HESI EXIT V4 Questions and Answers

The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which nursing intervention is appropriate for this child? A. Make certain the child is maintained in correct body alignment. B. Be sure the traction weights touch the end of the bed. C. Adjust the head and foot of the bed for the child's comfort D. Release the traction for 15-20 minutes every 6 hours PRN. - A. Make certain the child is maintained in correct body alignment. The nurse is assessing a healthy child at the 2 year check up. Which of the following should the nurse report immediately to the health care provider? A. Height and weight percentiles vary widely B. Growth pattern appears to have slowed C. Recumbent and standing height changes are uneven D. Short term weight changes are uneven - A. Height and weight percentiles vary widely The parents of a 2 year-old child report that he has been holding his breath whenever he has temper tantrums. What is the best action by the nurse? A. Teach the parents how to perform cardiopulmonary resuscitation B. Recommend that the parents give in when he holds his breath to prevent anoxia C. Advise the parents to ignore breath holding because breathing will begin as a reflex D. Instruct the parents on how to reason with the child about possible harmful effects - C. Advise the parents to ignore the breath holding because breathing will begin as a reflex The nurse is assessing a client in the emergency room. Which statement suggests that the problem is acute angina? A. "My pain is deep in my chest behind my sternum" B. "When I sit up the pain gets worse" C. "As I take a deep breath the pain gets worse" D. "The pain is right here in my stomach area" - A. "My pain is deep in my chest behind my sternum" The nurse is assessing the mental status of a client admitted with possible organic brain disorder. Which of these questions will best assess the function of the client's recent memory? A. "Name the year." What season is this?" (pause for answer after each question) B. "Subtract 7 from 100 and then subtract 7 from that." (pause for answer) "Now continue to subtract 7 from the new number." C. "I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen." D. "What is this on my wrist? (point to your watch) Then ask, "What is the purpose of it?" - C. "I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen." In planning care for a 6-month old infant, what must the nurse provide to assist in the development of trust? A. Food B. Warmth C. Security D. Comfort - C. Security A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication? A. "I cannot give the medication as it is written. I have no idea of what you mean." B. "Would you please clarify what you have written so I am sure I am reading it correctly?" C. "I am having difficulty reading your handwriting. It would save me time if you would be more careful." D. "Please print in the future so I do not have to spend extra time attempting to read your writing." - B. "Would you please clarify what you have written so I am sure I am reading it correctly?" What is the most important consideration when teaching parents how to reduce the risk in the home? A. Age and knowledge level of the parents B. Proximity to emergency services C. Number of children in the home D. Age of children in the home - D. Age of children in the home A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse enters the room to request something for pain. The nurse should A. Administer a placebo B. Encourage increased fluid intake C. Administer the prescribed analgesia D. Recommend relaxation exercises for pain control - C. Administer the prescribed analgeisa While caring for a toddler with croup, which initial sign of croup requires the nurse's immediate attention? A. Respiratory rate of 30 B. Lethargy for the past hour C. Apical pulse of 54 D. Coughing up copious secretions - C. Respiratory rate of 30 (or 42) A client is admitted with low T3 and T4 levels an elevated TSH level. On initial assessment, the nurse would anticipate which of the following assessment findings? A. Lethargy B. Heat intolerance C. Diarrhea D. Skin eruptions - A. Lethargy The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence, and denies any family history of epilepsy. What is the best response by the nurse? A. "Do not worry. Epilepsy can be treated with medications." B. "The seizure may or may not mean your child has epilepsy." C. "Since this was the first convulsion, it may not happen again." D. "Long term treatment will prevent future seizures." - B. "The seizure may or may not mean your child has epilepsy." Alcohol and drug abuse impairs judgement and increases risk taking behavior. What nursing diagnosis best applies? A. Risk for injury B. Risk for knowledge deficit C. Altered thought process D. Disturbance in self-esteem - A. Risk for injury The nurse is caring for a 10 month-old infant who has oxygen via mask. It is important for the nurse to maintain latency of which of the areas? A. Mouth B. Nasal passage C. Back of throat D. Bronchial - B. Nasal passages The nurse is providing instructions for a client with pneumonia. What is the most important information to convey to the client? A. "Take at least 2 weeks off from work." B. "You will need another chest x-ray in 6 weeks." C. "Take your temperature every day." D. "Complete all of the antibiotic even if your findings decrease." - D. "Complete all of the antibiotic even if your findings decrease." When counseling a 6 year old who is experiencing enuresis, what must the nurse understand about the pathophysiological basis of this disorder? A. Has no clear etiology B. May be associated with sleep phobia C. Has a definite genetic link D. Is a sign of willful misbehavior - A. Has no clear etiology The nurse is discussing negativism with the parents of a 30 month-old child. How should the nurse tell the parents to best respond to this behavior? A. Reprimand the child and give a 15 minute "time out" B. Maintain a permissive attitude for this behavior C. Use patience and a sense of humor to deal with this behavior D. Assert authority over the child through limit setting - C. Use patience and a sense of humor to deal with this behavior The nurse is talking by telephone with a parent of a 4 year-old child who has chickenpox. Which of the following demonstrates appropriate teaching by the nurse? A. Chewable aspirin is the preferred analgesic B. Topical cortisone ointment relieves itching C. Papule's, vesicles, and crusts will be present at one time. D. The illness is only contagious prior to lesion eruption - C. Papule's, vesicles, and crusts will be present at one time The nurse is assigned to a client who has heart failure. During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing intervention should be performed first? A. Take the client's vital signs B. Place the client in a sitting position with legs dangling C. Contact the health care provider D. Administer the PRN anti anxiety agent - B. Place the client in a sitting position with legs dangling The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the parents to A. Dress the child warmly to avoid chilling B. Keep the child away from other children for the duration of the rash C. Clean the affected areas with tepid water and detergent D. Wrap the child's hand in mittens or socks to prevent scratching - D. Wrap the child's hands in mittens or socks to prevent scractching A recovering alcoholic asked the nurse, "will it be ok for me to just drink at special family gatherings?" Which initial response by the nurse would be best? A. "A recovering person has to be very careful not to lose control, therefore, confine your drinking just at family gatherings" B. "At your next AA meeting discuss the possibility of limited drinking with your sponsor." C. " A recovering person needs to get in touch with their feelings. Do you want a drink?" D. "A recovering person cannot return to drinking without starting the addiction process over." - D. "A recovering person cannot return to drinking without starting the addiction process over." In taking the history of a pregnant woman, which of the following would the nurse recognize as the primary contraindication for breast feeding? A. Age of 40 years B. Lactose intolerance C. Family history of breast cancer D. Uses cocaine on weekends - D. Uses cocaine on weekends A client is receiving nitroprusside IV of the treatment of acute heart failure with pulmonary edema. What diagnostic lab value should the nurse monitor in relation to this medication? A. Potassium B. Arterial blood gasses C. Blood urea nitrogen D. Thiocyanate - D. Thiocyanate A victim of domestic violence tells the batterer she needs a little time away. How would the nurse expect that the batterer might respond? A. With acceptance and views the victim's comment as an indication that their marriage is in trouble B. With fear of rejection causing increased rage toward the victim C. With a new commitment to seek counseling to assist with their marital problems D. With relief, and welcomes the seperation as a means to have some personal time - B. With fear of rejection causing increased rage toward the victim A postpartum mother is unwilling to allow the father to participate in the newborn's care, although he is interested in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is for mother's, not fathers." The nurse's initial intervention should be what focus? A. Discuss with the mother sharing parenting responsibilities B. Set time aside to get the mother to express her feelings and concerns C. Arrange for the parents to attend infant care classes D. Talk with the father and help him accept the wife's decision - B. Set time aside to get the mother to express her feelings and concerns A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that the client A. Eat foods high in sodium increases sputum liquefaction B. Use oxygen during meals improves gas exchange C. Perform exercise after respiratory therapy enhances appetite D. Cleanse the mouth of dried secretions reduces risk of infection - B. Use oxygen during meals improves gas exchange Which of the following parents' comment for a newborn would most likely reveal an initial finding of a suspected pyloric stenosis? A. I noticed a little lump above the belly button B. The baby seems hungry all the time C. Mild vomiting that progressed to vomiting shooting across the room D. Irritation and spitting up immediately after feedings - C. Mild vomiting that progressed to vomiting shooting across the room The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse recognize as cause for the findings? A. Decreased Cardiac output B. Tissue hypoxia C. cerebra edema D. Reduced oxygen saturation - B. Tissue hypoxia The nurse would expect cystic fibrosis client to received supplemental pancreatic enzymes along with a diet A. High in carbohydrates and proteins B. Low in carbohydrates and proteins C. High in carbohydrates, low in proteins D. Low in carbohydrates, high in proteins - A. High in carbohydrates and proteins In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant? A. increased 10% in height B. 2 deciduous teeth C. Tripled in the birth weight D. Head > chest circumference - C. Tripled the birth weight A hispanic client in the postpartum period refuses the hospital food because it is "cold". The best initial action by the nurse is to A. Have the unlicensed assistive personnel (UAP) reheat the food if the client wishes B. Ask the client what foods are acceptable or bad C. Encourage her to eat for healing and strength D. Schedule the dietitian to meet with the client as soon as possible - B. Ask the client what foods are acceptable The father of an 8 month-old infant asks the nurse if his infant's vocalizations are normal for his age. Which of the following would the nurse expect at this age? A. Cooing B. Imitation of sounds C. Throaty sounds D. Laughter - B. Imitation of sounds The nurse should recognize that physical dependence is accompanied by what findings when alcohol consumption is first reduced or ended? A. Seizures B. Withdrawal C. Craving D. Marked tolerance - B. Withdrawal Immediately following an acute battering incident in a violent relationship, the batterer may respond to partner's injuries by A. Seeking medical help for the victim's injuries B. Minimizing the episode and underestimating the victim's injuries C. Contacting a close friend and asking for help D. Being remorseful and assisting the victim with medical care - B. Minimizing the episode and underestimating the victim's injuries The nurse is planning to give a 3 year-old child oral digoxin. Which of the following is the best approach by the nurse? A. "Do you want to take this pretty red medicine" B. "You will feel better if you take your medicine." C. "This is your medicine, and you must take it all right now." D. "Would you like to take your medicine from a spoon or a cup?" - D. "Would you like to take your medicine from a spoon or a cup." In planning care for a child diagnosed with minimal change of nephrotic syndrome, the nurse should understand the relationship between edema formation and A. Increased retention of albumin in the vascular system B. Decreased colloidal osmotic pressure in the capillaries C. Fluid shift from interstitial spaces into the vascular space D. Reduced tubular reabsorption of sodium and water - B. Decreased colloidal osmotic pressure in the capillaries And eighteen year old has been brought to the emergency room with irritability lethargy over 2 days, dry skin and increased pulse. Based upon the evaluation of these initial findings, the nurse would assess the child for additional findings of A. Septicemia B. Dehydration C. Hypokalemia D. Hypercalcemia - B. Dehydration A client who has been drinking for five years states that he drinks when he gets upset about "things" such as being unemployed or feeling like life is not leading everywhere. The nurse understands that the client is using alcohol as a way to deal with A. Recreational and social needs B. Feelings of anger C. Life's stressors D. Issues of guilt and disappointment - C. Life's stressors The nurse is monitoring and contractions of a woman in labor. A contraction is recorded as beginning of 10:00 A.M. and ending at 10:01 A.M. Another begins at 10:15 A.M. What is the frequency of the contractions? A. 14 minutes B. 10 minutes C. 15 minutes D. Nine minutes - C. 15 minutes The nurse is performing an assessment on a child with severe airway obstruction. Which finding would the nurse anticipate finding? A. Retractions in the intercostal tissues of the thorax B. Chest pain aggravated by the respiratory movement C. Cyanosis and mottling of the skin D. Rapid, shallow respirations - A. Retractions in the soft (intercostal) tissue of the thorax During the evaluation phase for a client, the nurse should focus on A. All finding of physical and psychosocial stressors of the client and in the family B. The client's status, progress toward goal achievement, and ongoing re-evaluation C. Setting short and long-term goals to insure continuity of care from hospital to home D. Select interventions that are measurable and achievable within selected timeframes - B. The client's status, progress toward goal achievement, and ongoing re-evaluation The school nurse suspects that a third-grade child might have attention deficit hyperactivity disorder (ADHD). Prior to referring the child for further evaluation, what should the nurse do? A. Observe the child's behavior on at least 2 occasions B. Consult with the teacher about how to control impulsivity C. Compile a history of behavior patterns and developmental accomplishments D. Compare the child's behavior with classic signs and symptoms - C. Compile a history of behavior patterns and developmental accomplishments Which of the following actions suggested to the RN by the PN during a planning conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the plan of care? A. Measure head circumference B. Place in airborne isolation C. Provide passive range of motion exercises D. Provide an over-the-crib protective top - A. Measure head circumference A client is admitted with a diagnosis of hepatitis B. In reviewing the initial laboratory results, the nurse would expect to find elevation in which of the following values? A. Blood urea nitrogen B. Acid phosphate C. Bilirubin D. Sedimentation rate - C. Bilirubin The nurse is discussing nutritional requirements with the parents of an 18 month-old child. Which of these statements about milk consumption is correct? A. May drink as much milk as desired B. Can have milk mixed with other foods C. Will benefit from fat-free cow's milk D. Should be limited to 3-4 cups of milk daily - D. Should be limited to 3-4 cups of milk daily The nurse is talking with a client. The client abruptly says to the nurse, "The moon is full. Astronaut walk on the moon. Walking is a good health habit." The client's behavior most likely indicates A. Neologisms B. Dissociation C. Flight of ideas D. Word salad - C. Flight of ideas A mother asks about expected motor skills for a 3 year-old child. Which of the following would the nurse emphasize as normal at this age? A. Jumping rope B. Tying shoelaces C. Riding a tricycle D. Playing hopscotch - C. Riding a tricycle A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is A. A transparent film dressing B. Wet dressing with debridement granules C. Wet to dry with hydrogen peroxide D. Moist saline dressing - D. Moist saline dressing The nurse enters a 2 year-old child's hospital room in order to administer an oral medication. When the child is asked if he is ready to take his medicine, he immediately says, "No!" What would be the most appropriate next action? A. Leave the room and return five minutes later and give the medicine B. Explain to the child that the medicine must be taken now C. Give the medication to the father and ask him to give it D. Mix the medication ice cream or applesauce - A. Leave the room and return five minutes later and give the medicine A nurse is doing pre conceptual counseling with a woman who is planning a pregnancy. Which of the following statements suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome? A. "I understand that a glass of wine with dinner is healthy" B. "Beer is not really hard alcohol, so I guess I can drink some" C. "If I drink, my baby may be harmed before I know I am pregnant" D. "Drinking with meals reduces the effects of alcohol" - C. "If I drink, my baby may be harmed before I know I am pregnant" The client who is receiving enteral nutrition through a gastrostomy tube has had 4 diarrhea stools in the past 24 hours. The nurse should A. Review the medications the client is receiving B. Increase the formula infusion rate C. Increase the amount of water used to flush the tube D. Attach a rectal bag to protect the skin - A. Review the medications the client is recieving A nurse is assigned to a client who is a new admission for the treatment of a frontal lobe brain tumor. Which history offered by the family members would be anticipated by the nurse associated with the diagnosis and communicated? A. "My partner's breathing rate is usually below 12" B. "I find the mood swings and the change from a calm person to being angry all the time hard to deal with" C. It seems our sex life is non existent over the past 6 months" D. In the morning and evening I hear complaints that reading is next to impossible from blurred print" - B. "I find the mood swings and the change from a calm person to being angry all the time hard to deal with" The nurse prepares for a Denver Screening test with a 3 year-old child in the clinic. The mother asks the nurse to explain the purpose of the test. What is the nurse's best response about the purpose of the Denver? A. It measures a child's intelligence B. It assess a child's development C. It evaluates psychological responses D. It helps to determine problems - B. It assess a child's development The nurses is preparing a 5 year-old for a scheduled tonsillectomy and adenoidectomy. The parents are anxious and concerned about the child's reaction to impending surgery. Which nursing intervention would be best to prepare the child? A. Introduce the child to all staff the day before surgery B. Explain the surgery 1 week prior to the procedure C. Arrange a tour of the operating and recovery rooms D. Encourage the child to bring a favorite toy to the hospital - B. Explain the surgery 1 week prior to the procedure The nurse, assisting is applying a cast to a client with a broken arm, knows that A. The cast material should be dipped several times into the wam water B. The cast should covered until it dries C. The wet cast should be handled with the palms of the hands D. The casted extremity should be placed on a cloth-covered surface - C. The wet cast should be handled with the palms of the hands Based on principles of teaching and learning, what is the best initial approach to pre-op teaching for a client scheduled for coronary artery bypass? A. Touring the coronary intensive unit B. Mailing a video tape to the home C. Assessing the client's learning style D. Administering a written pre-test - C. Assessing the client's learning style A 4 year-old is recovering from chicken pox (varicella). The parents would like to have the child return to day care as soon as possible. In order to ensure that the illness is no longer communicable, what should the nurse assess for in this child? A. All lesions crusted B. Elevated temperature C. Rhinorrhea and coryza D. Presence of vesicles - A. All lesions crusted The nurse is providing instructions to a new mother on the proper techniques for breast feeding her infant. Which statement by the mother indicates the need for additional instruction? A. "I should position my baby completely facing me with my baby's mouth in front of my nipple" B. "The baby should latch onto the nipple and areola areas" C. "There may be times that I will need to manually express milk" D. I can switch to a bottle if I need to take a break from breast feeding" - D. I can switch to a bottle if I need to take a break from breast feeding The nurse assess a client who has been re-admitted to the psychiatric unit in-patient unit for schizophrenia. His symptoms have been managed for several months with fluphenazine (Prolixin). Which should be a focus of the first assessment? A. Stressors in the home B. Medication compliance C. Exposure to hot temperatures D. Alcohol use - B. Medication compliance The nurse is caring for a client with unstable spinal cord injury at the T7 level. Which intervention should take priority in planning care? A. Increase fluid intake to prevent dehydration B. Place client on a pressure reducing support surface C. Use skin care products designed for use with incontinence D. Increase caloric intake to aid healing - B. Place client on a pressure reducing support surface A nurse is conducting a community wide seminar on childhood safety issues. Which of these children is at the highest risk for poisoning? A. 9 month old who stays with a sitter 5 days a week B. 20 month old who had just learned to climb stairs C. 10 year old who occasionally stays at home unattended D. 15 year old who likes to repair bicycles - B. 20 month old who has just learned to climb stairs During an examination of a 2 year old child with a tentative diagnosis of Wilm's tumor, the nurse would be most concerned about which statement by the mother? A. My child has lost 3 pounds in the last month B. Urinary output seemed to be less over the past 2 days C. All the pants have become tight around the waist D. The child prefers some salty foods more than others - C. All the pants have become tight around the waist What is the most important aspect to include when developing a home care plan for a client with severe arthritis A. Maintaining and preserving function B. Anticipating side effects of lethargy C. Supporting coping with limitations D. Ensuring compliance with medications - A. Maintaining and preserving function A mother asks the nurse if she should be concerned about the tendency of her child to stutter. What assessment data will be most useful in counseling the parent? A. Age of the child B. Sibling position in the family C. Stressful family events D. Parenteral discipline strategies - A. Age of the child A pre-term newborn is to be fed breastmilk through nasogastric tube. Why is breast milk preferred over formula for premature infants? A. Contains less lactose B. Is higher in calories/ounce C. Provides antibodies D. Has less fatty acid - C. Provides antibodies Which of the following nursing assessments in an infant is most valuable in identifying visual defects? A. Red relex test B. Visual acuity C. Pupil response to light D. Cover test - A. Red reflex test A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4cm by 7cm, the wound base is red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is most appropriate for this wound? A. Transparent dressing B. Dry sterile dressing with antibiotic ointment C. Wet to dry dressing D. Occlusive moist dressing - D. Occlusive moist dressing A 30-month old child is admitted to the hospital unit. Which of the following toys would be appropriate for the nurse to select from the toy room for this child? A. Cartoon stickers B. Large wooden puzzle C. Blunt scissors and paper D. Beach ball - B. Large wooden puzzle A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief, the nurse would explain that illness is attributed to the A. Yang, the positive force that represents light, warmth, and fullness B. Yin, the negative force that represents darkness, cold, and emptiness C. Use of improper hot foods, herbs and plants D. A failure to keep life in balance with nature and others - B. Yin, the negative force that represent darkness, cold, and emptiness A 2 year old child has just been diagnosed with cystic fibrosis. the child's father asks the nurse "What is our major concern now, and what will were have to deal with in the future?" Which of the following if the best response? A. "There is a probability of life-long complications." B. "Cystic fibrosis results in nutritional concerns that can be dealt with." C. "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis." D. "you will work with a team of experts and also have access to a support group that the family can attend." - C. "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis." Which type of accidental poisoning would the nurse expect to occur in children underage of 6? A. Oral ingestion B. Topical contact C. Inhalation D. Eye splashes - A. Oral ingestion A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. He constantly bothers other clients, tries to help that housekeeping staff, demonstrates pressured speech and demands and seeks constant attention from the staff. Which activity would be best for the client? A. Reading B. Checkers C. Cards D. Ping-pong - D. Ping-pong The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate? A. Widening pulse pressure B. Pleural friction rub C. Distended neck veins D. Bradycardia - C. Distended neck veins Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute glomerulonephritis? A. Assess for generalized edema B. Monitor for increased urinary output C. Encourage rest during hyperactive periods D. Note patterns of increased blood pressure - D. Note patterns of increased blood pressure The nurse is caring for a child receiving chest physiotherapy (CP) Which of the following actions by the nurse would be appropriate? A. Schedule the therapy thirty minutes after meals B. Teach the child not to cough during treatment C. Confine the precision to the rib cage area D. Place the child in a prone position for the therapy - C. Confine the percussion to the rib cage area A polydrug user has been in recovery for 8 months. The client has began skipping breakfast and not eating regular dinners. The client has also started frequenting bars to "see old buddies." The nurse understands that the client's behavior is a warning sign to indicate that the client may be A. headed for relapse B. feeling hopeless C. approaching recovery D. in need of increased socialization - A. headed for relapse A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to feeling sad and hopeless, the nurse would assess for A. Anxiety, unconscious anger, and hostility B. Guilt, indecisiveness, poor self-concept C. Psychomotor retardation or agitation D. Meticulous attention to grooming and hygiene - C. Psychomotor retardation or agitation A client is experiencing hallucinations that are markedly increased at night. The client is very frightened by the hallucinations. The client's partner asked to stay a few hours beyond the visiting time, in the client's private room. What would be the best response by the nurse demonstrating emotional support for the client? A. "No, it would be best if you brought the client some reading material that she could read at night." B. "No, your presence may cause the client to become more anxious." C. "Yes, staying with the client and orienting her to her surroundings may decrease her anxiety." D. "Yes, would you like to spend the night when the client's behavior indicates that she is frightened?" - C. "Yes, staying with the client and orienting her to her surroundings may decrease her anxiety." At a well baby clinic the nurse is assigned to assess an 8 month old child. Which of these devleopmental achievements would the nurse anticipate that the child would be able to perform? A. Say 2 words B. Pull up to stand C. Sit without support D. Drink from a cup - C. Sit without support The nurse is talking to parents about nutrition in school aged children. Which of the following is the most common nutritional disorder in this age group? A. Bulimia B. Anorexia C. Obesity D. Malnutrition - C. Obesity At the geriatric day care program, a client is crying and repeating, "I want to go home. Call my daddy to come for me." The nurse should A. Invite the client to join the exercise group B. Tell the client you will call someone to come for her C. Give the client simple information about what she will be doing D. Firmly direct the client to her assigned group activity - C. Give the client simple information about what she will be doing A victim of domestic violence states to the nurse, "If only I could change how my companion wants me to be, I know things wold be different." Which would be the best response by the nurse? A. "The violence is temporarily caused by unusual circumstances, don't stop hoping for a change." B. "Perhaps, if you understood the need to abuse, you could stop the violence." C. "No one deserves to be beaten. Are you doing anything to provoke your spouse into beating you?" D. "Batterer lose self control because of their own internal reasons, not because of what their partner did or did not do." - D. "Batterer lose self control because of their own internal reasons, not because of what their partner did or did not do." An 83 year old female client is admitted to the hospital with an acute exacerbation of asthma. This is her third admission for asthma in 7 months. She describes how she doesn't really like having to use her medications all the time. Which explanation by the nurse best describes the long term consequence of uncontrolled airway inflammation? A. Degeneration of the alveoli B. Chronic broncho constriction of the large airways C. Lung remodeling and permanent changes in lung function D. Frequent pneumonia - C. Lung remodeling and permanent changes in lung function A mother wants to switch her 9 month old infant from an iron fortified formula to whole milk because of the expense. Upon further assessment, the nurse finds that the baby eats table foods well, but drinks less milk than before. What is the best advice by the nurse? A. Change the baby to whole milk