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A series of multiple-choice questions covering various nursing topics, including seizure management, post-surgical care, pediatric cardiac conditions, poison control, pregnancy, dental health, medication interactions, acne, tonsillectomy, pancreatitis, trigeminal neuralgia, mental health, and portal hypertension. Each question includes the correct answer and a brief explanation, providing valuable insights into nursing concepts and practices.
Typology: Exams
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D) A 30 month-old who has swallowed a mouthful of charcoal lighter fluid - The correct answer is A: An 18 month-old who ate an undetermined amount of crystal drain cleaner. Drain cleaner is very alkaline. The orange juice is acidic and will help to neutralize this substance.
with pitting of the enamel. Which of the following conditions would most likely explain these findings? A) Ingestion of tetracycline B) Excessive fluoride intake C) Oral iron therapy D) Poor dental hygiene - Thterm-1e correct answer is B: Excessive fluoride intake The described findings are indicative of fluorosis, a condition characterized by an increase in the extent and degree of the enamel's porosity. This problem can be associated with repeated swallowing of toothpaste with fluoride or drinking water with high levels of fluoride.
If the client is losing weight because of poor appetite due to the pain, assist in selecting foods that are high in calories and nutrients, to provide more nourishment with less chewing. Suggest that frequent, small meals be eaten instead of three large ones. To minimize jaw movements when eating, suggest that foods be pureed.
D) "You're safe here. I won't let anyone poison you." - The correct answer is A: "You think that someone wants to poison you?" This response acknowledges perception through a reflective question which presents opportunity for discussion, clarification of meaning, and expressing doubt.
C) A 24 month-old who cries during examination D) A 30 month-old only drinking from a sippy cup - The correct answer is D: A 30 month-old only drinking from a sippy cup A 30 month-old should be able to drink from a cup without a cover.
D) Lack of trust - The correct answer is C: Dependence The client role fosters dependency. Adolescents may react to dependency with rejection, uncooperativeness, or withdrawal.
D) Contact with saliva - The correct answer is A: Immunosuppression The decreased immunity leads to frequent secondary infections. Herpes simplex virus type 1 is an opportunistic infection. The other options may result in HSV-1. However they are not the most likely cause in clients with HIV. The nurse measures the head and chest circumferences of a 20 month-old infant. After comparing the measurements, the nurse finds that they are approximately the same. What action should the nurse take? A) Notify the health care provider B) Palpate the anterior fontanel C) Feel the posterior fontanel D) Record these normal findings - The correct answer is D: Record these normal findings The question is D. The rate of increase in head circumference slows by the end of infancy, and the head circumference is usually equal to chest circumference at 1 to 2 years of age.
At a routine clinic visit, parents express concern that their 4 year- old is wetting the bed several times a month. What is the nurse's best response? A) "This is normal at this time of day." B) "How long has this been occurring?" C) "Do you offer fluids at night?" D) "Have you tried waking her to urinate?" - The correct answer is B: "How long has this been occurring?" Nighttime control should be present by this age, but may not occur until age 5. Involuntary voiding may occur due to infectious, anatomical and/or physiological reasons. A client was admitted to the psychiatric unit after refusing to get out of bed. In the hospital the client talks to unseen people and voids on the floor. The nurse could best handle the problem of voiding on the floor by A) Requiring the client to mop the floor B) Restricting the client's fluids throughout the day C) Withholding privileges each time the voiding occurs
D) Toileting the client more frequently with supervision - The correct answer is D: Toileting the client more frequently with supervision With altered thought processes the most appropriate nursing approach to alter the behavior is by attending to the physical need. The nurse is caring for a client with a sigmoid colostomy who requests assistance in removing the flatus from a 1 piece drainable ostomy pouch. Which is the correct intervention? A) Piercing the plastic of the ostomy pouch with a pin to vent the flatus B) Opening the bottom of the pouch, allowing the flatus to be expelled C) Pulling the adhesive seal around the ostomy pouch to allow the flatus to escape D) Assisting the client to ambulate to reduce the flatus in the pouch
1 piece drainable ostomy pouch is to instruct the client to obtain privacy (the release of the flatus will cause odor), and to open the bottom of the pouch, release the flatus and dose the bottom of the pouch The nurse is teaching parents of an infant about introduction of solid food to their baby. What is the first food they can add to the diet? A) Vegetables B) Cereal C) Fruit D) Meats - The correct answer is B: Cereal Cereal is usually introduced first because it is well tolerated, easy to digest, and contains iron. When counseling parents of a child who has recently been diagnosed with hemophilia, what must the nurse know about the offspring of a normal father and a carrier mother? A) It is likely that all sons are affected
