NSG 6435 Final Exam | Questions and Answers (Complete Solutions)

NSG 6435 Final Exam | Questions and Answers (Complete Solutions) The nurse is seeing an adolescent boy and his parents in the clinic for the first time. What should the nurse do first? introduce self What action is most likely to encourage parents to talk about their feelings related to their child's illness? Use open-ended questions. What is the single most important factor to consider when communicating with children? The child's developmental level What is an important consideration for the nurse who is communicating with a very young child? Use transition objects such as a doll. When introducing hospital equipment to a preschooler who seems afraid, the nurse's approach should be based on which principle? The child may think the equipment is alive. Which age group is most concerned with body integrity? School-age child An 8-year-old girl asks the nurse how the blood pressure apparatus works. The most appropriate nursing action is to: Explain in simple terms how it works. When the nurse interviews an adolescent, it is especially important to: Allow an opportunity to express feelings. The nurse is having difficulty communicating with a hospitalized 6-year-old child. What technique might be most helpful? Ask the child to draw a picture. The nurse is taking a health history on an adolescent. What best describes how the chief complaint should be determined? Ask adolescent, "Why did you come here today?" Where in the health history should the nurse describe all details related to the chief complaint? Present illness The nurse is interviewing the mother of an infant. She reports, "I had a difficult delivery, and my baby was born prematurely." This information should be recorded under which heading? Birth history When interviewing the mother of a 3-year-old child, the nurse asks about developmental milestones such as the age of walking without assistance. This should be considered because these milestones are: An important part of the child's past growth and development The nurse is taking a sexual history on an adolescent girl. The best way to determine whether she is sexually active is to: Ask her, "Are you having sex with anyone?" When doing a nutritional assessment on an Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. The nurse should recognize that this diet: May provide sufficient amino acids. Which parameter correlates best with measurements of the body's total protein stores? Upper arm circumference An appropriate approach to performing a physical assessment on a toddler is to: Use minimal physical contact initially. With the National Center for Health Statistics (NCHS) criteria, which body mass index (BMI)-for-age percentile indicates a risk for being overweight? 85th percentile The nurse is using the NCHS growth chart for an African-American child. The nurse should consider that: The NCHS charts are accurate for U.S. African-American children. Which tool measures body fat most accurately? Calipers By what age do the head and chest circumferences generally become equal? 1 to 2 years The earliest age at which a satisfactory radial pulse can be taken in children is: 2 years Where is the best place to observe for the presence of petechiae in dark-skinned individuals? Oral mucosa When palpating the child's cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm. The best explanation for this is: Infection or inflammation close to the site. The nurse has just started assessing a young child who is febrile and appears very ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. The most appropriate action is to: Refer for immediate medical evaluation. The nurse should expect the anterior fontanel to close at age: 12 to 18 months During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is: A normal finding. Binocularity, the ability to fixate on one visual field with both eyes simultaneously, is normally present by what age? 3 to 4 months The most frequently used test for measuring visual acuity is the: Snellen letter chart. The nurse is testing an infant's visual acuity. By what age should the infant be able to fix on and follow a target? 3 to 4 months The appropriate placement of a tongue blade for assessment of the mouth and throat is the: Side of the tongue. What type of breath sound is normally heard over the entire surface of the lungs except for the upper intrascapular area and the area beneath the manubrium? Vesicular What term is used to describe breath sounds that are produced as air passes through narrowed passageways? Wheezes The nurse must assess a child's capillary filling time. This can be accomplished by: Palpating the skin to produce a slight blanching. What heart sound is produced by vibrations within the heart chambers or in the major arteries from the back-and-forth flow of blood? Murmur Examination of the abdomen is performed correctly by the nurse in this order: inspection, auscultation, and palpation The nurse has a 2-year-old boy sit in "tailor" position during palpation for the testes. The rationale for this position is that: It prevents cremasteric reflex. During examination of a toddler's extremities, the nurse notes that the child is bowlegged. The nurse should recognize that this finding is: Normal because the lower back and leg muscles are not yet well developed. Kimberly is having a checkup before starting kindergarten. The nurse asks her to do the "finger-to-nose" test. The nurse is testing for: Cerebellar function. The nurse must check vital signs on a 2-year-old boy who is brought to the clinic for his 24-month checkup. Which criteria should the nurse use in determining the appropriate-size blood pressure cuff? Choose all that apply. The cuff bladder width is approximately 40% of the circumference of the upper arm. The cuff bladder length covers 80% to 100% of the circumference of the upper arm. Which data would be included in a health history? Choose all that apply Nutritional assessment Family medical history Sexual history Review of systems Which statement best describes the infant's physical development? Birth weight doubles by age 5 months and triples by age 1 year. The nurse is assessing a 6-month-old healthy infant who weighed 7 pounds at birth. The nurse should expect the infant to now weigh approximately: 15 pounds The nurse is doing a routine assessment on a 14-month-old infant and notes that the anterior fontanel is closed. This should be interpreted as A normal finding. Because the anterior fontanel normally closes between ages 12 and 18 months, By what age does the posterior fontanel usually close? 6 to 8 weeks The parents of a 9-month-old infant tell the nurse that they have noticed foods such as peas and corn are not completely digested and can be seen in their infant's stool. The nurse bases her explanation on knowing that: This is normal because of the immaturity of digestive processes at this age. A 3-month-old infant, born at 38 weeks of gestation, will hold a rattle if it is put in her hands, but she will not voluntarily grasp it. The nurse should interpret this as: Normal development. In terms of fine motor development, the infant of 7 months should be able to: Transfer objects from one hand to the other. In terms of gross motor development, what would the nurse expect a 5-month-old infant to do? Roll from abdomen to back At which age can most infants sit steadily unsupported? 8 months By what age should the nurse expect that an infant will be able to pull to a standing position? 11 to 12 months they can pull themselves up by 9 months According to Piaget, the 6-month-old infant would be in what stage of the sensorimotor phase Secondary circular reactions What behavior indicates that an infant has developed object permanence? Actively searches for a hidden object Most infants begin to fear strangers at age: 6 months The nurse is interviewing the father of 10-month-old Megan. She is playing on the floor when she notices an electrical outlet and reaches up to touch it. Her father says "No" firmly and removes her from near the outlet. The nurse should use this opportunity to teach the father that Megan: Is old enough to understand the word "No." Sara, age 4 months, was born at 35 weeks' gestation. She seems to be developing normally, but her parents are concerned because she is a "more difficult" baby than their other child, who was term. The nurse should explain that: Infants' temperaments are part of their unique characteristics. What information could be given to the parents of a 12-month-old child regarding appropriate play activities for this age? Give large push-pull toys for kinetic stimulation. An appropriate play activity for a 7-month-old infant to encourage visual stimulation is: Playing peek-a-boo. The best play activity for a 6-month-old infant to provide tactile stimulation is to: Allow to splash in bath. At what age should the nurse expect an infant to begin smiling in response to pleasurable stimuli? 2 months Latasha is a breastfed infant being seen in the clinic for her 6-month checkup. Her mother tells the nurse that she recently began to suck her thumb. The best nursing intervention is to: Reassure the mother that this is very normal at this age. Austin, age 6 months, has six teeth. The nurse should recognize that this is: Earlier-than-normal tooth eruption. The nurse notices that a 10-month-old infant being seen in the clinic is wearing expensive, inflexible, high-top shoes. The nurse should explain that: Soft and flexible shoes are generally better. A mother tells the nurse that she is discontinuing breastfeeding her 5-month-old infant. The nurse should recommend that the infant be given: Commercial iron-fortified formula. When is the best age for solid food to be introduced into the infant's diet? 4 to 6 months The parents of a 4-month-old infant tell the nurse that they are getting a microwave oven and will be able to heat the baby's formula faster. The nurse should recommend to: Always leave bottle top uncovered to allow heat to escape. Parents tell the nurse that their 1-year-old son often sleeps with them. They seem unconcerned about this. The nurse's response should be based on knowing that: This is a common and accepted practice, especially in some cultural groups. The parent of 2-week-old Sarah asks the nurse if Sarah needs fluoride supplements because she is exclusively breastfed. The nurse's best response is: She may need to begin taking them at age 6 months." A mother tells the nurse that she doesn't want her infant immunized because of the discomfort associated with injections. The nurse should explain that: A topical anesthetic, eutectic mixture of local anesthetic (EMLA), can be applied before injections are given. The parents of a 12-month-old child ask the nurse if the child can eat hot dogs. The nurse's reply should be based on knowing that: Hot dogs must be cut into small, irregular pieces to prevent aspiration. The clinic is lending a federally approved car seat to an infant's family. The nurse should explain that the safest place to put the car seat is: Rear facing in back seat. Pacifiers can be extremely dangerous because of the frequency of use and the intensity of the infant's suck. In teaching parents about appropriate pacifier selection, the nurse should explain that a pacifier should have which characteristics? Choose all that apply Easily grasped handle One-piece construction Sturdy, flexible material In terms of gross motor development, what would the nurse expect a 5-month-old infant to do? Choose all that apply. Roll from abdomen to back Put feet in mouth when supine A chest x-ray film is ordered for a child with suspected cardiac problems. The child's parent asks the nurse, "What will the radiograph show about the heart?" The nurse's response should be based on knowledge that the x-ray film will: Provide a permanent record of heart size and configuration. A complication that may occur after a cardiac catheterization is: Cardiac arrhythmia. José is a 4-year-old child scheduled for a cardiac catheterization. Preoperative teaching should be: Adapted to his level of development so that he can understand. The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells the nurse that her bandage is "too wet." The nurse finds the bandage and bed soaked with blood. The most appropriate initial nursing action is to: Apply direct pressure above the catheterization site. Which defect results in increased pulmonary blood flow? Atrial septal defect Which structural defects constitute tetralogy of Fallot? Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy What is best described as the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures? Congestive heart failure A clinical manifestation of the systemic venous congestion that can occur with congestive heart failure is: Peripheral edema. A beneficial effect of administering digoxin (Lanoxin) is that it: Decreases edema. Which drug is an angiotensin-converting enzyme (ACE) inhibitor? Captopril (Capoten) A common sign of digoxin toxicity is: Vomiting The parents of a young child with congestive heart failure tell the nurse that they are "nervous" about giving digoxin. The nurse's response should be based on knowing that: Parents must learn specific, important guidelines for administration of digoxin. As part of the treatment for congestive heart failure, the child takes the diuretic furosemide. As part of teaching home care, the nurse encourages the family to give the child foods such as bananas, oranges, and leafy vegetables. These foods are recommended because they are high in: Potassium. An 8-month-old infant has a hypercyanotic spell while blood is being drawn. The nurse's first action should be to Place the child in the knee-chest position The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The nurse recognizes that a risk of cerebrovascular accidents (strokes) exists. An important objective to decrease this risk is to: Prevent dehydration. Parents of a 3-year-old child with congenital heart disease are afraid to let their child play with other children because of possible overexertion. The nurse's reply should be based on knowing that: The child needs opportunities to play with peers. When preparing a school-age child and the family for heart surgery, the nurse should consider: Letting child hear the sounds of an electrocardiograph monitor. Seventy-two hours after cardiac surgery, a young child has a temperature of 37.7° C (101° F). The nurse should: Report findings to physician. An important nursing consideration when suctioning a young child who has had heart surgery is to: