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During a fundoscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is: A: An abnormal finding, the child needs a referral to an ophthalmologist B: A sign of a possible visual defect, the child needs a vision screening C: A sign of a small hemorrhage, which will usually resolve spontaneously D: A normal finding, the child needs no follow up - ANSWER D: A normal finding, the child needs no follow up The hallmark sign of retinoblastoma is: A: The red reflex B: Inflamed conjunctiva C: Eye discharge D: A white reflex - ANSWER D: A white reflex Parents of a newborn are concerned because the infant's eyes often "look crossed" when the infant is looking at an object. The nurse's response is that this is normal based on the knowledge that binocularity is normally present by what age? A: 1 month B: 3-4 months C: 6-8 months D: 12 months - ANSWER B: 3-4 months A red, bulging tympanic membrane is: A: Swimmer's ear B: Otitis externa C: Serous otitis media D: Acute otitis media - ANSWER B: Otitis externa
Which statement by a parent indicates understanding of prevention of childhood otitis media? A: "We will only prop the bottle during the daytime feedings" B: "We will be sure to keep immunizations up to date" C: "Breastfeeding will be discontinued after 4 months of age" D: "We will place the child flat right after feedings" - ANSWER B: "We will be sure to keep immunizations up to date" Which is the causative agent of scarlet fever? A: Enteroviruses B: Corynebacterium organisms C: Scarlet fever virus D: Group A B-hemolytic streptococci (GABHS) - ANSWER D: Group A B-hemolytic streptococci (GABHS) Which is an important nursing consideration when caring for a child with hepatic gingivostomatitis (HGS)? Select ALL that apply. A: Apply topical anesthetics before eating B: Drink from a cup, not a straw C: Wait to brush teeth until lesions are sufficiently healed D: Explain to parents how this is sexually transmitted E: Handwashing is essential - ANSWER A: Apply topical anesthetics before eating E: Handwashing is essential What is oral candidiasis (thrush) in the newborn? A: A bacterial infection that is life-threatening in the neonatal period B: A bacterial infection of the mucous membranes that responds readily to treatment C: A fungal infection of the mucous membranes that is relatively common D: A benign disorder that is transmitted from mother to newborn during the birth process only - ANSWER C: A fungal infection of the mucous membranes that is relatively common You are caring for a child immediately following a tonsillectomy and adenoidectomy. Which action should you include in the child's postoperative care plan?
C: Socioeconomic status D: Use of food as a positive reinforcer of desired behaviors E: Availability of energy-dense foods and drinks F: Positive self esteem - ANSWER B: Physical inactivity C: Socioeconomic status D: Use of food as a positive reinforcer of desired behaviors E: Availability of energy-dense foods and drinks
A 15-year-old female diagnosed previously with anorexia nervosa (AN) is admitted to the ED. Her mother states that her daughter has not voided in 24 hours and has been lethargic for the last 12 hours. The patient appears cachectic and pale, and her weight is recorded as 78 pounds. She is minimally responsive to painful stimulation. A number of diagnostic tests are obtained. Which one of these represents the most immediate threat to her life requiring intervention?
A: Serum sodium of 149 mEq B: Serum potassium of 2.6 mEq C: Hemoglobin of 6.8 mg D: Arterial pH of 7.30 - ANSWER B: Serum potassium of 2.6 mEq
A mother comments to a nurse working on the pediatric unit, "My second child just does not seem to be acting like or responding the same way as my first child." Nursing interventions to respond to this inquiry should include which of the following? Select ALL that apply.
A: Assessment for dysmorphic syndromes (e.g., multiple congenital anomalies, microcephaly) B: Inquiring about temperament: irritability or lethargy C: Explaining that all children are different and that is can be detrimental to compare them D: Noting language development appropriate for the child's age
E: Meeting the siblings to assess similarities that may be familial rather than problematic
- ANSWER A: Assessment for dysmorphic syndromes (e.g., multiple congenital anomalies, microcephaly) B: Inquiring about temperament: irritability or lethargy D: Noting language development appropriate for the child's age
When interacting with a parent at her child's well visit, which statement by the mother would be an indication for a speech referral? Select ALL that apply.