B) There is a 50% probability that sons will have the disease C) Every daughter is likely to be a carrier D) There is a 25% chance a daughter will be a carrier - The correct answer is D: There is a 25% chance a daughter will be a carrier Hemophilia A is a sex-linked recessive trait seen almost exclusively in males. With a normal father and carrier mother, affected individuals are male. There is a 25% chance of having an affected male, 25% chance of having a carrier female, 25% chance of having a normal female and 25% chance of having a normal male. When teaching a client with chronic obstructive pulmonary disease about oxygen by cannula, the nurse should also instruct the client's family to A) Avoid smoking near the client B) Turn off oxygen during meals C) Adjust the liter flow to 10 as needed D) Remind the client to keep mouth closed - The correct answer is A: Avoid smoking near the client Since oxygen supports combustion, there is a risk of fire if anyone smokes near
the oxygen equipment The nurse is caring for a post-op colostomy client. The client begins to cry saying, "I'll never be attractive again with this ugly red thing." What should be the first action by the nurse? A) Arrange a consultation with a sex therapist B) Suggest sexual positions that hide the colostomy C) Invite the partner to participate in colostomy care D) Determine the client's understanding of her colostomy - The correct answer is D: Determine the client's understanding of her colostomy. One of the greatest fears of colostomy clients is the fear that sexual intimacy is no longer possible. However, the specific concern of the client needs to be assessed before specific suggestions for dealing with the sexual concerns are given. A schizophrenic client talks animatedly but the staff are unable to understand what the client is communicating. The client is observed mumbling
to herself and speaking to the radio. A desirable outcome for this client's care will be A) Expresses feelings appropriately through verbal interactions B) Accurately interprets events and behaviors of others C) Demonstrates improved social relationships D) Engages in meaningful and understandable verbal communication - The correct answer is D: Engages in meaningful and understandable verbal communication. Data support impaired verbal communication deficit. The outcome must be related to the diagnosis and supporting data. No data is presented related to feelings or to thinking processes. A 7 year-old child is hospitalized following a major burn to the lower extremities. A diet high in protein and carbohydrates is recommended. The nurse informs the child and family that the most important reason for this diet is to A) Promote healing and strengthen the immune system B) Provide a well-balanced nutritional intake
C) Stimulate increased peristalsis absorption D) Spare protein catabolism to meet metabolic needs - The correct answer is D: Spare protein catabolism to meet metabolic needs. Because of the burn injury, the child has increased metabolism and catabolism. By providing a high carbohydrate diet, the breakdown of protein for energy is avoided. Proteins are then used to restore tissue. The parents of a 7 year-old tell the nurse their child has started to "tattle" on siblings. In interpreting this new behavior, how should the nurse explain the child's actions to the parents? A) The ethical sense and feelings of justice are developing B) Attempts to control the family use new coping styles C) Insecurity and attention getting are common motives D) Complex thought processes help to resolve conflicts - The correct answer is A: The ethical sense and feelings of justice are developing. The child is developing a sense of justice and a desire to do what is right. At seven, the child is increasingly aware of family roles and responsibilities. They also do what is right because of parental direction or to avoid punishment.
A school nurse is advising a class of unwed pregnant high school students. What is the most important action they can perform to deliver a healthy child? A) Maintain good nutrition B) Stay in school C) Keep in contact with the child's father D) Get adequate sleep - The correct answer is A: Maintaining good nutrition Nurses can serve a pivotal role in providing nutritional education and case management interventions. Weight gain during pregnancy is one of the strongest predictors of infant birth weight. Specifically, teens need to increase their intake of protein, vitamins, and minerals including iron. Pregnant teens who gain between 26 and 35 pounds have the lowest incidence of low-birth-weight babies. A client continually repeats phrases that others have just said. The nurse recognizes this behavior as A) Autistic B) Ecopraxic
C) Echolalic D) Catatonic - The correct answer is C: Echolalic Echolalic - repeating words heard. A client is admitted for hemodialysis. Which abnormal lab value would the nurse anticipate not being improved by hemodialysis? A) Low hemoglobin B) Hypernatremia C) High serum creatinine D) Hyperkalemia - The correct answer is A: Low hemoglobin Although hemodialysis improves or corrects electrolyte imbalances it has not effect on improving anemia. The nurse is caring for a 7 year-old child who is being discharged following a tonsillectomy. Which of the following instructions is appropriate for the nurse to teach the parents? A) Report a persistent cough to the health care provider B) The child can return to school in 4 days
C) Administer chewable aspirin for pain D) The child may gargle with saline as necessary for discomfort - The correct answer is A: Report a persistent cough to the health care provider. Persistent coughing should be reported to the health care provider as this may indicate bleeding The nurse is caring for a 14 month-old just diagnosed with Cystic Fibrosis. The parents state this is the first child in either family with this disease, and ask about the risk to future children. What is the best response by the nurse? A) 1in 4 chance for each child to carry that trait B) 1in 4 risk for each child to have the disease C) 1in 2 chance of avoiding the trait and disease D) 1in 2 chance that each child will have the disease - The correct answer is B: 1 in 4 risk for each child to have the disease Cystic Fibrosis is an autosomal recessive transmission pattern. In this situation, both parents must be carriers of the trait for the disease since neither one of them has the disease. Therefore, for each pregnancy, there is a 25% chance of