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Foundations of Nursing 6th Edition by Barbara Lauritsen Christensen, Elaine Oden Kockrow – Test Bank

 

Christensen: Foundations of Nursing, 6th Edition

 

Chapter 07: Documentation

 

Test Bank

 

MULTIPLE CHOICE

 

  1. Documentation of type of care, time of care, and signature of the person who is documenting proves that:
a. the person who signed the documentation did all the work noted.
b. no litigation can be brought against the person who signed.
c. interventions were implemented to meet the patient’s needs.
d. the patient’s response to the intervention was positive.

 

ANS:   C

This information results in recording the interventions that are implemented to meet the patient’s needs. Many charting entries include doctor’s visits, presence of family, or interventions by other departments. Patient response to some interventions is not always positive.

 

DIF:    Cognitive Level: Application             REF:    Page 138         OBJ:    6

TOP:    Documentation                                   KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: N/A

 

  1. In managed care, documentation is especially significant because:
a. the hospital needs to show that employees care for patients.
b. institutions are reimbursed only for patient care that is documented.
c. patients might bring lawsuits if care was not given.
d. documents may become part of a lawsuit.

 

ANS:   B

Institutions are reimbursed only for patient care that is documented.

 

DIF:    Cognitive Level: Application             REF:    Page 139         OBJ:    5

TOP:    Documentation                                   KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. When the nurse charts only additional treatments done, changes in patient condition, and new concerns, the system of documentation is:
a. SOAP.
b. block.
c. CBE.
d. focus.

 

ANS:   C

Charting additional treatments done, changes in a patient’s condition, and new concerns during the shift is charting by exception (CBE).

 

DIF:    Cognitive Level: Application             REF:    Page 145         OBJ:    7

TOP:    Documentation                                   KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. When events are not consistent with facility or national standards of expected care, the form that explains the lapse is the:
a. subjective data.
b. focus chart.
c. incident report.
d. nursing assessment.

 

ANS:   C

An incident report is completed when patient care was not consistent with facility or national standards. The form explains the event, time, extent of injury, and who was notified.

 

DIF:    Cognitive Level: Application             REF:    Page 145         OBJ:    6

TOP:    Documentation                                   KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. When staff from all disciplines develop integrated care plans for a projected length of stay for patients of a specific case type, it is known as a:
a. nursing order.
b. Kardex.
c. nursing care plan.
d. critical pathway.

 

ANS:   D

Critical pathways allow staff from all disciplines to develop integrated care plans for a projected length of stay for patients of a specific case type.

 

DIF:    Cognitive Level: Application             REF:    Pages 150-151

OBJ:    11                    TOP:    Documentation

KEY:   Nursing Process Step: Implementation                                  MSC:   NCLEX: N/A

 

  1. Home health care documentation is unique because:
a. some charting is retained at the hospital.
b. the physician’s office needs separate charting.
c. different health care providers need access.
d. the physician is the pivotal person in the charting.

 

ANS:   C

Home health care documentation has unique problems because of the need for different health care workers to access the medical record.

 

DIF:    Cognitive Level: Application             REF:    Page 151         OBJ:    10

TOP:    Documentation                                   KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. Standards for long-term care documentation are regulated by:
a. OBRA.
b. Title XXII.
c. nursing diagnoses.
d. the care plan.

 

ANS:   A

OBRA (Omnibus Budget Reconciliation Act) was a significant Medicare and Medicaid legislation for long-term health care documentation.

 

DIF:    Cognitive Level: Application             REF:    Page 152         OBJ:    9

TOP:    Documentation                                   KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. Adherence to the concept of confidentiality for the patient’s medical record requires that the nurse:
a. provide information only to another nurse.
b. provide information only to an attorney.
c. share information only with the family.
d. have a clinical reason for reading the record.

 

ANS:   D

The nurse should not read the patient’s medical record unless there is a clinical reason for doing so.

 

DIF:    Cognitive Level: Application             REF:    Page 152         OBJ:    3

TOP:    Confidentiality                                   KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. Documentation is necessary for the evaluation of patient care and is an integral part of the nursing process phase of:
a. assessment.
b. planning.
c. implementation.
d. evaluation.

 

ANS:   C

Documentation is part of the implementation phase of the nursing process.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 138         OBJ:    4

TOP:    Documentation                                   KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. When focus charting, what does the nurse use as a basis for documentation?
a. Problem list
b. Nursing orders
c. Nursing diagnoses
d. Evaluation

 

ANS:   C

In focus charting, instead of using the problem list, modified nursing diagnoses are used as an index for nursing documentation.

 

DIF:    Cognitive Level: Application             REF:    Page 144         OBJ:    7

TOP:    Documentation                                   KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. The purpose of QA (quality assurance) is to:
a. screen employment applications.
b. evaluate care results against accepted standards.
c. conduct in-services for “quality documentation.”
d. report deviation from standards to the state health department.

 

ANS:   B

QA is an in-house department that evaluates care services and results against accepted standards.

 

DIF:    Cognitive Level: Application             REF:    Page 139         OBJ:    3

TOP:    Documentation                                   KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. The process used to appraise the practice of an individual nurse is called:
a. quality assurance.
b. incident reporting.
c. OBRA.
d. peer review.

 

ANS:   D

Peer review is an in-house department study that may appraise the nursing practice of individual nurses.

 

DIF:    Cognitive Level: Application             REF:    Page 139         OBJ:    3

TOP:    Peer review     KEY:   Nursing Process Step: N/A                MSC:   NCLEX: N/A

 

 

  1. The documentation format that uses the acronym SOAPE is:
a. problem-oriented.
b. focused.
c. traditional.
d. crisis.

 

ANS:   A

The problem-oriented medical record uses the acronym SOAPE to format and focus charting on a list of patient problems/nursing diagnoses.

 

DIF:    Cognitive Level: Application             REF:    Pages 142-143

OBJ:    7                      TOP:    Problem-oriented medical record (POMR)

KEY:   Nursing Process Step: N/A                MSC:   NCLEX: N/A

 

  1. The nurse knows that for a hospitalized patient, the legal owner of the patient’s medical record is the:
a. patient.
b. physician.
c. institution.
d. state.

