Download NURS366 Exam 3 Questions With 100% Correct Answers. and more Exams Nursing in PDF only on Docsity!
NURS366 Exam 3 Questions With
100% Correct Answers
When assessing a child's injury if the ED, a nurse suspects physical abuse. Based on this suspicion, the nurse's primary legal responsibility is: A: Assist the family in identifying resources for support B: Report the case in which the abuse is suspected to the local authorities C: Document the child's physical assessment findings accurately and thoroughly D: Refer the family to the hospital support group - ANSWER B: Report the case in which the abuse is suspected to the local authorities Nursing care of a child in the hospital with suspected abuse should include: A: Assign a variety of nurses to the child so that he can get to know and trust the whole staff B: Praise the child's ability to minimize feelings of shame and guilt C: Treat the child as someone with a specific problem, not as an "abuse" victim, to promote self-esteem and minimize feelings of guilt D: Talk with and ask question as often as possible to show interest and get to know the child better - ANSWER C: Treat the child as someone with a specific problem, not as an "abuse" victim, to promote self-esteem and minimize feelings of guilt What should parents understand is one of the most common causes of injury and death for a 7-month-old infant?
- Poisoning.
- Child abuse.
- Aspiration.
- Dog bites. - ANSWER 3. Aspiration. Which approach should the nurse use to gather information from a child brought to the ED for suspected child abuse?
- Promise the child that her parents will not know what she tells the nurse.
- Promise the child that she will not have to see the suspected abuser again.
- Use correct anatomical terms to discuss body parts.
- Tell the child that the abuse is not her fault and that she is a good person. - ANSWER
- Tell the child that the abuse is not her fault and that she is a good person. A 3-year-old boy has been hospitalized because he fell down the stairs. His mother is crying and states, "This is all my fault." Which is the nurse's best response?
- "Accidents happen. You shouldn't blame yourself."
- "Falls are one of the most common injuries in this age group."
- "It may be a good idea to put a baby gate on the stairs."
- "Your son should be proficient at walking down the stairs by now." - ANSWER 2. "Falls are one of the most common injuries in this age group." Which assessment is most important after any injury in a child?
- History of loss of consciousness and length of time unconscious.
- Serial assessments of level of consciousness.
- Initial neurological assessment.
- Initial vital signs and oxygen saturation level. - ANSWER 2. Serial assessments of level of consciousness. Which statement most accurately describes child abuse?
- Intentional physical abuse and neglect.
- Intentional and unintentional physical and emotional abuse and neglect.
- Sexual abuse of children, usually by an adult.
- Intentional physical, emotional, and sexual abuse and neglect. - ANSWER 4. Intentional physical, emotional, and sexual abuse and neglect. What is the most likely cause of a child's illness if it is unexplained, prolonged, recurrent, and extremely rare, and usually occurs when the mother is present?
- Genetic disorder.
- Munchausen syndrome by proxy.
- Duchenne muscular dystrophy.
- Syndrome of inappropriate antidiuretic hormone. - ANSWER 2. Munchausen syndrome by proxy. Which statement would be most therapeutic to a child the nurse suspects has been
Which statement by the mother would lead the nurse to suspect sexual abuse in a 4-year-old?
- "She has just started masturbation."
- "She has lots more temper tantrums."
- "She now has an invisible friend."
- "She wants to spend time with her sister." - ANSWER 2. "She has lots more temper tantrums."
What would be the priority intervention when a 10-year-old comes to the nurse's office because of a headache, and the nurse notices various stages of bruising on the inner aspects of the upper arms?
- Call her mother and ask if acetaminophen can be given for the headache.
- Ask the child what happened to her arms, and have her describe the headache.
- Inquire about the child's headache and bruising on her arms; file mandatory reporting forms.
- Call her mother to pick her up from school, and complete required school nurse visit forms. - ANSWER 2. Ask the child what happened to her arms, and have her describe the headache.
Which statement is true of abused children?
- They will tell the truth if asked about their injuries.
- They will repeat the same story that their parents tell.
- They usually are not noted to have any changes in behavior.
- They will have outgoing personalities and be active in school activities. - ANSWER 2. They will repeat the same story that their parents tell.
Which statement is true of shaken baby syndrome?
- There may be absence of external signs of injury.
- Shaken babies usually do not have retinal hemorrhage.