A: Failure to speak any meaningful words spontaneously in a 2-year-old child B: Using different words or nicknames for certain people C: Failure to use sentences of three or more words in a 3-year-old D: Stuttering or any other type of dysfluency E: Omission of word endings (e.g., plurals, tenses of verbs) in a 3-year-old F: Frequent omission of final consonants in a 3-year-old - ANSWER A: Failure to speak any meaningful words spontaneously in a 2-year-old child C: Failure to use sentences of three or more words in a 3-year-old D: Stuttering or any other type of dysfluency F: Frequent omission of final consonants in a 3-year-old
A mother of a child born with Down syndrome is overwhelmed with the future and asks many questions. Which of the following facts should the nurse be aware of? Select ALL that apply.
A: 80% of infants with Down syndrome are born to women younger than 35 yrs old because younger women have higher fertility rates B: When feeding infants and young children, use a small, straight-handled spoon to push food to the side and back of the mouth. Feeding difficulties occur due to a protruding tongue and hypotonia C: Parents generally believe the experience of having this special child makes them stronger and more accepting of others
Understanding autism spectrum disorders (ASDs) is very important for those who care for children. Goals of treatment for these children include:
A: Helping with placement in a long-term care setting, because most children cannot remain at home B: Putting the child hospitalized with an ASD in a room with another child to help him or her feel more comfortable in the strange environment C: Providing a structured routine, whether at home or in the health care setting D: Providing comfort for young children by holding or cuddling when able, because the disruption of routine can be frightening - ANSWER C: Providing a structured routine, whether at home or in the health care setting
Clinical manifestations of Down syndrome - ANSWER -Separated sagittal suture -Oblique palpebral fissures (upward, outward slant) -Small nose with depressed nasal bridge -High, arched, narrow palate and protruding tongue -Excess skin in neck folds -Palmar creases -Wide space & plantar crease between big and 2nd toes -Hypotonia and hyper flexibility
Common physical problems of Down syndrome - ANSWER -Congenital heart malformations (most common are septal defects) -Respiratory tract infections -Hypotonicity of chest and abdominal muscles -Immune system dysfunction -Thyroid dysfunction (hypothyroidism) -Increased incidence of leukemia
-Dry, cracked skin d/t hypothyroidism
What is most important to assess in a child with Down syndrome? (Chief cause of death)
- ANSWER Congenital heart malformations & respiratory tract infections
Nursing care for a child with Down syndrome - ANSWER -Correct positioning and support -Reduce risk for respiratory tract infections -Support feeding and nutrition -Proper skin care to prevent cracking/infection
(Nasal saline and suction before feedings, use long, straight-handled spoon to push the food toward back and side of mouth, encourage fluids & high fiber foods)
Clinical manifestations of Fragile X Syndrome - ANSWER -Long, narrow face with prominent jaw (prognathism) -Large, protruding ears -Large testes (macroorchidism) in post pubertal males -Strabismus -Mitral valve prolapse and/or aortic root dilation -Hypotonia/hyperflexibility -Mild to severe cognitive impairment -ADHD/ADD and/or autistic-like behaviors
Management of Fragile X Syndrome - ANSWER -Serotonin agents to control violent temper outbursts -CNS stimulants to improve attention span and decrease hyperactivity -Etc.
e. decreased central venous pressure
The nursing care for a patient with hyponatremia and fluid volume excess includes:
A: Fluid restriction B: Administration of hypotonic IV fluids C: Administration of a cation-exchange resin D: Placement of an indwelling urinary catheter - ANSWER A: Fluid restriction
The nurse should be alert for which manifestations in a patient receiving a loop diuretic?
a. Restlessness and agitation b. Paresthesias and irritability c. Weak, irregular pulse and poor muscle tone d. Increased blood pressure and muscle spasms - ANSWER c. Weak, irregular pulse and poor muscle tone
Which patient is at greatest risk for developing hypermagnesemia?
A: 83 year old man with lung cancer and HTN B: 65 year old woman with HTN taking Beta blockers C: 42 year old woman with systemic lupus erythematous and renal failure D: 50 year old man with BPH and a UTI - ANSWER C: 42 year old woman with systemic lupus erythematous and renal failure
The typical fluid replacement for the patient with a fluid volume deficit is:
a. dextran
b. 0.45% saline c. lactated Ringer's d. 5% dextrose in 0.45% saline - ANSWER c. lactated Ringer's
The nurse is unable to flush a central venous access device and suspects occlusion. The best nursing intervention would be to:
a. apply warm moist compresses to the insertion site. b. attempt to force 10 mL of normal saline into the device. c. place the patient on the left side with head-down position. d. instruct the patient to change positions, raise arm, and cough. - ANSWER d. instruct the patient to change positions, raise arm, and cough.
The nurse is assessing a client in the emergency room. Which of the following statements suggests that the problem is acute angina?
A: "My pain is deep in my chest behind my sternum." B: "The pain is right here in my stomach area." C: "As I take a deep breath the pain gets worse." D: "When I sit up the pain gets worse." - ANSWER
A nurse is caring for a client with peripheral arterial insufficiency of the lower extremities. Which one of the following should be included in the plan of care to reduce leg pain?
A: Lower the legs to a dependent position B: Increase ingestion of caffeine products C: Apply cold compresses D: Elevate the legs above the heart - ANSWER
Analyze the following diagnostic findings for your patient with type 2 diabetes. Which result will need further assessment?
A) BP 126/ B) A1C 9% C)FBG 130mg/dL D) LDL cholesterol 100mg/dL - ANSWER B) A1C 9%
Which statement by the patient with type 2 diabetes is accurate?
A: "I will limit my alcohol intake to one drink" B: "I am not allowed to eat any sweets because of my diabetes" C: "I cannot exercise because I take a blood glucose-lowering medication D: "The amount of fat in my diet is not important. Only carbohydrates raise my blood sugar" - ANSWER A: "I will limit my alcohol intake to one drink"
Onset, peak, & duration of rapid-acting insulin (lisper, apart, glulisine) - ANSWER Onset: 5-15 min Peak: 45-75 min Duration: 2-4 hrs
Onset, peak, & duration of short-acting insulin (regular) - ANSWER Onset: 30 min Peak: 2-4 hrs Duration: 5-8 hrs
Onset, peak, & duration of intermediate-acting insulin (NPH) - ANSWER Onset: 2 hrs Peak: 4-12 hrs Duration: 18-28 hrs
Onset & peak of long-acting insulin (glargine, determir) - ANSWER Onset: 2 hrs Peak: 3-9 hrs
Pediatric blood glucose goals before meal & at bedtime - ANSWER Before meal: 90- mg/dL Bedtime: 90-150 mg/dL
Legal doctrine: law of the land, nurse practice act - ANSWER Constitutional
Legal doctrine: lead by congress, social security act (Medicare), worker compensation act, warning/probation, violation of nurse practice act - ANSWER Administrative
Legal doctrine: state and federal statutes, nurses risk violating by high doses of painkillers, failure to nourish, stealing meds/narcotics, witness without reporting for rape, murder, etc., protect your license and report suspicious findings, can include negligence, murder, unauthorized drug possession - ANSWER Criminal
Legal doctrine: agreement between two or more parties, bargain for exchange, verbal or oral agreements can be legally binding but prefer it in writing, nursing, employment relations is where this will be seen the most - ANSWER Contract
Legal doctrine: child abuse prevention act, privacy act, good samaritan act (you cannot do anything outside of your practice, cannot leave until someone relieves you, cannot accept any payment) - ANSWER Protective reporting laws
Legal doctrine: reparation of civil wrongs or injuries, an act or mission that harms someone, civil (violation requests money, not jail time), most deeply impacts nursing care - ANSWER Torts
6 legal doctrines that impact nursing practice - ANSWER -Constitutional
ANSWER Invasion of privacy
7 intentional torts - ANSWER -Assault -Battery -Conversion of property -Defamation -False imprisonment -Intentional infliction of emotional distress -Invasion of privacy
Non-intentional tort: failure to exercise the degree of care that a person of ordinary prudence, based on the reasonable man standard, would exercise under the same or similar circumstances
-You were in charge of something that harmed another person by accident - ANSWER Simply/ordinary negligence
Non-intentional tort: failure of a professional person to act in ordinance with the prevalent professional standards or failure to foresee potential consequences that a professional person, having necessary skills and expertise to act in a professional manner, should foresee
-Elements: duty, breach, cause, foreseeable injury, damages - ANSWER Malpractice
Liability for the acts of another under certain, limited circumstances - ANSWER Vicarious liability
Hospital or agency held liable - ANSWER Corporate liability
A unilateral, premature termination of the professional treatment relationship by the
care provider with neither adequate notice given the patient, nor the patient's consent - ANSWER Abandonment
