Obtain a fi ngerstick test for blood glucose

Children and Adolescents with Behavior Problems

1. Obtain a fi ngerstick test for blood glucose

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20.

A mother who is Mexican brings her 2-month- old son to the emergency department with a high fever and possible sepsis. A lumbar puncture is ordered, but the mother will not sign the consent until the father arrives to give permission. The nurse should:

■ 1. Report this to the social worker.

■ 2. Call Child Protective Services.

■ 3. Wait until the father arrives.

■ 4. Inform the physician that the mother has refused to have the procedure.

21.

A client with Alzheimer’s disease is started on a low dose of lorazepam (Ativan) because of agitation and a sleep disturbance. The nurse should assess the client for which of the following?

■ 1. Nighttime agitation.

■ 2. Extrapyramidal side effects.

■ 3. Vomiting.

■ 4. Anticholinergic side effects.

22.

A postmenopausal client with an intact uterus asks the nurse why her hormone medicine has two drugs, estrogen and progesterone. Which of the following statements by the nurse provides the client with accurate information?

■ 1. “The progesterone will help prevent cervical cancer.”

■ 2. “The progesterone will help prevent breast cancer.”

■ 3. “The progesterone will help prevent liver disease.”

■ 4. “The progesterone will help prevent endo- metrial cancer.”

23.

The nurse on the antenatal unit is planning care for four clients. The nurse should assess which of the following clients fi rst?

■ 1. A 29-year-old G3 P2 carrying twins, being treated for preterm labor at 29 weeks’ gesta- tion. She is receiving magnesium sulfate @ 2 g/hour. She has had no contractions for the past 2 hours and both twins appear stable, according to the nurse’s shift report.

■ 2. A 19-year-old 18 weeks’ IUP who is now 12 hours post motor vehicle accident with bright red vaginal bleeding.

■ 3. A G8 P4 Ab3 at 38 weeks’ gestation hospital- ized frequently during this pregnancy for pla- centa previa. Two days ago she was admitted with severe bright red vaginal bleeding that has tapered off now.

■ 4. A 9-week IUP hospitalized for hyperemesis gravidarum who has not vomited for the last 12 hours.

24.

The nurse should turn the client on bed rest every 2 hours to prevent the development of pres- sure ulcers. In addition, the nurse should:

■ 1. Have the client walk at least twice a day.

■ 2. Insert an indwelling urinary catheter.

■ 3. Monitor serum albumin.

■ 4. Monitor the white blood cell count.

16.

The nurse observes an 18-month-old who has been admitted with a respiratory tract infection (see fi gure). The nurse should fi rst:

■ 1. Position the child supine

■ 2. Call the rapid response team

■ 3. Offer the child a carbonated drink

■ 4. Place the child in a croup tent

17.

A nulliparous client visiting the clinic tells the nurse that she stopped taking oral contraceptives 6 months ago but doesn’t think she is ovulating.

Which of the following should the nurse anticipate that the physician would order if the client is ano- vulatory?

■ 1. Dienestrol (Ortho Dienestrol).

■ 2. Clomiphene citrate (Clomid).

■ 3. Medroxyprogesterone (Depo-Provera).

■ 4. Norgestrel (Ovrette).

18.

A client who has been recently diagnosed with acquired immunodefi ciency syndrome (AIDS) inquires about hospice services. The nurse explains that hospice care is appropriate:

■ 1. For clients with an inevitable death within weeks to months.

■ 2. For all clients with AIDS at any stage.

■ 3. Only for clients with cancer.

■ 4. When the client is ready to discuss his prog- nosis.

19.

While assessing a neonate at age 24 hours, the nurse observes several irregularly shaped, red, fl at patches on the back of the neonate’s neck. The nurse interprets this fi nding as which of the following?

■ 1. Stork bite.

■ 2. Port wine stain.

■ 3. Newborn rash.

■ 4. Café au lait spot.

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25.

A client has been hospitalized with heart failure. He is receiving digoxin (Lanoxin) and furo- semide (Lasix) intravenously. He tells the nurse that he hears a continuous ringing in his ears and that he has never had this problem before. What is the appropriate action for the nurse to take at this time?

■ 1. Obtain a digoxin level to check for toxicity.

■ 2. Note the observation in the chart and plan to reassess in 2 hours.

■ 3. Ask the client if he has been taking aspirin in addition to his other medications.

■ 4. Discontinue the furosemide and notify the physician.

26.

Which of the following discharge instruc- tions about thermal injury should be given to a cli- ent with peripheral vascular disease? Select all that apply.

■ 1. “Warm the fi ngers or toes by using an electric heating pad.”

■ 2. “Avoid sunburn during the summer.”

■ 3. “Wear extra socks in the winter.”

■ 4. “Choose loose, soft, cotton socks.”

■ 5. “Use an electric blanket when you are sleeping.”

27.

A client receives an I.V. dose of gentamicin sulfate (Garamycin). How long after the completion of the dose should the peak serum concentration level be measured?

■ 1. 10 minutes.

■ 2. 20 minutes.

■ 3. 30 minutes.

■ 4. 40 minutes.

28.

A client with hydrocephalus reports having had a headache in the morning on arising for the last 3 days, but it disappears later in the day. The nurse should:

■ 1. Notify the physician.

■ 2. Tell the client that this is normal because intracranial pressure fl uctuates throughout the day.

■ 3. Instruct the client to increase fl uid intake prior to going to bed to prevent headache in the morning.

■ 4. Advise the client to request pain medication from the physician.

29.

A primigravid client visits the clinic for a routine examination at 35 weeks’ gestation. The cli- ent’s blood pressure is near the baseline of 120/74 mm Hg with no proteinuria or evidence of facial edema. The client asks the nurse, “What should I take if I get an occasional headache after looking at my computer at work all day?” The nurse instructs the client that she can occasionally take which of the following?

■ 1. Acetaminophen (Tylenol).

■ 2. Aspirin.

■ 3. Ibuprofen (Advil).

■ 4. Naproxen (Aleve).

30.

A 19-year-old client has undergone an examination and had evidence collected after being raped. Her father is overheard yelling at his daugh- ter, “You’re going to tell me who did this to you.

What’s his name?” Which of the following is the nurse’s most immediate action?

■ 1. “Please come with me, sir. I need some important information.”

■ 2. “Stop yelling. You’re being inappropriate.”

■ 3. “Please be quiet. You’re not helping your daughter this way.”

■ 4. “If you don’t stop yelling, I’ll have to call Security.”

31.

Which of the following groups is more likely to develop severe hypertension?

■ 1. Asian.

■ 2. African American.

■ 3. European.

■ 4. American Indian.

32.

During a neonate’s assessment shortly after birth, the nurse observes a large pad of fat at the back of the neck, widely set eyes, simian hand creases, and epicanthal folds. Which of the follow- ing actions is most appropriate?

■ 1. Notify the physician immediately.

■ 2. Ask the mother to consent to genetic studies.

■ 3. Explain these deviations to the newborn’s mother.

■ 4. Document these fi ndings as minor deviations.

33.

A client with severe arthritis has been receiv- ing maintenance therapy of prednisone (Deltasone) 10 mg/day for the past 6 weeks. The nurse should instruct the client to immediately report symptoms of:

■ 1. Respiratory infection.

■ 2. Joint pain.

■ 3. Constipation.

■ 4. Joint swelling.

34.

A 90-year-old client discloses that he has two guns at home. The nurse asks him whether he has any grandchildren who come to visit or other school-age visitors because the most common risk factor for school-age children associated with injury or death from fi rearms is:

■ 1. An argument with a stranger.

■ 2. Firearm access.

■ 3. Substance use.

■ 4. Peer pressure.

35.

A 7-year-old child is admitted to the hospi- tal with the medical diagnosis of acute rheumatic fever. During the acute phase of the illness, it is least desirable to interest the child in which of the fol- lowing diversional activities?

■ 1. Reading a book to the father.

■ 2. Playing with a doll with the nurse.

■ 3. Watching the television with a sibling.

■ 4. Playing checkers with a roommate.

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36.

A woman is taking oral contraceptives. The nurse teaches the client to report which of the fol- lowing danger signs?

■ 1. Breakthrough bleeding.

■ 2. Severe calf pain.

■ 3. Mild headache.

■ 4. Weight gain of 3 lb.

37.

Which nursing action is most essential for the hospitalized client with a new tracheostomy?

■ 1. Decrease secretions.

■ 2. Provide client teaching regarding tracheostomy care.

■ 3. Relieve anxiety related to the tracheostomy.

■ 4. Maintain a patent airway.

38.

Immediately after the client receives an injec- tion of bupivacaine (Marcaine), he becomes restless and nervous and reports a feeling of impending doom. Which of the following actions by the nurse is appropriate at this time?

■ 1. Ask the client to talk more about what he is feeling.

■ 2. Reassure the client that it is normal to feel restless before a procedure.

■ 3. Assess the client’s vital signs.

■ 4. Administer epinephrine.

39.

A menopausal woman is taking hormone replacement therapy. The nurse teaches the client that a warning sign for endometrial cancer that needs to be reported is:

■ 1. Hot fl ashes.

■ 2. Irregular vaginal bleeding.

■ 3. Urinary urgency.

■ 4. Dyspareunia.

40.

When explaining the risk for having a child with cystic fi brosis to a husband and wife, the nurse should tell them?

■ 1. The risk is greatest when both clients have the recessive gene.

■ 2. The gene is carried on the X chromosome and there is little risk.

■ 3. The disease will only occur if the child is a male.

■ 4. The disease does not have a genetic basis.

41.

The client complains of a severe vulvar pruri- tus and a yellow-green, malodorous vaginal discharge.

The nurse recognizes that the symptoms suggest:

■ 1. Gonorrhea.

■ 2. Syphilis.

■ 3. Chlamydia.

■ 4. Trichomoniasis.

42.

Following surgery, to evaluate the effective- ness of the client’s use of an incentive spirometer, the nurse should determine if the client:

■ 1. Has increased circulation in the extremities.

■ 2. Is ready to ambulate without pain.

■ 3. Has stronger abdominal muscles.

■ 4. Can breathe easier.

43.

A client was talking with her husband by telephone, and then she began swearing at him. The nurse interrupts the call and offers to talk with the client. She says, “I can’t talk about that bastard right now. I just need to destroy something.” At this point, which of the following should the nurse do next?

■ 1. Tell her to write her feelings in her journal.

■ 2. Urge her to talk with the nurse now.

■ 3. Ask her to calm down or she will be restrained.

■ 4. Offer her a phone book to “destroy” while staying with her.

44.

The nurse is caring for a multigravid client in active labor when the nurse detects variable fetal heart rate decelerations on the electronic moni- tor. The nurse interprets this as the compression of which of the following structures?

■ 1. Head.

■ 2. Chest.

■ 3. Umbilical cord.

■ 4. Placenta.

45.

Which of the following assessment fi ndings should lead the nurse to suspect that a client who had a cesarean delivery 8 hours earlier is developing disseminated intravascular coagulation (DIC)? Select all that apply.

■ 1. Petechiae on the arm where the blood pres- sure was taken.

■ 2. Heart rate of 126 bpm.

■ 3. Abdominal incision dressing with bright red drainage.

■ 4. Platelet count of 80,000/mm³.

■ 5. Urine output of 350 mL in the past 8 hours.

■ 6. Temperature of 98.4° F (36.9° C).

46.

Two days after placement of a pleural chest tube, the tube is accidentally pulled out of the chest wall. The nurse should fi rst:

■ 1. Immerse the tube in sterile water.

■ 2. Apply an occlusive dressing such as petro- leum jelly gauze.

■ 3. Instruct the client to cough to expand the lung.

■ 4. Auscultate the lung to determine whether it collapsed.

47.

A client is admitted to the hospital with a diagnosis of a pulmonary embolism. Which of the following problems should the nurse address fi rst?

■ 1. Nonproductive cough.

■ 2. Activity intolerance.

■ 3. Ineffective breathing pattern.

■ 4. Impaired gas exchange.

48.

Which of the following is characteristic of cardiogenic shock?

■ 1. Hypovolemia.

■ 2. Increased cardiac output.

■ 3. Decreased myocardial contractility.

■ 4. Infarction.

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49.

The nurse is reviewing the laboratory results of a client with hypothyroidism. An expected fi nding is:

■ 1. Decreased thyroxine (T₄) and increased thyroid-stimulating hormone (TSH) levels.

■ 2. Decreased TSH and increased T₄ levels.

■ 3. Decreased creatine phosphokinase levels.

■ 4. Absence of antithyroid antibodies.

50.

The mother of a 7-month-old child born 6 weeks early asks the nurse what play activities and toys is appropriate for her child. Which of the fol- lowing should the nurse suggest?

■ 1. Picture books.

■ 2. Peek-a-boo.

■ 3. Rattle.

■ 4. Colored blocks.

51.

Which of the following is the most accurate method of determining the extent of a client’s fl uid loss?

■ 1. Measuring intake and output.

■ 2. Assessing vital signs.

■ 3. Weighing the client.

■ 4. Assessing skin turgor.

52.

The nurse is counseling a client regarding treatment of the client’s newly diagnosed depres- sion. The nurse emphasizes that full benefi t from antidepressant therapy usually takes how long?

■ 1. 1 week.

■ 2. 2 to 4 weeks.

■ 3. 5 to 7 weeks.

■ 4. 8 weeks.

53.

A 70-year-old, previously well client asks the nurse, “I notice I have tremors. Is this just normal for my age?” The best response for the nurse to make is which of the following?

■ 1. “I wouldn’t be worried because this is com- mon with aging.”

