The practical nurse (PN) is monitoring a child who is manifesting signs of shock
| | | | | | | | | | | | |
after a motor vehicle collision. Which finding is most important for the PN to
| | | | | | | | | | | | | |
report to the charge nurse?
| | | | |
a) narrowing pulse pressure
| | |
b) apprehension
|
c) irritability
|
d) thirst✅✅Answer: A
| |
Rationale:
As shock progresses, perfusion in the microcirculation becomes marginal
| | | | | | | |
despite compensatory adjustments, and the signs of decompensated shock
| | | | | | | | |
become pronounced, such as tachycardia and narrowing pulse pressure (A).
| | | | | | | | | |
(The difference between systolic and diastolic blood pressure), which should be
| | | | | | | | | | |
reported immediately. (B,C, and D) are not as significant as (A).
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The mother of a 9 month old male infant is concerned because he cries
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whenever she leaves him with a sitter. What is the best response for the
| | | | | | | | | | | | | |
practical nurse (PN) to provide?
| | | | |
a) "Have you noticed whether your baby is teething?"
| | | | | | | |
b) "Crying when you leave him in a healthy sign of attachment."
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,c) "Consider taking the baby to the doctor because he may be ill."
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d) "You could consider leaving the infant more often so he can
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adjust."✅✅Answer: B
| |
Rationale:
Healthy attachment is manifested by stranger anxiety in late infancy (B). Pain
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from teething expressed by the infant's cries does not occur only when the
| | | | | | | | | | | | |
mother leaves the infant with another person (A). The PN should evaluate the
| | | | | | | | | | | | |
infant's developmental needs (C) before suggesting the infant may be ill. An
| | | | | | | | | | | |
infant who manifests stranger anxiety is best supported by the mother if the
| | | | | | | | | | | | |
infant is left for shorter periods of time, not (D).
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Which preoperative action is most important for the practical nurse (PN) to
| | | | | | | | | | |
implement for a newborn with meningomyelocele?
| | | | | |
a) document vital signs
| | |
b) prevent skin breakdown
| | |
c) minimize the risk for infection
| | | | |
d) monitor neurologic functioning✅✅Answer: C
| | | |
Rationale:
A meningomyelocele provides a direct entry for bacteria into the central
| | | | | | | | | |
nervous system, leading to meningitis. Measures that protect the integrity of
| | | | | | | | | | |
the meningomyelocele sac and infection control measures should be
| | | | | | | | |
implemented to minimize the risk of infection (C). (A,B, and D) should be
| | | | | | | | | | | | |
implemented but do not have the priority of (C).
| | | | | | | | |
,The practical nurse is caring for a 6 year old girl who had surgery 12 hours ago.
| | | | | | | | | | | | | | | |
The child tells the PN that she does not have pain but a few minutes later, tells
| | | | | | | | | | | | | | | | |
her parents that she does. What child development concept is relevant to this
| | | | | | | | | | | | |
situation?
|
a) inconsistency in pain reporting suggests that pain not present
| | | | | | | | |
b) a child may have pain yet deny its presence to the nurse
| | | | | | | | | | | |
c) truthful reporting of pain should occur by this age
| | | | | | | | |
d) children use pain experiences to manipulate their parents✅✅Answer: B
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Rationale:
A child may fear receiving an injection for pain or may believe that pain is a
| | | | | | | | | | | | | | |
deserved punishment for some misdeed, so the pain is denied (D) when the
| | | | | | | | | | | | |
nurse asks the child, who then readily admits having pain to a parent. This
| | | | | | | | | | | | | |
behavior should not be interpreted as (C) but as a valid indication of pain. (A
| | | | | | | | | | | | | | |
and C) are incorrect interpretations of this behavior.
| | | | | | | |
A 6 year old who had a tonsillectomy 12 hours ago is complaining of thirst.
| | | | | | | | | | | | | |
What should the practical nurse (PN) offer?
