Ricci Chapter 42 - Test Bank - 4th Edition
correctly answered to pass
1. The nurse is teaching the mother of a 5-year-old boy with a history of
impaction how to administer enemas at home. Which response from the mother indicates a
need for further teaching?
A) "I should position him on his abdomen with knees bent."
B) "He will require 250 to 500 mL of enema solution."
C) "I should wash my hands and then wear gloves."
D) "He should retain the solution for 5 to 10 minutes." - correct answer ✔✔Ans: A
I should position him on his abdomen with knees bent.
Feedback:
A 5-year-old child should lie on his left side with his right leg flexed toward the
chest. An infant or toddler is positioned on his abdomen. Using 250 to 500 mL of
solution, washing hands and wearing gloves, and retaining the solution for 5 to 10
minutes are appropriate responses.
2. The nurse is taking a health history of an 11-year-old girl with recurrent
abdominal pain. Which response would lead the nurse to suspect irritable bowel
syndrome?
A) "I always feel better after I have a bowel movement."
B) "I don't take any medicine right now."
,C) "The pain comes and goes."
D) "The pain doesn't wake me up in the middle of the night." - correct answer ✔✔Ans: A
I always feel better after I have a bowl movement.
Feedback:
In cases of irritable bowel syndrome, the pain may be relieved by defecation. Use of
medications and pain that comes and goes or wakes the person up in the middle of
the night are all relevant findings pertinent to recurrent abdominal pain.
3. The nurse is caring for a 3-year-old girl with short bowel syndrome as a result of trauma to
the small intestine. The girl's mother is extremely anxious and tells the nurse she is afraid she
will never learn how to care for her daughter at home. How should the nurse respond?
A) "I will help you become an expert on your daughter's care."
B) "You must learn how to care for your daughter at home."
C) "You really need the support of your husband."
D) "There is a lot to learn and you need a positive attitude." - correct answer ✔✔Ans: A
I will help you become an expert on your daughters care.
Feedback:
The nurse needs to empower families to become the experts on their children's
needs and conditions via education and participation in care. The most positive
approach in this case is to let the mother know the nurse will support her and help
her become an expert on her daughter's care. Telling the mother that she must
learn how to care for her daughter or that she must have a positive attitude is not
helpful. Telling her that she needs the support of her husband is irrelevant and
unhelpful.
, 4. The nurse is conducting a physical examination of a child with suspected Crohn disease.
Which finding would be the most suspicious of Crohn disease?
A) Normal growth patterns
B) Perianal skin tags or fissures
C) Poor growth patterns
D) Abdominal tenderness - correct answer ✔✔Ans: B
Perianal skin tags or fissures
Feedback:
Perianal skin tags and/or fissures are highly suspicious of Crohn disease. Poor
growth patterns and abdominal tenderness are common to Crohn disease but are
also seen with many other conditions. Normal growth patterns would not point to
Crohn disease because of problems with absorbing nutrients.
5. The nurse is caring for an infant with a temporary ileostomy. As part of the plan of care, the
nurse monitors for skin breakdown around the stoma. If redness occurs, what would be most
appropriate to promote healing and prevent further skin breakdown?
A) Clean the area well with a scented diaper wipe.
B) Apply a barrier/healing cream or paste on the skin.
C) Use a barrier wafer to attach the appliance.
D) Sanitize the area with an alcohol wipe after each diaper change. - correct answer ✔✔Ans: B
Apply a barrier/healing cream or paste on the skin.
Feedback:
correctly answered to pass
1. The nurse is teaching the mother of a 5-year-old boy with a history of
impaction how to administer enemas at home. Which response from the mother indicates a
need for further teaching?
A) "I should position him on his abdomen with knees bent."
B) "He will require 250 to 500 mL of enema solution."
C) "I should wash my hands and then wear gloves."
D) "He should retain the solution for 5 to 10 minutes." - correct answer ✔✔Ans: A
I should position him on his abdomen with knees bent.
Feedback:
A 5-year-old child should lie on his left side with his right leg flexed toward the
chest. An infant or toddler is positioned on his abdomen. Using 250 to 500 mL of
solution, washing hands and wearing gloves, and retaining the solution for 5 to 10
minutes are appropriate responses.
2. The nurse is taking a health history of an 11-year-old girl with recurrent
abdominal pain. Which response would lead the nurse to suspect irritable bowel
syndrome?
A) "I always feel better after I have a bowel movement."
B) "I don't take any medicine right now."
,C) "The pain comes and goes."
D) "The pain doesn't wake me up in the middle of the night." - correct answer ✔✔Ans: A
I always feel better after I have a bowl movement.
Feedback:
In cases of irritable bowel syndrome, the pain may be relieved by defecation. Use of
medications and pain that comes and goes or wakes the person up in the middle of
the night are all relevant findings pertinent to recurrent abdominal pain.
3. The nurse is caring for a 3-year-old girl with short bowel syndrome as a result of trauma to
the small intestine. The girl's mother is extremely anxious and tells the nurse she is afraid she
will never learn how to care for her daughter at home. How should the nurse respond?
A) "I will help you become an expert on your daughter's care."
B) "You must learn how to care for your daughter at home."
C) "You really need the support of your husband."
D) "There is a lot to learn and you need a positive attitude." - correct answer ✔✔Ans: A
I will help you become an expert on your daughters care.
Feedback:
The nurse needs to empower families to become the experts on their children's
needs and conditions via education and participation in care. The most positive
approach in this case is to let the mother know the nurse will support her and help
her become an expert on her daughter's care. Telling the mother that she must
learn how to care for her daughter or that she must have a positive attitude is not
helpful. Telling her that she needs the support of her husband is irrelevant and
unhelpful.
, 4. The nurse is conducting a physical examination of a child with suspected Crohn disease.
Which finding would be the most suspicious of Crohn disease?
A) Normal growth patterns
B) Perianal skin tags or fissures
C) Poor growth patterns
D) Abdominal tenderness - correct answer ✔✔Ans: B
Perianal skin tags or fissures
Feedback:
Perianal skin tags and/or fissures are highly suspicious of Crohn disease. Poor
growth patterns and abdominal tenderness are common to Crohn disease but are
also seen with many other conditions. Normal growth patterns would not point to
Crohn disease because of problems with absorbing nutrients.
5. The nurse is caring for an infant with a temporary ileostomy. As part of the plan of care, the
nurse monitors for skin breakdown around the stoma. If redness occurs, what would be most
appropriate to promote healing and prevent further skin breakdown?
A) Clean the area well with a scented diaper wipe.
B) Apply a barrier/healing cream or paste on the skin.
C) Use a barrier wafer to attach the appliance.
D) Sanitize the area with an alcohol wipe after each diaper change. - correct answer ✔✔Ans: B
Apply a barrier/healing cream or paste on the skin.
Feedback:
