Nursing Evaluation 2011 Test 01

1. Which of the following nursing interventions is most important postoperatively for an infant who has received a ventriculoperitoneal shunt?

Initiating oral feedings.

Monitoring intake and output.

Allowing the infant to rest undisturbed.

Providing age-appropriate diversionary activities.

In the postoperative period, intake and output are carefully monitored to prevent fluid overload that could lead to increased intracranial pressure.

Explanation

In the postoperative period, intake and output are carefully monitored to prevent fluid overload that could lead to increased intracranial pressure.

2. A client asks, “Can my partner and I still engage in sexual intercourse while I’m pregnant?” The nurse’s response is based on which of the following?

Although sexual desire may change, intercourse is safe during an uncomplicated pregnancy.

Throughout the pregnancy, coitus interruptus is the preferred method for sexual activity.

Engaging in intercourse must be avoided until the client is at least 16 weeks pregnant.

The couple should refrain from engaging in sexual intercourse during the last trimester.

Generally, engaging in the usual pattern of sexual activity during pregnancy is safe as long as the client is comfortable and no complications arise. The client needs to be informed that some women find intercourse uncomfortable during the first and third trimesters owing to the common discomforts of pregnancy.

Explanation

Generally, engaging in the usual pattern of sexual activity during pregnancy is safe as long as the client is comfortable and no complications arise. The client needs to be informed that some women find intercourse uncomfortable during the first and third trimesters owing to the common discomforts of pregnancy.

3. When the nurse is teaching a group of parents about common childhood problems, a parent asks, “Why are children more likely to develop ear infections than adults are?” The nurse bases the response to this question on the understanding that the key anatomic difference between adults and children is due to which of the following structures?

Nasopharynx.

Eustachian tubes.

Ear canals.

Tympanic membranes.

In infants and young children, the Eustachian tubes are short and lie in a relatively horizontal position. This anatomic position favors the development of otitis media because it is easy for materials from the nasopharynx to enter the tubes.

Explanation

In infants and young children, the Eustachian tubes are short and lie in a relatively horizontal position. This anatomic position favors the development of otitis media because it is easy for materials from the nasopharynx to enter the tubes.

4. Which of the following instructions should the nurse include in the teaching plan about skin care for the mother of a child with atopic dermatitis?

Soaking the child in a tub for 30 minutes to soften the skin.

Using an antibacterial soap two times a week.

Using a mild soap followed by patting the skin to dry it.

Washing clothes in a strong detergent to prevent infections.

Care of the skin is basic to the treatment of atopic dermatitis. Treatment includes use of a mild soap, such as Dove; not allowing the child to soak in the tub, which dries the skin; and patting the skin with a towel after the bath to help keep moisture in the skin.

Explanation

Care of the skin is basic to the treatment of atopic dermatitis. Treatment includes use of a mild soap, such as Dove; not allowing the child to soak in the tub, which dries the skin; and patting the skin with a towel after the bath to help keep moisture in the skin.

5. Which of the following behaviors by a neonate attempting an initial feeding should indicate to the nurse that the neonate may have tracheoesophageal fistula?

Sucking attempts that are too poorly coordinated to be effective.

Projectile vomiting that occurs after drinking 4 oz.

Coughing, choking, and cyanosis that occur after several swallows of formula.

Sleeping that occurs after taking 10 ml of formula with an inability to be stimulated to take more.

The newborn with tracheoesophageal fistula swallows normally, but the fluids quickly fill the blind pouch. The infant then coughs, chokes, and becomes cyanotic while the fluid returns through the nose and mouth.

Explanation

The newborn with tracheoesophageal fistula swallows normally, but the fluids quickly fill the blind pouch. The infant then coughs, chokes, and becomes cyanotic while the fluid returns through the nose and mouth.

6. When preparing a teaching plan for a client who is to receive a rubella vaccine during the postpartum period, the nurse should include which of the following?

The vaccine prevents a future fetus from developing congenital anomalies.

Pregnancy should be avoided for 3 months after the immunization.

The client should avoid contact with children diagnosed with rubella.

The injection will provide immunity against the 7-day measles.

After administration of rubella vaccine, the client should be instructed to avoid pregnancy for at least 3 months to prevent the possibility of the vaccine’s toxic effects to the fetus.

Explanation

After administration of rubella vaccine, the client should be instructed to avoid pregnancy for at least 3 months to prevent the possibility of the vaccine’s toxic effects to the fetus.

