NUR 220 Exam 4 Questions and
Answers Rated A+
_______________ syndrome is a neurotoxic disorder that has been linked to febrile
illness and aspirin use in children less than 18 years of age. - ANSWER-Reye.
The presence of viral infection and the use of aspirin in children are linked to Reye
syndrome, a potentially fatal toxic encephalopathy. Avoid use of aspirin and non-aspirin-
containing salicylates during febrile illnesses in children.
A 1-year-old child grabs an Easter egg and attempts to throw it across the room. The
nurse knows that the child is exhibiting which scheme according to Piaget?
a. Adaptation
b. Assimilation
c. Accommodation
d. Equilibration - ANSWER-Assimilation.
Assimilation occurs when the child attempts to use a new object in the same fashion as
for a more familiar object. Adaptation is the process of adjusting schemes to new
applications. Accommodation occurs when the child understands that the object is
different from a more familiar object and cannot be used in the same way. Equilibration
occurs when a balance is achieved between the old understanding and the new.
A 14-year-old male is upset because he is shorter in stature and smaller in build than
the other boys in his class. He is concerned about never growing. How should the nurse
address his concern?
a. Reassure him that everyone grows at his own rate.
b. Reassure him that males often do not stop growing until they are 18-20 years old.
c. Tell him that most males start their growth spurt around 9-14 years of age.
d. Tell him to take in more protein in order to get his growth spurt started. - ANSWER-
Reassure him that males often do not stop growing until they are 18-20 years old.
In males, the adolescent growth spurt usually begins sometime between the ages of 10-
16 years of age and often does not end until 18-20 years. Although everyone grows at
his or her own rate, it does not specifically address this boy's concern. The remaining
options provide inaccurate information.
A 16-year-old male patient has been involved in a motor vehicle accident. Every time
the nurse enters his room, there are at least 4-5 friends laughing and talking with the
patient. The nurse is frustrated in trying to get things done. What is the nurse's best
action?
a. Call security to escort the visitors from the room.
b. Work with the boy and his friends to plan and coordinate activities to minimize
interruptions.
c. Ask the boy's parents to tell his friends to stay away.
,d. Post a "Do not disturb" sign on the door. - ANSWER-Work with the boy and his
friends to plan and coordinate activities to minimize interruptions.
Teenagers have strong bonds with peer groups, and this continues even with
hospitalization. The best approach is to plan activities so as to minimize interruptions.
Respecting the teen's need for socialization encourages better communication and
understanding between the nurse and the patient. The other options do not facilitate
open communication and trust.
A 2-year-old child insists on having a drink of water and having a story read to him and
says "Good night, sleep tight" at bedtime every night. The nurse knows the child is
exhibiting which type of behavior?
a. Controlling
b. Ritualism
c. Obsession
d. Compulsion - ANSWER-Ritualism.
Ritualism offers the toddler a sense of security and comfort. The child is not trying to
control his behavior with the ritual. Obsession and compulsion are terms commonly
used in patients in older age groups and describe maladaptive behaviors.
A Buddhist patient has end-stage pancreatic cancer. In what spiritual practice would this
patient most likely engage?
a. Reading passages in the Vedas
b. Visiting with the patient's guru
c. Practicing tai chi
d. Meditating on the meaning of life - ANSWER-Meditating on the meaning of life.
Buddhists believe in meditation. Vedas is associated with the Hindu faith, a guru is
associated with Sikhism, and tai chi is an exercise, not appropriate at end of life.
A father is upset because his preschool son has told him he wishes he were gone and
pushes him and his wife apart whenever they are together. What advice should the
nurse give the father?
a. This is normal at this age and should resolve on its own.
b. The child may need counseling to resolve his conflict.
c. Tell the child this is inappropriate and will not be tolerated.
d. The child needs to go to preschool to separate from his mother. - ANSWER-This is
normal at this age and should resolve on its own.
In the preschool years, feelings of resentment toward the parent of the same sex often
occur as the child develops a strong bond with the parent of the opposite sex. As the
child matures, these feelings usually resolve on their own. This is not something that
requires counseling. Setting limits with hostile behavior may be appropriate, but parents
need to understand that this is part of the Oedipus/Electra complex in development at
this age. Sending the child to preschool will aid in socialization but will not force the
child to separate from the mother.
,A kindergartener's mother is concerned because the child has had two bouts of
respiratory infections in the past three months since school started. What is the nurse's
best response?
a. "His immune system should be stronger by now; I think we will need to do some
further screening."
b. "His immune system is compromised because his schedule has changed. Be sure he
gets to bed on time."
c. "He is exposed to more germs now that he is in school. Let's go over good
handwashing."
d. "You should talk to the school about disinfecting the classroom." - ANSWER-"He is
exposed to more germs now that he is in school. Let's go over good handwashing."
The kindergartener is exposed to more pathogens when he or she enters school. It is
not unusual to see an increased rate of infections when the child begins school. It is not
an indication of immune system compromise in an otherwise healthy child. Although
disinfecting the classroom is useful in outbreaks of disease, reinforcement of proper
handwashing is the most effective way to reduce the spread of common childhood
illnesses.
A newborn's mother is concerned about Sudden Infant Death Syndrome (SIDS). What
would the nurse advise her is the best way to prevent SIDS?
a. To breastfeed
b. To allow the infant to sleep in her bed
c. To place the infant prone to sleep
d. To place the infant supine to sleep - ANSWER-To place the infant supine to sleep.
The best way to prevent SIDS is to place the infant on its back to sleep. Breastfeeding
has not been shown as a link to prevention of SIDS. Sleeping in bed with adults has
been linked to infant death in that the parent may inadvertently roll over on the infant.
Additionally, soft pillows and bed linens can contribute to accidental suffocation in young
infants. The prone position for sleeping has been linked to SIDS deaths.
A nurse assigned to the neonatal intensive care unit (NICU) has spent most of a day
working with a critically ill infant, with the mother standing by. The infant experiences a
cardiac arrest and does not survive. The mother spends an hour crying and holding the
baby, saying good-bye. Which spiritual care intervention(s) is/are most appropriate for
the nurse to implement? (Select all that apply.)
a. If desired, briefly hold the baby to say good-bye after the mother leaves.
b. Follow procedures to prepare the body for transport to the morgue.
c. Visit the mother the next day to see how she is doing.
d. Call the family spiritual adviser or the chaplain.
e. Ask the mother if you could call a family member or friend to be with her. - ANSWER-
a, d, e
It is important for nurses to take time to say "good-bye" to patients with whom they have
developed a relationship. In this case, it would be appropriate for the nurse to hold the
infant briefly, if desired, after the family has left before preparing the body for the
, morgue. With consent, the mother needs to be surrounded by appropriate persons to
provide spiritual support, including a chaplain, family members, and friends. Although it
is critical that the nurse follow procedures in preparing bodies for the morgue, it is not
considered spiritual care. Visiting the mother after her loss could be viewed as a
violation of professional boundaries, especially for a nurse who worked with the family
for a day only.
A nurse is caring for a patient in the acute care setting who has a do-not-resuscitate
order in place. The family approaches the nurse as he or she is walking down the hall
and says, "I think my mother has died." To facilitate acceptance of the death by the
family, an important nursing intervention is to
a. notify the physician that death has occurred while in the room with the family.
b. ask another nurse to come into the room to confirm that death has occurred.
c. assess the patient for pulse, respirations, or blood pressure with the family present.
d. check that the cardiac monitor that was in place still has the appropriate leads
attached. - ANSWER-assess the patient for pulse, respirations, or blood pressure with
the family present.
Experienced nurses will intuitively know when death has occurred, but the act of placing
the stethoscope on a patient's chest and listening for heart sounds while assessing for
any respiratory effort can act to confirm, thus facilitate the acceptance of death by family
members who may have been present at the time of death.
A nurse's role when communicating with a physician caring for a dying patient is
a. to make him or her see the situation correctly.
b. to carry out his or her orders.
c. to advocate for the patient's wishes.
d. to suggest an appropriate course of action. - ANSWER-to advocate for the patient's
wishes.
A major role of the nurse, in any setting, especially when a patient is dying is to
advocate for his or her wishes related to end-of-life care. It is not the role of the nurse to
diagnose or treat medical conditions, but it is the role of the nurse to advocate for the
patient and implement appropriately identified independent nursing interventions.
A parent of a preschool child is concerned because his teachers have complained about
his aggressive behavior toward other children. Which of the following pieces of
information is most important in helping the parent determine possible sources of this
behavior?
a. The types of playmates the child has
b. The kinds of toys the child plays with
c. Whether or not the child is allowed to roughhouse with his siblings
d. The types of television programs the child watches - ANSWER-The types of
television programs the child watches.
