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Foundations of Nursing- 7th Edition By Kim Cooper – Kelly Gosnell – Test Bank 

 

Chapter 3: Documentation

Cooper and Gosnell: Foundations of Nursing, 7th Edition

 

MULTIPLE CHOICE

 

  1. What does documentation of type of care, time of care, and signature of the person prove?
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

Documenting type of care, time of care, and signature of the person 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: Comprehension   REF:   Page               OBJ:   1

TOP:   Documentation                               KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: N/A

 

  1. Why is documentation especially significant in managed care?
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

Cost reimbursement rates by government plans (Medicare, Medicaid) are based on the prospective payment system of diagnosis-related groups (DRGs); a system that classifies patients by age, diagnosis, surgical procedure, and other information with hundreds of different categories to predict the use of hospital resources, including length of stay, resulting in a fixed payment amount.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   1

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

MSC:  NCLEX: N/A

 

  1. The nurse charts only additional treatments done, changes in patient condition, and new concerns. What is this system of documentation?
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: Comprehension   REF:   Page 145        OBJ:   1| 5| 7

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

MSC:  NCLEX: N/A

 

  1. What form explains the lapse when events are not consistent with facility or national standards of expected care?
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: Knowledge          REF:   Page               OBJ:   1| 7

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

MSC:  NCLEX: N/A

 

  1. The staff from all disciplines is developing integrated care plans for a projected length of stay for patients of a specific case type. This 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: Knowledge          REF:   Pages              OBJ:   8

TOP:   Documentation                               KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: N/A

 

  1. What makes home health care documentation unique?
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: Comprehension   REF:   Page               OBJ:   9

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

MSC:  NCLEX: N/A

 

  1. What regulates standards for long-term care documentation?
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: Knowledge          REF:   Page 152        OBJ:   10

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

MSC:  NCLEX: N/A

 

  1. What is the nurse required to do to adhere to the concept of confidentiality for the patient’s medical record?
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: Comprehension   REF:   Page 152        OBJ:   4

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

MSC:  NCLEX: N/A

 

  1. Documentation is necessary for the evaluation of patient care. Of which phase of the nursing process is this an integral part?
a. Assessment
b. Planning
c. Implementation
d. Evaluation

 

 

ANS:  C

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

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   1| 4

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

MSC:  NCLEX: N/A

 

  1. What does the nurse use as a basis for documentation in focus charting?
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: Knowledge          REF:   Page 144        OBJ:   7

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

MSC:  NCLEX: N/A

 

  1. What is the purpose of QA (quality assurance)?
a. To screen employment applications
b. To evaluate care results against accepted standards
c. To conduct in-services for “quality documentation”
d. To 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: Comprehension   REF:   Page               OBJ:   1

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

MSC:  NCLEX: N/A

 

  1. What is the process used to appraise the practice of an individual nurse known as?
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: Knowledge          REF:   Page 139        OBJ:   4

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

 

  1. What is the documentation format that uses the acronym SOAPE?
a. Problem-oriented
b. Focused
c. Traditional
d. Crisis

 

 

ANS:  A

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

 

DIF:    Cognitive Level: Comprehension   REF:   Pages              OBJ:   7

TOP:   Problem-oriented medical record (POMR)                                 KEY:   Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Who is the legal owner of the patient’s medical record?
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 physician in the case of private office visits.

 

DIF:    Cognitive Level: Knowledge          REF:   Page               OBJ:   4

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: Comprehension   REF:   Page               OBJ:   2

TOP:   Computer documentation               KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. What is the system that classifies patients by age, diagnosis, and surgical procedure and produces 300 different categories used for predicting the use of hospital resources?
a. Quality assurance
b. Resource assessment
c. Quality improvement
d. Diagnosis-related groups

 

 

ANS:  D

Cost reimbursement rates under 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: Knowledge          REF:   Page               OBJ:   5

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

MSC:  NCLEX: N/A

 

  1. A nurse is using the data, action, response, education (DARE) system of charting, and is completing the data portion. What data are the nurse’s focus?
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: Comprehension   REF:   Page               OBJ:   7

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

 

  1. A new patient is being admitted to a long-term care facility. 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: Comprehension   REF:   Page               OBJ:   4| 10

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

MSC:  NCLEX: N/A

 

  1. What will the nurse implement when an error is made when documenting in a patient’s chart?
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               OBJ:   6

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

MSC:  NCLEX: N/A

 

  1. What should the nurse be sure to do when documenting in a patient’s chart?
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: Application          REF:   Page               OBJ:   6

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

MSC:  NCLEX: N/A

 