■ 2. “You should report this to the physician because it may indicate a problem.”

■ 3. “You should drink orange juice when this occurs.”

■ 4. “You should have your blood pressure checked when this occurs.”

54.

A school-age child diagnosed with attention defi cit hyperactivity disorder is prescribed meth- ylphenidate (Ritalin). Which of the following should alert the school nurse to the possibility that the child is experiencing a common side effect of the drug?

■ 1. Loss of appetite.

■ 2. Vomiting.

■ 3. Photosensitivity.

■ 4. Weight gain.

55.

A client complains of a dull headache and dizziness and has an increased pulse rate. The results of arterial blood gas analysis are as fol- lows: pH 7.26; partial pressure of carbon dioxide, 50 mm Hg; and bicarbonate, 24 mEq/L. These fi ndings indicate which of the following acid-base imbalances?

■ 1. Respiratory alkalosis.

■ 2. Respiratory acidosis.

■ 3. Metabolic acidosis.

■ 4. Metabolic alkalosis.

56.

The nurse is planning a continuous quality improvement (CQI) process to decrease the infection rate on the nursing unit. The nurse should consider which of the following when planning the process?

Select all that apply.

■ 1. CQI processes are required by accrediting agencies.

■ 2. The approach to CQI can be retrospective or concurrent.

■ 3. Institutional Review Board (IRB) approval is required.

■ 4. CQI is conducted by people who are not part of the process.

■ 5. The CQI process has a fi xed endpoint.

57.

Which of the following is appropriate for a client with metabolic alkalosis?

■ 1. Monitor serum potassium levels.

■ 2. Maintain the client on bed rest.

■ 3. Have the client inhale carbon dioxide using a paper bag.

■ 4. Administer sodium bicarbonate as ordered.

58.

Which of the following demonstrates that the client needs further instruction after being taught about ciprofl oxacin (Cipro)?

■ 1. “I must drink 1,000 to 1,500 mL of water a day.”

■ 2. “I shouldn’t take an antacid before taking the Cipro.”

■ 3. “I should let the doctor know if I start vomit- ing from the Cipro.”

■ 4. “I may get light-headed from the Cipro.”

59.

When developing the plan of care for a client with Alzheimer’s disease, which of the following activities is least benefi cial to the client?

■ 1. Reminiscence group.

■ 2. Walking.

■ 3. Pet therapy.

■ 4. Stress management.

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60.

The nurse should instruct the parents of a school-age child with hemophilia to implement which of the following when the child develops bleeding into a joint? Select all that apply.

■ 1. Having the child rest.

■ 2. Applying heat to the joint area.

■ 3. Beginning factor VIII therapy.

■ 4. Starting physical therapy.

■ 5. Applying a topical antifi brinolytic.

61.

Which of the following nursing diagnoses should the nurse implement as part of the long-term care for a child with hemophilia?

■ 1. Defi cient knowledge.

■ 2. Risk for injury.

■ 3. Situational low self-esteem.

■ 4. Acute pain.

62.

When preparing a 3-year-old child to have blood specimens drawn for laboratory testing, the nurse should?

■ 1. Explain the procedure in advance.

■ 2. Explain why the blood needs to be drawn.

■ 3. Use distraction techniques during the procedure.

■ 4. Provide verbal explanations about what will occur.

63.

The client has been prescribed lisinopril (Prinivil) to treat hypertension. The nurse should assess the client for which of the following electro- lyte imbalances?

■ 1. Hyponatremia.

■ 2. Hypocalcemia.

■ 3. Hyperkalemia.

■ 4. Hypermagnesemia.

64.

A client with a chronic mental illness who does not always take her medications is separated from her husband and receives Supplemental Secu- rity Income. She lives with her mother and older sister and manages her own medication. The client’s mother is in poor health and receives Social Security benefi ts. The client’s sister works outside the home, and the client’s father is dead. Which of the follow- ing issues should the nurse need to address fi rst?

■ 1. Family.

■ 2. Marital.

■ 3. Financial.

■ 4. Medication.

65.

A client is receiving total parenteral nutrition (TPN). The nurse notices that the bag of TPN solution has been infusing for 24 hours but has 300 mL of solution left. The nurse should:

■ 1. Continue the infusion until the remaining 300 mL is infused.

■ 2. Change the fi lter on the tubing and continue with the infusion.

■ 3. Notify the physician and obtain orders to alter the fl ow rate of the solution.

■ 4. Discontinue the current solution, change the tubing, and hang a new bag of TPN solution.

66.

A client with a history of cardiac problems is having severe chest pain. What should be nurse’s fi rst response?

