make the client high risk for testicular cancer. Mumps. inguinal hernia in childhood. orchitis. and testicular cancer in the contralateral testis are other predisposing factors.

6. Which nursing approach would be most appropriate to use while administering an oral medication to a 4 month old?

Place medication in 45cc of formula

Place medication in an empty nipple

Place medication in a full bottle of formula

Place in supine position. Administer medication using a plastic syringe

This is a convenient method for administering medications to an infant. Option D is partially correct however. the infant is never placed in a reclining position during a procedure due to a potential aspiration.

Explanation

This is a convenient method for administering medications to an infant. Option D is partially correct however. the infant is never placed in a reclining position during a procedure due to a potential aspiration.

7. When observing 4-year-old children playing in the hospital playroom. what activity would the nurse expect to see the children participating in?

Competitive board games with older children

Playing with their own toys along side with other children

Playing alone with hand held computer games

Playing cooperatively with other preschoolers

Playing cooperatively with other preschoolers. Cooperative play is typical of the late preschool period.

Explanation

Playing cooperatively with other preschoolers. Cooperative play is typical of the late preschool period.

8. While performing a physical examination on a newborn. which assessment should be reported to the physician?

Head circumference of 40 cm

Chest circumference of 32 cm

Acrocyanosis and edema of the scalp

Heart rate of 160 and respirations of 40

Average circumference of the head for a neonate ranges between 32 to 36 cm. An increase in size may indicate hydrocephalus or increased intracranial pressure.

Explanation

Average circumference of the head for a neonate ranges between 32 to 36 cm. An increase in size may indicate hydrocephalus or increased intracranial pressure.

9. While caring for a client. the nurse notes a pulsating mass in the client's periumbilical area. Which of the following assessments is appropriate for the nurse to perform?

Measure the length of the mass

Auscultate the mass

Percuss the mass

Palpate the mass

Auscultate the mass. Auscultation of the abdomen and finding a bruit will confirm the presence of an abdominal aneurysm and will form the basis of information given to the provider. The mass should not be palpated because of the risk of rupture.

Explanation

Auscultate the mass. Auscultation of the abdomen and finding a bruit will confirm the presence of an abdominal aneurysm and will form the basis of information given to the provider. The mass should not be palpated because of the risk of rupture.

10. Which nursing intervention would be a priority during the care of a 2-month-old after surgery?

Minimize stimuli for the infant

Restrain all extremities

Encourage stroking of the infant

Demonstrate to the mother how she can assist with her infant’s care.

Tactile stimulation is imperative for an infant’s normal emotional development. After the trauma of surgery. sensory deprivation can cause failure to thrive.

Explanation

Tactile stimulation is imperative for an infant’s normal emotional development. After the trauma of surgery. sensory deprivation can cause failure to thrive.