 

ANS:   C

Ownership of a medical record belongs to the institution in the case of a hospitalized patient, or the doctor in the case of private office visits.

 

DIF:    Cognitive Level: Application             REF:    Page 152         OBJ:    3

TOP:    Legal ownership                                 KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity

 

  1. When using electronic (or computerized) documentation, which process should the nurse use to ensure that no one alters the information the nurse has entered?
a. Charting in code
b. Logging off
c. Charting in privacy
d. Signing on with a password

 

ANS:   B

Logging off closes the computer file that was opened with the nurse’s password. Any other data entry will require that person to sign on with their password.

 

DIF:    Cognitive Level: Application             REF:    Page 155, Box 7-5

OBJ:    8                      TOP:    Computer documentation

KEY:   Nursing Process Step: N/A                MSC:   NCLEX: N/A

 

  1. A system that classifies patients by age, diagnosis, and surgical procedure and produces 300 different categories used for predicting the use of hospital resources is known as:
a. quality assurance.
b. resource assessment.
c. quality improvement.
d. diagnosis-related groups.

 

ANS:   D

Cost reimbursement rates by the government plans are based on diagnosis-related groups (DRGs), which is a system that classifies patients by age, diagnosis, and surgical procedure, producing 300 different categories used in predicting the use of hospital resources, including length of stay.

 

DIF:    Cognitive Level: Application             REF:    Page 139         OBJ:    5

TOP:    Diagnostic related groups                  KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. When using the data, action, response, education (DARE) system of charting, the data portion focuses on:
a. planning.
b. assessment.
c. implementation.
d. patient teaching.

 

ANS:   B

DARE is the acronym for four different aspects of charting using the focus format. Data (D) is both subjective and objective and is equivalent to the assessment step of the nursing process. Action (A) is a combination of planning and implementation. Response (R) of the patient is the same as evaluation of effectiveness. Some facilities include education/patient teaching (E).

 

DIF:    Cognitive Level: Application             REF:    Page 144         OBJ:    7

TOP:    Charting          KEY:   Nursing Process Step: Assessment     MSC:   NCLEX: N/A

 

  1. Who has primary responsibility for each patient’s initial admission nursing history, physical assessment, and development of the care plan based on the nursing diagnoses identified?
a. Physician
b. Registered nurse
c. Nursing assistant
d. Licensed practical nurse/licensed vocational nurse

 

ANS:   B

The registered nurse (RN) has primary responsibility for each patient’s initial admission nursing history, physical assessment, and development of the care plan based on the nursing diagnoses identified.

 

DIF:    Cognitive Level: Application             REF:    Page 140         OBJ:    3

TOP:    Scope of practice                                KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. If the nurse makes an error while documenting in a patient’s chart, the nurse should:
a. scratch out the error.
b. apply correction fluid.
c. erase the error completely.
d. draw a single line through the error.

 

ANS:   D

A nurse should not erase, apply correction fluid, or scratch out errors made while recording in a patient’s chart. Instead, the nurse should draw a single line through the error, write the word “error” above it, and sign her name or initials.

 

DIF:    Cognitive Level: Application             REF:    Page 141, Table 7-2

OBJ:    3                      TOP:    Documentation

KEY:   Nursing Process Step: N/A                MSC:   NCLEX: N/A

 

  1. When documenting in a patient’s chart, the nurse should:
a. include speculation.
b. chart consecutively.
c. leave blank spaces.
d. include retaliatory comments.

 

ANS:   B

A nurse should not write retaliatory or critical comments about a patient or care by other health care professionals. The nurse should not leave blank spaces in the nurse’s notes. The nurse should be certain the entry is factual and not speculate or guess. The nurse should chart consecutively, line by line.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 141, Table 7-2

OBJ:    3                      TOP:    Documentation

KEY:   Nursing Process Step: N/A                MSC:   NCLEX: N/A

 

  1. What are categories of inadequate documentation that may lead to a malpractice claim? (Select all that apply.)
a. Incorrectly recording the time of an event
b. Failing to record verbal orders
c. Charting events in advance
d. Documenting an incorrect date
e. Marking out and initialing charting errors

ANS:   A, B, C, D

Marking out with a single line and initialing is an acceptable method to indicate a charting error.

 

DIF:    Cognitive Level: Application             REF:    Page 141, Table 7-2

OBJ:    3                      TOP:    Inadequate documentation

KEY:   Nursing Process Step: N/A                MSC:   NCLEX: N/A

 

  1. When documenting an incident in the nurse’s notes, what should the nurse include? (Select all that apply.)
a. Description of injury, including diagrams of injury placement
b. Date, time, and location of incident
c. Name of physician and family members notified
d. Chronological order of events of the incident
e. Confirmation that an incident report was initiated

 

ANS:   A, B, C, D

The documentation of the initiation of an incident report should not be included in the nurse’s notes. Nurse’s notes are part of the legal medical record; the incident report is not. To note that an incident report was initiated is a red flag that a problem has occurred.

 

DIF:    Cognitive Level: Application             REF:    Pages 145, 148

OBJ:    3                      TOP:    Documenting incident reports

KEY:   Nursing Process Step: N/A                MSC:   NCLEX: N/A

 

  1. What are some problems associated with electronic (or computerized) charting? (Select all that apply.)
a. Security
b. Expense of training staff
c. Legibility
d. Easy retrieval
e. New terminology

 

ANS:   A, B, E

Security, expensive staff training, and learning new terminology are all problems of electronic charting. Legibility and easy retrieval are advantages.