7. When assessing an 18 year old primipara who delivered a viable neonate under epidural anesthesia 24 hours ago, the nurse determines that the fundus is firm but to the right of midline. Based on this finding the nurse further assesses for which of the following?

Uterine inversion.

Paralyctic ileus.

Urinary retention.

Perineal hematoma.

A full bladder is likely to push the uterus to the right of midline, so the nurse should further assess for symptoms of urinary retention. A full bladder can prevent the uterus from contracting properly (uterine atony), possibly leading to hemorrhage. When the bladder is empty, it is normally nonpalpable and lies about in the midline.

Explanation

A full bladder is likely to push the uterus to the right of midline, so the nurse should further assess for symptoms of urinary retention. A full bladder can prevent the uterus from contracting properly (uterine atony), possibly leading to hemorrhage. When the bladder is empty, it is normally nonpalpable and lies about in the midline.

8. Which of the following families should the nurse determine as most in need of follow-up?

A single mother with a 7-month-old child whose immunizations are delayed.

A two-parent family whose 3-year-old has a fractured leg from an automobile accident.

A single parent with a toddler who has third-degree burns over 20% of the body.

A two-parent family with a foster child who has a history of caustic liquid ingestion.

Toddlers receive burns usually as the result of not being closely supervised. Toddlers are very inquisitive and need constant supervision; therefore, close follow-up is necessary. In addition, the child probably will need some type of wound care requiring involvement of the parent and possibly others.

Explanation

Toddlers receive burns usually as the result of not being closely supervised. Toddlers are very inquisitive and need constant supervision; therefore, close follow-up is necessary. In addition, the child probably will need some type of wound care requiring involvement of the parent and possibly others.

9. A mother brings her child to the emergency department after the child has taken “some white pills just a short while ago.” What should lead the nurse to determine that the pills taken were most probably acetaminophen?

Nausea and vomiting.

Nosebleed.

Seizure activity.

Deep, rapid respirations.

Acetaminophen is a common drug poisoning agent in children. Symptoms seen in the first 24 hours include nausea and vomiting, anorexia, malaise, and pallor.

Explanation

Acetaminophen is a common drug poisoning agent in children. Symptoms seen in the first 24 hours include nausea and vomiting, anorexia, malaise, and pallor.

10. A client who visits the clinic 2 months after having a Pap smear and beginning oral contraceptives tells the nurse that her menstrual flow has decreased since taking the oral contraceptives. The nurse should instruct the client that she most likely needs which of the following?

Another Pap smear.

Thorough endocrine workup.

Continuation of the oral contraceptives.

Lower dosage of oral contraceptives.

A common side effect of oral contraceptives is decreased menstrual flow. Other adverse effects include breast tenderness, irritability, nausea, headaches, cyclic weight gain, and increased vaginal yeast infections. More serious adverse effects include hypertentsion, myocardial infarction, and thrombophlebitis, The nurse should instruct the client that decreased menstrual flow is normal.

Explanation

A common side effect of oral contraceptives is decreased menstrual flow. Other adverse effects include breast tenderness, irritability, nausea, headaches, cyclic weight gain, and increased vaginal yeast infections. More serious adverse effects include hypertentsion, myocardial infarction, and thrombophlebitis, The nurse should instruct the client that decreased menstrual flow is normal.

11. After teaching the mother about the neonate’s positive Babinski’s reflex, the nurse determines that the mother understands the instructions when she says that a positive Babinski’s reflex indicates which of the following?

Possible spinal cord defect.

Immaturity of the central nervous system.

Possible partial paralysis.

Injury to the nerves innervating the legs.

A positive Babinski’s reflex in a neonate is a normal finding demonstrating the maturity of the central nervous system in corticospinal pathways.

Explanation

A positive Babinski’s reflex in a neonate is a normal finding demonstrating the maturity of the central nervous system in corticospinal pathways.

12. Which of the following client statements indicates that the nurse’s teaching about oral contraceptive agents has been successful?

“Despite their effectiveness, about 25% of women stop taking them after 1 year.”

“These agents usually only cause a few minor advrse effects when you take them.”

“Oral contraceptives inhibit ovulation and change the consistency of cervical mucus.”

“I can make these drugs more effective by monitoring my basal body temperature.”