| | | | | | |
a) popsicle
|
b) lemonade
|
c) orange juice
| |
d) chocolate milk✅✅Answer: A
| | |
Rationale:
, Small amounts of clear liquids without red dyes should be offered to the child.
| | | | | | | | | | | | |
Popsicles (A) are cold and help soothe a dry throat. Citrus drinks (B and C) are
| | | | | | | | | | | | | | | |
acidic and irritate the operative site in the posterior oropharynx. Milk (D)
| | | | | | | | | | | |
thickens oral mucus which makes swallowing more difficult and causes
| | | | | | | | | |
coughing.
|
The mother of a male newborn calls the clinic to inquire about the formation of
| | | | | | | | | | | | | |
a yellow crust over her son's circumcision area. What information should the
| | | | | | | | | | | |
practical nurse (PN) provide?
| | | |
a) do not remove the yellow crust from the site
| | | | | | | | |
b) stop using petroleum around the head of the penis
| | | | | | | | |
c) bring him into the clinic
| | | | |
d) tightly fasten the diaper✅✅Answer: A
| | | | |
Rationale:
Crust formation is part of the healing process and should be removed (A). (C) is
| | | | | | | | | | | | | |
not indicated at this time. The diaper should be fastened loosely, not tightly
| | | | | | | | | | | | |
(D) which can place pressure on the incision site. (B) assists in the healing
| | | | | | | | | | | | | |
process and should not be discontinued.
| | | | | |
The mother of a child with croup is having barking, coughing episodes calls the
| | | | | | | | | | | | |
clinic for assistance. What action should the practical nurse (PN) recommend
| | | | | | | | | | |
that the mother implement first?
| | | | |
a) take the child outside in the cool air
| | | | | | | |
b) bring the child directly to the emergency room
| | | | | | | |
c) sit with the child in bathroom with a hot shower running
| | | | | | | | | | |
| | | | | | | | | | | | |
after a motor vehicle collision. Which finding is most important for the PN to
| | | | | | | | | | | | | |
report to the charge nurse?
| | | | |
a) narrowing pulse pressure
| | |
b) apprehension
|
c) irritability
|
d) thirst✅✅Answer: A
| |
Rationale:
As shock progresses, perfusion in the microcirculation becomes marginal
| | | | | | | |
despite compensatory adjustments, and the signs of decompensated shock
| | | | | | | | |
become pronounced, such as tachycardia and narrowing pulse pressure (A).
| | | | | | | | | |
(The difference between systolic and diastolic blood pressure), which should be
| | | | | | | | | | |
reported immediately. (B,C, and D) are not as significant as (A).
| | | | | | | | | | |
The mother of a 9 month old male infant is concerned because he cries
| | | | | | | | | | | | |
whenever she leaves him with a sitter. What is the best response for the
| | | | | | | | | | | | | |
practical nurse (PN) to provide?
| | | | |
a) "Have you noticed whether your baby is teething?"
| | | | | | | |
b) "Crying when you leave him in a healthy sign of attachment."
| | | | | | | | | | |
,c) "Consider taking the baby to the doctor because he may be ill."
| | | | | | | | | | | |
d) "You could consider leaving the infant more often so he can
| | | | | | | | | | |
adjust."✅✅Answer: B
| |
Rationale:
Healthy attachment is manifested by stranger anxiety in late infancy (B). Pain
| | | | | | | | | | |
from teething expressed by the infant's cries does not occur only when the
| | | | | | | | | | | | |
mother leaves the infant with another person (A). The PN should evaluate the
| | | | | | | | | | | | |
infant's developmental needs (C) before suggesting the infant may be ill. An
| | | | | | | | | | | |
infant who manifests stranger anxiety is best supported by the mother if the
| | | | | | | | | | | | |
infant is left for shorter periods of time, not (D).
| | | | | | | | | |
Which preoperative action is most important for the practical nurse (PN) to
| | | | | | | | | | |
implement for a newborn with meningomyelocele?