MULTIPLE RESPONSE

 

  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               OBJ:   4

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. Chronologic 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              OBJ:   4| 6

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: Comprehension   REF:   Pages              OBJ:   1

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: Comprehension   REF:   Page               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: Comprehension   REF:   Pages              OBJ:   1

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

MSC:  NCLEX: N/A

 

COMPLETION

 

  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               OBJ:   4

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               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               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, quality assessment, quality 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: Knowledge          REF:   Page               OBJ:   1

TOP:   Quality assurance/assessment/improvement                              KEY:   Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

OTHER

 

  1. A nurse is receiving a telephone order from a physician. The nurse uses a safety measure of preventing errors that is recognized by The Joint Commission as one method of meeting National Patient Safety Goals. What is the correct order of this method?

 

  1. Read back
  2. Background
  3. Recommendation
  4. Situation
  5. Assessment

 

ANS:

D, B, E, C, A

 

SBAR (Situation, Background, Assessment, and Recommendation) is a method of communication among health care workers and a part of documentation (Kaiser Permanente, 2007). SBAR is considered a safety measure in preventing errors from poor communication during “hand-off” or “handover” interactions, the communication that occurs from one shift to the next or when a nurse phones a health care provider with information about a patient. An additional “R” is added. The additional “R” (SBARR) represents “read back” when the nurse reads back the order for clarification.

 

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

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

Chapter 17: Complementary and Alternative Therapies

Cooper and Gosnell: Foundations of Nursing, 7th Edition

http://science-forums.com/index.php?board=217.0

MULTIPLE CHOICE

 

  1. The nurse is caring for a patient recovering from a hip replacement and is providing education regarding exercises in physical therapy. What type of therapy should the nurse call these exercises?
a. Alternative therapies
b. Complementary therapies
c. Comfort therapies
d. Body therapies

 

 

ANS:  B

Complementary therapies are used in addition to conventional therapies.

 

DIF:    Cognitive Level: Knowledge          REF:   Page               OBJ:   1

TOP:   Complementary therapies               KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. An older adult patient tells the home health nurse, “My doctor hasn’t helped my arthritis at all. I am using the chiropractor now.” What change has the patient made?
a. Western medicine to complementary therapy
b. Complementary therapy to alternative therapy
c. Alternative therapy to allopathic medicine
d. Allopathic medicine to alternative therapy

 

 

ANS:  D

Alternative therapies may become the primary treatment modality; for instance, the patient switching from traditional (allopathic) medicine to chiropractic (alternative).

 

DIF:    Cognitive Level: Comprehension   REF:   Page 416        OBJ:   1

TOP:   Therapies       KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What is the responsibility of the National Center for Complementary and Alternative Medicine (NCCAM)?
a. To certify alternative medical practitioners
b. To evaluate effectiveness of alternative medical treatments
c. To set standards for the practice of alternative medicine
d. To train alternative medical practitioners

 

 

ANS:  B

The National Center for Complementary and Alternative Medicine was established to facilitate the evaluation of alternative medical treatment.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 418        OBJ:   1

TOP:   National Center for CAM               KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. What is the importance of the nurse asking about the patient’s use of alternative therapies when obtaining a health history?
a. Alternative therapies can be covered by insurance.
b. Alternative therapies have unfortunate interactions with traditional therapies.
c. Alternative therapies can be substituted for allopathic medicine.
d. Alternative therapies have curative and healing power.

 

 

ANS:  B

Some alternative therapies may have serious side effects. As a rule, complementary and alternative (CAM) therapies are not curative or healing as is allopathic medicine. Some complementary therapies are covered by insurance, but alternative remedies are not.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 421, Patient Teaching

OBJ:   3                    TOP:   Complementary and alternative (CAM) therapies

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

 

  1. The nurse is obtaining health history information on a new patient at a physician’s office and he or she records a barbiturate medication on the current list. What herb should the nurse ask if the patient is taking?
a. St. John’s wort
b. Aloe vera
c. Valerian
d. Ginkgo

 

 

ANS:  C

Valerian enhances the effect of barbiturates.

 

DIF:    Cognitive Level: Application          REF:   Page 420, Table 17-1

OBJ:   3| 5                 TOP:   Valerian         KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What should the nurse instruct a patient who takes tincture of rosemary to do several times a day?
a. Assess pulse frequently
b. Avoid constipation
c. Watch for hypoglycemia
d. Wear sunscreen

 

 

ANS:  D

Rosemary can cause photosensitivity.