 

DIF:    Cognitive Level: Application             REF:    Pages 152-153

OBJ:    8                      TOP:    Computer charting

KEY:   Nursing Process Step: N/A                MSC:   NCLEX: N/A

 

  1. What are the basic purposes of written patient records? (Select all that apply.)
a. Teaching
b. Legal record of care
c. Written communication
d. Research and data collection
e. Permanent record for accountability
f. Temporary record of hospitalization

 

ANS:   A, B, C, D, E

There are five basic purposes for written patient records: (1) written communication, (2) permanent record for accountability, (3) legal record of care, (4) teaching, and (5) research and data collection.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 138         OBJ:    1

TOP:    Medical record                                   KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. What should a medical record provide for all health care providers? (Select all that apply.)
a. Care given to the patient
b. Care planned for the patient
c. A patient’s nursing problems
d. A patient’s medical problems
e. Details about any incident reports
f. The patient’s response to treatment

 

ANS:   A, B, C, D, F

A medical record should furnish all health care providers with a concise, accurate, written picture of a patient’s medical and nursing problems, care planned and given, and the patient’s response to treatments.

 

DIF:    Cognitive Level: Analysis                  REF:    Pages 139, 148

OBJ:    1                      TOP:    Medical record

KEY:   Nursing Process Step: N/A                MSC:   NCLEX: N/A

 

  1. The best defense against malpractice claims associated with nursing care is accurate _____________.

 

ANS:

documentation

Accurate documentation can guard against malpractice claims because it should describe when, what, and how events occurred.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 140         OBJ:    3

TOP:    Documentation                                   KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

 

 

 

  1. Twenty-four–hour charting is designed to establish __________ levels to help determine staffing needs.

 

ANS:

acuity

Patient acuity, which is reflected in 24-hour charting compilation, can dictate staffing needs.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 149         OBJ:    7

TOP:    24-hour charting                                 KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. Documentation using the DARE format (Data, Action, Response, Education) includes elements of the __________ charting system.

 

ANS:

focused

Focused charting uses the acronym DARE to direct and formalize charting.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 144         OBJ:    7

TOP:    Focused charting                                KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. A health care audit that evaluates services provided and the results achieved compared with accepted standards is known as ____________ ________________.

 

ANS:

quality assurance/assessment/improvement

Quality assurance/assessment/improvement is an audit in health care that evaluates services provided and the results achieved compared with accepted standards.

 

DIF:    Cognitive Level: Application             REF:    Page 139         OBJ:    3

TOP:    Quality assurance/assessment/improvement

KEY:   Nursing Process Step: N/A                MSC:   NCLEX: N/A

Christensen: Foundations of Nursing, 6th Edition

 

Chapter 15: Body Mechanics and Patient Mobility

 

Test Bank

 

MULTIPLE CHOICE

 

  1. The nurse instructs a nursing assistant to use large muscle groups when lifting because:
a. workers’ compensation claims will be prevented.
b. big muscles work more effectively.
c. it guarantees no muscle strain.
d. it distributes workload more evenly.

 

ANS:   D

Proper body mechanics provide for even distribution of workload.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 372         OBJ:    2

TOP:    Body mechanics                                 KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. To reduce the effort of moving a heavy object, the nurse should:
a. bring the feet close together and flex the knees.
b. keep the back straight and bend at the waist.
c. widen the base of support in the direction of movement.
d. broaden the base of support and twist toward the direction of movement.

 

ANS:   C

The base of support should be broadened in the direction of movement.

 

DIF:    Cognitive Level: Application             REF:    Page 371, Table 15-1

OBJ:    2                      TOP:    Body mechanics

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. When lifting or moving a patient, the nurse should protect his or her back by:
a. lowering the height of the bed.
b. holding the back straight with locked knees.
c. bending knees and hips.
d. getting the patient to the side of the bed.

 

ANS:   C

The nurse’s back can be well protected when he or she bends knees and hips.

 

DIF:    Cognitive Level: Application             REF:    Page 371         OBJ:    12

TOP:    Body mechanics                                 KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. When carrying heavy objects, the nurse should place the load:
a. in a low position.
b. to the side of the body.
c. close to the body midline.
d. with another’s assistance.

 

ANS:   C

The nurse should carry objects close to the midline of the body.

 

DIF:    Cognitive Level: Application             REF:    Page 372         OBJ:    12

TOP:    Body mechanics                                 KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. The nurse informs the patient that to regain the ability to perform ADLs and maintain normal physiological activities requires:
a. strength.
b. wellness.
c. alertness.
d. mobility.

 

ANS:   D

The purpose of mobility is completing ADLs and maintaining physiological activities.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 375         OBJ:    4

TOP:    Mobility          KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse counsels the immobilized patient that to prevent muscle atrophy and contractures, the patient must have:
a. additional calcium.
b. additional protein.
c. some type of exercise.
d. a special protective bed.

 

ANS:   C

The immobilized patient must receive some type of exercise to prevent atrophy and contractures.

 

DIF:    Cognitive Level: Application             REF:    Page 378         OBJ:    6

TOP:    Immobility      KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse explains that when range of motion (ROM) is performed by the patient, it is called:
a. assisted.
b. passive.
c. active.
d. coordinated.

 

ANS:   C

ROM performed actively by the patient is designated as active ROM.

 

DIF:    Cognitive Level: Application             REF:    Page 379         OBJ:    9

TOP:    Range of motion (ROM)                    KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse performing passive range of motion (ROM) for the patient will move the joint through the ROM to:
a. the fullest extent.
b. place the joint in normal position.
c. the point of pain.
d. relax the patient.

 

ANS:   C

The joints are moved to the point of resistance or pain.

 

DIF:    Cognitive Level: Application             REF:    Pages 379, 388 Coordinated Care

OBJ:    9                      TOP:    Range of motion (ROM)

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. Because moving or ambulation may be painful for the patient, to assist the patient with moving, the nurse should:
a. be supportive.
b. apply heat before moving them.
c. administer medication before ambulation.
d. obtain assistance if the patient is heavy.

 

ANS:   C

The nurse may want to administer medication before an activity that may be painful.

 

DIF:    Cognitive Level: Application             REF:    Page 390         OBJ:    6

TOP:    Body mechanics                                 KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

  1. The 125-pound nurse assesses the weight of a patient she will need to lift because she is aware the heaviest patient she may safely lift by herself would weigh no more than:
a. 158.75 pounds.
b. 168.75 pounds.
c. 178.75 pounds.
d. 188.75 pounds.

