QUESTIONS
◉ The mother of an infant tells the nurse that the baby has not been
tolerating
feedings lately and she noticed an olive-shaped mass in the infant's
abdomen. The
nurse recognizes that this could be an expected finding if the infant
has
(a) intussusception
(b) Hirschsprung's disease
(c) umbilical hernia
(d) pyloric stenosis. Answer: D. Pyloric Stenosis is hypertrophy of
the muscles of the pylorus causing narrowing of the pyloric canal
between the stomach and duodenum. A characteristic olive shaped
mass may be palpated in the epigastrium to the right of the
umbilicus. Intussusception is characterized by currant jelly stools.
Hirschprung's disease (congenital mega colon) results in ribbon-like
foul smelling stools; a child with an umbilical hernia has swelling or
protrusion around the umbilicus that is reducible. Physiological
Integrity; Physiological Adaptation
,◉ The nurse is teaching a group of parents about the expected
growth and
development of three-year-old children. The nurse should include
that a three-year-
old should
(a) discriminate between fantasy and reality
(b) ride a tricycle independently
(c) have a vocabulary of 7,000 words
(d) play in a group of two or three with one being the leader.
Answer: D. By the age of 3, a toddler should be able to ride a tricycle
independently; the pre- school child is not able to discriminate
between fantasy and reality. This is the developmental task of a
school age child; at 3 years of age the vocabulary is at about 900
words; cooperative play with the incorporation of imaginary friends
is common in this age group. Health Promotion and Maintenance
◉ The nurse and the nursing assistant are caring for a group of
clients. Which of the following client care activities should the nurse
assign to the nursing assistant? Select all that apply.
(a)_____ reinforcing the dressing of a client who has a decubitus
ulcer
(b) _____monitoring the vital signs of a client who had a myocardial
infarction 12 hours
ago and is being transferred from the coronary care unit
,(c)______administering a prescribed Fleet's enema to a client who
will undergo a
colonoscopy in two hours
(d)______ placing a client who had an above the knee amputation 24
hours ago in a
prone position
(e)______ assisting a client who had a colon resection 36 hours ago to
ambulate
(f) ______showing a client who had a vaginal hysterectomy 36 hours
ago how to
perform perineal care. Answer: C, D, and E. All of these tasks are
within the job description of a Certified Nursing Assistant and can
be safely delegated; A, B, and F would require assessment, nursing
intervention and patient education which is the role of the nurse.
Safe Effective Care environment; Management of Care
◉ The nurse is caring for a client with Acquired immunodeficiency
syndrome (AIDS)
who was started on Zidovidine (AZT). It would be important for the
nurse to assess
(a) blood ammonia serum
(b) serum potassium
(c) complete blood count (CBC)
(d) serum uric acid. Answer: C. Clients being treated with
Zidovudine (AZT) should have routine monitoring of CBC (complete
, blood count), hepatic and renal function studies. Physiological
Integrity; Physiological Adaptation
◉ 37. The nurse is performing an abdominal assessment. Indicate
the correct sequence the nurse should use to perform this
assessment.
(a) percussion
(b) palpation
(c) auscultation
(d) inspection. Answer: D, C, B, and A. Inspection is done first.
Auscultation is performed before palpation to decrease the risk of
stimulating the bowel which could result in false positive findings.
Health Promotion and Maintenance
◉ The nurse has become aware of the following client situations.
The nurse should first assess the client who
(a) had received a unit of packed red blood cells four hours ago and
is requesting a
bedpan
(b) had an abdominal hysterectomy yesterday and is reporting calf
pain
(c) has history of multiple sclerosis and is reporting diplopia