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INSTANT DOWNLOAD COMPLETE TEST BANK WITH ANSWERS

 

Maternal Child Nursing 3rd Edition By Murray Ashwill James – Test Bank

 

Sample  Questions         

 

McKinney: Maternal-Child Nursing, 3rd Edition

 

Test Bank

 

Chapter 1: Foundations of Maternity, Women’s Health, and Child Health Nursing

 

              MULTIPLE CHOICE

 

  1. Which factor significantly contributed to the shift from home births to hospital births in the early twentieth century?
a. Puerperal sepsis was identified as a risk factor in labor and delivery.
b. Forceps were developed to facilitate difficult births.
c. The importance of early parental-infant contact was identified.
d. The number of hospital births decreased.

 

 

ANS:   B

A Puerperal sepsis has been a known problem for generations. In the late nineteenth century, Semmelweis discovered how it could be prevented.

B The development of forceps to facilitate difficult births by physicians was a strong factor in the decrease of home births and increase of hospital births.

C The shift to hospital births decreased the parental-infant contact.

D With the shift toward hospital births, the numbers increased.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 2

OBJ:    Nursing Process Step: Assessment

MSC:   Client Needs: Safe and Effective Care Environment

 

  1. Family-centered maternity care developed in response to:
a. demands by physicians for family involvement in childbirth.
b. the Sheppard-Towner Act of 1921.
c. parental requests that infants be allowed to remain with them rather than in a nursery.
d. changes in pharmacologic management of labor.

 

 

ANS:   C

A Family-centered care was a request by parents, not physicians.

B The Sheppard-Towner Act provided funds for state-managed programs for mothers and children.

C As research began to identify the benefits of early extended parent-infant contact, parents began to insist that the infant remain with them. This gradually developed into the practice of rooming-in and finally to family-centered maternity care.

D The changes in pharmacologic management of labor were not a factor in family-centered maternity care.

 

DIF:    Cognitive Level: Knowledge             REF:    pp. 3-4

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Psychosocial Integrity

 

  1. Which setting for childbirth allows the least amount of parent-infant contact?
a. Labor/delivery/recovery/postpartum room
b. Birth center
c. Traditional hospital birth
d. Home birth

 

 

ANS:   C

A The labor/delivery/recovery/postpartum room setting allows increased parent-infant contact.

B Birth centers are set up to allow an increase in parent-infant contact.

C In the traditional hospital setting, the mother may see the infant for only short feeding periods, and the infant is cared for in a separate nursery.

D Home births allow an increase in parent-infant contact.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 3

OBJ:    Nursing Process Step: Planning

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. As a result of changes in health care delivery and funding, a current trend seen in the pediatric setting is:
a. increased hospitalization of children.
b. decreased number of children living in poverty.
c. an increase in ambulatory care.
d. decreased use of managed care.

 

 

ANS:   C

A Hospitalization for children has decreased.

B Health care delivery has not altered the number of children living in poverty.

C One effect of managed care has been that pediatric health care delivery has shifted dramatically from the acute care setting to the ambulatory setting. One of the biggest changes in health care has been the growth of managed care. The number of hospital beds being used has decreased as more care is given in outpatient settings and in the home. The number of children living in poverty has increased over the last decade.

D Managed care has increased in order to control cost.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 6

OBJ:    Nursing Process Step: Planning

MSC:   Client Needs: Safe and Effective Care Environment

 

  1. The Women-Infants-Children (WIC) program provides:
a. well-child examinations for infants and children living at the poverty level.
b. immunizations for high-risk infants and children.
c. screening for infants with developmental disorders.
d. supplemental food supplies to low-income women who are pregnant or breastfeeding.

 

 

ANS:   D

A Medicaid’s Early and Periodic Screening, Diagnosis, and Treatment Program provides for well-child examinations and for treatment of any medical problems diagnosed during such checkups.

B Children in the WIC program are often linked with immunizations, but that is not the primary focus of the program.

C Public Law 99-457 provides financial incentives to states to establish comprehensive early intervention services for infants and toddlers with, or at risk for, developmental disabilities.

D WIC is a federal program that provides supplemental food supplies to low-income women who are pregnant or breastfeeding and to their children until age 5 years.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 9

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Physiologic Integrity

 

  1. In most states, adolescents who are not emancipated minors must have the permission of their parents before:
a. treatment for drug abuse.
b. treatment for sexually transmitted diseases (STDs).
c. accessing birth control.
d. surgery.

 

 

ANS:   D

A Most states allow minors to obtain treatment for drug or alcohol abuse without parental consent.

B Most states allow minors to obtain treatment for STDs without parental consent.

C In most states minors are allowed access to birth control without parental consent.

D If a minor receives surgery without proper informed consent, assault and battery charges against the care provider can result. This does not apply to an emancipated minor (a minor child who has the legal competency of an adult because of circumstances involving marriage, divorce, parenting of a child, living independently without parents, or enlistment in the armed services).

 

DIF:    Cognitive Level: Application             REF:    p. 18

OBJ:    Nursing Process Step: Planning

MSC:   Client Needs: Safe and Effective Care Environment

 

  1. The maternity nurse should have a clear understanding of the correct use of a clinical pathway. One characteristic of clinical pathways is that they:
a. are developed and implemented by nurses.
b. are used primarily in the pediatric setting.
c. set specific time lines for sequencing interventions.
d. are part of the nursing process.

 

 

ANS:   C

A Clinical pathways are developed by multiple health care professionals and reflect interdisciplinary interventions.

B They are used in multiple settings and for patients throughout the life span.

C Clinical pathways measure outcomes of patient care. Each pathway outlines specific time lines for sequencing interventions.

D The steps of the nursing process are assessment, diagnosis, planning, intervention, and evaluation.

 

DIF:    Cognitive Level: Application             REF:    p. 7

OBJ:    Nursing Process Step: Planning

MSC:   Client Needs: Safe and Effective Care Environment

 

  1. The fastest-growing group of homeless people is:
a. men and women preparing for retirement.
b. migrant workers.
c. single women and their children.
d. intravenous substance abusers.

 

 

ANS:   C

A Most people contemplating retirement have made provisions.

B Migrant workers may seek health care only when absolutely necessary; however, not all are homeless.

C Pregnancy and birth, especially for a teenager, are important contributing factors for becoming homeless.

D Not all substance abusers are homeless.

 

DIF:    Cognitive Level: Knowledge             REF:    p.14

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Physiologic Integrity

 

  1. The United States ranks twenty-eighth in infant mortality rates of the world. Which factor has a significant impact on decreasing the mortality rate of infants?
a. Resolving all language and cultural differences
b. Enrolling the pregnant woman in the Medicaid program by the eighth month of pregnancy
c. Ensuring early and adequate prenatal care
d. Providing more women’s shelters

 

 

ANS:   C

A Language and cultural differences are not infant mortality issues but must be addressed to improve overall health care.

B Medicaid provides health care for poor pregnant women, but the process may take weeks to take effect. The eighth month is too late to apply and receive benefits for this pregnancy.

C Because preterm infants form the largest category of those needing expensive intensive care, early pregnancy intervention is essential for decreasing infant mortality rates.

D The women in shelters have the same difficulties in obtaining health care as do other poor people, particularly lack of transportation and inconvenient hours of the clinics.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 2

OBJ:    Nursing Process Step: Assessment

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. The intrapartum woman sees no need for an admission fetal monitoring strip. If she continues to refuse, what is the first action the nurse should take?
a. Consult with the family of the woman.
b. Notify the physician.
c. Document the woman’s refusal in the nurse’s notes.
d. Make a referral to the hospital ethics committee.

 

 

ANS:   B

A The client must be allowed to make choices voluntarily without undue influence or coercion from others.

B Clients must be allowed to make choices voluntarily without undue influence or coercion from others. The physician, especially if unaware of the client’s decision, should be notified immediately. The nurse should notify the physician of the refusal of the agency’s protocol and document all aspects of the explanations given by the nurse, as well as any instructions from the physician.

C Documentation is important, but it should not be the first action.

D Fetal monitoring is not usually considered an ethical problem.

 

DIF:    Cognitive Level: Application             REF:    p. 18

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Safe and Effective Care Environment

 

  1. Which statement is true regarding the “quality assurance” or “incident” report?
a. The report assures the legal department that no problem exists.
b. Reports are a permanent part of the patient’s chart.
c. The nurse’s notes should contain, “Incident report filed, and copy placed in chart.”
d. This report is a form of documentation of an event that may result in legal action.

 

 

ANS:   D

A The report is a warning to the legal department to be prepared for a potential legal action.

B Incident reports are not a part of the patient’s chart.

C Incident reports are not mentioned in the nurse’s notes.

D Documentation on the chart should include all factual information regarding the client’s condition that would be recorded in any situation. Incident reports are not mentioned in the nurse’s notes. The nurse completes an incident report when something occurs that might result in a legal action against the clinic or hospital or is a variance from the standard of care.

 

DIF:    Cognitive Level: Application             REF:    p. 17

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Safe and Effective Care Environment

 

  1. Which of these situations best reflects the deontologic theory?
a. Initiating resuscitative measures on a 90-year-old patient with terminal cancer
b. Using experimental medications for the treatment of acquired immunodeficiency syndrome (AIDS)
c. Supporting the transplant of fetal tissue and organs
d. Approving of a physician-assisted suicide

 

 

ANS:   A

A In the deontologic theory, life must be maintained at all costs, regardless of quality of life.

B In the deontologic theory, life must be maintained at all costs, regardless of quality of life.

C In the deontologic theory, life must be maintained at all costs, regardless of quality of life.

D In the deontologic theory, life must be maintained at all costs, regardless of quality of life.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 1

OBJ:    Nursing Process Step: Planning         MSC:   Client Needs: Psychosocial Integrity

 

  1. Elective abortion is considered an ethical issue because:
a. abortion law is unclear about a woman’s constitutional rights.
b. the Supreme Court ruled that life begins at conception.
c. a conflict exists between the rights of the woman and the rights of the fetus.
d. it requires third-party consent.

 

 

ANS:   C

A Abortion laws are clear concerning a woman’s constitutional rights.

B The Supreme Court has not ruled on when life begins.

C Elective abortion is an ethical dilemma because two opposing courses of action are available.

D Abortion does not require third-party consent.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 12

OBJ:    Nursing Process Step: Assessment

MSC:   Client Needs: Safe and Effective Care Environment

 

  1. Which woman would be most likely to seek prenatal care?
a. A 15-year-old who tells her friends, “I don’t believe I am pregnant”
b. A 20-year-old who is in her first pregnancy and has access to a free prenatal clinic
c. A 28-year-old who is in her second pregnancy and abuses drugs and alcohol
d. A 30-year-old who is in her fifth pregnancy and delivered her last infant at home with the help of her mother and sister

 

 

ANS:   B

A Being in denial about the pregnancy will prevent her from seeking health care.

B The client who acknowledges the pregnancy early, has access to health care, and has no reason to avoid health care is most likely to seek prenatal care.

C Substance abusers are less likely to seek health care.

D Some women see pregnancy and delivery as a natural occurrence and do not seek health care.

 

DIF:    Cognitive Level: Comprehension       REF:    pp. 8, 15

OBJ:    Nursing Process Step: Assessment

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. A woman who delivered her baby 6 hours ago complains of headache and dizziness. The nurse administers an analgesic but does not perform any assessments. The woman then has a grand mal seizure, falls out of bed, and fractures her femur. How would the actions of the nurse be interpreted in relation to standards of care?
a. Negligent because the nurse failed to assess the woman for possible complications
b. Negligent because the nurse medicated the woman
c. Not negligent because the woman had signed a waiver concerning the use of side rails
d. Not negligent because the woman did not inform the nurse of her symptoms as soon as they occurred

 

 

ANS:   A

A By not assessing the woman, the nurse failed to meet the established standards of care. The first element of negligence relates to whether the nurse has a duty to provide care to the woman. The care that the nurse provides must meet the established standards of care.

B By not first assessing the woman, the nurse does not meet the established standards of care.

C The nurse could be found negligent.

D The nurse is responsible for assessing the woman.

 

DIF:    Cognitive Level: Application             REF:    p. 17

OBJ:    Nursing Process Step: Evaluation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. What client situation fails to meet the first requirement of informed consent?
a. The client does not understand the physician’s explanations.
b. The physician gives the client only a partial list of possible side effects and complications.
c. The client is confused and disoriented.
d. The client signs a consent form because his wife tells him to.

 

 

ANS:   C

A Understanding is an important element of the consent, but first the client has to be competent to sign.

B Full disclosure of information is an important element of the consent, but first the client has to be competent to sign.

C The first requirement of informed consent is that the client must be competent to make decisions about health care.

