ATI RN FUNDAMENTALS

ATI RN FUNDAMENTALS 1. Nurse observes assistive personnel (AP) reprimanding a client for not using urinal properly. The AP tells him she will put a diaper on him if he doesn't use urinal more carefully next time. Which of following torts is AP committing? A: Assault B: Battery C: False imprisonment D: Invasion of privacy A. Assult 2. Adult client who is competent tells the nurse that he is thinking about leaving the hospital against medical advice. Nurse believes that this is not in client's best interest, so she administers a PRN sedative med that the client has not requested along with his usual med. Which of following types of tort has nurse committed? A: Assault B: False imprisonment C: Negligence D: Breach of confidentiality B. False imprisonment 3.Client who will undergo neurosurgery in 1 week tells the nurse in office that he will prepare his advance directives before he goes to the hospital. Which of following statements by client indicates to nurse that he understands them? A: "I'd rather have my brother make decisions for me, but I know it has to be my wife." B: "I know they won't go ahead with the surgery unless I prepare these forms." C: "I plan to write that I don't want them to keep me on a breathing machine" D: "I will get my regular doctor to approve my plan before I hand it in at the hospital" C. "I plan to write that I don't want them to keep me on a breathing machine" 4. A Client is about to undergo an elective surgical procedure. Which of following actions are appropriate for nurse providing pre-op care regarding informed consent? (Select all that apply.) A: Make sure the surgeon obtained the client's consent B: Witness client's signature on consent form C: Explain the risks/benefits of procedure D: Describe consequences of choosing not to have surgery E: Tell client about alternatives to having surgery A. Make sure the surgeon obtained the client's consent, B. Witness client's signature on consent form 5. Nurse has noticed several times in past week when another nurse on unit seemed drowsy & unable to focus. Today, she found nurse asleep in chair in break room when she was not on a break. Which of following actions should nurse take? A: Remind nurse that safe client care is priority on unit B: Ask other s on team whether they have seen same behavior C: Report observations to nurse manager on unit D: Conclude her coworker's fatigue is not her problem to solve B. Report observations to nurse manager on unit 6. Nurse is preparing info for change-of-shift report. Which of following info should nurse include in report? A: Client's input & output for shift B: Client's blood pressure from previous day C: Bone scan that is scheduled for today D: Med routine from Med Admin Record C. Bone scan that is scheduled for today 7. Nurse enters a client's room & finds him sitting in his chair. He states, "I fell in the shower, but I got myself back up & into my chair." How should nurse document this in client's chart? A: Client fell in shower B: Client states he fell in shower & was able to get himself back into chair C: Nurse shouldn't document this info in chart b/c she didn't witness the fall D: Client fell in shower but is now resting comfortably B. Client states he fell in shower & was able to get himself back into chair 8.Nursing instructor reviewing documentation with students. Which of following legal guidelines should they follow when documenting in client record? (Select all that apply.) A: Cover arrows with correction fluid, & write in correct info B: Put date & time on all entries C: Document objective data, leaving out opinions D: Use as many abbreviations as possible E: Wait until the end of shift to document B. Put date & time on all entries, C. Document objective data, leaving out opinions 9.Nurse is receiving provider prescription by phone for morphine for client who is reporting moderate to severe pain Which of following actions are appropriate? (Select all that apply.) A: Repeat details of prescription back to provider B: Have another nurse listen to phone prescription C: Obtain prescribes signature on prescription within 24 hours D: Decline verbal prescription b/c it is not emergency situation E: Tell charge nurse that the provider has prescribed morphine by phone A. Repeat details of prescription back to provider, B. Have another nurse listen to phone prescription, C. Obtain prescribes signature on prescription within 24 hours 10. A nurse on med-surg unit has received change-of-shift report & will care for 4 clients. Which of following client's needs may nurse assign to AP? A: Feeding client who was admitted 24h ago with aspiration pneumonia B: Reinforcing teaching w/ client who is learning to walk using quad cane C: Reapplying a condom catheter for client who has urinary incontinence D: Applying sterile dressing to pressure ulcer C. Reapplying a condom catheter for client who has urinary incontinence 11. Nurse delegating ambulation of client who had knee arthroplasty 5 days ago to an AP. Which of following info should nurse share with the AP? (Select all that apply.) A: The roommate is up independently B: Client ambulates with his slippers on over his antiembolic stockings C: Client uses front-wheeled walker when ambulating D: Client had pain med 30 min ago E: Client is allergic to codeine F: Client ate 50% of his breakfast this morning B. Client ambulates with his slippers on over his antiembolic stockings C. Client uses front-wheeled walker when ambulating D. Client had pain med 30 min ago 12. RN is making assignments for client care to LPN at beginning of shift. Which of following assignments should LPN question? A: Assisting a client who is 24h post-op to use incentive spirometer B: Collecting clean-catch urine specimen from client who was admitted on previous shift C: Providing nasopharyngeal suctioning for client with pneumonia D: Replacing cartridge & tubing on PCA pump D. Replacing cartridge & tubing on PCA pump 13. Nurse is preparing in-service program about delegation. Which of following elements should she identify when presenting 5 rights of delegation? (Select all that apply.) A: Right client B: Right supervision/evaluation C: Right direction/communication D: Right time E: Right circumstances B. Right supervision/evaluation, C. Right direction/communication, E. Right circumstances 14. Nurse manager of med-surg unit is assigning care responsibilities for oncoming shift. Client is awaiting transfer back to unit from PACU following thoracic surgery. To which staff member should nurse assign to this client? A: Charge nurse B: RN C: LPN D: Assistive personnel (AP) C. RN 15. By 2nd post-op day, a client has not achieved satisfactory pain relief. Based on this evaluation, what should nurse do next according to nursing process? A: Reassess client to determine reasons for unsatisfactory pain relief B: See whether pain lessens during next 24h C: Change plan to ensure client achieves adequate pain relief D: Teach client about plan of care for managing his pain A. Reassess client to determine reasons for unsatisfactory pain relief 16. Nursing instructor is reviewing steps of nursing process with group of students. Students should identify which of following data as objective? (Select all that apply.) A: Respiratory rate of 22/min with even, unlabored respiration's B: "I can only walk 3 blocks before my legs start to hurt" C: Pain level 3/10 D: Skin pink, warm, dry E: Urine output 300 mL/8 hr F: Dressing clean, dry, intact A. Respiratory rate of 22/min with even, unlabored respiration's, D. Skin pink, warm, dry, E. Urine output 300 mL/8 hr, F. Dressing clean, dry, intact Nursing instructor is reviewing which actions nurses can initiate w/o provider's prescription. Students should identify which of following as nurse-initiated? (Select all that apply.) A: Give morphine sulfate 1-2 mg IV every 1h as needed for pain B: Insert NG tube to relieve client's gastric distension C: Show client how to use progressive muscle relaxation D: Perform daily bath after evening meal E: Re-position client every 2h to reduce pressure ulcer risk C: Show client how to use progressive muscle relaxation D: Perform daily bath after evening meal E: Re-position client every 2h to reduce pressure ulcer risk During eval, nurse must gather info about the client to... A: identify whether client outcomes have been met B: organize resources to proceed with implementing interventions C: establish client-centered, measurable & realistic outcomes D: determine priority of care & appropriate interventions A. identify whether client outcomes have been met Nurse tells client that she will call surgeon & ask about his request. Surgeon hears nurse's report & prescribes full liquid diet. Nurse used which of following levels of critical thinking? A: basic B: commitment C: complex D: integrity A. basic Nurse is caring for client who is 24h post-op following abdominal surgery. Nurse suspects client's pain management is inadequate. Which of following data reinforce suspicion? (Select all that apply.) A: client seems easily agitated B: client is nonadherent with coughing, deep breathing, dangling C: client may have pain med every 4-6h but accepts it every 6-7h D: client reports tenderness in his right lower leg E: client's vital signs are heart rate 110/min, respiratory rate 20/min, temp 37C, BP 136/80 mmHg B: client is nonadherent with coughing, deep breathing, dangling C: client may have pain med every 4-6h but accepts it every 6-7h E: client's vital signs are heart rate 110/min, Nurse caring for client who has new prescription. Prior to admin, nurse uses electronic database to gather info about med & effects it might have on this client. Which following component of critical thinking is nurse using when he reviews med info? A: knowledge B: experience C: intuition D: competence A. knowledge Nurse receives prescription for antibiotic for client with cellulitis. Nurse checks client's med record, discovers she's allergic to it, & calls provider to request different one. Which of following attitudes did the nurse demonstrate? A: fairness B: responsibility C: risk taking D: creativity B. responsibility Nurse uses head-to-toe approach to conduct physical assessment of a client who will undergo surgery in 1 week. Which of following attitudes did nurse demonstrate? A: confidence B: perseverance C: integrity D: discipline D. discipline Nurse performing an admission assessment for older adult client. After gathering assessment data & performing review of systems, which of following actions is priority for nursing? A: orient client to his room B: conduct client care conference C: review client's medical orders D: develop plan of care A. orient client to his room Nurse admitting client with acute cholecystitis to med-surg unit. Which of following actions are essential to admission procedure? (Select all that apply.) A: explain roles of other care delivery staff B: begin discharge planning C: provide info about advance directives D: document the client's wishes about organ donation E: introduce client to his roommate A: explain roles of other care delivery staff B: begin discharge planning C: provide info about advance