 

ANS:   B

Nurses should never attempt to lift more than 35% of their own body weight.

125 ´ 0.35 = 43.75 125 + 43.75 = 168.75

 

DIF:    Cognitive Level: Application             REF:    Page 390         OBJ:    12

TOP:    Body mechanics                                 KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. Although many nurses file worker’s compensation claims as a result of injury on the job, the most common injury is strain of the:
a. trapezius muscle group.
b. thoracic muscle group.
c. lumbar muscle group.
d. thigh muscle group.

 

ANS:   C

The most common back injury is strain of the lumbar muscle group.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 390         OBJ:    2

TOP:    Body mechanics                                 KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. An implementation the nurse may use to improve safety during a transfer is:
a. weighing the patient first.
b. using a transfer belt.
c. putting shoes on the patient.
d. supporting a flaccid arm.

 

ANS:   B

As a general rule, the nurse should use a transfer belt.

 

DIF:    Cognitive Level: Application             REF:    Page 390         OBJ:    5

TOP:    Body mechanics                                 KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment

 

 

  1. The nurse explains that the minimum number of hours of daily activity necessary to prevent the negative consequences of immobility is:
a. 2 hours.
b. 4 hours.
c. 6 hours.
d. 8 hours.

 

ANS:   A

The amount of exercise required to prevent physical disuse syndrome is 2 hours in 24 hours.

 

DIF:    Cognitive Level: Application             REF:    Pages 379, 382

OBJ:    6                      TOP:    Immobility      KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. When performing passive range-of-motion (ROM) exercises, the number of times the nurse should move each joint through the ROM is:
a. three.
b. four.
c. five.
d. six.

 

ANS:   C

Each movement should be repeated five times.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 381, Skill 15-2

OBJ:    10                    TOP:    Range of motion (ROM)

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. Studies of workers’ compensation claims show that the profession that has the highest claim rates of any occupation or industry is:
a. firefighters.
b. truck drivers.
c. law enforcement.
d. nursing personnel.

 

ANS:   D

Studies of workers’ compensation claims show that nursing personnel have the highest claim rates of any occupation or industry.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 369         OBJ:    2

TOP:    Workers’ compensation                      KEY:   Nursing Process Step: N/A

MSC:   NCLEX: Physiological Integrity

 

  1. A nurse instructing a nursing assistant about moving older adult patients in bed should intervene after observing the nursing assistant:
a. using simple language.
b. avoiding jerky movements.
c. avoiding sudden movements.
d. pulling the patient across bed linens.

 

ANS:   D

The skin of older adults is more fragile and susceptible to injury. When moving or transferring older adults, it is essential to avoid pulling them across bed linens because this may cause shearing or tearing of the skin. The nurse should explain each step in simple language and avoid jerky, sudden movements.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 370, Life Span Considerations

OBJ:    3                      TOP:    Moving patients

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The most common cause of musculoskeletal disorders in nurses involves a movement that requires the nurse to ________ and _________ at the same time.

 

ANS:

twist, lift

lift, twist

The motion of twisting and lifting at the same time frequently strains the muscles of the lower back.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 369         OBJ:    2

TOP:    Muscle strain                                      KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. To maintain a wide base of support, the nurse should stand with the feet separated by the distance of _______ times the length of the nurse’s shoe.

 

ANS:

1.5

one and one half

A wide base of support of 1.5 times the length of the nurse’s shoe is

recommended.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 371         OBJ:    2

TOP:    Base of support                                  KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. When a fall occurs, the nurse should document the incident and initiate a(n) ___________ report.

 

ANS:

incident

The nurse must initiate an incident report describing the events of a patient’s fall.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 377, Box 15-2

OBJ:    6                      TOP:    Incident report

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. Place the nursing activities in priority order for the preparation of a patient to ambulate.
  2. Dangle the patient at the side of the bed.
  3. Apply a gait belt.
  4. Assist the patient to stand.
  5. Inform the patient of activity.
  6. Roll up the head of the bed.

Put a comma between each answer choice (1, 2, 3, 4, etc.).

 

ANS:

4, 5, 1, 2, 3

4,5,1,2,3

The order that is most organized is inform, roll up head of bed, dangle, apply belt, and assist to stand.

 

DIF:    Cognitive Level: Knowledge             REF:    Page 376, Box 15-2

OBJ:    6                      TOP:    Preparation to ambulate

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment

 

 

  1. The nurse points to the X in the illustration below and describes this point as the ________ of _________.

 

ANS:

center, gravity

The center of gravity is the centermost point from the base of support.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 371, Figure 15-1

OBJ:    2                      TOP:    Center of gravity

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

Christensen: Foundations of Nursing, 6th Edition

 

Chapter 31: Care of the Child with a Physical Disorder

 

Test Bank

 

MULTIPLE CHOICE

 

  1. The nurse uses a diagram to show that tetralogy of Fallot involves a combination of which four congenital defects?
a. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy
b. Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
c. Aortic stenosis, atrial septal defect, overriding aorta, right ventricular hypertrophy
d. Pulmonary stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy

 

ANS:   B

Tetralogy of Fallot involves a combination of four congenital defects: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy.

 

DIF:    Cognitive Level: Application             REF:    Page 990         OBJ:    1

TOP:    Heart defect    KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. When caring for a child with coarctation of the aorta, the nurse assesses for the most common clinical manifestation, which is:
a. clubbing of the digits.
b. upper extremity hypertension.
c. pedal edema and portal congestion.
d. loud systolic ejection murmur.

 

ANS:   B

Coarctation of the aorta results in hypertension in the upper extremities.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 991         OBJ:    1

TOP:    Heart defect    KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. Parents of a 6-month-old child who has just been diagnosed with iron deficiency anemia ask why it was not diagnosed earlier. The nurse’s best response is:
a. “Are you sure your child has iron deficiency anemia?”
b. “This happens when the maternal stores of iron are depleted at about 6 months.”
c. “This anemia is caused by blood loss.”
d. “The child may not have had it for a long time.”

 

ANS:   B

Iron deficiency anemia becomes apparent at about 6 months of age in a full-term infant, when maternal stores of iron are depleted.

 

DIF:    Cognitive Level: Application             REF:    Page 992         OBJ:    2

TOP:    Anemia           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. Therapeutic management of iron deficiency anemia includes administration of what?
a. Multivitamins
b. Calcium
c. Ferrous sulfate
d. Iodine

 

ANS:   C

Therapeutic management of iron deficiency anemia is iron supplementation.

 

DIF:    Cognitive Level: Knowledge             REF:    Pages 992-993

OBJ:    2                      TOP:    Anemia           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The parents of a child who has been diagnosed with sickle cell anemia ask why their child experiences pain. The nurse explains that the child’s pain is caused by:
a. inflammation of the vessels.
b. obstructed blood flow.
c. overhydration.
d. stress-related headaches.

 

ANS:   B

The signs and symptoms of sickle cell anemia include the sickle-shaped cells clumping and obstructing blood flow, which causes pain.

 

DIF:    Cognitive Level: Application             REF:    Page 993         OBJ:    2

TOP:    Blood disorders                                  KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The parents of a child diagnosed with sickle cell anemia ask what to do to avoid a sickle cell crisis. The nurse explains that the medical management of sickle cell crisis includes:
a. information for the parents including home care.
b. providing adequate hydration and pain management.
c. pain management and administration of iron supplements.
d. adequate oxygenation and factor VIII.

 

ANS:   B

Medical management of sickle cell crisis includes palliative analgesics, hydration, and oxygen.

 

DIF:    Cognitive Level: Application             REF:    Page 994         OBJ:    2

TOP:    Blood disorders                                  KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. When reviewing laboratory results for a child with hemophilia, the nurse anticipates finding an abnormal:
a. prothrombin time.
b. bleeding time.
c. platelet count.
d. partial thromboplastin time.

 

ANS:   D

Expected laboratory findings for a child with hemophilia include a prolonged partial thromboplastin time.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 995         OBJ:    3

TOP:    Blood disorders                                  KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. The parents of a child with acute lymphoblastic leukemia ask about the best approach for maintaining remission of the disease. The nurse informs them that the most effective therapy would be:
a. surgery to remove enlarged lymph nodes.
b. long-term chemotherapy.
c. nutritional supplements to enhance blood cell production.
d. blood transfusions to replace ineffective red cells.

 

ANS:   B

The drug of choice is methotrexate, a chemotherapeutic agent, to produce remission.

 

DIF:    Cognitive Level: Application             REF:    Page 998         OBJ:    4

TOP:    Blood disorders                                  KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse teaches parents that the severity of infant respiratory distress syndrome (RDS) is most influenced by:
a. poor cough and gag reflex.
b. the gestational age at birth.
c. administering high concentrations of oxygen.
d. the sex of the infant.

ANS:   B

RDS is caused by a deficiency of surfactant and occurs almost exclusively in preterm, low-birth-weight infants.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 1003       OBJ:    7

TOP:    Respiratory distress syndrome (RDS)

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. A 2-year-old child with laryngotracheobronchitis (LTB) is fussy and restless in the oxygen tent. The oxygen level in the tent is 25%, and blood gases are normal. The nurse should:
a. restrain the child in the tent and notify the physician.
b. increase the oxygen concentration in the tent.
c. take the child out of the tent and into the playroom.
d. ask the mother for help in comforting the child.

 

ANS:   B

The child with LTB should be placed in the mist tent with 30% oxygen. Restlessness is caused by poor oxygenation.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 1009       OBJ:    7

TOP:    Laryngotracheobronchitis (LTB)       KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The mother of a child with acute laryngotracheobronchitis (LTB) asks why her child must be kept NPO. The nurse explains that:
a. the epinephrine given causes nausea and vomiting.
b. the child is being hydrated with IV fluids.
c. swollen respiratory passages make eating difficult.
d. the child’s rapid respirations pose a risk for aspiration.

 

ANS:   D

Rapid respirations predispose to aspiration.

 

DIF:    Cognitive Level: Application             REF:    Page 1009       OBJ:    7

TOP:    Laryngotracheobronchitis (LTB)       KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse teaches the parents of a child with acute epiglottitis that the child could suddenly suffer:
a. increased carbon dioxide levels.
b. airway obstruction.
c. inability to swallow.
d. bronchial collapse.

 

ANS:   B

Immediate treatment of acute epiglottitis includes an artificial airway.

 

DIF:    Cognitive Level: Application             REF:    Page 1009       OBJ:    7

TOP:    Epiglottis        KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. The mother of a child who has pneumonia is asking what could have been done to prevent the infection. The nurse teaches the mother that children older than 2 years:
a. are still protected by antibodies from the mother.
b. can be inoculated against pneumococcal pneumonia.
c. may have nutritional deficits that make them vulnerable.
d. are frequently sedentary, which makes them susceptible to infections.

 

ANS:   B

The new recommendations for inoculations include protection against pneumonia.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 1042       OBJ:    7

TOP:    Pneumonia      KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. When conducting a class for parents about sudden infant death syndrome (SIDS), the nurse instructs the class that new information suggests not placing the infant in which position?
a. Right side-lying
b. Left side-lying
c. Prone
d. Supine

 

ANS:   C

The American Academy of Pediatrics recommends placing the infant supine or side-lying rather than prone as a defense against SIDS.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 1006       OBJ:    7

TOP:    Sudden infant death syndrome (SIDS)

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. When interacting with the parents of a SIDS infant, one of the things the nurse attempts to assist with is:
a. referring the parents to a psychologist.
b. encouraging the parents to remain stoic.
c. allaying feelings of guilt and blame.
d. learning how the event could have been prevented.

ANS:   C

As parents try to cope, they have feelings of guilt and blame.

 

DIF:    Cognitive Level: Application             REF:    Page 1007       OBJ:    7

TOP:    Sudden infant death syndrome (SIDS)

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity

 

  1. The nurse educates the family of a newly admitted child with cystic fibrosis that the therapy will be centered on:
a. chest physiotherapy.
b. mucus-drying agents.
c. prevention of diarrhea.
d. insulin therapy.