Answers Rated A+
_______________ syndrome is a neurotoxic disorder that has been linked to febrile
illness and aspirin use in children less than 18 years of age. - ANSWER-Reye.
The presence of viral infection and the use of aspirin in children are linked to Reye
syndrome, a potentially fatal toxic encephalopathy. Avoid use of aspirin and non-aspirin-
containing salicylates during febrile illnesses in children.
A 1-year-old child grabs an Easter egg and attempts to throw it across the room. The
nurse knows that the child is exhibiting which scheme according to Piaget?
a. Adaptation
b. Assimilation
c. Accommodation
d. Equilibration - ANSWER-Assimilation.
Assimilation occurs when the child attempts to use a new object in the same fashion as
for a more familiar object. Adaptation is the process of adjusting schemes to new
applications. Accommodation occurs when the child understands that the object is
different from a more familiar object and cannot be used in the same way. Equilibration
occurs when a balance is achieved between the old understanding and the new.
A 14-year-old male is upset because he is shorter in stature and smaller in build than
the other boys in his class. He is concerned about never growing. How should the nurse
address his concern?
a. Reassure him that everyone grows at his own rate.
b. Reassure him that males often do not stop growing until they are 18-20 years old.
c. Tell him that most males start their growth spurt around 9-14 years of age.
d. Tell him to take in more protein in order to get his growth spurt started. - ANSWER-
Reassure him that males often do not stop growing until they are 18-20 years old.
In males, the adolescent growth spurt usually begins sometime between the ages of 10-
16 years of age and often does not end until 18-20 years. Although everyone grows at
his or her own rate, it does not specifically address this boy's concern. The remaining
options provide inaccurate information.
A 16-year-old male patient has been involved in a motor vehicle accident. Every time
the nurse enters his room, there are at least 4-5 friends laughing and talking with the
patient. The nurse is frustrated in trying to get things done. What is the nurse's best
action?
a. Call security to escort the visitors from the room.
b. Work with the boy and his friends to plan and coordinate activities to minimize
interruptions.
c. Ask the boy's parents to tell his friends to stay away.
,d. Post a "Do not disturb" sign on the door. - ANSWER-Work with the boy and his
friends to plan and coordinate activities to minimize interruptions.
Teenagers have strong bonds with peer groups, and this continues even with
hospitalization. The best approach is to plan activities so as to minimize interruptions.
Respecting the teen's need for socialization encourages better communication and
understanding between the nurse and the patient. The other options do not facilitate
open communication and trust.
A 2-year-old child insists on having a drink of water and having a story read to him and
says "Good night, sleep tight" at bedtime every night. The nurse knows the child is
exhibiting which type of behavior?
a. Controlling
b. Ritualism
c. Obsession
d. Compulsion - ANSWER-Ritualism.
Ritualism offers the toddler a sense of security and comfort. The child is not trying to
control his behavior with the ritual. Obsession and compulsion are terms commonly
used in patients in older age groups and describe maladaptive behaviors.
A Buddhist patient has end-stage pancreatic cancer. In what spiritual practice would this
patient most likely engage?
a. Reading passages in the Vedas
b. Visiting with the patient's guru
c. Practicing tai chi
d. Meditating on the meaning of life - ANSWER-Meditating on the meaning of life.
Buddhists believe in meditation. Vedas is associated with the Hindu faith, a guru is
associated with Sikhism, and tai chi is an exercise, not appropriate at end of life.
A father is upset because his preschool son has told him he wishes he were gone and
pushes him and his wife apart whenever they are together. What advice should the
nurse give the father?
a. This is normal at this age and should resolve on its own.
b. The child may need counseling to resolve his conflict.
c. Tell the child this is inappropriate and will not be tolerated.
d. The child needs to go to preschool to separate from his mother. - ANSWER-This is
normal at this age and should resolve on its own.
In the preschool years, feelings of resentment toward the parent of the same sex often
occur as the child develops a strong bond with the parent of the opposite sex. As the
child matures, these feelings usually resolve on their own. This is not something that
requires counseling. Setting limits with hostile behavior may be appropriate, but parents
need to understand that this is part of the Oedipus/Electra complex in development at
this age. Sending the child to preschool will aid in socialization but will not force the
child to separate from the mother.
,A kindergartener's mother is concerned because the child has had two bouts of
respiratory infections in the past three months since school started. What is the nurse's
best response?
a. "His immune system should be stronger by now; I think we will need to do some
further screening."
b. "His immune system is compromised because his schedule has changed. Be sure he
gets to bed on time."
c. "He is exposed to more germs now that he is in school. Let's go over good
handwashing."
d. "You should talk to the school about disinfecting the classroom." - ANSWER-"He is
exposed to more germs now that he is in school. Let's go over good handwashing."
The kindergartener is exposed to more pathogens when he or she enters school. It is
not unusual to see an increased rate of infections when the child begins school. It is not
an indication of immune system compromise in an otherwise healthy child. Although
disinfecting the classroom is useful in outbreaks of disease, reinforcement of proper
handwashing is the most effective way to reduce the spread of common childhood
illnesses.
A newborn's mother is concerned about Sudden Infant Death Syndrome (SIDS). What
would the nurse advise her is the best way to prevent SIDS?
a. To breastfeed
b. To allow the infant to sleep in her bed
c. To place the infant prone to sleep
d. To place the infant supine to sleep - ANSWER-To place the infant supine to sleep.
The best way to prevent SIDS is to place the infant on its back to sleep. Breastfeeding
has not been shown as a link to prevention of SIDS. Sleeping in bed with adults has
been linked to infant death in that the parent may inadvertently roll over on the infant.
Additionally, soft pillows and bed linens can contribute to accidental suffocation in young
infants. The prone position for sleeping has been linked to SIDS deaths.
A nurse assigned to the neonatal intensive care unit (NICU) has spent most of a day
working with a critically ill infant, with the mother standing by. The infant experiences a
cardiac arrest and does not survive. The mother spends an hour crying and holding the
baby, saying good-bye. Which spiritual care intervention(s) is/are most appropriate for
the nurse to implement? (Select all that apply.)
a. If desired, briefly hold the baby to say good-bye after the mother leaves.
b. Follow procedures to prepare the body for transport to the morgue.
c. Visit the mother the next day to see how she is doing.
d. Call the family spiritual adviser or the chaplain.
e. Ask the mother if you could call a family member or friend to be with her. - ANSWER-
a, d, e
It is important for nurses to take time to say "good-bye" to patients with whom they have
developed a relationship. In this case, it would be appropriate for the nurse to hold the
infant briefly, if desired, after the family has left before preparing the body for the
, morgue. With consent, the mother needs to be surrounded by appropriate persons to
provide spiritual support, including a chaplain, family members, and friends. Although it
is critical that the nurse follow procedures in preparing bodies for the morgue, it is not
considered spiritual care. Visiting the mother after her loss could be viewed as a
violation of professional boundaries, especially for a nurse who worked with the family
for a day only.
A nurse is caring for a patient in the acute care setting who has a do-not-resuscitate
order in place. The family approaches the nurse as he or she is walking down the hall
and says, "I think my mother has died." To facilitate acceptance of the death by the
family, an important nursing intervention is to
a. notify the physician that death has occurred while in the room with the family.
b. ask another nurse to come into the room to confirm that death has occurred.
c. assess the patient for pulse, respirations, or blood pressure with the family present.
d. check that the cardiac monitor that was in place still has the appropriate leads
attached. - ANSWER-assess the patient for pulse, respirations, or blood pressure with
the family present.
Experienced nurses will intuitively know when death has occurred, but the act of placing
the stethoscope on a patient's chest and listening for heart sounds while assessing for
any respiratory effort can act to confirm, thus facilitate the acceptance of death by family
members who may have been present at the time of death.
A nurse's role when communicating with a physician caring for a dying patient is
a. to make him or her see the situation correctly.
b. to carry out his or her orders.
c. to advocate for the patient's wishes.
d. to suggest an appropriate course of action. - ANSWER-to advocate for the patient's
wishes.
A major role of the nurse, in any setting, especially when a patient is dying is to
advocate for his or her wishes related to end-of-life care. It is not the role of the nurse to
diagnose or treat medical conditions, but it is the role of the nurse to advocate for the
patient and implement appropriately identified independent nursing interventions.
A parent of a preschool child is concerned because his teachers have complained about
his aggressive behavior toward other children. Which of the following pieces of
information is most important in helping the parent determine possible sources of this
behavior?
a. The types of playmates the child has
b. The kinds of toys the child plays with
c. Whether or not the child is allowed to roughhouse with his siblings
d. The types of television programs the child watches - ANSWER-The types of
television programs the child watches.