■ 1. Notify the physician.

■ 2. Administer an analgesic to control the pain.

■ 3. Assess the client’s pain.

■ 4. Start oxygen at 2 L/minute via nasal cannula.

67.

Which of the following characteristics should the nurse include in the teaching plan for a multipa- rous client after delivering a neonate diagnosed with trisomy 13?

■ 1. Webbed neck.

■ 2. Small testes.

■ 3. Congenital heart defects.

■ 4. Polydactyly.

68.

A client is being treated for acute low back pain. Which of these clinical manifestations must be reported to the physician immediately?

■ 1. Diffuse, aching sensation in the L4 to L5 area.

■ 2. New onset of footdrop.

■ 3. Pain in the lower back when the leg is lifted.

■ 4. Pain in the lower back that radiates to the hip.

69.

A client with type 1 diabetes mellitus asks the nurse whether he can take ginseng at home. The nurse should tell the client:

■ 1. “No, there are no therapeutic benefi ts of gin- seng.”

■ 2. “Taking ginseng will increase the risk of hypoglycemia.”

■ 3. “You can take the ginseng to help improve your memory.”

■ 4. “You can take ginseng if you take it with a carbohydrate”

70.

The nurse teaches the client with cirrhosis that he is achieving the expected effect of lactulose (Cephulac) when he has:

■ 1. One regular bowel movement a day.

■ 2. Two to three soft stools per day.

■ 3. Four to fi ve loose stools per day.

■ 4. Five to six loose stools per day.

71.

The nurse is evaluating the laboratory results of a client who was recently admitted to the hospi- tal. Which one of the following results indicates the presence of infl ammation?

■ 1. Decreased sedimentation rate.

■ 2. Thrombocytopenia.

■ 3. Leukocytosis.

■ 4. Erythrocytosis.

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72.

The nurse is assessing teenaged girls at a well child clinic. The nurse should describe the girl shown in the fi gure as having:

■ 1. Normal posture.

■ 2. Kyphosis.

■ 3. Scoliosis.

■ 4. Lordosis.

73.

A client reports having pain in his casted left arm that is unrelieved by pain medication. The nurse assesses the arm and notes that the fi ngers are swollen and diffi cult to separate. Which action is most appropriate for the nurse to take at this time?

■ 1. Administer morphine 2 mg intravenously.

■ 2. Apply an ice bag to the fi ngers to relieve pain.

■ 3. Elevate the arm on two pillows and reassess in 30 minutes.

■ 4. Call the physician to report swelling and pain.

74.

A primiparous client develops uterine atony and postpartum hemorrhage 1 hour after a vaginal delivery. The physician has ordered I.M. prosta- glandin-F_2a. After administration of the medication, the nurse should observe the client for which of the following?

■ 1. Tachycardia.

■ 2. Hypotension.

■ 3. Constipation.

■ 4. Abdominal distention.

75.

While caring for a mother and her 1-day-old neonate delivered vaginally at 30 weeks’ gestation, the nurse explains about the neonate’s need for gavage feeding at this time instead of the mother’s plan for bottle feeding. Which of the following should the nurse include as the rationale for this feeding plan?

■ 1. The neonate has diffi culty coordinating sucking, swallowing, and breathing.

■ 2. A high-calorie formula, presently needed at this time, is more easily delivered via gavage.

■ 3. Gavage feedings can minimize the neo- nate’s increased risk of developing hypoglycemia.

■ 4. This type of feeding, easily given in the isolette, decreases the neonate’s risk of cold stress.

76.

The nurse is teaching a client with rheu- matoid arthritis about how to manage the fatigue associated with this disease. Which statement by the client indicates she understands how to manage the fatigue?

■ 1. “I sleep for 8 to 10 hours every night so that I’ll have the energy to care for my children during the day.”

■ 2. “I schedule afternoon rest periods for myself in addition to sleeping 10 hours every night.”

■ 3. “I spend one weekend day a week resting in bed while my husband cares for the

children.”

■ 4. “I get up early in the morning and get all my household chores completed before my chil- dren wake up.”

77.

The nurse is caring for a child with hemo- philia who is actively bleeding from the leg. The nurse should apply:

■ 1. Direct pressure, checking every few minutes to see if the bleeding has stopped.

■ 2. Ice to the injured leg area several times a

■ 3. Direct pressure to the injured area continu-day.

ously for 10 minutes.

■ 4. Ice bag with elevation of the leg twice a day.

78.

Which of the following is least likely a dan- ger associated with pancytopenia?

■ 1. Anemia.

■ 2. Bleeding.

■ 3. Infection.

■ 4. Hypothyroidism.

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