D Voluntary consent is an important element of the consent, but first the client has to be competent to sign.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 18

OBJ:    Nursing Process Step: Assessment

MSC:   Client Needs: Safe and Effective Care Environment

 

  1. Which situation reflects a potential ethical dilemma for the nurse?
a. A nurse administers analgesics to a client with cancer as often as the physician’s order allows.
b. A neonatal nurse provides nourishment and care to a newborn having a defect that is incompatible with life.
c. A labor nurse, whose religion opposes abortion, is asked to assist with an elective abortion.
d. A postpartum nurse provides information about adoption to a new mother who feels she cannot adequately care for her infant.

 

 

ANS:   C

A There is no element of conflict for the nurse, therefore a dilemma does not exist.

B There is no element of conflict for the nurse, therefore a dilemma does not exist.

C A dilemma exists in this situation because the nurse is being asked to assist with a procedure that she or he believes is morally wrong. The other situations do not contain elements of conflict for the nurse.

D There is no element of conflict for the nurse, therefore a dilemma does not exist.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 11

OBJ:    Nursing Process Step: Assessment

MSC:   Client Needs: Safe and Effective Care Environment

 

MULTIPLE RESPONSE

 

  1. Many communities now offer the availability of free-standing birth centers to provide care for low-risk women during pregnancy, birth, and postpartum. When counseling the newly pregnant woman regarding this option, the nurse should be aware that this type of care setting includes which advantages? Choose those that apply.
a. Less expensive than acute-care hospitals
b. Access to follow-up care for 6 weeks postpartum
c. Equipped for obstetric emergencies
d. Safe, home-like births in a familiar setting
e. Staffing by lay midwives

 

 

ANS:   A, B, D

Correct A, B, D. Women who are at low risk and desire a safe, home-like birth are very satisfied with this type of care setting. The new mother may return to the birth center for postpartum follow-up care, breastfeeding assistance, and family planning information for 6 weeks postpartum. Since birth centers do not incorporate advanced technologies into their services, costs are significantly less than a hospital setting.

Incorrect C, E. The major disadvantage of this care setting is that these facilities are not equipped to handle obstetric emergencies. Should unforeseen difficulties occur, the woman must be transported by ambulance to the nearest hospital. Birth centers are usually staffed by certified nurse-midwives (CNMs); however, in some states lay midwives may provide this service.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 4

OBJ:    Nursing Process Step: Planning

MSC:   Client Needs: Safe and Effective Care Environment

 

  1. In an effort to reduce prohibitive health care costs, many facilities have incorporated the use of unlicensed assistive personnel into their care delivery model. Nurses supervising these employees must be aware of what each such employee is competent to do within his or her scope of practice. Which tasks can be delegated with supervision? Choose the tasks that apply.
a. Blood draws
b. Medication administration
c. Nursing assessment
d. Housekeeping tasks
e. Other diagnostic tests, such as electrocardiograms (ECGs or EKGs)

 

 

ANS:   A, B, D, E

Correct A, B, D, E. With proper supervision and adequate instruction, unlicensed assistive personnel may perform all of these functions. In long-term care settings, these personnel are often responsible for medication administration under the direction of the registered nurse (RN).

Incorrect C. The nurse is always responsible for client assessments and must make critical judgments to ensure client safety. Use of the expert nurse to complete housekeeping or other mundane tasks is not a good use of human resources. For more information about the use of unlicensed personnel, refer to www.awhonn.org.

 

DIF:    Cognitive Level: Application             REF:    p. 20

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Safe and Effective Care Environment

McKinney: Maternal-Child Nursing, 3rd Edition

 

Test Bank

 

Chapter 3: The Childbearing and Child-Rearing Family

 

              MULTIPLE CHOICE

 

  1. The formula to use to guide time-out as a disciplinary method is:
a. 1 minute per each year of the child’s age.
b. to relate the length of the time-out to the severity of the behavior.
c. never to use time-out for a child younger than 4 years.
d. to follow the time-out with a treat.

 

 

ANS:   A

A It is important to structure time-out in a time frame that allows the child to understand why he or she has been removed from the environment.

B Relating time to a behavior is subjective and is inappropriate when the child is very young.

C Time-out can be used with the toddler.

D Negative behavior should not be reinforced with a positive action.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 46

OBJ:    Nursing Process Step: Assessment

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. The nurse observes that when an 8-year-old boy enters the playroom, he frequently causes disruption by taking toys from other children. The nurse’s best approach for this behavior is to:
a. ban the child from the playroom.
b. explain to the children in the playroom that he is very ill and should be allowed to have the toys.
c. approach the child in his room and ask, “Would you like it if the other children took your toys from you?”
d. approach the child in his room and state, “I am concerned that you are taking the other children’s toys. It upsets them and me.”

 

 

ANS:   D

A Banning the child from the playroom will not solve the problem. The problem is his behavior, not the place where he exhibits it.

B Illness is not a reason for a child to be undisciplined. When the child recovers, the parents will have to deal with a child who is undisciplined and unruly.

C Children should not be made to feel guilty and to have their self-esteem attacked.

D By the nurse’s using “I” rather than the “you” message, the child can focus on the behavior. The child and the nurse can begin to explore why the behavior occurs.

 

DIF:    Cognitive Level: Application             REF:    p. 46

OBJ:    Nursing Process Step: Planning

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. Families who deal effectively with stress have which behavior pattern?
a. Focus on family problems c. Expect that some stress is normal
b. Feel weakened by stress d. Feel guilty when stress exists

 

 

ANS:   C

A Healthy families focus on family strengths rather than on the problems and know that stress is temporary and may be positive.

B If families are dealing effectively with stress, then weakening of the family unit should not occur.

C Healthy families recognize that some stress is normal in all families.

D Because some stress is normal in all families, feeling guilty is not reasonable. Guilt only immobilizes the family and does not lead to resolution of the stress.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 39

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Psychosocial Integrity

 

  1. Which family will most likely have the most difficulty coping with an ill child?
a. A single-parent mother who has the support of her parents and siblings
b. Parents who have just moved to the area and are living in an apartment while they look for a house
c. The family of a child who has had multiple hospitalizations related to asthma and has adequate relationships with the nursing staff
d. A family in which there is a young child and four older married children who live in the area

 

 

ANS:   B

A Although only one parent is available, she has the support of her extended family, which will assist her in adjusting to the crisis.

B Parents in a new environment will have increased stress related to their lack of a support system. They have no previous experiences in the setting from which to draw confidence.

C Because this family has had positive experiences in the past, family members can draw from those experiences and feel confident about the setting.

D This family has an extensive support system that will assist the parents in adjusting to the crisis.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 39

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Psychosocial Integrity

 

  1. What is the priority nursing intervention for the family of a child who has been admitted to the hospital?
a. Begin discharge teaching.
b. Assess the family’s knowledge.
c. Include the parents in the care of their child.
d. Instruct the parents on normal growth and development.

 

 

ANS:   C

A Although discharge teaching is begun as soon as possible, it is not effective if a trust level has not been established with the parents or if they are at a stress level that precludes learning.

B It is difficult to assess a family’s knowledge if the family is feeling out of control and experiencing stress.

C Encouraging and giving parents permission to continue to parent their child can allow them to feel more in control, give them more trust, feel less threatened and less stressed, and ultimately more open to information and teaching their children.

D Normal growth and development should be interwoven into teaching, but teaching cannot take place until the parents have less stress and are open to information.

 

DIF:    Cognitive Level: Application             REF:    p. 48

OBJ:    Nursing Process Step: Planning         MSC:   Client Needs: Psychosocial Integrity

 

  1. What characteristic would most likely be found in a Mexican-American family?
a. Stoicism
b. Close extended family
c. Docile children are considered weak
d. Very interested in health-promoting lifestyles

 

 

ANS:   B

A Although stoicism may be present in any family, Mexican-American families tend to be more expressive.

B Most Mexican-American families are very close, and it is not unusual for children to be surrounded by parents, siblings, grandparents, and godparents. It is important to respect this cultural characteristic and to see it as a strength, not a weakness.

C Considering docile children weak is a characteristic of Native Americans.

D Although everyone tends now to embrace more health-promoting lifestyles, they are more prominent in Anglo-Americans.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 42

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Psychosocial Integrity

 

  1. While reviewing dietary-intake documentation on a 7-year-old Mexican-American boy with a fractured femur, the nurse notes that he consistently refuses to eat the food on his tray. What assumption is most likely accurate?
a. He is a picky eater.
b. He needs less food because he is on bed rest.
c. He may have culturally related food preferences.
d. He is probably eating between meals and spoiling his appetite.

 

 

ANS:   C

A Although the child may be a picky eater, the key point is that he is from a different culture. The foods he is being served may seem strange to him.

B Nutrition plays an important role in healing. Although the energy the child expends has decreased while on bed rest, he has increased needs for good nutrition.

C When cultural differences are noted, food preferences should always be obtained. A child will often refuse to eat unfamiliar foods.

D Although the nurse should determine whether the child is eating food the family has brought from home, the more important point is to determine whether he has food preferences.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 40

OBJ:    Nursing Process Step: Evaluation      MSC:   Client Needs: Physiologic Integrity

 

  1. To resolve family conflict, it is necessary to have open communication, accurate perception of the problem, and:
a. an intact family structure.
b. an arbitrator.
c. a willingness to consider the view of others.
d. a balance in personality types.

 

 

ANS:   C

A The structure of a family may affect family dynamics, but it is still possible to resolve conflict without an intact family structure if all of the ingredients of conflict resolution are present.

B Conflicts can be resolved without the assistance of an arbitrator.

C Without the willingness of the members of a group to consider the views of others, conflict resolution cannot take place.

D Most families have diverse personality types among their members. This diversity may make conflict resolution more difficult, but should not impede it as long as the ingredients of conflict resolution are present.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 39

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Psychosocial Integrity

 

  1. Which statement is true about the characteristics of a healthy family?
a. The parents and children have rigid assignments for all the family tasks.
b. Young families assume the total responsibility for the parenting tasks, refusing any assistance.
c. The family is overwhelmed by the significant changes that occur as a result of childbirth.
d. Adults agree on the majority of basic parenting principles.

 

 

ANS:   D

A Healthy families remain flexible in their role assignments.

B Members of a healthy family accept assistance without feeling guilty.

C Healthy families can tolerate irregular sleep and meal schedules, which are common during the months after childbirth.

D Adults in a healthy family communicate with each other so that minimal discord occurs in areas such as discipline and sleep schedules.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 38

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Psychosocial Integrity

 

MULTIPLE RESPONSE

 

  1. The consequences technique will assist children to learn the direct result of their behavior. This technique can be used with children from toddler age to adolescence. If children learn to understand consequences, they are less likely to repeat the offending behavior. Consequences fall into which categories? Select all that apply.
a. Corporal
b. Natural
c. Logical
d. Unrelated
e. Behavioral

 

 

ANS:   B, C, D

Correct B, C, D. Natural consequences are those that occur spontaneously. For example, a child leaves a toy outside and it is lost. Logical consequences are those that are directly related to the misbehavior. If two children are fighting over a toy, it is removed and neither child has it. Unrelated consequences are purposely imposed, for example, the child is late for dinner so is not allowed to watch television.

Incorrect A, E. Corporal punishment is not part of this behavioral approach and usually takes the approach of spanking the child. Corporal punishment is highly controversial and is strongly discouraged by the American Academy of Pediatrics. Behavior modification is another disciplinary technique that rewards positive behavior and ignores negative behavior.

 

DIF:    Cognitive Level: Comprehension       REF:    pp. 46-47

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Psychosocial Integrity

 

COMPLETION

 

  1. A ____________________ family is one formed when single, divorced, or widowed parents bring children from a previous union into the new relationship.

 

ANS:

Blended

These families must overcome differences in parenting styles and values to form a cohesive blended family. Often they wish to have children with each other in the new relationship. Differing expectations of the children’s development and beliefs regarding discipline may lead to conflict. Older children often resent the introduction of a stepmother or stepfather.

 

DIF:    Cognitive Level: Comprehension       REF:    pp. 36-37

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Psychosocial Integrity

 

TRUE/FALSE

 

  1. Parents of children with special needs often require specialized care and experience frequent hospitalizations. When caring for these families the nurse should be aware that they may experience financial hardship due to their child’s condition and require assistance in obtaining referrals to resources.

 

ANS:   T

These families often suffer financial hardship, which can lead to issues related to coping and other strains on the family. Health insurance benefits may quickly reach their maximum. Even if the child is on special assistance for health care, one parent may have to remain home with the child rather than work outside of the home. Social work and financial or prescription assistance may all be necessary and appropriate sources of support.

 

DIF:    Cognitive Level: Application             REF:    p. 39

OBJ:    Nursing Process Step: Assessment and Planning

MSC:   Client Needs: Safe and Effective Care Environment

McKinney: Maternal-Child Nursing, 3rd Edition

 

Test Bank

 

Chapter 11: Reproductive Anatomy and Physiology

 

              MULTIPLE CHOICE

 

  1. What men could have abnormal sperm formation resulting in infertility?
a. A 20-year-old man with undescended testicles
b. An uncircumcised 40-year-old man
c. A 35-year-old man with previously treated sexually transmitted disease
d. A 16-year-old adolescent who is experiencing nocturnal emissions

 

 

ANS:   A

A For normal sperm formation, a man’s testes must be cooler than his core body temperature.