 

DIF:    Cognitive Level: Application          REF:   Page 422, Table 17-2

OBJ:   2| 5                 TOP:   Rosemary      KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. What is true regarding manufacturers of herbal remedy products?
a. They do extensive field testing on the products.
b. They must show dosage equivalents.
c. They must adhere to standards of strength.
d. They do not have to demonstrate their safety.

 

 

ANS:  D

Herbal remedy manufacturers are not required by law to demonstrate the safety of their products.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 418        OBJ:   4

TOP:   Herbal remedies                             KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. Herbs have not been approved for use as drugs. How are herbs allowed to be sold?
a. For pain relief
b. To improve body strength
c. To prolong life
d. As diet supplements

 

 

ANS:  D

Herbs are sold as food supplements.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 418        OBJ:   4

TOP:   Herbal remedies                             KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. What is the goal of herbal therapy?
a. Treat symptoms
b. Restore balance
c. Treat disease
d. Improve nutrition

 

 

ANS:  B

The goal of herbal therapy is to restore balance.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 418        OBJ:   4

TOP:   Herbal therapy                                          KEY:              Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Confusion and misinformation relative to herbal medicine can make patients reluctant to disclose their herbal use to health care providers. What should be the nurse’s approach?
a. Instructive
b. Nonjudgmental
c. Inquisitive
d. Determined

 

 

ANS:  B

A nonjudgmental open attitude will encourage the patient to share information about the use of CAM (complementary and alternative medicine).

 

DIF:    Cognitive Level: Application          REF:   Pages 417-418

OBJ:   2                    TOP:   Health interview

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. What will placing an herb in alcohol or vinegar make?
a. A suspension
b. An emulsion
c. An infusion
d. A tincture

 

 

ANS:  D

Tinctures are made by placing the herb in alcohol or vinegar.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 421        OBJ:   5

TOP:   Making herbal remedies                 KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. During a follow-up visit with a patient recently started on Coumadin, the home health nurse is concerned after seeing an herbal remedy that enhances the effect of anticoagulants by the patient’s bedside. What is this herbal remedy?
a. Cayenne
b. Aloe vera
c. Asian ginseng
d. Kava

 

 

ANS:  C

Asian ginseng may enhance the effect of Coumadin.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 419, Table 17-1

OBJ:   5                    TOP:   Ginseng         KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. Acupuncture is a complementary therapy that uses fine needles placed in acupoints. What is the believed purpose of these acupoints?
a. “Close the gate” for pain transmission
b. Align the internal organs
c. Open meridians to release qi
d. Stimulate the “centering” of qi

 

 

ANS:  C

Acupuncture therapy uses needles placed in acupoints to open meridians to release qi (life force).

 

DIF:    Cognitive Level: Comprehension   REF:   Page 423        OBJ:   7

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

 

  1. The nurse is educating a patient with phlebitis of the left leg. What alternative therapy should this patient avoid until the condition is resolved?
a. Acupuncture
b. Therapeutic massage
c. Yoga
d. Acupressure

 

 

ANS:  B

Therapeutic massage is contraindicated in conditions such as thrombosis, phlebitis, and infective skin diseases.

 

DIF:    Cognitive Level: Application          REF:   Page 424        OBJ:   9

TOP:   Therapeutic massage                                 KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. What type of alternative therapy is the nurse practicing when using essential oils to provide inhalation treatments?
a. Magnet therapy
b. Respiratory therapy
c. Herbal therapy
d. Aromatherapy

 

 

ANS:  D

Aromatherapy uses pure essential oils to provide health benefits.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 424        OBJ:   10

TOP:   Aromatherapy                                           KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is educating a patient regarding reflexology. Information includes that reflexology is a therapy based on the theory that the entire body can be reached by applying pressure to specific areas. Where is pressure mainly applied?
a. Hands
b. Head
c. Back
d. Feet

 

 

ANS:  D

In reflexology it is thought that the entire body can be reached by applying pressure to specific areas on the feet.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 424        OBJ:   2| 11

TOP:   Reflexology   KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychological Integrity

 

  1. What type of therapy is thought to increase circulation to the affected area, promote healing, and stimulate acupuncture points?
a. Relaxation therapy
b. Magnetic therapy
c. Yoga therapy
d. Imagery therapy

 

 

ANS:  B

Magnets are thought to increase circulation to affected areas, promote healing, and stimulate acupuncture points.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 426        OBJ:   12

TOP:   Magnetic therapy                            KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Which term describes using the conscious mind to create situations that evoke physical changes in the body?
a. Imagination
b. Self-hypnosis
c. Imagery
d. Visualization

 

 

ANS:  C

Imagery uses the conscious mind to create images that evoke physical changes in the body.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 426        OBJ:   1

TOP:   Imagery          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse describes a therapy that can produce a state of decreased cognitive, physiological, and/or behavioral arousal. To what alternative therapy is the nurse referring?
a. Subconscious
b. Imagery
c. Sleep
d. Relaxation

 

 

ANS:  D

Relaxation is the state of general decreased cognitive, physiological, and/or behavior arousal.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 426        OBJ:   1| 2

TOP:   Relaxation      KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. What is a therapeutic treatment that joins the mind and body and increases muscle tone and flexibility?
a. Acupressure
b. Spiritual enrichment
c. Yoga therapy
d. Therapeutic massage

 

 

ANS:  C

Yoga therapy is the joining of the mind, body, and spirit to enrich the quality of one’s life. Yoga also increases muscle tone and flexibility.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 428        OBJ:   14

TOP:   Yoga              KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. What training system may help prevent osteoporosis?
a. Acupressure
b. Yoga
c. Therapeutic massage
d. Tai chi

 

 

ANS:  D

Tai chi, although a martial arts skill, increases balance and timing and may prevent osteoporosis.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 429        OBJ:   15

TOP:   Tai chi            KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. A patient wants to use aromatherapy to treat pneumonia, but the hospital policy will not allow burning of eucalyptus-scented candles. What should the nurse suggest the patient use instead?
a. Another essential oil
b. Prescribed medications
c. A topical eucalyptus product
d. Massage therapy

 

 

ANS:  C

Eucalyptus oils can be used for inhalation or may be applied topically.

 

DIF:    Cognitive Level: Application          REF:   Page 424        OBJ:   10

TOP:   Aromatherapy                                           KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. A patient admitted with lower back pain is not sure that the prescribed treatment is helping and asks what alternative therapies might help. What should the nurse suggest?
a. Herbal therapy
b. Chiropractic therapy
c. Acupressure
d. Reflexology

 

 

ANS:  B

Chiropractic therapy is currently viewed as an acceptable treatment for certain disorders, including back pain.

 

DIF:    Cognitive Level: Application          REF:   Page 423        OBJ:   6

TOP:   Chiropractic   KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

MULTIPLE RESPONSE

 

  1. Herbal remedies vary from pharmaceutical remedies in what way(s)? (Select all that apply.)
a. Herbal remedies use the whole plant.
b. Herbal remedies have no quality control.
c. Herbal remedies have no standard dose.
d. Herbal remedies are sold as food supplements.
e. Herbal remedies are always safe and effective.

 

 

ANS:  A, B, C, D

Herbal remedies are not always safe and effective.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 418        OBJ:   1

TOP:   Herbal remedies                             KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Founded in 1992, the National Center for Complementary and Alternative Medicine (NCCAM) has the responsibility for what actions? (Select all that apply.)
a. Evaluating alternative treatments
b. Distributing information to the public
c. Coordinating and conducting research
d. Removing defective products from the market
e. Regulating third-party reimbursement

 

 

ANS:  A, B, C

The National Center for Complementary and Alternative Medicine has the responsibility to evaluate treatments, distribute information, and conduct research. It has no power to remove defective products from the market or deal with insurance payments.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 418        OBJ:   1

TOP:   National Center for CAM               KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. The nurse recommends that a patient have animal-assisted therapy sessions (AAT) because this therapy has been found to have what effect(s)? (Select all that apply.)
a. Improvement in mood
b. Decrease in blood pressure
c. Decrease in blood sugar
d. Reduction of allergies
e. Increase in socialization skills

 

 

ANS:  A, B, E

Animal-assisted therapy (AAT) has been found to improve mood, decrease blood pressure, and increase socialization skills. AAT has not been found to decrease blood sugar or reduce allergies.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages 427-428

OBJ:   13                  TOP:   Animal-assisted therapy (AAT)

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. Why do people often choose complementary and alternative medicine (CAM)? (Select all that apply.)
a. CAM is less invasive.
b. CAM is more holistic.
c. CAM is focused on treatment of disease.
d. CAM is dedicated to health maintenance.
e. CAM is within the control of the patient.

 

 

ANS:  A, B, D, E

CAM is less invasive, more holistic, dedicated to health maintenance, and within control of the patient. CAM is focused on prevention, not treatment.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 417        OBJ:   1

TOP:   CAM              KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

COMPLETION

 

  1. The nurse reassures a patient that almost _____% of all health care consumers in the United States take some form of herbal or natural supplement alone or in combination with conventional medicines but rarely report this practice to their health care providers.