Oral contraceptive agents inhibit ovulation by suppressing follicle-stimulating hormone and luteinizing hormone. Despite the effectiveness of this method, about 25% of users discontinue this method after 1 year, primarily due to unwanted adverse effects.

Explanation

Oral contraceptive agents inhibit ovulation by suppressing follicle-stimulating hormone and luteinizing hormone. Despite the effectiveness of this method, about 25% of users discontinue this method after 1 year, primarily due to unwanted adverse effects.

13. Twenty four hours after delivery, the nurse documents that involution is progressing normally after palpating the client’s fundus at which of the following locations?

Slightly below the level of the umbilicus.

Midway between the umbilicus and the symphysis pubis.

Barely above the upper margain of the symphysis pubis.

Slightly above the level of the umbilicus.

Approximately 24hours after delivery, the height of the uterus is normally felt slightly below the umbilicus. Unless complications occur, this client can expect the fundus to descend at a rate of about 1 fingerbreadth per day.

Explanation

Approximately 24hours after delivery, the height of the uterus is normally felt slightly below the umbilicus. Unless complications occur, this client can expect the fundus to descend at a rate of about 1 fingerbreadth per day.

14. When instructing s pregnant client diagnosed with a chlamydial infection at 28 weeks’ gestation, which of the following should the nurse include about this infection during pregnancy?

Possible central nervous systems disorders in the fetus.

Cesarean delivery most likely necessary.

Usual treatment with a 10-day course of erythromycin.

Possible fetal death before delivery.

Chlamydial infection during pregnancy has been associated with preterm labor, resulting in a low-birth-weight infant and with preterm rupture of the membranes. Chlamydial infection is usually treated with a 10-day course of erythromycin, tetracycline, or doxycycline.

Explanation

Chlamydial infection during pregnancy has been associated with preterm labor, resulting in a low-birth-weight infant and with preterm rupture of the membranes. Chlamydial infection is usually treated with a 10-day course of erythromycin, tetracycline, or doxycycline.

15. Parents of a child with cystic fibrosis demonstrate knowledge of the effects of hot weather on their child when they state that hot weather is hazardous because the child has which of the following?

Poor ability to concentrate urine.

Little skin pigment to prevent sunburn.

Poorly functioning temperature control center.

Abnormally high salt loss through perspiration.

One characteristic of cystic fibrosis is the excessive loss of salt through perspiration. Salt supplements are almost always necessary during warm weather or any other time the child with cystic fibrosis perspires more than usual.

Explanation

One characteristic of cystic fibrosis is the excessive loss of salt through perspiration. Salt supplements are almost always necessary during warm weather or any other time the child with cystic fibrosis perspires more than usual.

16. A 30 year old multiparous client has been prescribed oral contraceptives as a method of birth control. The nurse instructs the client that decreased effectiveness may occur if the client is prescribed which drug?

Indomethacin (Indocin).

Amitriptyline (Elavil).

Omeprazole (Prilosec).

Ampicillin.

Oral contraceptives may interact with other medications and the effectiveness may be decreased if the client is prescribed ampicillin, tetracycline, or antivonvulsants, such as phentytoin (Dilantin)

Explanation

Oral contraceptives may interact with other medications and the effectiveness may be decreased if the client is prescribed ampicillin, tetracycline, or antivonvulsants, such as phentytoin (Dilantin)

17. During a home visit on the fifth postpartum day, the client begins to cry and says that she is worried about her ability to care for her baby adequately. She tells the nurse. “I wish I could just get organized…I need 8 hours of sleep!” The nurse determines that she is experiencing which of the following?

Taking-in phase of childbearing; she is exhibiting typical signs of adaptation.

Postpartum blues phase of childbearing; she needs psychological counseling.

Letting-go phase of childbearing; she needs help to assume the maternal role.

Taking-hold phase of childbearing; she is feeling inadequate about neonatal care.

A primipara often has concerns about her ability to care for her infant properly during the taking-hold phase. She is working toward independence and autonomy and wants to be able to perform well in her new role as mother. She needs emotional support, advice on how to manage, reassurance, and reinforcement of appropriate behavior.

Explanation

A primipara often has concerns about her ability to care for her infant properly during the taking-hold phase. She is working toward independence and autonomy and wants to be able to perform well in her new role as mother. She needs emotional support, advice on how to manage, reassurance, and reinforcement of appropriate behavior.