B Circumcision does not prevent infertility.

C Scar tissue in the fallopian tubes as a result of a sexually transmitted disease can be a cause of infertility in women.

D Nocturnal emissions of seminal fluid are normal and expected in teenagers.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 228

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Physiologic Integrity

 

  1. Which combination of sex chromosomes is present in a female?
a. XY c. XXY
b. XYY d. XX

 

 

ANS:   D

A An XY is the indication for a male.

B There are normally only two sex chromosomes.

C There are normally only two sex chromosomes.

D The combination of an X chromosome from each parent produces a female.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 218

OBJ:    Nursing Process Step: Assessment

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. Which of these is a secondary sexual characteristic?
a. Female breast development
b. Production of sperm
c. Maturation of ova
d. Secretion of gonadotropin-releasing hormone

 

 

ANS:   A

A A secondary sexual characteristic is one not directly related to reproduction, such as development of the characteristic female body form.

B Production of sperm is directly related to reproduction and is a primary sexual characteristic.

C Maturation of ova is directly related to reproduction and is a primary sexual characteristic.

D Secretion of hormones is directly related to reproduction and is a primary sexual characteristic.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 218

OBJ:    Nursing Process Step: Assessment

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. Fertilization of the ovum takes place in which part of the fallopian tube?
a. Interstitial portion c. Isthmus
b. Ampulla d. Infundibulum

 

 

ANS:   B

A The interstitial portion runs into the uterine cavity. This area is too close to the uterine body for fertilization to occur; it would lead to improper placement for implantation.

B The ampulla is the wider middle part of the tube lateral to the isthmus and is where fertilization occurs.

C The isthmus is the narrowest portion of the tube.

D The infundibulum is the end of the tube that opens into the abdominal cavity. Fertilization at this area may lead to an abdominal pregnancy.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 223

OBJ:    Nursing Process Step: Assessment

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. Which 16-year-old woman is most likely to experience secondary amenorrhea?
a. A woman who is 5 ft 2 in, 130 lb c. A woman who is 5 ft 7 in, 96 lb
b. A woman who is 5 ft 9 in, 150 lb d. A woman who is 5 ft 4 in, 120 lb

 

 

ANS:   C

A This woman’s (5 ft 2 in, 130 lb) body mass index (BMI) is sufficient to assist with sex hormone production. A low BMI (or body fat) is a risk factor for secondary amenorrhea.

B This woman’s (5 ft 9 in, 150 lb) BMI is sufficient to assist with sex hormone production. Low body fat is a risk factor for secondary amenorrhea.

C Because of her height and low body weight, a woman who is 5 ft 7 in and 96 lb is at risk of developing secondary amenorrhea, which occurs in women who are thin and have a low percentage of body fat. Fat is necessary to make sex hormones that stimulate ovulation and menstruation.

D This woman’s (5 ft 4 in, 120 lb) body fat is sufficient to assist with sex hormone production. Low BMIs are a risk factor for secondary amenorrhea.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 220

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Physiologic Integrity

 

  1. It is important for the nurse to understand that the levator ani is:
a. an imaginary line that divides the true and false pelvis.
b. a basin-shaped structure at the lower end of the spine.
c. a collection of three pairs of muscles.
d. a division of the fallopian tube.

 

 

ANS:   C

A The linea terminalis is the imaginary line that divides the false from the true pelvis.

B The basin-shaped structure at the lower end of the spine is the bony pelvis.

C The levator ani is a collection of three pairs of muscles that support internal pelvic structures and resist increases in intraabdominal pressure.

D The fallopian tube divisions are the interstitial portion, isthmus, ampulla, and infundibulum.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 223

OBJ:    Nursing Process Step: Assessment

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. In describing the size and shape of the nonpregnant uterus to a client, the nurse would say it is about the size and shape of a:
a. cantaloupe. c. pear.
b. grapefruit. d. large orange.

 

 

ANS:   C

A A cantaloupe would be too large and the wrong shape for the uterus.

B A grapefruit is too large for the nonpregnant uterus, and the uterus is larger at the upper end and tapers down.

C The nonpregnant uterus is about 7.5 ´ 5 ´ 2.5 cm, which is close to the size and shape of a pear.

D An orange may be the appropriate size, but it is not the appropriate shape.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 222

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. If a woman’s menstrual cycle began on June 2 and normally lasts 28 days, ovulation would mostly likely occur on:
a. June 10. c. June 21.
b. June 16. d. June 29.

 

 

ANS:   B

A This would just be 8 days into the cycle and too early for ovulation.

B Ovulation occurs about 12 to 14 days after the beginning of the menstrual period in a 28-day cycle. Ovulation normally occurs about 14 days before the beginning of the next period.

C This would be 18 days into the cycle. Ovulation should have already occurred at this point.

D This would be 27 days into the cycle and about time for the next period.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 225

OBJ:    Nursing Process Step: Assessment

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. A client states, “My breasts are so small, I don’t think I will be able to breastfeed.” The nurse’s best response is:
a. “It may be difficult, but you should try anyway.”
b. “You can always supplement with formula.”
c. “All women have about the same amount of glandular tissue to secrete milk.”
d. “The ability to produce breast milk depends on increased levels of estrogen and progesterone.”

 

 

ANS:   C

A The size of the breasts does not ensure success or failure in breastfeeding.

B Supplementation decreases the production of breast milk by decreasing stimulation. Stimulation of the breast, not the size of the breast, brings about milk production.

C All women have 15 to 20 lobes arranged around and behind the nipple and areola. These lobes, not the size of the breast, are responsible for milk production.

D Increased levels of estrogen decrease the production of milk by affecting prolactin.

 

DIF:    Cognitive Level: Application             REF:    p. 227

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Physiologic Integrity

 

  1. The function of the cremaster muscle in men is to:
a. aid in voluntary control of excretion of urine.
b. entrap blood in the penis to produce an erection.
c. assist with transporting sperm.
d. aid in temperature control of the testicles.

 

 

ANS:   D

A The urinary meatus aids in controlling the excretion of urine.

B Entrapment of the blood in the penis is due to its spongy tissue.

C Seminal fluid assists with transporting sperm.

D A cremaster muscle is attached to each testicle. Its function is to bring the testicle closer to the body to warm it or allow it to fall away from the body to cool it, thus promoting normal sperm production.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 228

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Physiologic Integrity

 

  1. The average man is taller than the average woman at maturity because of:
a. a longer period of skeletal growth.
b. earlier development of secondary sexual characteristics.
c. earlier onset of growth spurt.
d. starting puberty at an earlier age.

 

 

ANS:   A

A The man’s greater height at maturity is the combined result of beginning the growth spurt at a later age and continuing it for a longer period.

B Girls develop earlier than boys.

C Boys’ growth spurts start at a later age.

D Girls start puberty about 6 months to 1 year earlier than boys.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 220

OBJ:    Nursing Process Step: Assessment

MSC:   Client Needs: Health Promotion and Maintenance

 

MULTIPLE RESPONSE

 

  1. A young female client comes to the health unit at school to discuss her irregular periods. In providing education regarding the female reproductive cycle, the nurse describes the regular and recurrent changes related to the ovaries and the uterine endometrium. Although this is generally referred to as the menstrual cycle, the ovarian cycle includes which phases? Choose those that apply.
a. Follicular
b. Ovulatory
c. Luteal
d. Proliferative
e. Secretory

 

 

ANS:   A, B, C

Correct A, B, C. The follicular phase is the period during which the ovum matures. It begins on day 1 and ends around day 14. The ovulatory phase occurs near the middle of the cycle about 2 days before ovulation. After ovulation and under the influence of the luteinizing hormone, the luteal phase corresponds with the last 12 days of the menstrual cycle.

Incorrect D, E. The proliferative and secretory phases are part of the endometrial cycle. The proliferative phase takes place during the first half of the ovarian cycle when the ovum matures. The secretory phase occurs during the second half of the cycle when the uterus is prepared to accept the fertilized ovum. These are followed by the menstrual phase if fertilization does not occur.

 

DIF:    Cognitive Level: Comprehension       REF:    pp. 225-226

OBJ:    Nursing Process Step: Assessment

MSC:   Client Needs: Health Promotion and Maintenance

McKinney: Maternal-Child Nursing, 3rd Edition

 

Test Bank

 

Chapter 21: Postpartum Adaptations

 

              MULTIPLE CHOICE

 

  1. A postpartum woman overhears the nurse tell the obstetrics clinician that she has a positive Homans sign and asks what it means. The nurse’s best response is:
a. “You have pitting edema in your ankles.”
b. “You have deep tendon reflexes rated 2+.”
c. “You have calf pain when the nurse flexes your foot.”
d. “You have a ‘fleshy’ odor to your vaginal drainage.”

 

 

ANS:   C

A Edema is within normal limits for the first few days until the excess interstitial fluid is remobilized and excreted.

B Deep tendon reflexes should be 1+ to 2+.

C Discomfort in the calf with sharp dorsiflexion of the foot may indicate a deep vein thrombosis.

D A “fleshy” odor, not a foul odor, is within normal limits.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 470

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Physiologic Integrity

 

  1. Which woman would be most likely to have severe afterbirth pains and request a narcotic analgesic?
a. Gravida 5, para 5
b. Woman who is bottle-feeding her first child
c. Primipara who delivered a 7-lb boy
d. Woman who wishes to breastfeed as soon as her baby is out of the neonatal intensive care unit

 

 

ANS:   A

A The discomfort of afterpains is more acute for multiparas because repeated stretching of muscle fibers leads to loss of uterine muscle tone.

B Afterpains are particularly severe during breastfeeding, not bottle-feeding.

C The uterus of a primipara tends to remain contracted.

D The nonnursing mother may have engorgement problems. She should empty her breasts regularly to stimulate milk production so she will have the milk when the baby is strong enough to nurse.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 458

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Physiologic Integrity

 

  1. Which maternal event is abnormal in the early postpartum period?
a. Diuresis and diaphoresis
b. Flatulence and constipation
c. Extreme hunger and thirst
d. Lochial color changes from rubra to alba

 

 

ANS:   D

A The body rids itself of increased plasma volume. Urine output of 3000 mL/day is common for the first few days after delivery and is facilitated by hormonal changes in the mother.

B Bowel tone remains sluggish for days. Many women anticipate pain during defecation and are unwilling to exert pressure on the perineum.

C The new mother is hungry because of energy used in labor and thirsty because of fluid restrictions during labor.

D For the first 3 days after childbirth, lochia is termed rubra. Lochia serosa follows, and then at about 11 days, the discharge becomes clear, colorless, or white.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 458

OBJ:    Nursing Process Step: Assessment

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. Which finding 12 hours after birth would require further assessment?
a. The fundus is palpable two fingerbreadths above the umbilicus.
b. The fundus is palpable at the level of the umbilicus.
c. The fundus is palpable one fingerbreadth below the umbilicus.
d. The fundus is palpable two fingerbreadths below the umbilicus.

 

 

ANS:   A

A The fundus rises to the umbilicus after delivery and remains there for about 24 hours. A fundus that is above the umbilicus may indicate uterine atony or urinary retention.

B This is an appropriate assessment finding for 12 hours postpartum.

C This is an appropriate assessment finding for 12 hours postpartum.

D This is an unusual finding for 12 hours postpartum, but still appropriate.

 

DIF:    Cognitive Level: Application             REF:    p. 468

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Physiologic Integrity

 

  1. If the client’s white blood cell (WBC) count is 25,000/mm on her second postpartum day, the nurse should:
a. tell the physician immediately.
b. have the laboratory draw blood for reanalysis.
c. recognize that this is an acceptable range at this point postpartum.
d. begin antibiotic therapy immediately.

 

 

ANS:   C

A Since this is a normal finding there is no reason to alert the physician.

B There is no need for reassessment since it is expected for the WBCs to be elevated.

C An increase in WBC count to 25,000/mm during the postpartum period is considered normal and not a sign of infection.

D Antibiotics are not needed because the elevated WBCs are due to stress of labor and not an infectious process.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 460

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. Postpartal overdistention of the bladder and urinary retention can lead to which complication?
a. Postpartum hemorrhage and eclampsia
b. Fever and increased blood pressure
c. Postpartum hemorrhage and urinary tract infection
d. Urinary tract infection and uterine rupture

 

 

ANS:   C

A There is no correlation between bladder distention and eclampsia.

B There is no correlation between bladder distention and blood pressure or fevers.

C Incomplete emptying and overdistention of the bladder can lead to urinary tract infection. Overdistention of the bladder displaces the uterus and prevents contraction of the uterine muscle.

D The risk of uterine rupture decreases after the birth.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 460

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Physiologic Integrity

 

  1. A postpartum client asks, “Will these stretch marks go away?” The nurse’s best response is:
a. “They will continue to fade and should be gone by your 6-week checkup.”
b. “No, never.”
c. “Yes, eventually.”
d. “They will fade to silvery lines but won’t disappear completely.”

 

 

ANS:   D

A Stretch marks do not disappear.

B This is true, but more information can be added, such as the changes that will occur with the stretch marks.

C This is not a true statement; they will not disappear.

D Stretch marks never disappear altogether, but they gradually fade to silvery lines.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 462

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. A pregnant client asks when the dark line on her abdomen (linea nigra) will go away. The nurse knows the pigmentation will decrease after delivery because of:
a. increased estrogen.
b. increased progesterone.
c. decreased melanocyte-stimulating hormone.
d. decreased human placental lactogen.

 

 

ANS:   C

A Estrogen levels decrease after delivery.

B Progesterone levels decrease after delivery.

C Melanocyte-stimulating hormone increases during pregnancy and is responsible for changes in skin pigmentation; the amount decreases after delivery.

D Human placental lactogen production continues to aid in lactation. However, it does not affect pigmentation.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 461

OBJ:    Nursing Process Step: Assessment

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. If the fundus is palpated on the right side of the abdomen above the expected level, the nurse should suspect that the client has:
a. been lying on her right side too long.
b. a distended bladder.
c. stretched ligaments that are unable to support the uterus.
d. a normal involution.

 

 

ANS:   B

A Position of the client should not alter uterine position.

B The presence of a full bladder will displace the uterus.

C The problem is a full bladder displacing the uterus.

D This is not an expected finding.

 

DIF:    Cognitive Level: Comprehension       REF:    pp. 466-467

OBJ:    Nursing Process Step: Assessment

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. The Centers for Disease Control and Prevention (CDC) recommends the use of personal protective equipment when the nurse is likely to come into contact with:
a. any client at any time.
b. any body fluids.
c. blood and blood products.
d. any client suspected of being human immunodeficiency virus (HIV) positive.

 

 

ANS:   C

A It is not necessary to wear protective equipment continually with all clients.

B Only certain body fluids can cause contamination.

C Possible contamination of medical personnel can result from contact with blood, blood products, and only certain body fluids.

D Protective equipment is important with this client if the nurse is at risk for contamination with blood or certain body fluids. The equipment does not have to be worn with casual contact.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 463

OBJ:    Nursing Process Step: Assessment

MSC:   Client Needs: Safe and Effective Care Environment

 

  1. Rho immune globulin will be ordered postpartum if which situation occurs?
a. Mother Rh–, baby Rh+ c. Mother Rh+, baby Rh+
b. Mother Rh–, baby Rh– d. Mother Rh+, baby Rh–

 

 

ANS:   A

A An Rh– mother delivering an Rh+ baby may develop antibodies to fetal cells that entered her bloodstream when the placenta separated. The Rho immune globulin works to destroy the fetal cells in the maternal circulation before sensitization occurs.

B The blood types are alike, so no antibody formation would be anticipated.

C The blood types are alike, so no antibody formation would be anticipated.

D If the Rh+ blood of the mother comes in contact with the Rh– blood of the infant, no antibodies would develop because the antigens are in the mother’s blood, not the infant’s.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 463

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Physiologic Integrity

 

  1. If rubella vaccine is indicated for a postpartum client, instructions to the client should include:
a. drinking plenty of fluids to prevent fever.
b. no specific instructions.
c. the recommendation to stop breastfeeding for 24 hours after injection.
d. an explanation of the risks of becoming pregnant within 3 months after injection.

 

 

ANS:   D

A The mother should be afebrile before the vaccine.

B The mother does need to understand potential side effects, and that pregnancy is discouraged for 3 months.

C Small amounts of the vaccine do cross the breast milk, but it is believed that there is no need to discontinue breastfeeding.

D Potential risks to the fetus can occur if pregnancy results within 3 months after rubella vaccine administration.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 463

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. Which nursing action is most appropriate to correct a boggy uterus that is displaced above and to the right of the umbilicus?
a. Notify the physician of an impending hemorrhage.
b. Assess the blood pressure and pulse.
c. Evaluate the lochia.
d. Assist the client in emptying her bladder.

 

 

ANS:   D

A Nursing actions need to be implemented before notifying the physician.

B This is an important assessment if the bleeding continues. However, the focus should be on controlling the bleeding.

C The focus needs to be on controlling the bleeding.

D Urinary retention can cause overdistention of the urinary bladder, which lifts and displaces the uterus.

 

DIF:    Cognitive Level: Application             REF:    p. 468

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. When caring for a newly delivered woman, the nurse is aware that the best measure to prevent abdominal distention after a cesarean birth is:
a. rectal suppositories.
b. early and frequent ambulation.
c. tightening and relaxing abdominal muscles.
d. carbonated beverages.

 

 

ANS:   B

A Rectal suppositories can be helpful after distention occurs, but do not prevent it.

B Activity can aid the movement of accumulated gas in the gastrointestinal tract.

C Ambulation is the best prevention.

D Carbonated beverages may increase distention.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 472

OBJ:    Nursing Process Step: Planning         MSC:   Client Needs: Physiologic Integrity

 

  1. What documentation on a woman’s chart on postpartum day 14 indicates a normal involution process?
a. Moderate bright red lochial flow
b. Breasts firm and tender
c. Fundus below the symphysis and not palpable
d. Episiotomy slightly red and puffy

 

 

ANS:   C

A The lochia should be changed by this day to serosa.

B Breasts are not part of the involution process.

C The fundus descends 1 cm/day, so by postpartum day 14 it is no longer palpable.

D The epiosotomy should not be red or puffy at this stage.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 457

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Physiologic Integrity

 

  1. To assess fundal contraction 6 hours after cesarean delivery, the nurse should:
a. palpate forcefully through the abdominal dressing.
b. gently palpate, applying the same technique used for vaginal deliveries.
c. place hands on both sides of the abdomen and press downward.
d. rely on assessment of lochial flow rather than palpating the fundus.

 

 

ANS:   B

A Forceful palpation should never be used.

B Assessment of the fundus is the same for both vaginal and cesarean deliveries.

C The top of the fundus, not the sides, should be palpated and massaged.

D The fundus should be palpated and massaged to prevent bleeding.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 469

OBJ:    Nursing Process Step: Assessment

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. The mother-baby nurse is able to recognize reciprocal attachment behavior. This refers to:
a. the positive feedback an infant exhibits toward parents during the attachment process.
b. behavior during the sensitive period when the infant is in the quiet alert stage.
c. unidirectional behavior exhibited by the infant, initiated and enhanced by eye contact.
d. behavior by the infant during the sensitive period to elicit feelings of “falling in love” from the parents.

 

 

ANS:   A

A In this definition, reciprocal refers to the feedback from the infant during the attachment process.

B This is a good time for bonding, but it does not define reciprocal attachment.

C Reciprocal attachment is not unidirectional.

D Reciprocal attachment deals with feedback behavior and is not unidirectional.

 

DIF:    Cognitive Level: Application             REF:    p. 478

OBJ:    Nursing Process Step: Assessment

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. The postpartum woman who continually repeats the story of her labor, delivery, and recovery experiences is:
a. providing others with her knowledge of events.
b. making the birth experience “real.”
c. taking hold of the events leading to her labor and delivery.
d. accepting her response to labor and delivery.

 

 

ANS:   B

A This is to satisfy her needs, not others.

B Reliving the birth experience makes the event real and helps the mother realize that the pregnancy is over and that the infant is born and is now a separate individual.

C She is in the taking-in phase, trying to make the birth experience seem real.

D She is trying to make the event real and is trying to separate the infant from herself.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 479

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Psychosocial Integrity

 

  1. During which stage of role attainment do the parents become acquainted with their baby and combine parenting activities with cues from the infant?
a. Anticipatory c. Informal
b. Formal d. Personal

 

 

ANS:   B

A The anticipatory stage begins during the pregnancy when the parents choose a physician and attend childbirth classes.

B A major task of the formal stage of role attainment is getting acquainted with the infant.

C The informal stage begins once the parents have learned appropriate responses to their infant’s cues.

D The personal stage is attained when parents feel a sense of harmony in their role.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 480

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Psychosocial Integrity

 

  1. On observing a woman on her first postpartum day sitting in bed while her newborn lies awake in the bassinet, the nurse should:
a. realize that this situation is perfectly acceptable.
b. offer to hand the baby to the woman.
c. hand the baby to the woman.
d. explain “taking in” to the woman.

 

 

ANS:   C

A This is expected behavior during the taking-in phase. However, interventions can facilitate infant bonding.

B The woman is dependent and passive at this stage and may have difficulty making a decision.

C During the “taking-in” phase of maternal adaptation, in which the mother may be passive and dependent, the nurse should encourage bonding when the infant is in the quiet alert stage. This is done best by simply giving the baby to the mother.

D She learns best during the taking-hold phase.

 

DIF:    Cognitive Level: Application             REF:    p. 479

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Psychosocial Integrity

 

  1. A nurse is observing a family. The mother is holding the baby she delivered less than 24 hours ago. Her husband is watching his wife and asking questions about newborn care. The 4-year-old brother is punching his mother on the back. The nurse should:
a. report the incident to the social services department.
b. advise the parents that the toddler needs to be reprimanded.
c. report to oncoming staff that the mother is probably not a good disciplinarian.
d. realize that this is a normal family adjusting to family change.

 

 

ANS:   D

A There is no need to report this one incident.

B Giving advice at this point would make the parents feel inadequate as parents.

C This is normal for an adjusting family.

D The observed behaviors are normal variations of families adjusting to change.

 

DIF:    Cognitive Level: Analysis                  REF:    pp. 481, 483

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Psychosocial Integrity

 

  1. The best way for the nurse to promote and support the maternal-infant bonding process is to:
a. help the mother identify her positive feelings toward the newborn.
b. encourage the mother to provide all newborn care.
c. assist the family with rooming-in.
d. return the newborn to the nursery during sleep periods.

 

 

ANS:   C

A Having the mother express her feelings is important, but it is not the best way to promote bonding.

B The mother needs time to rest and recuperate; she should not be expected to do all of the care.

C Close and frequent interaction between mother and infant, which is facilitated by rooming-in, is important in the bonding process.

D The mother needs to observe the infant during all stages so she will be aware of what to expect when they go home.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 478

OBJ:    Nursing Process Step: Planning         MSC:   Client Needs: Psychosocial Integrity

 

  1. During which phase of maternal adjustment will the mother relinquish the baby of her fantasies and accept the real baby?
a. Letting-go c. Taking-in
b. Taking-hold d. Taking-on

 

 

ANS:   A

A Accepting the real infant and relinquishing the fantasy infant occurs during the letting-go phase of maternal adjustment.

B During the taking-hold phase the mother assumes responsibility for her own care and shifts her attention to the infant.

C In the taking-in phase the mother is primarily focused on her own needs.

D There is no taking-on phase of maternal adjustment.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 480

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Psychosocial Integrity

 

  1. A 25-year-old gravida 1 para 1 who had an emergency cesarean birth 3 days ago is scheduled for discharge. As you prepare her for discharge, she begins to cry. Your initial action should be to:
a. assess her for pain.
b. point out how lucky she is to have a healthy baby.
c. explain that she is experiencing postpartum blues.
d. allow her time to express her feelings.

 

 

ANS:   D

A This is an assumption that she is in pain.

B This is blocking communication.

C She needs the opportunity to express her feelings first. Later, client teaching can occur.

D Although many women experience transient postpartum blues, they need assistance in expressing their feelings.

 

DIF:    Cognitive Level: Application             REF:    p. 481

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Psychosocial Integrity

 

  1. A man calls the nurse’s station stating that his wife, who delivered 2 days ago, is happy one minute and crying the next. The man says, “She was never like this before the baby was born.” The nurse’s initial response should be to:
a. tell him to ignore the mood swings, as they will go away.
b. reassure him that this behavior is normal.
c. advise him to get immediate psychological help for her.
d. instruct him in the signs, symptoms, and duration of postpartum blues.

 

 

ANS:   B

A This blocks communication and may belittle the husband’s concerns.

B Before providing further instructions, inform family members of the fact that postpartum blues are a normal process to allay anxieties and increase receptiveness to learning.

C Postpartum blues are a normal process that is short lived; no medical intervention is needed.

D Client teaching is important; however, his anxieties need to be allayed before he will be receptive to teaching.

 

DIF:    Cognitive Level: Application             REF:    p. 481

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Psychosocial Integrity

 

  1. To promote bonding and attachment immediately after delivery, the nurse should:
a. allow the mother quiet time with her infant.
b. assist the mother in assuming an en face position with her newborn.
c. teach the mother about the concepts of bonding and attachment.
d. assist the mother in feeding her baby.

