NUR404 exam 4 Questions With Complete Solutions
20. The nurse visits the foster home of a newborn with failure to
thrive syndrome.Which observation indicates a successful
outcome for this child's care?
A. Birth mother has stopped visiting the child.
B. Birth father comes by the home to bring toys.
C. Child eagerly takes a bottle and is gaining weight.
D. Child is crying and has bruises over the lower legs. Correct
Answers C
A successful outcome for the care of a child with failure to
thrive syndrome would be that the child shows interest in bottle
feedings and begins to gain weight. The child crying and having
bruises over the legs could indicate physical abuse or another
medical problem. The mother not visiting the child indicates
ongoing psychological issues with the mother bonding with the
child. The father bringing toys does not indicate that the care of
the child has been successful. The father's bonding with the
child cannot be determined by this action of bringing toys.
A 1-year-old is a victim of child abuse (child maltreatment).
Which factor obtained on history is most apt to be associated
with the risk of medical child abuse (formerly Munchausen
syndrome by proxy) in children?
A. The family has a low socioeconomic level.
B. The mother was abused as a child.
C. The parents are outgoing, gregarious people.
,D. The family is an extended one. Correct Answers B
Parents tend to parent the same way as their parents. Abuse,
therefore, continues from generation to generation.
A 14-year-old adolescent is suspected of having scoliosis. When
doing scoliosis screening, what observation would be important
for the nurse to note?
A. The posterior spine when bending forward
B. The angle of the iliac crest when bending forward
C. The posterior spine when bending sideways
D. The angle of the lower chest when sitting down Correct
Answers A
Diagnosis of scoliosis is best made with inspection and
observation. When inspecting the back with the child in a
standing position, the nurse should note asymmetries such as
shoulder elevation, the prominence of one scapula, an uneven
curve at the waistline, or a rib hump on one side. A lateral
curvature of the spine is best revealed when the child bends
forward. The child should bend forward with the arms hanging
freely. The curve and asymmetry of the back can be observed.
The height of the iliac crest, not the angle, is measured on both
sides and the difference is noted. Bending to the side would not
provide an accurate assessment of the spine because the
curvature cannot be seen from the side. The lower chest angle
would not be an accurate assessment as it would be more
associated with the ribs as opposed to the spine.
,A 15-year-old adolescent is seen at a health care facility for
facial acne. When counseling the teen, the nurse would teach
that the basic cause of acne is:
A. lack of showering adequately after gym class.
B. activation of androgen hormones.
C. vitamin deficiency from an inadequate diet.
D. thyroid-gland secretions increasing with adolescence.
Correct Answers B
Acne occurs in adolescence as the result of hormone influence.
With increased androgen production the sebaceous glands
become more active. With increased testosterone production (in
both boys and girls) increased sebum is produced. These
increased hormone productions lead to the development of acne.
Showering will certainly lead to cleaner skin and the removal of
oils but the lack of showering does not cause acne. Diet and
thyroid hormones do not play a role in the development of acne.
A 16-year-old girl presents to the emergency department
following a rape. Which action will the nurse complete first?
A. Provide the client privacy and assess for injuries.
B. Counsel the client to help increase self-esteem.
C. Arrange for a follow-up visit for treatment.
D. Assist the client with showering and hygiene. Correct
Answers A
Following sexual assault (rape), the nurse's first action should
focus on physical safety for the client, which includes providing
privacy to help the client feel safe and assessing for physical
, injuries that may require medical treatment. After stabilizing the
client, the nurse will allow the sexual assault nurse examiner
(SANE) to collect evidence, if desired by the client, before
assisting the client with showering/hygiene. Next, the nurse can
arrange for counseling and a follow-up visit as needed to ensure
appropriate psychological and physical care is provided.
A 16-year-old girl who has been confined to a wheelchair since
early childhood has been acting rebellious and rude. Her parents
ask the nurse, "Are all adolescents like this?" What is the nurse's
best response?
A. "Yes. Although your daughter's behaviors are more like those
of an adolescent boy."
B. "No. Your daughter must need some help in dealing with her
feelings."
C. "Your daughter's behavior seems to be typical adolescent
behavior. Let'stalk more about it."
D. "Your daughter's behavior results from feelings about her
disability; ignorethem." Correct Answers C
As adolescents strive to separate from parents, a period of stress
and turmoil can result. Frank discussion can clear the air and
help bring resolution.
A 3-month-old infant is diagnosed with failure to thrive. For
which cause should the nurse include interventions when
planning care for this client?
A. a reaction to severe stress
B. limited calcium metabolism
20. The nurse visits the foster home of a newborn with failure to
thrive syndrome.Which observation indicates a successful
outcome for this child's care?
A. Birth mother has stopped visiting the child.
B. Birth father comes by the home to bring toys.
C. Child eagerly takes a bottle and is gaining weight.
D. Child is crying and has bruises over the lower legs. Correct
Answers C
A successful outcome for the care of a child with failure to
thrive syndrome would be that the child shows interest in bottle
feedings and begins to gain weight. The child crying and having
bruises over the legs could indicate physical abuse or another
medical problem. The mother not visiting the child indicates
ongoing psychological issues with the mother bonding with the
child. The father bringing toys does not indicate that the care of
the child has been successful. The father's bonding with the
child cannot be determined by this action of bringing toys.
A 1-year-old is a victim of child abuse (child maltreatment).
Which factor obtained on history is most apt to be associated
with the risk of medical child abuse (formerly Munchausen
syndrome by proxy) in children?
A. The family has a low socioeconomic level.
B. The mother was abused as a child.
C. The parents are outgoing, gregarious people.
,D. The family is an extended one. Correct Answers B
Parents tend to parent the same way as their parents. Abuse,
therefore, continues from generation to generation.
A 14-year-old adolescent is suspected of having scoliosis. When
doing scoliosis screening, what observation would be important
for the nurse to note?
A. The posterior spine when bending forward
B. The angle of the iliac crest when bending forward
C. The posterior spine when bending sideways
D. The angle of the lower chest when sitting down Correct
Answers A
Diagnosis of scoliosis is best made with inspection and
observation. When inspecting the back with the child in a
standing position, the nurse should note asymmetries such as
shoulder elevation, the prominence of one scapula, an uneven
curve at the waistline, or a rib hump on one side. A lateral
curvature of the spine is best revealed when the child bends
forward. The child should bend forward with the arms hanging
freely. The curve and asymmetry of the back can be observed.
The height of the iliac crest, not the angle, is measured on both
sides and the difference is noted. Bending to the side would not
provide an accurate assessment of the spine because the
curvature cannot be seen from the side. The lower chest angle
would not be an accurate assessment as it would be more
associated with the ribs as opposed to the spine.
,A 15-year-old adolescent is seen at a health care facility for
facial acne. When counseling the teen, the nurse would teach
that the basic cause of acne is:
A. lack of showering adequately after gym class.
B. activation of androgen hormones.
C. vitamin deficiency from an inadequate diet.
D. thyroid-gland secretions increasing with adolescence.
Correct Answers B
Acne occurs in adolescence as the result of hormone influence.
With increased androgen production the sebaceous glands
become more active. With increased testosterone production (in
both boys and girls) increased sebum is produced. These
increased hormone productions lead to the development of acne.
Showering will certainly lead to cleaner skin and the removal of
oils but the lack of showering does not cause acne. Diet and
thyroid hormones do not play a role in the development of acne.
A 16-year-old girl presents to the emergency department
following a rape. Which action will the nurse complete first?
A. Provide the client privacy and assess for injuries.
B. Counsel the client to help increase self-esteem.
C. Arrange for a follow-up visit for treatment.
D. Assist the client with showering and hygiene. Correct
Answers A
Following sexual assault (rape), the nurse's first action should
focus on physical safety for the client, which includes providing
privacy to help the client feel safe and assessing for physical
, injuries that may require medical treatment. After stabilizing the
client, the nurse will allow the sexual assault nurse examiner
(SANE) to collect evidence, if desired by the client, before
assisting the client with showering/hygiene. Next, the nurse can
arrange for counseling and a follow-up visit as needed to ensure
appropriate psychological and physical care is provided.
A 16-year-old girl who has been confined to a wheelchair since
early childhood has been acting rebellious and rude. Her parents
ask the nurse, "Are all adolescents like this?" What is the nurse's
best response?
A. "Yes. Although your daughter's behaviors are more like those
of an adolescent boy."
B. "No. Your daughter must need some help in dealing with her
feelings."
C. "Your daughter's behavior seems to be typical adolescent
behavior. Let'stalk more about it."
D. "Your daughter's behavior results from feelings about her
disability; ignorethem." Correct Answers C
As adolescents strive to separate from parents, a period of stress
and turmoil can result. Frank discussion can clear the air and
help bring resolution.
A 3-month-old infant is diagnosed with failure to thrive. For
which cause should the nurse include interventions when
planning care for this client?
A. a reaction to severe stress
B. limited calcium metabolism