 

ANS:   A

Chest physiotherapy and aerosol medications are the center of treatment for cystic fibrosis.

 

DIF:    Cognitive Level: Application             REF:    Page 1012       OBJ:    7

TOP:    Cystic fibrosis                                    KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. When reviewing the pathophysiology of cystic fibrosis, the nurse recognizes that it is characterized by:
a. multiple upper respiratory infections.
b. an underproduction of exocrine glands.
c. excessive, thick mucus.
d. an overproduction of thin mucus.

 

ANS:   C

The pathophysiology of cystic fibrosis includes excessive, thick mucus.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 1011       OBJ:    7

TOP:    Cystic fibrosis                                    KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse selects which time as the best to administer the pancreatic enzyme replacement?
a. Before meals and snacks
b. Before bedtime
c. Early in the morning
d. After meals and snacks

 

ANS:   A

Pancreatic enzymes are administered before meals and snacks.

 

DIF:    Cognitive Level: Application             REF:    Page 1012       OBJ:    7

TOP:    Cystic fibrosis                                    KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. Following surgical repair of a cleft palate, when soft food is introduced, the nurse modifies the care plan to include feeding safety based on the knowledge that to avoid injury to the suture line, it is best to avoid the use of a:
a. feeding dropper.
b. spoon.
c. syringe.
d. cup.

 

ANS:   B

When feeding a child with a repaired cleft palate, the nurse should avoid utensils.

 

DIF:    Cognitive Level: Application             REF:    Page 1017       OBJ:    8

TOP:    Cleft lip and palate                             KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Safe, Effective Care Environment

 

  1. The nurse is assisting the parents of a child born with a cleft lip and palate to deal with the deformity. An appropriate nursing diagnosis for the parents is:
a. parental role conflict.
b. risk for delayed growth and development.
c. risk for impaired attachment.
d. anticipatory grieving.

 

ANS:   C

A goal is to promote bonding between parents and infant.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 1017       OBJ:    8

TOP:    Cleft lip and palate                             KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Psychosocial Integrity

 

  1. When discussing long-term complications of a child with cleft lip and palate, the nurse tells the parents that one of the complications is:
a. cognitive impairment.
b. altered growth and development.
c. faulty dentition.
d. physical abilities.

 

ANS:   C

The older child with cleft lip and palate may experience psychologic difficulties because of the cosmetic appearance of the defect, problems with impaired speech, and faulty dentition.

 

DIF:    Cognitive Level: Application             REF:    Page 1016       OBJ:    8

TOP:    Cleft lip and palate                             KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse measures intake and output for an infant with dehydration by:
a. attaching a urine collecting bag.
b. wringing out the diaper.
c. weighing the diaper.
d. inserting a catheter.

 

ANS:   C

Wet diapers can be weighed to assess the amount of output.

 

DIF:    Cognitive Level: Application             REF:    Page 1018       OBJ:    8

TOP:    Dehydration    KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. A school-age child has been rehydrated following a bout of diarrhea. The nurse offers foods that are nonirritating to the bowel, including:
a. apricots and peaches.
b. chocolate milk.
c. applesauce and milk.
d. bananas and rice.

 

ANS:   D

When rehydration has been completed, the nurse should offer bananas and rice, which are nonirritating.

 

DIF:    Cognitive Level: Application             REF:    Page 1019       OBJ:    8

TOP:    Nutrition         KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse explains that gastroesophageal reflux (GER) usually begins within the first week of life in infants and is usually treated by:
a. making the infant NPO.
b. thickening the food with cereal.
c. placing the infant in an upright position.
d. feeding the infant in a car seat.

 

ANS:   B

GER is treated with small feedings thickened with cereal.

DIF:    Cognitive Level: Application             REF:    Page 1021       OBJ:    8

TOP:    Nutrition         KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse assessing an infant who has been diagnosed with hypertrophic pyloric stenosis anticipates:
a. a history of diarrhea following each feeding.
b. gastric pain evidenced by vigorous crying.
c. poor appetite due to a poor sucking reflex.
d. an olive-shaped mass at the midline.

 

ANS:   D

Examination of the abdomen may assist in the diagnosis and reveal key signs of hypertrophic pyloric stenosis. Visible peristaltic waves that move from left to right across the epigastric region may be evident, and palpation may reveal an olive-shaped mass in this area to the right of the midline.

 

DIF:    Cognitive Level: Application             REF:    Page 1022       OBJ:    8

TOP:    Pyloric stenosis                                   KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. When assessing a child admitted with intussusception, the nurse discovers the hallmark sign of intussusception, which is:
a. mucus-like stools.
b. currant jelly–like stools.
c. tarry, black stools.
d. green, soft stools.

 

ANS:   B

The hallmark sign of intussusception is currant jelly stools.

 

DIF:    Cognitive Level: Application             REF:    Page 1023       OBJ:    8

TOP:    Gastrointestinal disorders                  KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. When a 2-year-old child is admitted with a diagnosis of Hirschsprung’s disease, the nurse explains that the causative factor of this disease is:
a. frequent evacuation of solids, liquid, and gases.
b. excessive peristaltic movement.
c. the absence of parasympathetic ganglion cells in a portion of the colon.
d. one portion of the bowel telescoping into another.

 

ANS:   C

The causative factor in Hirschsprung’s disease is the absence of parasympathetic ganglion cells in a portion of the colon.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 1024       OBJ:    8

TOP:    Gastrointestinal disorders                  KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse caring for a 6-year-old child with acute glomerulonephritis anticipates that the most difficult part of the care will be implementing:
a. forced fluids.
b. increased feedings.
c. bed rest.
d. frequent position changes.

 

ANS:   C

During the acute phase of glomerulonephritis, bed rest is usually recommended. A diet of restricted fluid, sodium, potassium, and phosphate is initially required.

 

DIF:    Cognitive Level: Application             REF:    Page 1028       OBJ:    10

TOP:    Genitourinary disorders                     KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. When selecting nursing diagnoses for the 4-year-old child with nephrosis, the nurse places priority on risk for:
a. impaired body image.
b. skin impairment.
c. nutritional deficit.
d. injury.