 

ANS:

50

fifty

 

It is estimated that almost half of all health care consumers in the United States take some form of herbal or natural product supplement alone or in combination with conventional medicines but rarely report this practice to their health care providers.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 417        OBJ:   3

TOP:   Herbal supplements                        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. People with fractures, rheumatoid arthritis, and osteoporosis are not candidates for ____________ therapy.

 

ANS:

chiropractic

 

Contraindications for chiropractic therapy include acute myelopathy, fractures, dislocations, rheumatoid arthritis, and osteoporosis.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 423        OBJ:   6

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

 

  1. ___________________is a noninvasive method an individual can employ to learn control of the body to manage certain conditions. Monitoring equipment is used to measure vital signs and muscle tension. The messages are sent back to the individual.

 

ANS:

Biofeedback

 

Biofeedback is a noninvasive method an individual can employ to learn control of the body to manage certain conditions. It may be considered when other therapies have not been successful or in conjunction with other treatments. Health concerns such as anxiety, stress, irritable bowel syndrome, and asthma may be managed using biofeedback.

 

DIF:    Cognitive Level: Knowledge          REF:   Page               OBJ:   16

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

Chapter 31: Care of the Child with a Physical and Mental or Cognitive Disorder

Cooper and Gosnell: Foundations of Nursing, 7th Edition

 

MULTIPLE CHOICE

 

  1. The nurse uses a diagram to show that the tetralogy of Fallot involves a combination of four congenital defects. What are the 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: Knowledge          REF:   Page 990        OBJ:   1

TOP:   Heart defect   KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. What is the most common clinical manifestation of coarctation of the aorta?
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. The pressure in the arms is typically 20 mm Hg higher than in the legs.

 

DIF:    Cognitive Level: Knowledge          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. What would be the best response by the nurse?
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. What should the therapeutic management of iron deficiency anemia include?
a. Multivitamins
b. Calcium
c. Ferrous sulfate
d. Iodine

 

 

ANS:  C

Therapeutic management of iron deficiency anemia is iron (ferrous sulfate) supplementation, nutritional counseling, and treatment of any underlying condition.

 

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. What is the most likely cause of the pain?
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 severe tissue hypoxia and necrosis leading to 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 recently diagnosed with sickle cell anemia ask what can be done to avoid a sickle cell crisis. What should be included in the medical management of sickle cell crisis?
a. Information for the parents including home care
b. Provisions for 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. Which laboratory results should the nurse anticipate to be abnormal in a child with hemophilia?
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. The prothrombin time, bleeding time, and platelet count are typically normal.

 

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. What would be the most effective therapy?
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 treatment 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. What most influences the severity of respiratory distress syndrome (RDS)?
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 it occurs almost exclusively in preterm, low-birth-weight infants.

 

DIF:    Cognitive Level: Comprehension   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. What would be the correct action by the nurse?
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. The child should not be taken out of the oxygenated tent. While the mother could be asked to help comfort the child, and the physician may be notified, the priority is to set the oxygen at the correct level.

 

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. Which responses would be the most correct?
a. The epinephrine given causes nausea and vomiting
b. The child is being hydrated with IV fluids
c. The child is not hungry
d. The child’s rapid respirations pose a risk for aspiration

 

 

ANS:  D

Rapid respirations predispose to aspiration. The child is kept hydrated with IV fluids, but this is not the reason that the child must be kept NPO.

 

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

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

MSC:  NCLEX: Physiological Integrity

 

  1. What could suddenly occur in a child with acute epiglottitis?
a. Increased carbon dioxide levels
b. Airway obstruction
c. Inability to swallow
d. Bronchial collapse

 

 

ANS:  B

In acute epiglottitis, the infected epiglottis becomes inflamed and causes total airway obstruction. Immediate treatment of acute epiglottitis includes an artificial airway.

 

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

TOP:   Epiglottitis      KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. When conducting a class for parents about sudden infant death syndrome (SIDS), the nurse instructs the class that the infant should be placed in which position to sleep?
a. Right side-lying
b. Left side-lying
c. Prone
d. Supine

 

 

ANS:  D

The American Academy of Pediatrics recommends placing the infant on its back, or supine, to sleep.

 

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,  the nurse should attempt to assist the parents with:
a. encouraging the parents to have another baby.
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 treatment will be centered on what therapy?
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. What is the main characteristic of cystic fibrosis?
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: Comprehension   REF:   Page 1011      OBJ:   7

TOP:   Cystic fibrosis                                           KEY:              Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What is the best time to administer 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 to digest carbohydrates, fats, and proteins.