| | | | | |
a) document vital signs
| | |
b) prevent skin breakdown
| | |
c) minimize the risk for infection
| | | | |
d) monitor neurologic functioning✅✅Answer: C
| | | |
Rationale:
A meningomyelocele provides a direct entry for bacteria into the central
| | | | | | | | | |
nervous system, leading to meningitis. Measures that protect the integrity of
| | | | | | | | | | |
the meningomyelocele sac and infection control measures should be
| | | | | | | | |
implemented to minimize the risk of infection (C). (A,B, and D) should be
| | | | | | | | | | | | |
implemented but do not have the priority of (C).
| | | | | | | | |
,The practical nurse is caring for a 6 year old girl who had surgery 12 hours ago.
| | | | | | | | | | | | | | | |
The child tells the PN that she does not have pain but a few minutes later, tells
| | | | | | | | | | | | | | | | |
her parents that she does. What child development concept is relevant to this
| | | | | | | | | | | | |
situation?
|
a) inconsistency in pain reporting suggests that pain not present
| | | | | | | | |
b) a child may have pain yet deny its presence to the nurse
| | | | | | | | | | | |
c) truthful reporting of pain should occur by this age
| | | | | | | | |
d) children use pain experiences to manipulate their parents✅✅Answer: B
| | | | | | | | |
Rationale:
A child may fear receiving an injection for pain or may believe that pain is a
| | | | | | | | | | | | | | |
deserved punishment for some misdeed, so the pain is denied (D) when the
| | | | | | | | | | | | |
nurse asks the child, who then readily admits having pain to a parent. This
| | | | | | | | | | | | | |
behavior should not be interpreted as (C) but as a valid indication of pain. (A
| | | | | | | | | | | | | | |
and C) are incorrect interpretations of this behavior.
| | | | | | | |
A 6 year old who had a tonsillectomy 12 hours ago is complaining of thirst.
| | | | | | | | | | | | | |
What should the practical nurse (PN) offer?
| | | | | | |
a) popsicle
|
b) lemonade
|
c) orange juice
| |
d) chocolate milk✅✅Answer: A
| | |
Rationale:
, Small amounts of clear liquids without red dyes should be offered to the child.
| | | | | | | | | | | | |
Popsicles (A) are cold and help soothe a dry throat. Citrus drinks (B and C) are
| | | | | | | | | | | | | | | |
acidic and irritate the operative site in the posterior oropharynx. Milk (D)
| | | | | | | | | | | |
thickens oral mucus which makes swallowing more difficult and causes
| | | | | | | | | |
coughing.
|
The mother of a male newborn calls the clinic to inquire about the formation of
| | | | | | | | | | | | | |
a yellow crust over her son's circumcision area. What information should the
| | | | | | | | | | | |
practical nurse (PN) provide?
| | | |
a) do not remove the yellow crust from the site
| | | | | | | | |
b) stop using petroleum around the head of the penis
| | | | | | | | |
c) bring him into the clinic
| | | | |
d) tightly fasten the diaper✅✅Answer: A
| | | | |
Rationale:
Crust formation is part of the healing process and should be removed (A). (C) is
| | | | | | | | | | | | | |
not indicated at this time. The diaper should be fastened loosely, not tightly
| | | | | | | | | | | | |
(D) which can place pressure on the incision site. (B) assists in the healing
| | | | | | | | | | | | | |
process and should not be discontinued.
| | | | | |
The mother of a child with croup is having barking, coughing episodes calls the
| | | | | | | | | | | | |
clinic for assistance. What action should the practical nurse (PN) recommend
| | | | | | | | | | |
that the mother implement first?
| | | | |
a) take the child outside in the cool air
| | | | | | | |
b) bring the child directly to the emergency room
| | | | | | | |
c) sit with the child in bathroom with a hot shower running
| | | | | | | | | | |