 

 

ANS:   B

A The mother should be given as much privacy as possible; however, nursing assessments must still be continued during this critical time.

B Assisting the mother in assuming an en face position with her newborn will support the bonding process.

C The mother has just delivered and is more focused on the infant; she will not be receptive to teaching at this time.

D This is a good time to initiate breastfeeding, but first the mother needs time to explore the new infant and begin the bonding process.

 

DIF:    Cognitive Level: Application             REF:    p. 487

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. While the nurse is demonstrating a baby bath, the client states, “The other nurse told me to do it this way.” The nurse should:
a. tell her to do the procedure whichever way works best for her.
b. tell her the other nurse does not have much experience in caring for newborns.
c. reassure her that procedures are based on principles and may vary.
d. confront the other nurse about her knowledge of the procedure.

 

 

ANS:   C

A This is not answering her concern.

B This is not answering her concern.

C Procedures may vary as long as basic principles are included.

D There is no evidence that the other nurse gave incorrect information.

 

DIF:    Cognitive Level: Application             REF:    p. 487

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. Anticipatory guidance provided by the nurse can make the role transition to parenthood easier if the nurse:
a. recommends employing baby sitters frequently.
b. tells the parents about the realities of parenthood.
c. offers her home phone number to provide herself as a resource.
d. helps the new parents identify resources.

 

 

ANS:   D

A Some parents may not be able to afford this suggestion. Plus this removes them from the parenthood role.

B Each adult sees parenthood in different lights. They cannot be compared.

C Searching out resources for the parents is an important task. However, the nurse should not give her personal number to clients.

D Available resources within the community can assist the parents in role transition.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 489

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Psychosocial Integrity

 

  1. To provide support and encouragement to the new mother, the nurse should:
a. recount how she solved her own problems.
b. praise the mother’s early attempts at infant care.
c. correct the new mother at every opportunity.
d. explain to the new mother that everything will be fine.

 

 

ANS:   B

A The mother needs to learn how to solve problems on her own. Each person may use different techniques that work for that person.

B Positive reinforcement of the mother’s attempt to provide care to the newborn will promote a healthy self-concept.

C This would be discouraging to a new mother. She needs encouragement.

D This is blocking communication and further teaching.

 

DIF:    Cognitive Level: Application             REF:    p. 487

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. In providing support to a new mother who must return to full-time employment 6 weeks after a vaginal delivery, the nurse should:
a. allow her to express her positive and negative feelings freely.
b. reassure her that she’ll get used to leaving her baby.
c. discuss child care arrangements with her.
d. allow her to solve the problem on her own.

 

 

ANS:   A

A Allowing the client to express feelings will provide positive support in her process of maternal adjustment.

B This blocks communication and belittles the client’s feelings.

C This is an important step in anticipatory guidance, but is not the best way to offer support.

D She should be instrumental in solving the problem; however, allowing her time to express her feelings and talk the problem over will assist her in making this decision.

 

DIF:    Cognitive Level: Application             REF:    p. 475

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Psychosocial Integrity

 

  1. A new father states, “I know nothing about babies,” but he seems to be interested in learning. The nurse should:
a. continue to observe his interaction with the newborn.
b. tell him when he does something wrong.
c. show no concern, as he will learn on his own.
d. include him in teaching sessions.

 

 

ANS:   D

A It is important to note the bonding process of the mother and the father, but that does not satisfy the expressed needs of the father.

B He should be encouraged by pointing out the correct procedures he does. By criticizing he will be discouraged.

C This is not a nursing role. Nurses need to be sensitive to client’s needs.

D The nurse must be sensitive to the father’s needs and include him whenever possible.

 

DIF:    Cognitive Level: Application             REF:    pp. 481, 483

OBJ:    Nursing Process Step: Planning

MSC:   Client Needs: Health Promotion and Maintenance

 

TRUE/FALSE

 

  1. The nurse evaluating the amount of lochia on a newly delivered client knows that a moderate amount of flow constitutes a 4- to 6-inch stain on the peripad.

 

ANS:   T

Since estimating the amount of lochia is difficult, nurses frequently record flow by estimating the amount of lochia in 1 hour using the following labels:

Scant—less than a 1-inch stain on the peripad

Light—a 1- to 4-inch stain

Moderate—a 4- to 6-inch stain

Heavy—saturated peripad

Excessive—saturated peripad in 15 minutes

Determining the time interval that the peripad is in place is also important. Lochia is less for women who have had a cesarean birth since some of the endometrial lining is removed during surgery.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 458

OBJ:    Nursing Process Step: Assessment

MSC:   Client Needs: Health Promotion and Maintenance

 

COMPLETION

 

  1. The acronym ____________________ is used as a reminder that the site of an episiotomy or perineal laceration should be assessed for five physical signs.

 

ANS:

REEDA

The acronym REEDA indicates redness, edema, ecchymosis or bruising, discharge, and approximation (the edges of the wound should be close). If redness is accompanied by pain or tenderness, this may indicate infection. Edema may illustrate soft tissue damage and delay wound healing. There should be no discharge. The edges of the wound should be closely approximated as if held together by glue.

 

DIF:    Cognitive Level: Application             REF:    p. 469

OBJ:    Nursing Process Step: Assessment

MSC:   Client Needs: Health Promotion and Maintenance

McKinney: Maternal-Child Nursing, 3rd Edition

 

Test Bank

 

Chapter 31: Women’s Health Care

 

              MULTIPLE CHOICE

 

  1. Which piece of the usual equipment setup for a pelvic examination is omitted with a Pap smear?
a. Gloves and eye protectors c. Fixative agent
b. Speculum d. Lubricant

 

 

ANS:   D

A The examiner should always use Universal Precautions.

B A speculum is needed to see the cervix.

C A fixative agent is applied to the slide to prevent drying or disruption of the specimen.

D Lubricants interfere with the accuracy of the cytology report.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 768

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Physiologic Integrity

 

  1. When providing instruction to a client, the nurse should explain which side effect of medroxyprogesterone is predictable and expected?
a. Vaginal bleeding after medication is discontinued
b. Leg or calf pain
c. Headache or visual changes
d. Jaundice during the first 3 weeks

 

 

ANS:   A

A Approximately 3 to 7 days after the last cyclic dose of medroxyprogesterone, the woman should expect to have withdrawal bleeding.

B The drug is contraindicated in thromboembolic disease.

C Headaches and visual problems should be reported to the clinician as soon as possible.

D The drug is metabolized by the liver and contraindicated in liver disease.

 

DIF:    Cognitive Level: Application             REF:    p. 776

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Physiologic Integrity

 

  1. The nurse providing care in a women’s health care setting must be aware that which sexually transmitted disease (STD) can be cured?
a. Herpes
b. Acquired immunodeficiency syndrome (AIDS)
c. Venereal warts
d. Chlamydia

 

 

ANS:   D

A Because no cure is known for herpes, treatment focuses on pain relief and preventing secondary infections.

B Because no cure is known for AIDS, prevention and early detection are the main focus.

C Condylomata acuminata is caused by the human papillomavirus. No treatment eradicates the virus.

D The usual treatment for chlamydia bacterial infection is doxycycline hyclate or tetracycline. Concurrent treatment of all sexual partners is needed to prevent recurrence.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 789

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Physiologic Integrity

 

  1. Which statement by a woman diagnosed with premenstrual syndrome indicates that further health teaching is needed?
a. “I will not eat chips or pickles.”
b. “Coffee and chocolate can make me more irritable and nervous.”
c. “Drinking alcohol makes me more depressed.”
d. “I’ll eat only three meals per day.”

 

 

ANS:   D

A Less intake of salty foods helps decrease fluid retention.

B Caffeine consumption increases irritability, insomnia, anxiety, and nervousness.

C Alcohol consumption aggravates depression.

D The woman should be encouraged to eat six small meals a day to decrease risk of hypoglycemia.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 778

OBJ:    Nursing Process Step: Evaluation      MSC:   Client Needs: Physiologic Integrity

 

  1. Which statement by the client indicates that she understands breast self-examination?
a. “I will examine both breasts in two different positions.”
b. “I will perform breast self-examination 1 week after my menstrual period starts.”
c. “I will examine the outer upper area of the breast only.”
d. “I will use the palm of the hand to perform the examination.”

 

 

ANS:   B

A She should use four positions: standing with arms at her sides, standing with arms raised above her head, standing with hands pressed against hips, and lying down.

B The woman should examine her breasts when hormonal influences are at a low level.

C The entire breast needs to be examined, including the outer upper area.

D She should use the sensitive pads of the middle three fingers.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 764

OBJ:    Nursing Process Step: Evaluation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. A benign breast condition that includes dilation and inflammation of the collecting ducts is called:
a. ductal ectasia. c. chronic cystic disease.
b. intraductal papilloma. d. fibroadenoma.

 

 

ANS:   A

A Generally occurring in women approaching menopause, ductal ectasia results in a firm irregular mass in the breast, enlarged axillary nodes, and nipple discharge.

B Intraductal papillomas develop in the epithelium of the ducts of the breasts; as the mass grows, it causes trauma or erosion within the ducts.

C Chronic cystic disease causes pain and tenderness. The cysts that form are multiple, smooth, and well delineated.

D Fibroadenoma is fibrous and glandular tissues. They are felt as firm, rubbery, and freely mobile nodules.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 769

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Physiologic Integrity

 

  1. Which client is most at risk for fibroadenoma of the breast?
a. A 38-year-old woman c. A 16-year-old woman
b. A 50-year-old woman d. A 27-year-old woman

 

 

ANS:   C

A Ductal ectasia becomes more common as a woman approaches menopause.

B Intraductal papilloma develops most often just before or during menopause.

C Although it may occur at any age, fibroadenoma is most common in the teenage years.

D Fibrocystic breast changes are more common during the reproductive years.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 769

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Physiologic Integrity

 

  1. Adjuvant treatment with tamoxifen may be recommended for clients with breast cancer if the tumor is:
a. smaller than 5 cm.
b. located in the upper outer quadrant only.
c. contained only in the breast.
d. estrogen receptive.

 

 

ANS:   D

A Tamoxifen is used depending on age, stage, and hormone receptor status, not size.

B Location of the cancer does not determine the usefulness of tamoxifen.

C Stage of the cancer is a consideration, but more important is its sensitivity to estrogen.

D Tamoxifen is antiestrogen therapy for tumors stimulated by estrogen.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 771

OBJ:    Nursing Process Step: Planning         MSC:   Client Needs: Physiologic Integrity

 

  1. Which statement is true about primary dysmenorrhea?
a. It occurs in young multiparous women.
b. It is experienced by all women.
c. It may be due to excessive endometrial prostaglandin.
d. It is unaffected by oral contraceptives.

 

 

ANS:   C

A It occurs in young nulliparous women.

B It is not experienced by all women.

C Some women produce excessive endometrial prostaglandin during the luteal phase of the menstrual cycle. Prostaglandin diffuses into endometrial tissue and causes uterine cramping.

D Oral contraceptives can be a treatment choice.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 774

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Physiologic Integrity

 

  1. A client states, “I’m sure that I am suffering from PMS. How can I get my doctor to take this seriously?” The nurse’s best response is:
a. “You are probably right. You should remind him of your symptoms every time you see him.”
b. “Because you feel certain you are right, you should just treat yourself with over-the-counter medications.”
c. “Men are not usually sympathetic to PMS sufferers.”
d. “You should keep a daily record of the occurrence and severity of your symptoms for 3 months.”

 

 

ANS:   D

A This will not assist in making a diagnosis. Listing symptoms for 3 months will help the physician better assess the diagnosis.

B This is inappropriate.

C This is inaccurate and will not help the client with the present problem.

D Assessment of symptom charting from at least 3 months is necessary to make an accurate diagnosis of PMS.

 

DIF:    Cognitive Level: Application             REF:    p. 778

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. In teaching the client to deal with the symptoms of PMS, the nurse stresses that the client should:
a. decrease her fluid intake to prevent fluid retention.
b. decrease consumption of caffeine.
c. eat three large meals a day to maintain glucose levels.
d. drink a small glass of wine with the evening meal.

 

 

ANS:   B

A Fluid intake should not be decreased.

B Caffeine increases irritability, insomnia, anxiety, and nervousness.

C Six smaller meals a day will help maintain glucose levels.

D Alcohol aggravates depression and should be avoided.

 

DIF:    Cognitive Level: Application             REF:    p. 778

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. A 49-year-old client confides to the nurse that she has started experiencing pain with intercourse and asks, “Is there anything I can do about this?” The nurse’s best response is:
a. “You need to be evaluated for a sexually transmitted disease.”
b. “Water-soluble vaginal lubricants may provide relief.”
c. “No, it is part of the aging process.”
d. “You may have vaginal scar tissue that is producing the discomfort.”

 

 

ANS:   B

A This is a normal occurrence with the aging process and does not indicate STDs.

B Loss of lubrication with resulting discomfort in intercourse is a symptom of estrogen deficiency.

C It is part of the aging process, but the use of lubrication will help relieve the symptoms.

D It is due to loss of lubrication with the decrease in estrogen. Scar tissue problems would have occurred earlier.

 

DIF:    Cognitive Level: Application             REF:    p. 780

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. A 70-year-old woman should be taught to report what condition to her health care provider?
a. Vaginal bleeding c. Breasts become smaller
b. Pain with intercourse d. Skin becomes thinner

 

 

ANS:   A

A Vaginal bleeding after menopause should always be investigated. It is highly suggestive of endometrial cancer.

B Pain with intercourse is an expected change that occurs due to the aging process.

C Breast shrinkage is an expected change that occurs due to the aging process.

D Skin thinning is an expected change that occurs due to the aging process.

 

DIF:    Cognitive Level: Application             REF:    p. 787

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. Which woman is most likely to have osteoporosis?
a. A 50-year-old woman receiving estrogen therapy
b. A 60-year-old woman who takes supplemental calcium
c. A 55-year-old woman with a sedentary lifestyle
d. A 65-year-old woman who walks 2 miles each day

 

 

ANS:   C

A Hormone therapy may prevent bone loss.

B Supplemental calcium will help prevent bone loss, especially when combined with vitamin D.

C Risk factors for the development of osteoporosis include smoking, alcohol consumption, sedentary lifestyle, family history of the disease, and a high-fat diet.

D Weight-bearing exercises have been shown to increase bone density.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 782

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Physiologic Integrity

 

  1. A woman with a history of a cystocele should contact the physician if she experiences:
a. involuntary loss of urine when she coughs.
b. constipation.
c. backache.
d. urinary frequency and burning.

 

 

ANS:   D

A Involuntary loss of urine during coughing is stress incontinence and is not an emergency.

B Constipation may be a problem with rectoceles.

C Back pain is a symptom of uterine prolapse.

D Urinary frequency and burning are symptoms of cystitis, a common problem associated with cystocele.

 

DIF:    Cognitive Level: Application             REF:    p. 783

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Physiologic Integrity

 

  1. To assist the woman in regaining control of the urinary sphincter, the nurse should teach her to:
a. do Kegel exercises.
b. void every hour while awake.
c. allow the bladder to become distended before voiding.
d. drink 8 to 10 glasses of water each day.

 

 

ANS:   A

A Kegel exercises, tightening and relaxing the pubococcygeal muscle, will improve control of the urinary sphincter.

B A prescribed schedule may help, but every hour is too frequent.

C Overdistention of the bladder will cause incontinence.

D Restricting fluids will cause bladder irritation that increases the problem. Drinking adequate fluids will not help the problem.

 

DIF:    Cognitive Level: Application             REF:    p. 785

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. The physician diagnoses a 3 cm ovarian cyst in a 28-year-old woman. The nurse expects the initial treatment to include:
a. beginning hormone therapy.
b. examining the woman after her next menstrual period.
c. scheduling a laparoscopy as soon as possible, to remove the cyst.
d. aspirating the cyst as soon as possible and sending the fluid to pathology.

 

 

ANS:   B

A Cysts in women of childbearing age may decrease within one cycle, so treatment is not necessary at this point.

B Most ovarian cysts regress spontaneously.

C It is too early to anticipate removal of the cysts. Most ovarian cysts regress spontaneously within one cycle.

D A transvaginal ultrasound examination will help determine if the cyst is fluid filled or solid. The cyst can then be removed if warranted.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 786

OBJ:    Nursing Process Step: Planning         MSC:   Client Needs: Physiologic Integrity

 

  1. The drug of choice to treat gonorrhea is:
a. penicillin G. c. ceftriaxone.
b. tetracycline. d. acyclovir.

 

 

ANS:   C

A Penicillin is used to treat syphilis.

B Tetracycline is used to treat chlamydial infections.

C Ceftriaxone is effective for treatment of all gonococcal infections.

D Acyclovir is used to treat herpes genitalis.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 789

OBJ:    Nursing Process Step: Planning         MSC:   Client Needs: Physiologic Integrity

 

MULTIPLE RESPONSE

 

  1. While interviewing a 48-year-old client during her annual physical examination, the nurse learns that she has never had a mammogram. The American Cancer Society recommends annual mammography screening starting at age 40. Before the nurse encourages this client to begin annual screening, it is important for her to understand the reasons why women avoid testing. These reasons include: (Choose those that apply.)
a. reluctance to hear bad news.
b. fear of x-ray exposure.
c. belief that lack of family history makes this test unnecessary.
d. expense of the procedure.
e. having heard that the test is painful.

 

 

ANS:   A, B, D, E

Correct A, B, D, E. All of these are reasons for women to avoid having a mammogram done. Although the test is expensive, it is usually covered by health insurance, and many communities offer low-cost or free screening to women without insurance. It is important to acknowledge that some discomfort occurs with screening. Scheduling the test immediately at the end of a period makes it less painful. The risk of radiation exposure is minimal to none. Nurses play a vital role in providing information and reassurance to help women overcome these fears.

Incorrect C. Even clients with no family history should have regular screening done. The nurse should emphasize that a combination of breast self-examination and mammography needs to be performed at regular intervals. Women with a family history may need to begin screening at a younger age and have additional testing such as ultrasound performed.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 767

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Health Promotion and Maintenance

 

TRUE/FALSE

 

  1. The nurse understands that further health teaching is necessary when her young client who has just had an abortion states, “I guess I’ll have to wear a tampon for the next week.”

 

ANS:   T

Bleeding and cramping are normal after the procedure and will last for 1 to 2 weeks. Sanitary pads should be used rather than a tampon for the first week after an abortion to prevent infection. Other necessary health teaching that should be done includes the following: no intercourse for the first week; no douching for the first week, or perhaps not at all; temperature evaluation twice per day to identify infection; follow-up appointment in 2 weeks; and no strenuous work for a few days.

 

DIF:    Cognitive Level: Application             REF:    p. 779

OBJ:    Nursing Process Step: Evaluation      MSC:   Client Needs: Physiologic Integrity

McKinney: Maternal-Child Nursing, 3rd Edition

 

Test Bank

 

Chapter 41: The Child with an Immunologic Alteration

 

              MULTIPLE CHOICE

 

  1. Which statement about the immune system is correct?
a. The immune system distinguishes and actively protects the body’s own cells from foreign substances.
b. The immune system is fully developed by 1 year of age.
c. The immune system protects the child against communicable diseases in the first 6 years of life.
d. The immune system responds to an offending agent by producing antigens.

 

 

ANS:   A

A The immune system responds to foreign substances, or antigens, by producing antibodies and storing information. Intact skin, mucous membranes, and processes such as coughing, sneezing, and tearing help maintain internal homeostasis.

B Children up to age 6 or 7 years have limited antibodies against common bacteria. The immunoglobins reach adult levels at different ages.

C Immunization is the basis from which the immune system activates protection against some communicable diseases.

D Antibodies are produced by the immune system against invading agents, or antigens.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 1041

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Physiologic Integrity

 

  1. Which of the following organs and tissues control the two types of specific immune functions?
a. The spleen and mucous membranes
b. Upper and lower intestinal lymphoid tissue
c. The skin and lymph nodes
d. The thymus and bone marrow

 

 

ANS:   D

A Both the spleen and mucous membranes are secondary organs of the immune system that act as filters to remove debris and antigens and foster contact with T lymphocytes.

B Gut-associated lymphoid tissue is a secondary organ of the immune system. This tissue filters antigens entering the gastrointestinal tract.

C The skin and lymph nodes are secondary organs of the immune system.

D The thymus controls cell-mediated immunity (cells that mature into T lymphocytes), and bone marrow controls humoral immunity (stem cells for B lymphocytes).

 

DIF:    Cognitive Level: Comprehension       REF:    pp. 1041, 1043

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Physiologic Integrity

 

  1. Which of the following statements is true regarding how infants acquire immunity?
a. The infant acquires humoral and cell-mediated immunity in response to infections and immunizations.
b. The infant acquires maternal antibodies that ensure immunity up to 12 months age.
c. Active immunity is acquired from the mother and lasts 6 to 7 months.
d. Passive immunity develops in response to immunizations.

 

 

ANS:   A

A Infants acquire long-term active immunity from exposure to antigens and vaccines. Immunity is acquired actively and passively.

B The term infant’s passive immunity is acquired from the mother and begins to dissipate during the first 6 to 8 months of life.

C Passive immunity is acquired from the mother.

D Active immunity develops in response to immunizations.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 1043

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Physiologic Integrity

 

  1. Which of the following is the most common mode of transmission of human immunodeficiency virus (HIV) in the pediatric population?
a. Perinatal transmission c. Blood transfusions
b. Sexual abuse d. Poor handwashing

 

 

ANS:   A

A Perinatal transmission accounts for the highest percentage of HIV infections in children. Infected women can transmit the virus to their infants across the placenta during pregnancy, at delivery, and through breastfeeding.

B Cases of HIV infection from sexual abuse have been reported; however, perinatal transmission accounts for most pediatric HIV infections.

C Although in the past some children became infected with HIV through blood transfusions, improved laboratory screening has significantly reduced the probability of contracting HIV from blood products.

D Poor handwashing is not an etiology of HIV infection.

 

DIF:    Cognitive Level: Application             REF:    pp. 1043, 1046

OBJ:    Nursing Process Step: Planning         MSC:   Client Needs: Physiologic Integrity

 

  1. Which of the following is an American Academy of Pediatrics recommendation for immunizing infants who are HIV positive?
a. Follow the routine immunization schedule.
b. Routine immunizations are administered. Assess CD4+ counts before administering the MMR and varicella vaccinations.
c. Do not give immunizations because of the infant’s altered immune status.
d. Eliminate the pertussis vaccination because of the risk of convulsions.

 

 

ANS:   B

A Routine immunizations are appropriate; however, CD4+ cell counts should be assessed before administering the MMR and varicella vaccines to establish adequate immune system function.

B Routine immunizations are appropriate. CD4+ cells are monitored when deciding whether to provide live virus vaccines. If the child is severely immunocompromised, the MMR vaccine is not given. The varicella vaccine can be considered on the basis of the child’s CD4+ counts. Only inactivated polio virus (IPV) should be used for HIV-infected children.

C Immunizations are given to infants who are HIV positive.

D The pertussis vaccination is not eliminated for an infant who is HIV positive.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 1050

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. Which of the following suggestions is appropriate to teach a mother who has a preschool child who refuses to take the medications for HIV infection?
a. Mix medications with chocolate syrup or follow with chocolate candy.
b. Mix the medications with milk or an essential food.
c. Skip the dose of medication if the child protests too much.
d. Mix the medication in a syringe, hold the child down firmly, and administer the medication.

 

 

ANS:   A

A Liquid forms of HIV medications may be foul tasting or have a gritty texture. Chocolate would help to make these foods more palatable and is liked by most children.

B Medications should be mixed with nonessential foods.

C Doses of medication should never be skipped.

D Fighting with the child or using force should be avoided. A nonessential food that will make the taste of the medication more palatable for the child should be the correct action. The administration of medications for the child with HIV becomes part of the family’s everyday routine for years.

 

DIF:    Cognitive Level: Application             REF:    p. 1053

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Physiologic Integrity

 

  1. Which of the following is the primary nursing concern for a hospitalized child with HIV infection?
a. Maintaining growth and development
b. Eating foods that the family brings to the child
c. Consideration of parental limitations and weaknesses
d. Resting for 2 to 3 hours twice a day

 

 

ANS:   A

A Maintaining growth and development is a major concern for the child with HIV infection. Frequent monitoring for failure to thrive, neurologic deterioration, or developmental delay is important for HIV-infected infants and children.

B Nutrition, which contributes to a child’s growth, is a nursing concern; however, it is unnecessary for family members to bring food to the child.

C Although an assessment of parental strengths and weaknesses is important, it will be imperative for health care providers to focus on the parental strengths, not weaknesses. This is not as important as the frequent assessment of the child’s growth and development.

D Rest is a nursing concern, but it is not as high a priority as maintaining growth and development. Rest periods twice a day for 2 to 3 hours may not be appropriate.

 

DIF:    Cognitive Level: Application             REF:    p. 1049

OBJ:    Nursing Process Step: Evaluation      MSC:   Client Needs: Physiologic Integrity

 

  1. What would the nurse include in a teaching plan for the mother of a toddler who will be taking prednisone for several months?
a. The medication should be taken between meals.
b. The medication needs to be discontinued because of the risks associated with long-term usage.
c. The medication should not be stopped abruptly.
d. The medication may lower blood glucose, so the mother needs to observe for signs of hypoglycemia.