directives E: introduce client to his roommate Nurse transferring client from acute-care hospital to rehab facility. Which of following info about client should nurse include in transfer report? (Select all that apply.) A: alert & oriented B: refuses to eat spinach C: has shellfish allergy D: requests morphine every 4h E: misses the 2 cats he has at home A: alert & oriented C: has shellfish allergy D: requests morphine every 4h Nurse is preparing discharge summary for client whose had knee surgery & is going home. Which following info about client should nurse include in it? (select all that apply) A: advance directives status B: where to go for follow-up care C: instructions for diet/meds D: most recent vital sign data E: contact info for home healthcare agency B: where to go for follow-up care C: instructions for diet/meds E: contact info for home healthcare agency As part of admission process, nurse at long-term care facility is gathering nutrition history for client with dementia. Which component is priority to determine from their family? A: BMI B: usual times for meals/snacks C: favorite foods D: any difficulty swallowing D: any difficulty swallowing When entering client's room to change dressing, nurse notes client is coughing & sneezing. When preparing sterile field, it's important the nurse... A: keep sterile field at least 6 ft away from client's bedside B: instruct client to not cough/sneeze during dressing change C: place mask on client to limit spread of microorganisms into surgical wound D: keep box of Kleenex nearby for client to use during dressing change C: place mask on client to limit spread of microorganisms into surgical wound Nurse wearing sterile gloves in prep for performing sterile procedure. Which of following objects may nurse touch without breaching sterile technique? (Select all that apply.) A: bottle containing sterile solution B: edge of sterile drape at base of filed C: inner wrapping of an item on sterile field D: irrigation syringe on sterile field E: 1 gloved hand with the other gloved hand C: inner wrapping of an item on sterile field D: irrigation syringe on sterile field E: 1 gloved hand with the other gloved hand Nurse has removed sterile pack from its outside cover & placed it on clean work surface in prep for invasive procedure. Which of following flaps should nurse unfold first? A: flap closest to bodies B: right side flap C: left side flap D: flap farthest from the body D: flap farthest from the body Nurse is reviewing hand hygiene techniques with group of AP; which instructions should nurse include when discussing handwashing? (Select all that apply.) A: apply 3-5 mL of liquid soap to dry hands B: wash hands with soap & water for at least 15 seconds C: rinse hands with hot water D: use clean paper towel to turn off hand faucets E: allow hands to air dry after washing B: wash hands with soap & water for at least 15 seconds D: use clean paper towel to turn off hand faucets Nurse has prepared sterile field for assisting provider with chest tube insertion. Which should nurse recognize as contaminating sterile field? (Select all that apply.) A: provider drops sterile instrument onto near side of sterile field B: nurse moistens cotton ball with sterile NS & places it on sterile field C: procedure is delayed 1h b/c provider receives emergency call D: nurse turns to speak to someone who enters through door behind nurse E: client's hand brushes against outer edge of sterile field B: nurse moistens cotton ball with sterile NS & places it on sterile field C: procedure is delayed 1h b/c provider receives emergency call D: nurse turns to speak to someone who enters through door behind nurse Nurse is caring for client with SARS. Nurse is aware that healthcare professionals are required to report communicable & infectious diseases. Which of these illustrate rationale for reporting? (Select all that apply.) A: planning & evaluating control & prevention strategies B: determining public health priorities C: ensuring proper medical treatment D: identifying endemic disease E: monitoring for common-source outbreaks A: planning & evaluating control & prevention strategies B: determining public health priorities C: ensuring proper medical treatment E: monitoring for common-source outbreaks Nurse contributing to care plan for client being admitted to facility with suspected dx of pertussis. Which should nurse include in care plan? (Select all that apply.) A: place client in room with negative air pressure of at least 6 exchanges per hour B: wear mask when providing care within 3 ft of client C: place mask on client if transportation to another dept is unavoidable D: use sterile gloves when handling soiled linens E: wear gown when performing care that may result in contamination from secretions B: wear mask when providing care within 3 ft of client C: place mask on client if transportation to another dept is unavoidable E: wear gown when performing care that may result in contamination from secretions Nurse is caring for client who presents with linear clusters of fluid-containing vesicles with some crustings. Which should nurse suspect? A: allergic reaction B: ringworm C: systemic lupus erythematosus D: herpes zoster D: herpes zoster Nurse caring for client who reports severe sore throat, pain with swallowing, swollen lymph nodes. Client is experiencing which of following stages of infection? A: prodromal B: incubation C: convalescence D: illness C: convalescence Nurse educator is reviewing with newly hired nurse the difference in clinical manifestations of localized vs. systemic infection. Nurse indicates understanding when she states that which are manifestations of systemic? (Select all that apply.) A: fever B: malaise C: edema D: pain/tenderness E: increase in pulse & respiratory rate A: fever B: malaise E: increase in pulse & respiratory rate Nurse caring for client just admitted after falling. This client is oriented 3x & can follow directions Which action(s) by nurse are appropriate to decrease risk of fall? (select all that apply) A: place belt restraint on him when he's sitting on bedside commode B: keep bed in low position with full side rails up C: ensure client's call light is within reach D: provide client with nonskid footwear E: complete fall-risk assessment C: ensure client's call light is within reach D: provide client with nonskid footwear E: complete fall-risk assessment Nurse manager is reviewing care of client with seizures with nurses on unit. which statements by nurse requires more instruction? A: "I will place the client on his side" B: "I will go to the nurses' station for assistance" C: "I will administer meds as prescribed" D: "I will be prepared to insert an airway" B: "I will go to the nurses' station for assistance" Nurse observes smoke coming form under door of staff lounge. Which is priority action by the nurse? A: extinguish fire B: pull fire alarm C: evacuate the clients D: close all open doors on the unit C: evacuate the clients Charge nurse is designating room assignments for clients. Based on her knowledge of fall prevention, which should be assigned to room closest to nursing station? A: 43 yo client post-op following laparoscopic cholecystectomy B: 61 yo client being admitted for telemetry to rule out MI C: 50 yo client post-op following open reduction internal fixation of ankle D: 79 yo client post-op following below-the-knee amputation D: 79 yo client post-op following below-the-knee amputation Nurse is caring for newly admitted client with history of falls. Which is priority action by nurse? A: complete fall-risk assessment B: educate client & family on fall risks C: complete physical assessment D: survey client's belongings A: complete fall-risk assessment Nurse providing discharge instructions to client with prescription for oxygen use in home. Which should nurse teach about using oxygen safely in his home? (Select all that apply.) A: family members who smoke must be at least 10 ft from client when his oxygen is on B: nail polish shouldn't be sued near client receiving oxygen C: a "no smoking" sign should be placed on front door D: cotton bedding/clothing should be replaced with items made from wood E: fire extinguisher should be readily available in home B: nail polish shouldn't be sued near client receiving oxygen C: a "no smoking" sign should be placed on front door E: fire extinguisher should be readily available in home Nurse educator conducting parenting class for new parents. Which statement made by participant indicates need for further teaching? A: "I will begin swimming lessons as soon as my baby can close her mouth under water" B: "Once my baby can sit up, he should be safe in bathtub" C: "I will test the temp of water before placing baby in bath" D: "Once my infant starts to push up, I will remove mobile from over the bed" B: "Once my baby can sit up, he should be safe in bathtub" A home health nurse is discussing dangers of carbon monoxide poisoning with client. Which of following info should nurse include in her counseling? A: carbon monoxide has distinct odor B: water heaters should be inspected every 5 years C: lungs are damaged from carbon monoxide inhalation D: carbon monoxide binds with Hgb in body D: carbon monoxide binds with Hgb in body Nurse educator presenting on basic first aid for new home health nurses. She evaluates teaching as effective when new nurse states client who has heat stroke will have which of following? A: hypotension B: bradycardia C: clammy skin D: bradypnea A: hypotension Home health nurse is discussing dangers of food poisoning with client. Which info should nurse include in counseling? (Select all that apply.) A: most food poisoning is caused by virus B: immunocompromised individuals are at risk for complications from food poisoning C: clients who are esp. at risk are instructed to eat/drink only pasteurized milk, yogurt, cheese, other dairy products D: healthy people usually recover from illness in few weeks E: handling raw & fresh food separately to avoid cross contamination may prevent food poisoning B: immunocompromised individuals are at risk for complications from food poisoning C: clients who are esp. at risk are instructed to eat/drink only pasteurized milk, yogurt, cheese, other dairy products E: handling raw & fresh food separately to avoid cross contamination may prevent food poisoning Nurse is caring for client receiving enteral tube feedings d/t dysphagia. Which of following bed positions is appropriate for safe care of this client? A: supine B: semi-fowler's C: semi-prone D: trendelenburg B: semi-fowler's Nurse is caring for client sitting in chair & asks to return to bed. Which is priority action for nurse to take at this time? A: obtain walker for client to use to transfer back to bed B: call for additional personnel to assist with transfer C: use transfer belt & assist client to bed D: assess client's ability to help with transfer D: assess client's ability to help with transfer Nurse is completing discharge teaching to client with COPD. Client verbalizes understanding of orthopneic position when he states, "When I have difficulty breathing at night, I will... A: lie on my back with head & shoulders elevated on a pillow" B: lie flat on my stomach with head to one side" C: sit on side of my bed & rest my arms over pillows on top of my raised bedside table" D: lie on my side with my weight on my hips & shoulder with my arms flexed in front of me" C: sit on side of my bed & rest my arms over pillows on top of my raised bedside table" Nurse manager is reviewing guidelines to prevent injury with staff nurses. Which of the followign should nurse manager include in teaching? (Select all that apply.) A: request assistance when repositioning a client B: avoid twisting spine or bending at waist C: keep knees slightly lower than hips when sitting for long periods of time D: use smooth movements when lifting & moving clients E: take break from repetitive movements every 2-3h to flex & stretch joints & muscles A: request assistance when repositioning a client B: avoid twisting spine or bending at waist D: use smooth movements when lifting & moving clients Nurse educator is teaching module on proper body mechanics during employee orientation. Which statements by new nurse indicates need for more teaching? A: "My line of gravity should fall outside my base of support" B: "The lower my center of gravity, the more stability I have" C: "To broaden my base of support, I should spread my feet apart" D: "When I lift an object, I should hold it as close to my body as possible" A: "My line of gravity should fall outside my base of support" Nurse is caring for many clients during mass casualty event. Which client is highest priority? A: client with crush injuries to chest/abdomen & expected to die B: client with 4-inch laceration to head C: client with partial & full-thickness burns to face, neck, chest D: client with fractured fibula & tibia C: client with partial & full-thickness burns to face, neck, chest Nurse on med-surg unit is informed that mass casualty event occurred & it's necessary to discharge clients to make beds available for injury victims. Which clients can be safely discharged? (Select all that apply.) A: client who's dehydrated & receiving IV fluid/electrolytes B: client with NG tube to treat small bowel obstruction C: client who's scheduled for TURP (prostate resection) D: client who is 24h post-op after mastectomy E: client scheduled for appendectomy C: client who's scheduled for TURP (prostate resection) D: client who is 24h post-op after mastectomy Nurse educator is discussing facility protocol for tornados with staff. Which should nurse include in instructions? (Select all that apply.) A: open doors to client rooms B: place blankets over clients who are confined to beds C: move beds away from windows D: draw shades & close drapes E: relocate ambulatory clients in hallways back to rooms B: place blankets over clients who are confined to beds C: move beds away from windows D: draw shades & close drapes Occupational health nurse is caring for employee with chemical burn from unknown chemical. Which intervention should nurse include in care plan? A: irrigate affected area with running water B: wash affected area with antibacterial soap C: brush chemical off skin & clothing D: apply neutralizing agent C: brush chemical off skin & clothing Security officer reviewing actions to take in event of bomb threat by phone. Which statement indicates proper understanding of procedure? A: "I will get the caller off the phone ASAP to alert the staff" B: "I will use overhead paging to alert entire facility" C: "I will not ask any questions & just let the caller talk" D: "I will listen for background noises" D: "I will listen for background noises" Nurse caring for 19 yo client who is sexually active & has come to college health clinic for first time for checkup. Which intervention should nurse perform to determine client's health promotion & disease prevention? A: measure the vital signs B: encourage HIV screening C: determine client's risk factors D: instruct client to use condoms C: determine client's risk factors Nurse in clinic caring for 21 yo client who reports sore throat. Client tells nurse he hasn't seen a doctor since high school. Which health screening should nurse expect provider to perform for this client? A: testicular exam B: blood glucose C: fecal occult blood D: prostate-specific antigen A: testicular exam Nurse is talking with 45 yo client with no specific family hx of cancer or DM, about planning routine screenings. Which client statement indicates client understands how to proceed? A: "So I don't need colon cancer procedure for another 2-3 yrs" B: "For now, I should continue to have mammogram each year" C: "B/c doctor just did pap smear, I'll come back next year for another" D: "I had my blood glucose test last year so I won't need it again till next year" B: "For now, I should continue to have mammogram each year" Nurse is caring for client with many risk factors for CV disease. When planning health promotion & disease prevention strategies for this client, which intervention should nurse include? (Select all that apply.) A: help client see benefits of her actions B: identify client's support systems C: suggest & recommend community resources D: devise & set goals for client E: teach stress management strategies A: help client see benefits of her actions B: identify client's support systems C: suggest & recommend community resources E: teach stress management strategies When nurse is observing client drawing up & mixing insulin injections, which best demonstrates psychomotor learning has taken place? A: client able to discuss appropriate technique B: client able to demonstrate appropriate technique C: client states he understands D: client is able to write steps on piece of paper B: client able to demonstrate appropriate technique Nurse is collecting data from mother of 1 yo. Client states her child is old enough for toilet training. Following teaching by nurse, client now states her earlier ideas have changed. She's now willing to postpone toilet training until child is older. Learning has occurred in which of following domains? A: cognitive B: affective C: psychomotor D: kinesthetic B: affective Nurse providing pre-op teaching for client scheduled for mastectomy next day. Which client statement indicates client is ready to learn? A: "I don't want my spouse to see my incision" B: "Will you be able to give me pain meds after surgery?" C: "Can you tell me about how long the surgery will take?" D: "My roommate listens to everything I say" C: "Can you tell me about how long the surgery will take?" Nurse preparing instructional session about managing stress incontinence for older adult. Which actions should nurse take first when meeting with client? A: encourage client to participate actively in learning B: select instructional materials appropriate for older adult C: identify goals nurse & client can agree are reasonable D: determine what client knows about stress incontinence D: determine what client knows about stress incontinence Nurse evaluating how well client learned the info presented in teaching about heart-healthy diet. Client states she understands what to do now. Which actions by nurse should assist evaluation of client's learning? A: encourage client to ask questions B: ask client to explain how to select or prepare meals C: encourage client to fill out eval form D: ask client if she has resources for further instruction on topic B: ask client to explain how to select or prepare meals Nurse talking with parents of 6 mo infant about gross motor development. Which gross motor skills are expected in next 3 mo? (Select all that apply.) A: rolls from back to front B: bears weight on legs C: walks holding onto furniture D: sits unsupported E: sits down from standing position A: rolls from back to front B: bears weight on legs D: sits unsupported Nurse cautioning mother of 8 mo infant about safety. Which statement by mother indicates understanding of safety for infant? A: "My baby loved to play with crib gym, but I took it from him" B: "I just bought a soft mattress so my baby will sleep better" C: "My baby really likes sleeping on fluffy pillow we just got for him" D: "I just bought a child-safety gate that folds like accordion" A: "My baby loved to play with crib gym, but I took it from him" Nurse reviewing carseat safety with parents of 1 mo infant. When reviewing this, which instructions should nurse include? A: use car seat that has 3-point harness B: position car seat so that infant is rear-facing C: secure car seat in front passenger seat of car D: put soft padding in car seat behind infants back & neck B: position car seat so that infant is rear-facing Mother of 7 mo infant tells nurse that her baby has been fussy with occasional loose stools since she started feeding him fruits & veggies. Which responses by nurse are appropriate? (Select all that apply.) A: "It might be good to add bananas, as they help with loose stools" B: "Let's make list of foods he's eating so we can spot problems" C: "Did the changes begin after you started 1 particular food?" D: "Has he been vomiting since he started these new foods?" E: "Most babies react with indigestion when you start new foods" B: "Let's make list of foods he's eating so we can spot problems" C: "Did the changes begin after you started 1 particular food?" D: "Has he been vomiting since he started these new foods?" Nurse is giving presentation about accident prevention to group of parents & toddlers. Which strategies should nurse include? (Select all that apply.) A: keep toxic agents in locked cabinets B: keep toilet seats up C: turn pot handles toward back of stove D: place safety gates across stairways E: make sure balloons are fully inflated A: keep toxic agents in locked cabinets C: turn pot handles toward back of stove D: place safety gates across stairways Nurse planning diversionary activities for children on an inpatient unit. Which should nurse incorporate as appropriate play activities for toddler? (Select all that apply.) A: building simple models B: working with clay C: filling & emptying containers D: playing with blocks E: looking at books C: filling & emptying containers D: playing with blocks E: looking at books Nurse is talking with parents of toddler. Which should nurse suggest regarding discipline? A: establish consistent boundaries B: place him in room with door closed C: have him learn by trial & error D: use favorite snacks as rewards A: establish consistent boundaries A mother tells nurse that her 2 yo has temper tantrums. Child says "no" every time mother tries to help her get dressed. Nurse explains that developmentally the toddler is... A: trying to gain her independence B: developing sense of trust C: manifesting anger management problem D: attempting to finish a project she started A: trying to gain her independence Nurse is reviewing nutrition guidelines with parents of 2 yo. Which parent statement should indicate to nurse that they understand feeding guidelines for this age group? A: "I should keep feeding my son whole milk until he's 3 yo" B: "It's okay for me to give him a cup of apple juice with each meal" C: "I'll give my son about 2 tablespoons of each food at mealtimes" D: "My son loves popcorn, & I know it's better for him than sweets" C: "I'll give my son about 2 tablespoons of each food at mealtimes" Nurse is planning diversionary activities for children on inpatient peds unit. Which should nurse incorporate as appropriate play activities for preschoolers? (Select all that apply.) A: assembling puzzles B: pulling wheeled toys C: using musical toys D: using finger paints E: coloring with crayons A: assembling puzzles C: using musical toys E: coloring with crayons Nurse caring for 5 yo whose parents report she fears painful procedures, like shots. Which strategies should nurse use to try to help ease child's fear? (Select all that apply.) A: invite child to assist with mealtime activities B: cluster invasive procedures whenever possible C: assign caregivers with whom the child is familiar D: have parents bring in favorite toy from home E: engage child in pretend play with toy medical kit A: invite child to assist with mealtime activities D: have parents bring in favorite toy from home E: engage child in pretend play with toy medical kit Nurse reviewing CDC's immunization recommendations with parents of 2 preschoolers. Which recommendations should nurse include in this discussion? (Select all that apply.) A: Haemophilus influenzae type b B: Varicella C: polio D: hepatitis A E: seasonal influenza B: Varicella C: polio E: seasonal influenza Nurse talking to parents of school-age child who describe many issues that concern them. Which problem should nurse identify as priority for more assessment & intervention? A: "He doesn't keep up with other kids in activities like running & jumping" B: "He keeps trying to find ways around household rules; he always wants to make deals with us" C: "We think he is trying too hard to excel in math just to get top grades in his class" D: "He is always afraid the kids at school will laugh at him b/c he likes to sing & write poems" A: "He doesn't keep up with other kids in activities like running & jumping" Nurse planning diversionary activities for children on peds unit. Which should nurse incorporate as appropriate play activities for school-age children? (Select all that apply.) A: building models B: playing video games C: reading books D: using toy carpentry tools E: shaping modeling clay A: building models B: playing video games C: reading books Nurse reviewing nutrition guidelines with parents of 11 yo. Which parent statement should indicate to nurse that they understand guidelines for school-age children? A: "She wants to eat as much as us, but we're afraid she'll be overweight." B: "She skips lunch sometimes but we figure it's okay as long as she has healthy breakfast & dinner." C: "We limit fast food restaurant meals to 3x/week now" D: "We reward her school achievements with point system instead of pizza or ice cream" D: "We reward her school achievements with point system instead of pizza or ice cream" Nurse at elementary school is planning health promotion & primary prevention class. Which topics are appropriate for parents of school-age children? (Select all that apply.) A: childhood obesity B: substance use disorders C: scoliosis screening D: front-seat seatbelt use E: stranger awareness A: childhood obesity B: substance use disorders C: scoliosis screening E: stranger awareness Nurse is talking with father of 12 yo boy who's concerned he hasn't observed any signs his son is approaching puberty. Nurse should explain that first sign of sexual maturation in boys is... A: appearance of downy hair on upper lip B: hair growth in axillae C: enlargement of testes & scrotum C: enlargement of testes & scrotum Nurse on peds unit is caring for adolescent with multiple fractures. Which interventions are appropriate for client? (Select all that apply.) A: suggest his parents room in with him B: provide a TV & DVDs for him to watch C: limit visitors to immediate family D: devise a regular schedule for inpatient routines E: allow him to perform his own morning care B: provide a TV & DVDs for him to watch E: allow him to perform his own morning care Nurse talking with adolescent who describes having difficulty dealing with several issues. Which problem should nurse identify as priority for further assessment & intervention? A: "I kind of like this girl in my class, but she doesn't like me back like that." B: "I like hanging out with the guys in the science club, but the jocks pick on them." C: "I just don't seem to be good at anything. I can't play sports at all." D: "My dad wants me to be a lawyer like him, but I don't want to learn all that stuff." C: "I just don't seem to be good at anything. I can't play sports at all." Nurse reviewing CDC's immunization recommendations with parents of adolescent. Which should nurse include in this discussion? (Select all that apply.) A: rotavirus B: varicella C: herpes zoster D: HPV E: seasonal influenza B: varicella D: HPV E: seasonal influenza Nurse preparing wellness presentation for families at community center. When discussing health screenings for adolescents, which info about scoliosis should nurse include? (Select all that apply.) A: scoliosis is more common in girls than in boys B: loss of height is often first sign of scoliosis C: scoliosis screening is essential during adolescent growth spurt D: slouching is common cause of scoliosis, esp. in adolescents E: scoliosis is forward curvature of spine A: scoliosis is more common in girls than in boys C: scoliosis screening is essential during adolescent growth spurt Nurse is teaching young adult about health promotion & illness prevention. Which client statement indicates understanding? A: "I already had my immunizations as a child, so I'm protected in that area." B: "It's important to schedule routine healthcare visits even if I'm feeling well" C: "If I'm having any discomfort, I'll just go to an urgent care center" D: "If I'm feeling stressed, I will remind myself that this is something I should expect" B: "It's important to schedule routine healthcare visits even if I'm feeling well" Nursing instructor explaining various stages of lifespan to students. Nurse should offer which following behavior by young adult as example of appropriate psychosocial development? A: becoming actively involved in providing guidance to next generation B: adjusting to major changes in roles/relationships due to losses C: devoting great deal of time to establishing occupation D: finding oneself "sandwiched" between being responsible for 2 generations C: devoting great deal of time to establishing occupation Nurse counseling young adult who describes having difficulty dealing with several issues. Which problem should nurse identify as priority for further assessment & intervention? A: "I have my own apt now, but it's not easy living away from my parents" B: "It's been so stressful for me to even think about having my own family" C: "I don't even know who I am yet, & now I'm supposed to know what to do" D: "My girlfriend is pregnant, & I don't think I have what it takes to be a good father" C: "I don't even know who I am yet, & now I'm supposed to know what to do" Nurse is reviewing safety precautions with group of young adults at community health fair. Which recommendations should nurse include specifically for this age group? (Select all that apply.) A: install bath rails & grab bars in bathrooms B: wear helmet while skiing C: install carbon monoxide detector D: secure firearms in safe location E: remove throw rugs from the home B: wear helmet while skiing C: install carbon monoxide detector D: secure firearms in safe location Nurse reviewing CDC's immunization recommendations for young adult. Which should nurse include in this discussion? (Select all that apply.) A: HPV B: measles, mumps, rubella C: varicella D: Haemophilus influenzae type b E: polio A: HPV B: measles, mumps, rubella C: varicella Nursing instructor is explaining various stages of lifespan to students. Nurse should offer which of following behaviors by young adult as example of accomplishing Erikson's tasks for psychosocial development during middle adulthood? A: client evaluates his behavior after social interaction B: client states he is learning to trust others C: client wishes to find meaningful relationships D: client expresses concerns about next generation D: client expresses concerns about next generation Nurse collecting data to evaluate middle adult's psychosocial development. Nurse should expect middle adults to demonstrate which capabilities? (Select all that apply.) A: develop acceptance of diminished strength & increased dependence on others B: feel frustrated that time is too short for trying to start another life C: welcome opportunities to be creative & productive D: commit to finding friendship & companionship E: become involved in community issues & activities C: welcome opportunities to be creative & productive E: become involved in community issues & activities Nurse collecting hx & physical exam data from middle adult. Nurse should expect to find decreases in which physiologic functions? (Select all that apply.) A: metabolism B: ability to hear low-pitched sounds C: gastric secretion D: far vision E: glomerular filtration A: metabolism C: gastric secretion E: glomerular filtration Nurse reviewing CDC's immunizations recommendations with middle adult. Which should nurse include in this discussion? (Select all that apply.) A: Haemophilus influenzae type b B: varicella C: herpes zoster D: HPV E: seasonal influenza B: varicella C: herpes zoster E: seasonal influenza Nurse counseling middle adult who describes having difficulty with many issues. Which problem should nurse identify as priority for more assessment & intervention? A: "I'm struggling to accept my parents are aging & need so much help" B: "It's been so stressful for me to think about having intimate relationships" C: "I know I should volunteer my time for good cause, but maybe I'm just selfish" D: "I love my grandchildren, but my son expects me to relive my parenting days" B: "It's been so stressful for me to think about having intimate relationships" Nurse is counseling older adult who describes having difficulty with several issues. Which problem should nurse identify as priority for more assessment & intervention? A: "I spent my whole life dreaming about retirement, & now I wish I had my job back" B: "It's been so stressful for me to have to depend on my son to help around the house" C: "I just heard my friend Al died. That's the 3rd one in 3 months." D: "I'm struggling with helping out in my community. I just don't know what I can do." D: "I'm struggling with helping out in my community. I just don't know what I can do." Nurse is admitting older adult who lost 4.5 kg since last admission 6 mo ago. Which questions should nurse ask to investigate source of weight loss? (Select all that apply.) A: "Do you eat alone or with someone?" B: "Do you watch TV while eating your meals?" C: "Have you started any new meds in past 6 mo?" D: "What foods have you eaten in past 24 hrs?" E: "Are you on a fixed income?" A: "Do you eat alone or with someone?" C: "Have you started any new meds in past 6 mo?" D: "What foods have you eaten in past 24 hrs?" E: "Are you on a fixed income?"