 

ANS:   B

Nephrosis is a clinical state characterized by gross edema, which makes skin care a priority.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 1027       OBJ:    10

TOP:    Genitourinary disorders                     KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. When caring for a 7-week-old infant with hypothyroidism, the nurse explains that the administration of oral thyroid replacement therapy is critical for this child to prevent:
a. excessive growth.
b. cognitive impairment.
c. damage to the nervous system.
d. damage to the urinary system.

 

ANS:   B

The treatment of choice for congenital and acquired hypothyroidism is oral thyroid hormone replacement therapy. Prompt treatment is especially critical in the infant with congenital hypothyroidism to avoid permanent cognitive impairment.

 

DIF:    Cognitive Level: Application             REF:    Page 1030       OBJ:    11

TOP:    Hypothyroidism                                 KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse explains to the parents of a child with developmental hip dysplasia that the application of a Pavlik harness will hold the child’s femurs in:
a. abduction.
b. adduction.
c. flexion.
d. extension.

 

ANS:   A

The use of the Pavlik harness maintains abduction for 4 to 6 months.

 

DIF:    Cognitive Level: Application             REF:    Page 1035       OBJ:    12

TOP:    Pavlik              KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. A teenage girl has been placed in a body cast for the treatment of scoliosis, the most common skeletal deformity of adolescence. When the family asks what they can do to be more supportive, the nurse suggests:
a. enrolling her in a health club.
b. taking her to the mall in a wheelchair.
c. purchasing clothes to disguise the cast.
d. spending a majority of their time with her.

 

ANS:   C

The adolescent is trying to fit in with peers and has concerns about body image.

 

DIF:    Cognitive Level: Analysis                  REF:    Pages 1036-1038

OBJ:    12                    TOP:    Scoliosis          KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity

 

  1. A newborn has talipes and has been casted. The nurse explains that the casts must be changed:
a. daily.
b. weekly.
c. bi-weekly.
d. monthly.

 

ANS:   B

Treatment of talipes consists of manipulation and the application of a series of short leg casts. The foot is gently manipulated into a more normal position and then casted to maintain the correction. Casts are changed weekly to allow for further manipulation and to accommodate the rapidly growing infant.

 

DIF:    Cognitive Level: Application             REF:    Pages 1038-1039

OBJ:    12                    TOP:    Club foot        KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. A child with Duchenne’s muscular dystrophy rises from the floor by walking up the thighs with the hands. The nurse records this observation as:
a. hand-assistance.
b. leg crawling.
c. Gowers’ sign.
d. Bright’s sign.

 

ANS:   C

Using the hands to walk up the thighs is known as Gowers’ sign.

 

DIF:    Cognitive Level: Comprehension       REF:    Page 1039       OBJ:    12

TOP:    Duchenne’s muscular dystrophy (DMD)

KEY:   Nursing Process Step: Assessment     MSC:   NCLEX: Physiological Integrity

 

  1. When assessing a child for classical signs of meningeal irritation, the nurse records:
a. positive Kernig’s sign, diarrhea, and headache.
b. negative Brudzinski’s sign, positive Kernig’s sign, and irritability.
c. positive Brudzinski’s and Kernig’s signs and photophobia.
d. negative Kernig’s sign, vomiting, and fever.

 

ANS:   C

Manifestations of meningitis include photophobia and positive Kernig’s and Brudzinski’s signs.

 

DIF:    Cognitive Level: Application             REF:    Page 1041       OBJ:    13

TOP:    Meningitis       KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. The physician is treating a child with meningitis with a course of antibiotic therapy. The nurse assures the parents that the child will be out of isolation when:
a. the course of antibiotics is complete.
b. a negative CNS culture is obtained.
c. the antibiotics have been initiated for 24 hours.
d. the child has no symptoms of the disease.

 

ANS:   C

The child with bacterial meningitis is isolated until antibiotic therapy has been administered for at least 24 hours.

 

DIF:    Cognitive Level: Application             REF:    Page 1041       OBJ:    13

TOP:    Meningitis       KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse caring for a 4-year-old child with cerebral palsy recognizes that the priority nursing interventions are designed to:
a. assist with referral to specialized education.
b. support the child with independent toileting.
c. assist the child to develop effective communication.
d. encourage the child to ambulate independently.

 

ANS:   D

A clinical manifestation of cerebral palsy is usually the need of support with communication, locomotion, and self-help.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 1045       OBJ:    13

TOP:    Cerebral palsy                                     KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse is caring for a newborn with a myelomeningocele. Before surgery, the nursing interventions should include:
a. leaving the lesion uncovered and placing the infant supine.
b. covering the lesion with a sterile, saline-soaked gauze.
c. applying lotion to the lesion to keep it moist.
d. covering the lesion with a dry, sterile gauze.

 

ANS:   B

Nursing interventions for an infant with myelomeningocele include covering the lesion with a sterile, saline-soaked gauze.

 

DIF:    Cognitive Level: Application             REF:    Page 1047, Box 31-10

OBJ:    13                    TOP:    Spina bifida    KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. Which additional congenital malformation is expected in 80% of infants with a myelomeningocele?
a. Cerebral palsy
b. Hydrocephalus
c. Meningitis
d. Neuroblastoma

 

ANS:   B

Hydrocephalus is present in 80% of infants affected by a myelomeningocele.

 

DIF:    Cognitive Level: Application             REF:    Page 1047       OBJ:    13

TOP:    Spina bifida    KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. When speaking to young parents, the nurse states that lead poisoning is one of the most common preventable health problems affecting children. When lead levels exceed the amount that can be absorbed by the bones, it leads to:
a. malnutrition.
b. anemia.
c. bone pain.
d. diarrhea.

 

ANS:   B

When the amount of lead ingested exceeds the amount that can be absorbed by the bone, it leads to anemia.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 1049       OBJ:    14

TOP:    Lead poisoning                                   KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. An infant has been diagnosed with cradle cap. The nurse recognizes that the intervention to treat the scaly patches on the scalp is to apply:
a. alcohol.
b. mineral oil.
c. calamine.
d. A&D ointment.

 

ANS:   B

Crusty patches can be removed with the application of mineral oil.

 

DIF:    Cognitive Level: Application             REF:    Page 1053       OBJ:    15

TOP:    Skin disorders                                    KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. An adolescent female asks the nurse about taking retinoic acid (Accutane). The nurse instructs that the medication:
a. should be used only for 10 weeks.
b. requires that sexually active females use contraception.
c. lowers hemoglobin very quickly.
d. has few side effects.

 

ANS:   B

Accutane has many side effects and can produce birth defects. Effective contraception is necessary during treatment and 1 month after the 20 weeks it is to be taken.

 

DIF:    Cognitive Level: Application             REF:    Page 1055       OBJ:    15

TOP:    Acne               KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. A new mother asks the clinic nurse if she must continue giving her baby nystatin for thrush since the white lesions on his tongue have disappeared. The nurse replies:
a. “No. When the lesions have gone you may stop the nystatin.”
b. “Yes. You should continue it for the full 7 days.”
c. “No. Thrush is a self-limiting disorder and nystatin is given for comfort only.”
d. “Yes. The medication should be refilled for a second week of therapy.”

 

ANS:   B

Nystatin should be given for the full 7 days even if the lesions are no longer present.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 1057       OBJ:    15

TOP:    Skin disorders                                    KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The mother brings the child to the nurse because of exposure to varicella. The nurse explains that early signs of the disease are:
a. high fever over 101° F.
b. general malaise.
c. increased appetite.
d. crusty sores.

 

ANS:   B

Early signs of varicella will develop during the prodromal period and are mainly low-grade fever, malaise, and anorexia. Lesions do not appear until later.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 1059, Table 31-7

OBJ:    15                    TOP:    Skin disorders

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The mother of a child who has been diagnosed with varicella asks the nurse when the child can return to school. The nurse states that the child is no longer contagious:
a. when the fever dissipates.
b. after the incubation period.
c. when the lesions have healed.
d. when the lesions are crusted over.

 

ANS:   D

Varicella is no longer contagious when the lesions are dry.

 

DIF:    Cognitive Level: Application             REF:    Page 1059, Table 31-7

OBJ:    15                    TOP:    Skin disorders

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. A child has developed a diaper rash, and the parents are using zinc oxide to treat it. The nurse is instructing the parents about removal of the ointment and suggests using:
a. mild soap and water.
b. a cotton ball.
c. mineral oil.
d. alcohol swabs.

 

ANS:   C

To completely remove ointment, especially zinc oxide, mineral oil should be used.

 

DIF:    Cognitive Level: Application             REF:    Page 1052, Box 31-12

OBJ:    15                    TOP:    Diaper rash     KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse instructs the parents of a child who has had a myringotomy to position the child:
a. supine.
b. on the affected side.
c. on the unaffected side.
d. in a Trendelenburg position.

 

ANS:   B

Lying on the affected side facilitates drainage following a myringotomy.

 

DIF:    Cognitive Level: Application             REF:    Page 1062       OBJ:    16

TOP:    Myringotomy                                     KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse instructs parents about the signs of otitis media, which include:
a. earache, wheezing, vomiting.
b. coughing, rhinorrhea, headache.
c. fever, irritability, pulling on ear.
d. wheezing, cough, drainage in ear canal.

 

ANS:   C

Clinical manifestations of otitis media include fever, irritability, and pulling on the ear.

 

DIF:    Cognitive Level: Application             REF:    Page 1058       OBJ:    16

TOP:    Otitis media    KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse instructs the mother of a child with a ventricular septal defect that she can expect the child to become cyanotic when the child does what?
a. Experiences an elevation in temperature
b. Sleeps on the left side
c. Cries vigorously
d. Is held upright
e. Eats

 

ANS:   C

Crying vigorously will increase the pressure in the right ventricle, which will allow unoxygenated blood to enter the circulating volume.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 990         OBJ:    1

TOP:    Septal defects                                     KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. When assessing the laboratory values of a child with nephrosis, the nurse anticipates which result(s)? (Select all that apply.)
a. High levels of protein in the urine
b. High serum lipid levels
c. Low serum protein levels
d. Low hemoglobin
e. High white blood cell count

 

ANS:   A, B, C

A patient with nephrotic syndrome presents with high levels of serum lipids, low serum protein, and albumin in urine that is dark and frothy with a high specific gravity. The hemoglobin and WBC are usually normal.

 

DIF:    Cognitive Level: Application             REF:    Pages 1026-1027

OBJ:    10                    TOP:    Nephrosis        KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity

 

  1. When the mother of a child with gastroesophageal reflux calls the clinic nurse to report that her baby is vomiting small amounts of blood, the nurse explains that the esophagus has been irritated by _______ ________.

 

ANS:

gastric acid

Gastric acid that has repeatedly come in contact with the esophageal mucosa will erode the mucosa, and bleeding will result.

DIF:    Cognitive Level: Application             REF:    Page 1021       OBJ:    8

TOP:    Gastroesophageal reflux (GER)         KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse reassures the anxious mother of a child with pyloric stenosis who is to have surgery that the surgical procedure, called a __________, is quickly done and the child recovers almost immediately.

 

ANS:

pyloromyotomy

When the muscle is cut, the obstruction is immediately relieved and the child who is hungry will begin to eat and keep food down.

 

DIF:    Cognitive Level: Comprehension       REF:    Pages 1022-1023

OBJ:    8                      TOP:    Pyloromyotomy

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity

 

  1. The nurse anticipates that the cerebrospinal fluid (CSF) taken from a child with bacterial meningitis would have a low __________ level.

 

ANS:

glucose

The glucose level in the CSF of a child with bacterial meningitis is low because the bacteria in the fluid have digested the glucose.

 

DIF:    Cognitive Level: Analysis                  REF:    Page 1041       OBJ:    13

TOP:    Cerebrospinal fluid (CSF)                  KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity