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1. 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. - CORRECT
ANSWER-A: Make certain the child is maintained in correct body alignment.
2. 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 are different
D) Short term weight changes are uneven - CORRECT ANSWER-A: Height and
weight percentiles vary widely
,3. 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 - CORRECT ANSWER-C: Advise the parents to ignore breath holding
because breathing will begin as a reflex
4. 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." - CORRECT ANSWER-A: "My pain
is deep in my chest behind my sternum."
5. 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?" - CORRECT ANSWER-C: "I am going to say the names of three
things and I want you to repeat them after me: blue, ball, pen."
6. 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 - CORRECT ANSWER-C: Security
7. A nurse has just received a medication order which is not legible. Which
statement best reflects assertive communication?
A) "I cannot give this 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." - CORRECT ANSWER-B) "Would you please clarify what you
have written so I am sure I am reading it correctly?"
10. While caring for a toddler with croup, which initial sign of croup requires the
nurse's immediate attention?
A) Respiratory rate of 42
B) Lethargy for the past hour
C) Apical pulse of 54
D) Coughing up copious secretions - CORRECT ANSWER-A: Respiratory rate of
30
11. A client is admitted with low T3 and T4 levels and an elevated TSH level. On
initial assessment, the nurse would anticipate which of the following assessment
findings?
A) Lethargy
B) Heat intolerance