- Shaken babies usually do not have signs of a subdural hematoma.
- Shaken babies have signs of external head injury. - ANSWER 1. There may be absence of external signs of injury.
A 2-month-old infant is brought to the emergency room after experiencing a seizure. The infant appears lethargic with very irregular respirations and periods of apnea. The parents report the baby is no longer interested in feeding and before the seizure, rolled off the couch. What additional testing should the nurse immediately prepare for?
- Computed tomography (CT) scan of the head and dilation of the eyes.
- Computed tomography (CT) scan of the head and electroencephalogram (EEG).
- X-rays of the head.
- X-rays of all long bones. - ANSWER 1. Computed tomography (CT) scan of the head and dilation of the eyes.
*A CT scan of the head will reveal trauma. Dilating the eye is performed to check for retinal hemorrhages that are seen in an infant who has experienced SBS
- The client comes to the emergency department complaining of pain in the left lower leg following a puncture wound from a nail in a board. The left lower leg is reddened with streaks, edematous, and hot to the touch, and the client has a temperature of 100. ̊ F. Which condition would the nurse suspect the client is experiencing?
- Cellulitis.
- Lyme disease.
- Impetigo.
- The nurse writes the client problem of "acute pain and itching secondary to bacterial skin lesions." Which interventions should be included in the care plan? Select all that apply.
- Keep humidity at less than 20%.
- Maintain a cool environment.
- Use a mild soap for sensitive skin.
- Keep lesions covered at all times.
- Apply skin lotion after bathing. - ANSWER 2. Maintain a cool environment.
- Use a mild soap for sensitive skin.
- Apply skin lotion after bathing.
- The client is diagnosed with acne vulgaris. Which psychosocial problem is priority?
- Impaired skin integrity.
- Ineffective grieving.
- Body image disturbance.
- Knowledge deficit. - ANSWER 3. Body image disturbance.
- The female teacher comes to the school nurse's office and shows the nurse a rash on her hands. The nurse tells the teacher she has probably contracted impetigo from one of the students. Which intervention should the nurse implement?
- Instruct the teacher to go to her HCP today.
- Tell the teacher to wash her hands with soap and water.
- Encourage the teacher to rub vitamin E oil on the lesions.
- Explain that the rash will go away in a few days. - ANSWER 1. Instruct the teacher to go to her HCP today.
- The nurse is teaching a class on how to prevent Lyme disease. Which intervention should be included in the discussion?
- Instruct the clients to wear dark clothes when hunting.
- Use a sunscreen of at least SPF 30 when outside.
- Avoid dense undergrowth when in a wooded area.
- Do not use any type of insect repellant when deer hunting. - ANSWER 3. Avoid dense undergrowth when in a wooded area.
- The nurse is discussing the prevention of herpes simplex 2. Which intervention should the nurse discuss with the client?
- Encourage the client to get the chickenpox immunization.
- Do not engage in oral sex if you have a cold sore on the mouth.
- Wear nonsterile gloves when cleaning the genital area.
- Do not share any type of towel or washcloth with another person. - ANSWER 2. Do not engage in oral sex if you have a cold sore on the mouth.
- The client is complaining of burning, lancinating, stabbing pain that radiates around the left rib cage area. The nurse cannot find any type of skin abnormality. Which action should the nurse implement?
- Transfer the client to the ED for a cardiac work-up.
- Inform the client that the nurse can't see anything.
- Administer a nonnarcotic analgesic to the client.
- Ask the client if he or she has ever had chickenpox. - ANSWER 4. Ask the client if he or she has ever had chickenpox.
- The client is diagnosed with herpes simplex 2 and prescribed the antiviral
- Measure and document the client's skin lesions.
- Apply the antihistamine cream to the lesions.
- Set up the isolation equipment for the client.
- Determine if the client has prepared an advance directive. - ANSWER 3. Set up the isolation equipment for the client.
- The nurse is assessing a young mother who came to the clinic complaining of sores on her skin. Which assessment data would support that the client has chickenpox?
- Crops of lesions that have pus and reddened base.
- Oval scaling lesions that occur on the legs and arms.
- Severe itching of the scalp with tiny eggs visible.
- Ringed red lesions on the face, neck, trunk, and extremities. - ANSWER 1. Crops of lesions that have pus and reddened base.
- The school nurse is assessing a teacher who has pediculosis. Which statement by the teacher makes the nurse suspect that the teacher did not comply with the instructions that were discussed in the classroom with the children?
- "I used the comb to remove all the nits."
- "I washed my hair with Kwell shampoo."
- "I removed all the sheets from my bed."
- "I had to fix my daughter's hair with my brush." - ANSWER 4. "I had to fix my daughter's hair with my brush."
- There is an outbreak of scabies in a long-term care facility. Which instruction should the infection control nurse provide to all client care staff concerning the transmission of this parasitic infection?
- Use only hand-washing foam when caring for clients with scabies.
- Wear gloves when providing hands-on care for a client with scabies.
- Wash all linen and clothes in cold water and dry them outside in the sun.
- Instruct clients to use plastic eating utensils for meals. - ANSWER 2. Wear gloves when providing hands-on care for a client with scabies.
- The nurse is assessing the client diagnosed with scabies. Which assessment technique would be most appropriate?
- Gently palpate the affected area using sterile gloves.
- Apply vinegar to the affected area to identify the scabies.
- Use a magnifying glass and a penlight to visualize the skin.
- Obtain a Doppler to assess the movement of the mites. - ANSWER 3. Use a magnifying glass and a penlight to visualize the skin.
The primary function of the skin is:
A: Insulation B: Protection C: Sensation D: Absorption - ANSWER B: Protection
Age-related changes in the hair and nails include (select all that apply):
A: Oily scalp B: Scaly scalp C: Thinner nails D: Thicker, brittle nails E: Longitudinal nail ridging - ANSWER B: Scaly scalp
D: avoid exposure to the sun, especially during midday
The nurse determines that a patient with a diagnosis of which disorder is most at risk for spreading the disease?
A: tine pedia B: impetigo on the face C: candidiasis of the nails D: psoriasis on the palms and soles - ANSWER B: impetigo on the face
A common site for the lesions associated with atopic dermatitis is the
A) buttocks B) temporal area C) antecubital space D) plantar surface of the feet - ANSWER C) antecubital space
During the assessment of a patient, you note an area of red, sharply defined plaques covered with silvery scales that are mildly itchy on the patient's knees and elbows. You recognize this finding as:
A: lentigo B: psoriasis C: actinic keratosis D: seborrheic keratosis - ANSWER B: psoriasis
A patient with acne vulgaris tells the nurse that she quit her job as a receptionist because she believes her facial appearance is unattractive to customers. The nursing diagnosis that best describes this patient response is:
A: ineffective coping r/t lack of social support B: impaired skin integrity r/t presence of lesions C: anxiety r/t lack of knowledge of the disease process D: social isolation r/t decreased activities secondary to fear of rejection - ANSWER D: social isolation r/t decreased activities secondary to fear of rejection
- The client comes to the clinic complaining of itching on the left wrist near a wristwatch. The nurse notes an erythematous area along with pruritic vesicles around the left wrist. Which condition should the nurse suspect?
- Contact dermatitis.
- Herpes simplex 1.
- Impetigo.
- Seborrheic dermatitis. - ANSWER 1. Contact dermatitis.
- Which client signs and symptoms indicate contact dermatitis to the nurse?
- Erythema and oozing vesicles.
- Pustules and nodule formation.
- Varicosities and edema.
- Telangiectasia and flushing. - ANSWER 1. Erythema and oozing vesicles.
- The nurse is caring for the client diagnosed with contact dermatitis. Which collaborative intervention should the nurse implement?
- Encourage the use of support stockings.
- Administer a topical anti-inflammatory cream.
- Remove scales frequently by shampooing.
- The nurse is assessing the client diagnosed with psoriasis. Which data would support that diagnosis?
- Appearance of red, elevated plaques with silvery white scales.
- A burning, prickling row of vesicles located along the torso.
- Raised, flesh-colored papules with a rough surface area.
- An overgrowth of tissue with an excessive amount of collagen. - ANSWER 1. Appearance of red, elevated plaques with silvery white scales.
- The nurse is preparing the plan of care for a client diagnosed with psoriasis. Which intervention should the nurse include in the plan of care?
- Apply a thin dusting with Mycostatin, an antifungal powder, over the area.
- Cover the area with an occlusive dressing after applying a steroid cream.
- Administer Acyclovir, an antiviral medication, to the affected areas six (6) times a day.
- Teach the client the risks and hazards of implanted radiation therapy. - ANSWER 2. Cover the area with an occlusive dressing after applying a steroid cream.
- The nurse has completed the teaching plan for the client diagnosed with psoriasis. Which statement indicates the need for further teaching?
- "I will check my skin every day for redness with tenderness."
- "I must take my psoralen medication two (2) hours before my treatment."
- "I will wear dark glasses during my treatment and the rest of the day."
- "The coal-tar ointments and lotions will not stain my clothes." - ANSWER 4. "The coal-tar ointments and lotions will not stain my clothes."
- The nurse is planning the care of a client diagnosed with psoriasis. Which psychosocial problem should be included in the plan?
- Alteration in comfort.
- Altered body image.
- Anxiety.
- Altered family processes. - ANSWER 2. Altered body image.
- The elderly client is admitted from the long-term care facility diagnosed with congestive heart failure. The client complains of severe itching on both hands and the nurse notes wavy, brown, threadlike lesions between the client's fingers. Which comorbid condition would the nurse suspect the client of having based on these assessment data?
- Tinea capitis.
- Herpes simplex 2.
- Scabies.
- Psoriasis. - ANSWER 3. Scabies.
- The nurse and an unlicensed assistive personnel (UAP) are caring for a client with a stage IV pressure ulcer. Which action by the UAP warrants intervention by the nurse?
- The UAP turns the client every two (2) hours.
- The UAP keeps the sheets wrinkle free.
- The UAP encourages the client to drink high-protein drinks.
- The UAP places multiple diapers on the client. - ANSWER 4. The UAP places multiple diapers on the client.
- The nurse is planning the care for the client with multiple stage IV pressure ulcers. Which complication results from these pressure ulcers?
- Wasting syndrome.
- Osteomyelitis.
- "Why would you say that? We are doing our best."
- "Have you made out an advance directive to let the HCP know your wishes?" - ANSWER 2. "Are you tired of the treatments and needing to be cared for?"
- The nurse writes the problem "impaired skin integrity" for a client with stage IV pressure ulcers. Which interventions should be included in the plan of care? Select all that apply.
- Turn the client every three (3) to four (4) hours.
- Ask the dietitian to consult.
- Have the client sign a consent for pictures of the wounds.
- Obtain an order for a low air-loss bed.
- Elevate the head of the bed at all times. - ANSWER 2. Ask the dietitian to consult.
- Which client is at the greatest risk for the development of skin cancer?
- The African American male who lives in the northeast.
- The elderly Hispanic female who moved from Mexico as a child.
- The client who has a family history of basal cell carcinoma.
- The client with fair complexion who cannot get a tan. - ANSWER 4. The client with fair complexion who cannot get a tan.
- The school nurse is preparing to teach a health promotion class to high school seniors. Which information regarding self-care should be included in the teaching?
- Wear a sunscreen with a protection factor of 10 or less when in the sun.
- Try to stay out of the sun between 0300 and 0500 daily.
- Perform a thorough skin check monthly.
- Remember caps and long sleeves do not help prevent skin cancer. - ANSWER 3.
Perform a thorough skin check monthly.
- The client diagnosed with diabetes mellitus type 2 is admitted to the hospital with cellulitis of the right foot secondary to an insect bite. Which intervention should the nurse implement first?
- Administer intravenous antibiotics.
- Apply warm moist packs every two (2) hours.
- Elevate the right foot on two (2) pillows.
- Teach the client about skin and foot care. - ANSWER 3. Elevate the right foot on two (2) pillows.
- Which discharge instruction should the nurse discuss with the client to prevent recurrent episodes of cellulitis?
- Soak your feet daily in Epsom salts for 20 minutes.
- Wear thick white socks when working in the yard.
- Use a mosquito repellant when going outside.
- Inspect the feet between the toes for cracks in the skin. - ANSWER 4. Inspect the feet between the toes for cracks in the skin.
- The client comes to the emergency department complaining of pain in the right forearm. The nurse notes a large area of redness and edema over the forearm, and the client has an elevated temperature. Which condition should the nurse suspect?
- Cellulitis.
- Intravenous drug abuse.
- Raynaud's phenomenon.
- Thromboangiitis obliterans. - ANSWER 1. Cellulitis.