 

 

ANS:   C

A Prednisone should be taken with food to minimize or prevent gastrointestinal bleeding.

B Although there are adverse effects from long-term steroid use, the medication must not be discontinued without consulting a physician. Acute adrenal insufficiency can occur if the medication is withdrawn abruptly. The dosage needs to be tapered.

C The dosage must be tapered before the drug is discontinued to allow the gradual return of function in the pituitary-adrenal axis.

D The medication puts the child at risk for hyperglycemia.

 

DIF:    Cognitive Level: Application             REF:    pp. 1056, 1058

OBJ:    Nursing Process Step: Planning         MSC:   Client Needs: Physiologic Integrity

 

  1. Children receiving long-term systemic corticosteroid therapy are most at risk for which of the following?
a. Hypotension
b. Dilation of blood vessels in the cheeks
c. Growth delays
d. Decreased appetite and weight loss

 

 

ANS:   C

A Hypertension is a clinical manifestation of long-term systemic steroid administration.

B Dilation of blood vessels in the cheeks is associated with an excess of topically administered steroids.

C Growth delay is associated with long-term steroid use related to protein catabolism and decreased growth hormone.

D Increased appetite and weight gain are clinical manifestations of excess systemic corticosteroid therapy.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 1057

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Physiologic Integrity

 

  1. Which of the following statements by a parent about antiretroviral agents for the management for her 5-year-old child with acquired immunodeficiency syndrome (AIDS) indicates that she has a good understanding?
a. “When my child’s pain increases, I double the recommended dosage of antiretroviral medication.”
b. “Addiction is a risk, so I only use the medication as ordered.”
c. “Doses of the antiretroviral medication are selected on the basis of my child’s age and growth.”
d. “By the time my child is an adolescent she will not need her antiretroviral medications any longer.”

 

 

ANS:   C

A Antiretroviral medications are not administered for pain relief. Doubling the recommended dosage of any medication is not appropriate without an order from the physician.

B Addiction is not a realistic concern with antiretroviral medications.

C Doses of antiretroviral medication to treat HIV infection for infants and children are based on individualized age and growth considerations.

D Antiretroviral medications are still needed during adolescence. Doses for adolescents are based on pubertal status by Tanner staging.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 1050

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Physiologic Integrity

 

  1. The mother of a child in the terminal stages of AIDS tells the nurse that her child wants to celebrate his birthday early because he won’t be here on his birthday. What is the best response the nurse can make to this mother?
a. “What does your husband think about giving the party for the child?”
b. “How does the family feel about your giving in to the child?”
c. “Ill children can be very manipulative.”
d. “Is this the first time he has spoken about death?”

 

 

ANS:   D

A The major concern is the child’s disclosure of awareness of death, not the husband’s reaction.

B Making statements such as “giving in” is inappropriate when seeking information.

C Manipulation is not a major concern during the terminal stage of disease.

D Dying children know they are dying. Disclosure of awareness of death comes in various ways and needs to be identified by the family and the nurse.

 

DIF:    Cognitive Level: Application             REF:    p. 1052

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Psychosocial Integrity

 

  1. Which of the following interventions is appropriate for a child receiving high doses of steroids?
a. Limit activity and receive home schooling.
b. Decrease the amount of potassium in the diet.
c. Substitute a killed virus vaccine for live-virus vaccines.
d. Monitor for seizure activity.

 

 

ANS:   C

A Limiting activity and home schooling are not routine for a child receiving high doses of steroids.

B The child receiving steroids is at risk for hypokalemia and needs potassium in the diet.

C The child on high doses of steroids should not receive live virus vaccines because of immunosuppression.

D Children on steroids are not typically at risk for seizures.

 

DIF:    Cognitive Level: Application             REF:    p. 1057

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. The nurse observes a red butterfly-shaped rash that spreads across the child’s cheeks and nose. This assessment finding is characteristic of which of the following conditions?
a. Systemic lupus erythematosus (SLE) c. Kawasaki disease
b. Rheumatic fever d. Anaphylactic reaction

 

 

ANS:   A

A A red, flat or raised malar “butterfly” rash over the cheeks and bridge of the nose is a clinical manifestation of SLE.

B A major manifestation of rheumatic fever is erythema marginatum, which appears as red skin lesions spread peripherally over the trunk.

C An erythematous rash, induration of the hands and feet, and erythema of the palms and soles are manifestations of Kawasaki disease.

D Initial symptoms of anaphylaxis include severe itching and rapid development of erythema.

 

DIF:    Cognitive Level: Application             REF:    p. 1059

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Physiologic Integrity

 

  1. What is the primary nursing concern for a child having an anaphylactic reaction?
a. Identifying the offending allergen c. Increased cardiac output
b. Ineffective breathing pattern d. Positioning to facilitate comfort

 

 

ANS:   B

A Determining the cause of an anaphylactic reaction is important to implement the appropriate treatment, but the primary concern is the airway.

B Laryngospasms resulting in ineffective breathing patterns is a life-threatening manifestation of anaphylaxis. The primary action is to assess airway patency, respiratory rate and effort, level of consciousness, oxygen saturation, and urine output.

C During anaphylaxis, the cardiac output is decreased.

D During the acute period of anaphylaxis, the nurse’s primary concern is the child’s breathing. Positioning for comfort is not a primary concern during a crisis.

 

DIF:    Cognitive Level: Application             REF:    p. 1062

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Physiologic Integrity

 

  1. What is the drug of choice the nurse would administer in the acute treatment of anaphylaxis?
a. Diphenhydramine c. Epinephrine
b. Histamine inhibitor (cimetidine) d. Albuterol

 

 

ANS:   C

A Although diphenhydramine may be indicated, epinephrine is the first drug of choice in immediate treatment of anaphylaxis.

B Although a histamine inhibitor such as cimetidine may be indicated, epinephrine is the first drug of choice in immediate treatment of anaphylaxis.

C Epinephrine is the first drug of choice in immediate treatment of anaphylaxis. Treatment must be initiated immediately because it may only be a matter of minutes before shock occurs.

D Albuterol is not usually indicated for treatment of anaphylaxis.

 

DIF:    Cognitive Level: Application             REF:    p. 1062

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Physiologic Integrity

 

MULTIPLE RESPONSE

 

  1. The mother of an HIV-positive infant who is 2 months old questions the nurse about which childhood immunizations her child will be able to receive. Which immunizations would an HIV-positive child be able to receive according to the American Academy of Pediatrics recommendation for immunizing infants who are HIV positive? (Choose all that apply.)
a. Hepatitis B
b. DTaP
c. MMR
d. IPV
e. HIB

 

 

ANS:   A, B, D, E

Correct A, B, D, E. Routine immunizations are appropriate.

Incorrect C. The MMR vaccination is not given at 2 months of age. If it were indicated, CD4+ counts are monitored when deciding whether to provide live virus vaccines. If the child is severely immunocompromised, the MMR vaccine is not given. The varicella vaccine can be considered on the basis of the child’s CD4+ counts. Only inactivated polio virus (IPV) should be used for HIV-infected children.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 1050

OBJ:    Nursing Process Step: Planning

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. A child who is hospitalized has just received a dose of IV morphine for pain and has an anaphylactic reaction. Which features of anaphlaxis does the nurse identify?
a. Itching of the skin c. Hypertension
b. Cyanosis d. Wheezing

 

 

ANS:   A, B, D

Correct A, B, D. These are all caused by an anaphylactic reaction. Histamine action precipitates bronchoconstricton, bronchospasm, wheezing, cyanosis, edema, itching, tingling, vomiting, diarrhea, circulatory collapse, increased vascular permeability, hypotensive shock, and cardiac arrest. Anaphylactic reactions need to be identified and treated promptly.

Incorrect C. Hypotension is a serious feature of anaphylaxis, not hypertension.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 1062

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Physiologic Integrity

McKinney: Maternal-Child Nursing, 3rd Edition

 

Test Bank

 

Chapter 51: The Child with an Endocrine or Metabolic Alteration

 

              MULTIPLE CHOICE

 

  1. New parents ask the nurse, “Why is it necessary for our baby to have the newborn blood test?” The nurse explains that the priority outcome of mandatory newborn screening for inborn errors of metabolism is:
a. appropriate community referral for affected infants.
b. parental education about raising a special needs child.
c. early identification of serious genetically transmitted metabolic diseases.
d. early identification of electrolyte imbalances.

 

 

ANS:   C

A Community referral is appropriate after a diagnosis is made.

B With early identification and treatment, serious complications such as mental retardation are prevented.

C Early identification of hypothyroidism is basic to the prevention of mental retardation in the child.

D Although electrolyte imbalances could occur with some of the inborn errors of metabolism, this is not the priority outcome, nor would the newborn screen detect electrolyte imbalances.

 

DIF:    Cognitive Level: Application             REF:    p. 1424

OBJ:    Nursing Process Step: Planning

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. What is the priority nursing goal for a 14-year-old with Graves’ disease?
a. Relief of constipation
b. Allowing the adolescent to make decisions about whether or not to take her medication
c. Verbalization of the importance of adherence to the medication regimen
d. Development of alternative educational goals

 

 

ANS:   C

A The adolescent with Graves’ disease is not constipated.

B Adherence to the medication schedule is important to ensure optimal health and wellness. Medications should not be skipped and dose regimens should not be tapered by the child without consultation with the child’s medical provider.

C To adhere to the medication schedule, children need to understand that the medication must be taken two or three times per day.

D The management of Graves’ disease does not interfere with school attendance and does not require alternative educational plans.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 1429

OBJ:    Nursing Process Step: Planning

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. Which symptoms should be reported to the health care provider when a child is taking propylthiouracil?
a. Nausea and vomiting c. Increased appetite and tremors
b. Fever and sore throat d. Weight gain and mood swings

 

 

ANS:   B

A Nausea and vomiting are not common side effects of propylthiouracil.

B Propylthiouracil or methimazole is the treatment of choice for childhood hyperthyroidism. Fever and sore throat are clinical manifestations of neutropenia, a side effect of propylthiouracil.

C Increased appetite and tremors are clinical manifestations of Graves’ disease.

D Weight gain and mood swings are not considered side effects of propylthiouracil.

 

DIF:    Cognitive Level: Application             REF:    p. 1429

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. What information provided by the nurse would be helpful to a 15-year-old adolescent taking propylthiouracil three times a day?
a. Pill dispensers and alarms on her watch can remind her to take the medication as ordered.
b. She can take the medication when she is nervous and feels she needs it.
c. She can take two pills before school and one pill at dinner, which will be easier for her to remember.
d. Her mother can be responsible for reminding her when it is time to take her medication.

 

 

ANS:   A

A Propylthiouracil is an antithyroid medication that should be taken three times a day. Reminders will facilitate taking medication as ordered.

B This medication needs to be taken regularly, not on an as-needed basis.

C The dosage cannot be combined to reduce the frequency of administration.

D Because of the adolescent’s school schedule and activities, she, rather than her mother, needs to be responsible for her medication.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 1430

OBJ:    Nursing Process Step: Evaluation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. Which sign, when exhibited by a hospitalized child, would the nurse recognize as a characteristic of diabetes insipidus?
a. Weight gain c. Increased urination
b. Increased urine specific gravity d. Serum sodium level of 130 mEq/L

 

 

ANS:   C

A Weight gain results from retention of water when there is an excessive production of antidiuretic hormone; in diabetes insipidus there is a decreased production of antidiuretic hormone.

B Concentrated urine is a sign of the syndrome of inappropriate antidiuretic hormone (SIADH), in which there is an excessive production of antidiuretic hormone.

C The deficiency of antidiuretic hormone associated with diabetes insipidus causes the body to excrete large volumes of dilute urine.

D A deficiency of antidiuretic hormone, as with diabetes insipidus, results in an increased serum sodium concentration (greater than 145 mEq/L).

 

DIF:    Cognitive Level: Application             REF:    p. 1431

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Physiologic Integrity

 

  1. What would the nurse include in the teaching plan for parents of a child with diabetes insipidus who is receiving DDAVP?
a. Increase the dosage of DDAVP as the urine specific gravity (SG) increases.
b. Give DDAVP only if urine output decreases.
c. The child should have free access to water and toilet facilities at school.
d. Cleanse skin before administering the transdermal patch.

 

 

ANS:   C

A DDAVP needs to be given as ordered by the physician. If the parents are monitoring urine SG at home, they would not increase the medication dose for increased SG; the physician may order an increased dosage for very dilute urine with decreased SG.

B DDAVP needs to be given continuously as ordered by the physician.

C The child’s teachers should be aware of the diagnosis, and the child should have free access to water and toilet facilities at school.

D DDAVP is typically given intranasally or by subcutaneous injection. For nocturnal enuresis, it may be given orally.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 1432

OBJ:    Nursing Process Step: Planning

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. What metabolic alteration is related to growth hormone deficiency?
a. Hypocalcemia c. Diabetes insipidus
b. Hypoglycemia d. Hyperglycemia

 

 

ANS:   B

A Symptoms of hypocalcemia are associated with hypoparathyroidism.

B Growth hormone helps maintain blood sugar at normal levels.

C Diabetes insipidus is a disorder of the posterior pituitary. Growth hormone is produced by the anterior pituitary.

D Hyperglycemia results from an insufficiency of insulin, which is produced by the beta cells in the islets of Langerhans in the pancreas.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 1436

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Physiologic Integrity

 

  1. What is the most appropriate intervention for the parents of a 6-year-old child with precocious puberty?
a. Advise the parents to consider birth control for their daughter.
b. Explain the importance of having the child foster relationships with same-age peers.
c. Assure the child’s parents that there is no increased risk for sexual abuse because of her appearance.
d. Counsel parents that there is no treatment currently available for this disorder.

 

 

ANS:   B

A Advising the parents of a 6-year-old to put their daughter on birth control is not appropriate and will not reverse the effects of precocious puberty.

B Despite the child’s appearance, the child needs to be treated according to her chronologic age and to interact with children in the same age-group. An expected outcome is that the child will adjust socially by exhibiting age-appropriate behaviors and social interactions.

C Parents need to be aware that there is an increased risk of sexual abuse for a child with precocious puberty.

D Treatment for precocious puberty is the administration of gonadotropin-releasing hormone blocker, which slows or reverses the development of secondary sexual characteristics and slows rapid growth and bone aging.

 

DIF:    Cognitive Level: Application             REF:    p. 1435

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. A neonate is displaying mottled skin, has a large fontanel and tongue, is lethargic, and is having difficulty feeding. The nurse recognizes that this is most suggestive of which of the following?
a. hypocalcemia. c. hypoglycemia.
b. hypothyroidism. d. phenylketonuria (PKU).

 

 

ANS:   B

A When hypocalcemia is present, neonates may display twitching, tremors, irritability, jitteriness, electrocardiographic changes, and, rarely, seizures.

B An infant with hypothyroidism may exhibit skin mottling, a large fontanel, a large tongue, hypotonia, slow reflexes, a distended abdomen, prolonged jaundice, lethargy, constipation, feeding problems, and coldness to touch.

C Hypoglycemia causes the neonate to exhibit jitteriness, poor feeding, lethargy, seizures, respiratory alterations including apnea, hypotonia, high-pitched cry, bradycardia, cyanosis, and temperature instability.

D Infants with PKU may initially have digestive problems with vomiting, and they may have a musty or mousy odor to the urine, infantile eczema, hypertonia, and hyperactive behavior.

 

DIF:    Cognitive Level: Application             REF:    p. 1426

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Physiologic Integrity

 

  1. What is the best time for the nurse to assess the peak effectiveness of subcutaneously administered Regular insulin?
a. Two hours after administration c. Immediately after administration
b. Four hours after administration d. Thirty minutes after administration

 

 

ANS:   A

A The peak action for Regular (short-acting) insulin is 2 to 3 hours after subcutaneous administration.

B The duration of Regular (short-acting) insulin is only 3 to 6 hours. Peak action occurs 2 to 3 hours after the insulin is administered.

C Subcutaneously administered Regular (short-acting) insulin has an onset of action of 30 to 60 minutes after injection. The effectiveness of subcutaneously administered, short-acting insulin cannot be assessed immediately after administration.

D Thirty minutes corresponds to the onset of action for Regular (short-acting) insulin.

 

DIF:    Cognitive Level: Application             REF:    p. 1440

OBJ:    Nursing Process Step: Evaluation      MSC:   Client Needs: Physiologic Integrity

 

  1. Which statement by a 14-year-old adolescent newly diagnosed with type 1 diabetes mellitus indicates the need for further teaching?
a. “I should eat meals and snack at the same time every day.”
b. “Exercise will decrease my insulin requirements.”
c. “It is okay to drink chocolate milk anytime I want.”
d. “I need to check my sugars before meals and at bedtime.”

 

 

ANS:   C

A Meals and snacks should be eaten at regular times.

B Exercise decreases insulin requirements.

C Chocolate milk is high in carbohydrates. Carbohydrates raise blood glucose levels. A beverage low in carbohydrates is a better choice.

D Checking serum glucose before breakfast and dinner is appropriate.

 

DIF:    Cognitive Level: Application             REF:    p. 1445

OBJ:    Nursing Process Step: Evaluation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. What is the primary concern for a 7-year-old child with type 1 diabetes mellitus who asks his mother not to tell anyone at school that he has diabetes?
a. The child’s safety c. Development of a sense of industry
b. The privacy of the child d. Peer group acceptance

 

 

ANS:   A

A Safety is the primary issue. School personnel need to be aware of the signs and symptoms of hypoglycemia and hyperglycemia and the appropriate interventions.

B Privacy is not a life-threatening concern.

C The treatment of type 1 diabetes should not interfere with the school-age child’s development of a sense of industry.

D Peer group acceptance, along with body image, are issues for the early adolescent with type 1 diabetes. This is not of greater priority than the child’s safety.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 1446

OBJ:    Nursing Process Step: Evaluation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. What is the best nursing action when a child with type 1 diabetes mellitus is sweating, trembling, and pale?
a. Offer the child a glass of water.
b. Give the child 5 units of regular insulin subcutaneously.
c. Give the child a glass of orange juice.
d. Give the child glucagon subcutaneously.

 

 

ANS:   C

A A glass of water is not indicated in this situation. An easily digested carbohydrate is indicated when a child exhibits symptoms of hypoglycemia.

B Insulin would lower blood glucose and is contraindicated for a child with hypoglycemia.

C Four ounces of orange juice is an appropriate treatment for the conscious child who is exhibiting signs of hypoglycemia.

D Subcutaneous injection of glucagon is used to treat hypoglycemia when the child is unconscious.

 

DIF:    Cognitive Level: Application             REF:    pp. 1442, 1446

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Physiologic Integrity

 

  1. Which sign is the nurse most likely to assess in a child with hypoglycemia?
a. Urine positive for ketones and serum glucose greater than 300 mg/dL
b. Normal sensorium and serum glucose greater than 160 mg/dL
c. Irritability and serum glucose less than 70 mg/dL
d. Increased urination and serum glucose less than 120 mg/dL

 

 

ANS:   C

A Serum glucose greater than 300 mg/dL and urine positive for ketones are indicative of diabetic ketoacidosis.

B Normal sensorium and serum glucose greater than 160 mg/dL are associated with hyperglycemia.

C Irritability and serum glucose less than 70 mg/dL are neuroglycopenic manifestations of hypoglycemia.

D Increased urination is an indicator of hyperglycemia. A serum glucose level less than 120 mg/dL is within normal limits.

 

DIF:    Cognitive Level: Application             REF:    p. 1438

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Physiologic Integrity

 

  1. When would a child diagnosed with type 1 diabetes mellitus most likely demonstrate a decreased need for insulin?
a. During the “honeymoon” phase c. During growth spurts
b. During adolescence d. During minor illnesses

 

 

ANS:   A

A During the “honeymoon” phase, which may last from a few weeks to a year or longer, the child is likely to need less insulin.

B During adolescence, physical growth and hormonal changes contribute to an increase in insulin requirements.

C Insulin requirements are typically increased during growth spurts.

D Stress either from illness or from events in the environment can cause hyperglycemia. Insulin requirements are increased during periods of minor illness.

 

DIF:    Cognitive Level: Application             REF:    p. 1439

OBJ:    Nursing Process Step: Evaluation      MSC:   Client Needs: Physiologic Integrity

 

  1. What would a nurse advise the parents of a child with type 1 diabetes mellitus who is not eating as a result of a minor illness?
a. Give the child half his regular morning dose of insulin.
b. Substitute simple carbohydrates or calorie-containing liquids for solid foods.
c. Give the child plenty of unsweetened, clear liquids to prevent dehydration.
d. Take the child directly to the emergency department.

 

 

ANS:   B

A The child should receive his regular dose of insulin even if he does not have an appetite.

B A sick-day diet of simple carbohydrates or calorie-containing liquids will maintain normal serum glucose levels and decrease the risk of hypoglycemia.

C If the child is not eating as usual, he needs calories to prevent hypoglycemia.

D During periods of minor illness, the child with type 1 diabetes mellitus can be managed safely at home.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 1449

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. Which is the nurse’s best response to the parents of a 10-year-old child newly diagnosed with type 1 diabetes mellitus who are concerned about the child’s continued participation in soccer?
a. “Consider the swim team as an alternative to soccer.”
b. “Encourage intellectual activity rather than participation in sports.”
c. “It is okay to play sports such as soccer unless the weather is too hot.”
d. “Give the child an extra 15 to 30 g of carbohydrate snack before soccer practice.”

 

 

ANS:   D

A Soccer is an appropriate sport for a child with type 1 diabetes as long as the child prevents hypoglycemia by eating a snack.

B Participation in sports is not contraindicated for a child with type 1 diabetes.

C The child with type 1 diabetes may participate in sports activities regardless of climate.

D Exercise lowers blood glucose levels. A snack with 15 to 30 g of carbohydrates before exercise will decrease the risk of hypoglycemia.

 

DIF:    Cognitive Level: Application             REF:    p. 1441

OBJ:    Nursing Process Step: Planning

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. Which comment by a 12-year-old child with type 1 diabetes indicates deficient knowledge?
a. “I rotate my insulin injection sites every time I give myself an injection.”
b. “I keep records of my glucose levels and insulin sites and amounts.”
c. “I’ll be glad when I can take a pill for my diabetes like my uncle does.”
d. “I keep Lifesavers in my school bag in case I have a low-sugar reaction.”

 

 

ANS:   C

A Rotating injection sites is appropriate because insulin absorption varies at different sites.

B Keeping records of serum glucose and insulin sites and amounts is appropriate.

C Children with type 1 diabetes will require life-long insulin therapy.

D Prompt treatment of hypoglycemia reduces the possibility of a severe reaction. Keeping hard candy on hand is an appropriate action.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 1439

OBJ:    Nursing Process Step: Evaluation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. Which laboratory finding would confirm that a child with type 1 diabetes is experiencing diabetic ketoacidosis?
a. No urinary ketones c. Elevated serum carbon dioxide
b. Low arterial pH d. Elevated serum phosphorus

 

 

ANS:   B

A Urinary ketones, often in large amounts, are present when a child is in diabetic ketoacidosis.

B Severe insulin deficiency produces metabolic acidosis, which is indicated by a low arterial pH.

C Serum carbon dioxide is decreased in diabetic ketoacidosis.

D Serum phosphorus is decreased in diabetic ketoacidosis.

 

DIF:    Cognitive Level: Application             REF:    p. 1449

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Physiologic Integrity

 

MULTIPLE RESPONSE

 

  1. Which nursing intervention would be appropriate for a child with type 1 diabetes who is experiencing deficient fluid volume related to abnormal fluid losses through diuresis and emesis? Select the interventions that apply.
a. Initiate IV access
b. Begin IV fluid replacement with normal saline
c. Begin IV fluid replacement with D5 1/2 NS
d. Weigh on arrival to the unit and then every other day
e. Maintain strict intake and output monitoring

 

 

ANS:   A, B, E

Correct A, B, E. IV access should always be obtained on a hospitalized child with dehydration and a history of type 1 diabetes. Maintaining circulation is a priority nursing intervention. If the child is vomiting and unable to maintain adequate hydration, fluid volume replacement/rehydration is needed. Normal saline is the initial IV rehydration fluid, followed by half-normal saline. Maintaining strict intake and output is essential in calculating rehydration status.

Incorrect C, D. D5 1/2 NS is not the recommended fluid for rehydration of this patient. Weighing the patient on arrival is important, but following the initial weight the child needs to be weighed more frequently than every other day. Comparison of admission weight and a weight every 8 hours provides an indication of hydration status.

 

DIF:    Cognitive Level: Analysis                  REF:    pp. 1449-1450

OBJ:    Nursing Process Step: Implementation

MSC:   Client Needs: Physiologic Integrity

 

  1. Which children admitted to the pediatric unit would the nurse monitor closely for development of syndrome of inappropriate antidiuretic hormone (SIADH)? Select the children who apply.
a. A newly diagnosed preschooler with type 1 diabetes
b. A school-age child returning from surgery for removal of a brain tumor
c. An infant with suspected meningitis
d. An adolescent with blunt abdominal trauma following a car accident
e. A school-age child with head trauma

 

 

ANS:   B, C, E

Correct B, C, E. Childhood SIADH usually is caused by disorders affecting the central nervous system, such as infections (meningitis), head trauma, and brain tumors.

Incorrect A, D. These conditions do not usually cause SIADH.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 1432

OBJ:    Nursing Process Step: Assessment     MSC:   Client Needs: Physiologic Integrity