A 10-year-old client with autism spectrum disorders hospitalized for a diagnostic workup.
what is the most appropriate nursing action?
encouraging visits by friends to decrease social isolation
giving the client a schedule of the daily activities
placing the client and restraints during invasive procedures
providing the client with a variety of toys - ANSWER giving the client a schedule of the
daily activities
A 14 year old client confides to the school nurse that she is pregnant likely in the second
trimester and has not had prenatal care. which of the following topics should the nurse
discuss with the client at this time? select all that apply.
1 desire for adoption planning services
2 em emotional response to the pregnancy
3 family social support systems
4 nutritional habits and substance abuse
5 plan for finishing High School - ANSWER ANS 234
Adolescent clients who are pregnant are a unique population because of their increased risk
for complications during pregnancy (Eg low birth weight, preterm birth preeclampsia) and
developmental needs. during an initial counter, the nurse should discussed the client's
emotional response to the pregnancy to build rapport and provide psychosocial support
(option 2). discussing the client's level of family/social support or fear of social
discrimination is appropriate because these factors May prevent the client from obtaining
prenatal care (option 3).
adolescents who are pregnant are vulnerable to poverty, dangerous living conditions,
exposure to tetrotogens (eg tobacco, alcohol, recreational drugs), poor nutritional status and
1
,physical or sexual abuse which can cause adverse fetal/maternal outcomes. therefore,
discussing these topics openly as soon as possible is appropriate to prevent harm (option 4).
Option 1 discussing adoption planning a parenting is not necessary at this time but should
be addressed later in collaboration with a social worker
Option 5 young adolescents (ie age <16) are less mature emotionally and developmentally
and may resist planning for the future. education planning may be approached during
subsequent encounters but it is not a priority for maternal and Fetal Health at this time.
Educational objective adolescent clients are increased risk for complications during
pregnancy. factors such as emotional response to the pregnancy, family social support
nutritional status and substance use impact the pregnancy and should be discussed during
an initial counter to establish Rapport and prevent harm.
A 2-year-old is suspected of having retinoblastoma. the nurse recognizes which sign as being
most characteristic of this disease?
1 absence of red reflex
2 fixed in mid dilated pupil
3 ptosis of the eye
4 purulent eye discharge - ANSWER ANS A
Retinoblastoma a unilateral or bilateral retina tumor is the most common childhood
intraocular malignancy. It is typically diagnosed in children under age 2 and is usually first
recognized when parents report a white glow of the people (leukocoria). light reflecting off
the tumor will cause the people to appear white instead of displaying the usual red reflex
(option 1). parents may even accidentally visualize leukocoria when taking a photograph of
the child using a flash. Strabismus (misalignment of the eyes) is a second most common sign;
visual impairment is a late sign indicative Advanced disease.
treatment depends on severity and may include radiation therapy or enucleation ( removal
of the eye) and fitting of prosthesis. siblings should undergo regular ocular screening as
some forms of retinoblastoma are hereditary.
Option 2 a fixed and mid dilated pupil is seen in acute glaucoma
Option 3 ptosis is dripping of the upper eyelid often associated with injury of the ocular
motor nerve (Cranial nerve III). ptosis is is also characteristic for myasthenia gravis.
Option 4 bacterial conjunctivitis causes eyelid swelling, a red conjunctiva, eye discomfort,
and purulent eye discharge.
2
,Educational objective: retinoblastoma is a malignancy of the eye typically diagnosed in
children under age 2. thought people will reflect a white color and the child will not have the
normal red eye reflex. treatment may include radiation therapy or enucleation ( removal of
the eye)
A behavioral health clinic nurse assesses 23 year old client who started taking paroxetine 3
weeks ago. which statement made by the client is most important for the nurse to
investigate?
1 I don't have much of an appetite since starting this medication
2 I have a lot more energy, but I'm feeling just as depressed
3 I have been feeling dizzy when I walk around at home
4 I have experienced frequent headaches lately - ANSWER ANS 2 selective serotonin
reuptake inhibitors (SSRIs) (eg fluoxetine, paroxetine, sertraline, citalopram) Are used to
treat a number of psychiatric conditions (eg major depressive disorder, generalized anxiety
disorder). clients usually see therapeutic effects in 1 to 4 weeks. SSRIs may increase the risk
of suicide especially in young children during initial therapy or after a dosage increase. a
client who reports increased energy without a change and depressive feelings needs to be
assessed and monitored for suicidal ideation or actions as a client may now have the energy
to execute the suicide plan (option 2)
common expected side effects of SSRIs include:
loss of appetite, weight loss or weight gain (option 1)
gastrointestinal disturbances (nausea, vomiting, diarrhea)
headaches dizziness drowsiness insomnia (options 3 and 4)
sexual dysfunction
side effects should gradually diminish over 3 months although some may persist. if
symptoms are intolerable or a particular SSRI is ineffective the client may be switched to a
different antidepressant.
A blizzard is predicted to hit a large city within a few hours. the Home Care nurses
prioritizing and revising the schedule and estimates of three home visits can be made before
the blizzard hits. Which clients should the nurse see? select all that apply
1 a client who fell and hit the head but refuses to go to the emergency department
2 a client who's due for a maintenance dose of cyanocobalamin
3
, 3 a client who needs pre-filled insulin syringes
4 a client whose discharged from the hospital yesterday after heart failure treatment
5 a client with stage 3 pressure injury in need of addressing change - ANSWER 135
A cardiac catheterization was performed on a client 2 hours ago. The catheter was inserted
into the left femoral artery. What signs of potential complications should the nurse report
immediately to the healthcare provider? select all that apply
1 Bleeding at the catheterization site
2 client lying down and quiet Watching television
3 client taking only sips
4 left foot remarkably cooler than the right foot
5 urine output of 100 ml since the procedure - ANSWER 1,4
Bleeding at the puncture site indicates that a clot has not formed at the insertion site. this is
an arterial blade as catheterization was done via the femoral artery. arterial bleeds can lead
to hypovolemic shock and death if not treated immediately. we're just warmth the lower
extremity of the insertion site is a sign of decreased profusion to the extremity and could
result in teaching necrosis of the affected area.
OPTION 2 the client May lie flat for several hours and is encouraged to engage in quite
activities for 24 hours after the procedure to prevent dislodging the clot at the insertion site
OPTION 3 although clients are encouraged to drink fluids into flush dyes out of their system
and prevent dehydration, decreased fluid intake would not warrant notifying the hcp.
OPTION 5 you're an output in this client is above a 30 ml/hr and considered to be within
normal range
A child is scheduled to have an electroencephalogram (EEG). which statement by the parent
indicates understanding of the teaching?
1 I will let my child drink cocoa as usual the morning of the procedure
2 I will wash my child's hair using shampoo the morning of the procedure
3 my child may have scalp tenderness where the electrodes were applied
4 my child will not remember the procedure - ANSWER ANS B
4
what is the most appropriate nursing action?
encouraging visits by friends to decrease social isolation
giving the client a schedule of the daily activities
placing the client and restraints during invasive procedures
providing the client with a variety of toys - ANSWER giving the client a schedule of the
daily activities
A 14 year old client confides to the school nurse that she is pregnant likely in the second
trimester and has not had prenatal care. which of the following topics should the nurse
discuss with the client at this time? select all that apply.
1 desire for adoption planning services
2 em emotional response to the pregnancy
3 family social support systems
4 nutritional habits and substance abuse
5 plan for finishing High School - ANSWER ANS 234
Adolescent clients who are pregnant are a unique population because of their increased risk
for complications during pregnancy (Eg low birth weight, preterm birth preeclampsia) and
developmental needs. during an initial counter, the nurse should discussed the client's
emotional response to the pregnancy to build rapport and provide psychosocial support
(option 2). discussing the client's level of family/social support or fear of social
discrimination is appropriate because these factors May prevent the client from obtaining
prenatal care (option 3).
adolescents who are pregnant are vulnerable to poverty, dangerous living conditions,
exposure to tetrotogens (eg tobacco, alcohol, recreational drugs), poor nutritional status and
1
,physical or sexual abuse which can cause adverse fetal/maternal outcomes. therefore,
discussing these topics openly as soon as possible is appropriate to prevent harm (option 4).
Option 1 discussing adoption planning a parenting is not necessary at this time but should
be addressed later in collaboration with a social worker
Option 5 young adolescents (ie age <16) are less mature emotionally and developmentally
and may resist planning for the future. education planning may be approached during
subsequent encounters but it is not a priority for maternal and Fetal Health at this time.
Educational objective adolescent clients are increased risk for complications during
pregnancy. factors such as emotional response to the pregnancy, family social support
nutritional status and substance use impact the pregnancy and should be discussed during
an initial counter to establish Rapport and prevent harm.
A 2-year-old is suspected of having retinoblastoma. the nurse recognizes which sign as being
most characteristic of this disease?
1 absence of red reflex
2 fixed in mid dilated pupil
3 ptosis of the eye
4 purulent eye discharge - ANSWER ANS A
Retinoblastoma a unilateral or bilateral retina tumor is the most common childhood
intraocular malignancy. It is typically diagnosed in children under age 2 and is usually first
recognized when parents report a white glow of the people (leukocoria). light reflecting off
the tumor will cause the people to appear white instead of displaying the usual red reflex
(option 1). parents may even accidentally visualize leukocoria when taking a photograph of
the child using a flash. Strabismus (misalignment of the eyes) is a second most common sign;
visual impairment is a late sign indicative Advanced disease.
treatment depends on severity and may include radiation therapy or enucleation ( removal
of the eye) and fitting of prosthesis. siblings should undergo regular ocular screening as
some forms of retinoblastoma are hereditary.
Option 2 a fixed and mid dilated pupil is seen in acute glaucoma
Option 3 ptosis is dripping of the upper eyelid often associated with injury of the ocular
motor nerve (Cranial nerve III). ptosis is is also characteristic for myasthenia gravis.
Option 4 bacterial conjunctivitis causes eyelid swelling, a red conjunctiva, eye discomfort,
and purulent eye discharge.
2
,Educational objective: retinoblastoma is a malignancy of the eye typically diagnosed in
children under age 2. thought people will reflect a white color and the child will not have the
normal red eye reflex. treatment may include radiation therapy or enucleation ( removal of
the eye)
A behavioral health clinic nurse assesses 23 year old client who started taking paroxetine 3
weeks ago. which statement made by the client is most important for the nurse to
investigate?
1 I don't have much of an appetite since starting this medication
2 I have a lot more energy, but I'm feeling just as depressed
3 I have been feeling dizzy when I walk around at home
4 I have experienced frequent headaches lately - ANSWER ANS 2 selective serotonin
reuptake inhibitors (SSRIs) (eg fluoxetine, paroxetine, sertraline, citalopram) Are used to
treat a number of psychiatric conditions (eg major depressive disorder, generalized anxiety
disorder). clients usually see therapeutic effects in 1 to 4 weeks. SSRIs may increase the risk
of suicide especially in young children during initial therapy or after a dosage increase. a
client who reports increased energy without a change and depressive feelings needs to be
assessed and monitored for suicidal ideation or actions as a client may now have the energy
to execute the suicide plan (option 2)
common expected side effects of SSRIs include:
loss of appetite, weight loss or weight gain (option 1)
gastrointestinal disturbances (nausea, vomiting, diarrhea)
headaches dizziness drowsiness insomnia (options 3 and 4)
sexual dysfunction
side effects should gradually diminish over 3 months although some may persist. if
symptoms are intolerable or a particular SSRI is ineffective the client may be switched to a
different antidepressant.
A blizzard is predicted to hit a large city within a few hours. the Home Care nurses
prioritizing and revising the schedule and estimates of three home visits can be made before
the blizzard hits. Which clients should the nurse see? select all that apply
1 a client who fell and hit the head but refuses to go to the emergency department
2 a client who's due for a maintenance dose of cyanocobalamin
3
, 3 a client who needs pre-filled insulin syringes
4 a client whose discharged from the hospital yesterday after heart failure treatment
5 a client with stage 3 pressure injury in need of addressing change - ANSWER 135
A cardiac catheterization was performed on a client 2 hours ago. The catheter was inserted
into the left femoral artery. What signs of potential complications should the nurse report
immediately to the healthcare provider? select all that apply
1 Bleeding at the catheterization site
2 client lying down and quiet Watching television
3 client taking only sips
4 left foot remarkably cooler than the right foot
5 urine output of 100 ml since the procedure - ANSWER 1,4
Bleeding at the puncture site indicates that a clot has not formed at the insertion site. this is
an arterial blade as catheterization was done via the femoral artery. arterial bleeds can lead
to hypovolemic shock and death if not treated immediately. we're just warmth the lower
extremity of the insertion site is a sign of decreased profusion to the extremity and could
result in teaching necrosis of the affected area.
OPTION 2 the client May lie flat for several hours and is encouraged to engage in quite
activities for 24 hours after the procedure to prevent dislodging the clot at the insertion site
OPTION 3 although clients are encouraged to drink fluids into flush dyes out of their system
and prevent dehydration, decreased fluid intake would not warrant notifying the hcp.
OPTION 5 you're an output in this client is above a 30 ml/hr and considered to be within
normal range
A child is scheduled to have an electroencephalogram (EEG). which statement by the parent
indicates understanding of the teaching?
1 I will let my child drink cocoa as usual the morning of the procedure
2 I will wash my child's hair using shampoo the morning of the procedure
3 my child may have scalp tenderness where the electrodes were applied
4 my child will not remember the procedure - ANSWER ANS B
4