 

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, what should be used to prevent injury to the suture line?
a. Straw
b. Spoon
c. Syringe
d. Cup

 

 

ANS:  D

When feeding a child with a repaired cleft palate, the nurse should avoid utensils, straws, droppers, and syringes.

 

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. What is the priority nursing diagnosis for the parents of a newborn born with cleft lip and palate?
a. Parental role conflict
b. Risk for delayed growth and development
c. Risk for impaired attachment
d. Anticipatory grieving

 

 

ANS:  C

Parents of a child with cleft lip and palate may have difficulty bonding with their child due to the appearance of the child. The priority nursing diagnosis is risk for impaired attachment. 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. Which is a long-term complication of cleft lip and palate?
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 psychological difficulties because of the cosmetic appearance of the defect, problems with impaired speech, and faulty dentition.

 

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

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

MSC:  NCLEX: Physiological Integrity

 

  1. How should the nurse measure urinary output for an infant with dehydration?
a. Attaching a urine collecting bag
b. Wringing out the diaper
c. Weighing the diaper
d. Inserting a catheter

 

 

ANS:  C

Wet diapers are 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. Following a bout of diarrhea, which foods should be offered to the school-age child?
a. Apricots and peaches
b. Chocolate milk
c. Applesauce and milk
d. Bananas and rice

 

 

ANS:  D

When rehydration has been completed, foods that are nonirritating to the bowel should be offered to the child. Bananas and rice would be the least irritating to the bowel, as fruits and milk could cause GI irritation.

 

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

TOP:   Nutrition        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. How is the infant with gastroesophageal reflux (GER) typically treated?
a. By making the infant NPO
b. By thickening the formula or breast milk with cereal
c. By placing the infant to sleep on the side
d. By switching the infant to cow’s milk

 

 

ANS:  B

GER is treated with small feedings thickened with cereal. The infant should not be made NPO or switched to cow’s milk. Infants should only be placed on the back to sleep due to the risk of SIDS.

 

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

TOP:   Nutrition        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. What should the nurse assess in an infant who has been diagnosed with hypertrophic pyloric stenosis?
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 right of 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. What is the hallmark sign of intussusception?
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: Knowledge          REF:   Page 1023      OBJ:   8

TOP:   Gastrointestinal disorders               KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. Which is a causative factor of Hirschsprung disease?
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 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. What should the nurse caring for a 6-year-old child with acute glomerulonephritis anticipate as the most difficult part of the care to implement?
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. Bed rest can be very hard to implement with an active 6-year-old child.

 

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, what should be a priority for the nurse?
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 prevention of what complication is dependent on the administration of oral thyroid replacement therapy and is critical for the child?
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 is necessary. In what position will the harness hold the child’s femurs?
a. Abduction
b. Adduction
c. Flexion
d. Extension

 

 

ANS:  A

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

 

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

TOP:   Pavlik harness                                           KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. A teenage girl has been placed in a brace for the treatment of scoliosis, the most common skeletal deformity of adolescence. The family asks what they can do to be more supportive. What suggestion of the nurse is the most appropriate?
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 is wearing casts. How often should the casts 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 placed in a cast 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 muscular dystrophy rises from the floor by walking up the thighs with the hands. How should the nurse record this observation?
a. Hand assistance
b. Leg crawling
c. Gowers sign
d. Bright sign

 

 

ANS:  C

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

 

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

TOP:   Duchenne muscular dystrophy (DMD)

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

 

  1. Which signs/symptoms would be considered classical signs of meningeal irritation?
a. Positive Kernig sign, diarrhea, and headache
b. Negative Brudzinski sign, positive Kernig sign, and irritability
c. Positive Brudzinski sign, positive Kernig sign, and photophobia
d. Negative Kernig sign, vomiting, and fever

 

 

ANS:  C

Classical manifestations of meningitis include positive Kernig and Brudzinski signs.

 

DIF:    Cognitive Level: Comprehension   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. When should the nurse expect the child to be out of isolation?
a. When the course of antibiotics is complete
b. When a negative CNS culture is obtained
c. When the antibiotics have been initiated for 24 hours
d. When the child has no symptoms of the disease

 

 

ANS:  C

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

 

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

TOP:   Meningitis      KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. What are priority nursing interventions designed to do for a 4-year-old child with cerebral palsy?
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 child with cerebral palsy is usually in need of support with communication, locomotion, and self-help.

 

DIF:    Cognitive Level: Application          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, what should the nursing interventions 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: Comprehension   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. What condition occurs when the level of lead ingested exceeds the amount that can be absorbed by the bone?
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: Application          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. What is the correct intervention to treat the scalp?
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). What guidance should be provided by the nurse?
a. The medication should be used only for 10 weeks
b. The medication requires that sexually active females use contraception
c. The medication lowers hemoglobin very quickly
d. The medication has few side effects

 

 

ANS:  B

Accutane has many side effects and can produce birth defects. Effective contraception is necessary during treatment and for 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. What response by the nurse is most appropriate?
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. What are early signs of  varicella disease?
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: Comprehension   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. When is the child 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. What does the nurse suggest to aid in the removal of the zinc oxide?
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 place the child in which position?
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 ear 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. What are the clinical manifestations of otitis media?
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: Comprehension   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. 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. Parents of a 5-year-old child diagnosed as cognitively impaired have come to the nurse to discuss different approaches to the ongoing care of their child. The nurse should suggest focusing on what activity?
a. Acquiring job skills
b. Making decisions
c. Performing self-care activities
d. Reading and doing simple math

 

 

ANS:  C

The cognitively impaired young child should be encouraged to learn simple skills for doing self-care.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   19

TOP:   Cognitive impairment                                KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. The nurse explains that cognitive impairment is categorized by four levels that depend on the intelligence quotient (IQ). How is a child with an IQ of 45 classified?
a. Within the normal low range
b. Educable
c. Trainable
d. Severe

 

 

ANS:  C

The category of trainable is identified on the basis of an IQ of 35 to 55.

 

DIF:    Cognitive Level: Application          REF:   Page 1067      OBJ:   17

TOP:   Cognitive impairment                                KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. What is the major criterion for diagnosing a child as cognitively impaired?
a. An IQ of 75 or less
b. Subaverage functioning
c. An IQ of 70 or less
d. Onset before 18

 

 

ANS:  C

Cognitive impairment is based upon IQs from 20 to 70.

 

DIF:    Cognitive Level: Application          REF:   Page 1067      OBJ:   17

TOP:   Cognitive impairment                                KEY:              Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. Which is a priority nursing intervention for the cognitively impaired child?
a. The family will provide good nutrition.
b. The family will provide loving interactions.
c. Stimulation will improve.
d. There will be contact with peers.

 

 

ANS:  B

Nursing interventions focus on promoting optimal development and loving interactions with family.

 

DIF:    Cognitive Level: Application          REF:   Page 1068      OBJ:   19

TOP:   Cognitive impairment                                KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. Which statement correctly explains the etiology of Down syndrome?
a. There is an extra chromosome on the 21st pair.
b. There is a missing chromosome on the 21st pair.
c. There are two pairs of the 21st chromosome.
d. The chromosome’s 21st pair is missing.

 

 

ANS:  A

Down syndrome is attributed to an extra chromosome on the 21st pair.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 1069      OBJ:   18

TOP:   Cognitive impairment                                KEY:              Nursing Process Step: Evaluation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. What other congenital defects are common in children with Down syndrome?
a. Hypospadias
b. Pyloric stenosis
c. Heart defects
d. Hip dysplasia

 

 

ANS:  C

Many children with Down syndrome have congenital heart defects.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 1070      OBJ:   18

TOP:   Congenital impairment                   KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. What assessment findings should lead the nurse to suspect Down syndrome in a newborn?
a. Hypertonia and dark skin
b. Low-set ears and a simian crease
c. Inner epicanthal folds and a high, domed forehead
d. Long, thin fingers and excessive hair

 

 

ANS:  B

Manifestations of the Down syndrome infant include low-set ears, simian crease, protruding tongue, and hypotonic extremities.

 

DIF:    Cognitive Level: Analysis               REF:   Page 1069      OBJ:   18

TOP:   Congenital impairment                   KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. Parents of a school-age child ask the nurse for suggestions in helping the child who is demonstrating school avoidance. What is an appropriate suggestion by the nurse?
a. Take the child to the physician for testing.
b. Be firm and insist the child go to school.
c. Allow the child to stay home and rest.
d. Consult with the teacher at school.

 

 

ANS:  B

Parents should be firm and insist the child go to school.

 

DIF:    Cognitive Level: Application          REF:   Page 1074      OBJ:   20

TOP:   Nursing interventions                                KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. The nurse is caring for a child who has been diagnosed as having an attention deficit hyperactivity disorder (ADHD). What is the most important intervention for the nurse?
a. Have the child enrolled in a special education class.
b. Allay any feelings of guilt the parents may have.
c. Counsel the parents that the medications are lifelong.
d. Teach the parents to set limits.

 

 

ANS:  B

It is most important to allay any feelings of guilt the parents may have.

 

DIF:    Cognitive Level: Application          REF:   Page 1076      OBJ:   21

TOP:   Attention deficit hyperactivity disorder (ADHD)

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. Since children with attention deficit hyperactivity disorder (ADHD) take medication for long periods of time, side effects must be considered. How often should children be assessed for side effects of the drug therapy?
a. Every 2 months
b. Every 4 months
c. Every 6 months
d. Every 8 months

 

 

ANS:  C

Children should be checked for medication side effects every 6 months.

 

DIF:    Cognitive Level: Application          REF:   Page 1076      OBJ:   21

TOP:   Attention deficit hyperactivity disorder (ADHD)

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The parents of a child suffering from depression ask the nurse what causes depression in children. Which answer is an appropriate response by the nurse?
a. The causes of major depression are unknown.
b. Major affective disorders in parents increase depression in children.
c. Boys are more likely than girls to be depressed.
d. The prevalence rate is higher in prepubescent children.

 

 

ANS:  A

The causes of depression have not been established. However, many studies have shown that children have a three times greater rate of suffering from depression if their parents have a major affective disorder.

 

DIF:    Cognitive Level: Application          REF:   Page 1076      OBJ:   22

TOP:   Depression     KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Psychosocial Integrity

 

  1. When the nurse performs the initial assessment of an adolescent with depression, what is the most important question to ask?
a. “What is making you depressed?”
b. “Have you ever thought about suicide?”
c. “What could we do to make you happy?”
d. “Would you like your friends to visit?”

 

 

ANS:  B

Ask direct questions about suicidal thoughts. The discovery of whether the person has an actual plan is an indicator of the seriousness of the situation.

 

DIF:    Cognitive Level: Analysis               REF:   Page 1078      OBJ:   23

TOP:   Suicide           KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Psychosocial Integrity

 

  1. What is the most common method of attempted suicide?
a. Hanging
b. Medication ingestion
c. Gunshot
d. Slashing the wrists

 

 

ANS:  B

Ingesting medication is the most common method of attempted suicide.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 1077      OBJ:   23

TOP:   Suicide           KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Psychosocial Integrity

 

  1. Recurrent abdominal pain (RAP) is most often seen in school-age or adolescent children. The nurse should assess closely for what potential problems?
a. Physical problems
b. Relational problems
c. Eating disorders
d. Emotional problems

 

 

ANS:  D

RAP is often related to emotional factors in the child.

 

DIF:    Cognitive Level: Application          REF:   Page 1079      OBJ:   22

TOP:   Recurrent abdominal pain (RAP)    KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Psychosocial Integrity

 

  1. When performing an assessment of a child with recurrent abdominal pain (RAP), the nurse recognizes the child will most likely experience what symptom?
a. Increased temperature
b. Constipation
c. Right quadrant pain
d. Exercise-associated pain

 

 

ANS:  B

The child may be constipated with periumbilical pain unrelated to eating, defecation, or exercise.

 

DIF:    Cognitive Level: Analysis               REF:   Page 1079      OBJ:   22

TOP:   Recurrent abdominal pain (RAP)    KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is recording a history for a child who has been diagnosed with recurrent abdominal pain (RAP). What is a finding that is characteristic of this disorder?
a. Morning headaches
b. Pain for 3 consecutive months
c. Febrile episodes in the late afternoon
d. Diaphoresis when attacks occur

 

 

ANS:  B

Recurrent abdominal pain occurring consecutively for 3 months supports a diagnosis of RAP once other causes have been ruled out.

 

DIF:    Cognitive Level: Application          REF:   Page 1079      OBJ:   22

TOP:   Recurrent abdominal pain (RAP)    KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

MULTIPLE RESPONSE

 

  1. When assessing the laboratory values of a child with nephrosis, the nurse anticipates which results? (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 has 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. The nurse explains that which diagnostic studies are needed for the diagnosis of cognitive impairment? (Select all that apply.)
a. Denver Developmental Screening Test
b. Stanford-Binet Intelligence Scale
c. Wechsler Intelligence Scale
d. Miller’s Analogies
e. Strong Personality Assessment

 

 

ANS:  A, B, C

The Denver, Stanford-Binet, and Wechsler are standard intelligence tests that aid in the diagnosis of a cognitively impaired child.

 

DIF:    Cognitive Level: Analysis               REF:   Page 1068      OBJ:   17

TOP:   Intelligence tests                             KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

COMPLETION

 

  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

 

  1. The nurse reminds a family that people with autism are also referred to as ________.

 

ANS:

savants

 

Autistic people are referred to as savants.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 1071      OBJ:   19

TOP:   Autism           KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance