Critical Thinking

1. The nurse is working in the emergency department (ED) of a children's medical center. Which client should the nurse assess first?

1. The 1-month-old infant who has developed colic and is crying.

2. The 2-year-old toddler who was bitten by another child at the day-care center. 3. The 6-year-old school-age child who was hit by a car while riding a bicycle.

4. The 14-year-old adolescent whose mother suspects her child is sexually active.

Rationale

Correct - 3-The child hit by a car should be assessed first because he or she may have life- threatening injuries that must be assessed and treated promptly.

1. In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking?

A) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors.

B) Note-taking allows the patient to continue at his or her own pace as the nurse records what is said.

C) Note-taking allows the nurse to shift attention away from the patient, resulting in an increased comfort level.

D) Note-taking allows the nurse to break eye contact with the patient, which may increase his or her level of comfort.

A) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors.

Page: 31 Some use of history forms and note-taking may be unavoidable. But be aware that note-taking during the interview has disadvantages. It breaks eye contact too often, and it shifts attention away from the patient, which diminishes his or her sense of importance. It also may interrupt the patient's narrative flow, and it impedes the observation of the patient's nonverbal behavior.

2. The 8-year-old client diagnosed with a vaso-occlusive sickle cell crisis is complaining of a severe headache. Which intervention should the nurse implement first?

1. Administer 6 L of oxygen via nasal cannula.

2. Assess the client's neurological status.

3. Administer a narcotic analgesic by intravenous push (IVP). 4. Increase the client's intravenous (IV) rate.

Rationale

Correct - 2-Because the client is complaining of a headache, the nurse should first rule out cerebrovascular accident (CVA) by assess- ing the client's neurological status and then determine whether it is a headache that can be treated with medication.

2. During an interview, the nurse states, "You mentioned shortness of breath. Tell me more about that." Which verbal skill is used with this statement?

A) Reflection

B) Facilitation

C) Direct question

D) Open-ended question

D) Open-ended question

Page: 32 The open-ended question asks for narrative information. It states the topic to be discussed but only in general terms. The nurse should use it to begin the interview, to introduce a new section of questions, and whenever the person introduces a new topic.

3. The 6-year-old client who has undergone abdominal surgery is attempting to make a pinwheel spin by blowing on it with the nurse's assistance. The child starts crying because the pinwheel won't spin. Which action should the nurse implement first?

1. Praise the child for the attempt to make the pinwheel spin.

2. Notify the respiratory therapist to implement incentive spirometry. 3. Encourage the child to turn from side to side and cough.

4. Demonstrate how to make the pinwheel spin by blowing on it.

Rationale

Correct -1. The nurse should always praise the child for attempts at cooperation even if the child did not accomplish what the nurse asked.

4. The nurse is caring for clients on the pediatric medical unit. Which client should the nurse assess first?

1. The child diagnosed with type 1 diabetes who has a blood glucose level

of 180 mg/dL.

2. The child diagnosed with pneumonia who is coughing and has a temperature of

100°F.

3. The child diagnosed with gastroenteritis who has a potassium (K+) level

of 3.9 mEq/L.

4. The child diagnosed with cystic fibrosis who has a pulse oximeter reading of 90%.

Rationale

Correct - 4. A pulse oximeter reading of less than 93% is significant and indicates hypoxia, which is life threatening; therefore, this child should be assessed first.

4. During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer begins to discuss his son's treatment, however, he suddenly crosses his arms against his chest and crosses his legs. This would suggest that the parent is:

A) just changing positions.

B) more comfortable in this position.

C) tired and needs a break from the interview.

D) uncomfortable talking about his son's treatment.

D) uncomfortable talking about his son's treatment.

Page: 37 Note the person's position. An open position with the extension of large muscle groups shows relaxation, physical comfort, and a willingness to share information. A closed position with the arms and legs crossed tends to look defensive and anxious. Note any change in posture. If a person in a relaxed position suddenly tenses, it suggests possible discomfort with the new topic.

5. The nurse has received the a.m. shift report for clients on a pediatric unit. Which medication should the nurse administer first?

1. The third dose of the aminoglycoside antibiotic to the child diagnosed with

methicillin-resistant Staphylococcus aureus (MRSA).

2. The IVP steroid methylprednisolone (Solu-Medrol) to the child diagnosed with

asthma.

3. The sliding scale insulin to the child diagnosed with type 1 diabetes mellitus.

4. The stimulant methylphenidate (Ritalin) to a child diagnosed with attention

deficit-hyperactivity disorder (ADHD).

Rationale

Correct - 3-Sliding scale insulin is ordered ac, which is before meals; therefore, this medication must be administered first after receiving the a.m. shift report.

4-Routine medications have a 1-hour leeway before and after the scheduled time; therefore, this medication does not have to be adminis- tered first.

6. The nurse enters the client's room and realizes the 9-month-old infant is not breath- ing. Which interventions should the nurse implement? Prioritize the nurse's actions from first (1) to last (5).

1. Perform cardiac compression 30:2.

2. Check the infant's brachial pulse. 3. Administer two puffs to the infant. 4. Determine unresponsiveness.

5. Open the infant's airway.

Rationale

Correct Answer: 4, 5, 3, 2, 1

4. The nurse must first determine the

infant's responsiveness by thumping the

baby's feet.

5. The nurse should then open the child's

airway using the head-tilt chin-lift tech- nique, with care taken not to hyperextend the neck. Then the nurse should look, listen, and feel for respirations.

3. The nurse then administers quick puffs of air while covering the child's mouth and nose, preferably with a rescue mask.

2. The nurse should determine whether the infant has a pulse by checking the brachial artery.

1. If the infant has no pulse, the nurse should begin chest compressions using two fingers at a rate of 30:2.

7. The 3-year-old client has been admitted to the pediatric unit. Which task should the nurse instruct the unlicensed assistive personnel (UAP) to perform first?

1. Orient the parents and child to the room.

2. Obtain an admission kit for the child.

3. Post the child's height and weight at the HOB. 4. Provide the child with a meal tray.

Rationale

Correct - 1.The first intervention after the child is ad- mitted to the unit is to orient the parents and child to the room, the call system, and the hospital rules, such as not leaving the child alone in the room.

8. The clinic nurse is preparing to administer an intramuscular (IM) injection to the 2-year-old toddler. Which intervention should the nurse implement first?

1. Immobilize the child's leg.

2. Explain the procedure to the child.

3. Cleanse the area with an alcohol swab. 4. Administer the medication in the thigh.

Rationale

Correct - 2-The nurse must explain any procedure in words the child can understand. It does not matter how old the child is.

9. The nurse is writing a care plan for the 5-year-old child diagnosed with gastroenteritis. Which client problem is priority?

1. Imbalanced nutrition.

2. Fluid volume deficit.

3. Knowledge deficit. 4. Risk for infection.

Rationale

Correct - 2-The child diagnosed with gastroenteritis is at high risk for hypovolemic shock resulting from vomiting and diarrhea; therefore, maintaining fluid and elec- trolyte homeostasis is priority.

10. Which data would warrant immediate intervention from the pediatric nurse? 1. Proteinuria for the child diagnosed with nephrotic syndrome.

2. Petechiae for the child diagnosed with leukemia.

3. Drooling for a child diagnosed with acute epiglottitis.

4. Elevated temperature in a child diagnosed with otitis media.

Rationale

Correct - 3-Drooling indicates the child is having trouble swallowing, and the epiglottis is at risk of completely occluding the air- way. This warrants immediate interven- tion. The nurse should notify the HCP and obtain an emergency tracheostomy tray for the bedside.

11. Which client should the pediatric nurse assess first after receiving the a.m. shift report? 1. The 6-month old child diagnosed with bacterial meningitis who is irritable and

crying.

2. The 9-month old child diagnosed with tetralogy of Fallot (TOF) who has edema of

the face.

3. The 11-month old child diagnosed with Reye syndrome who is lethargic and

vomiting.

4. The 13-month-old child diagnosed with diarrhea who has sunken eyeballs and

decreased urine output.

Rationale

Correct - 4. Sunken eyeballs and decreased urine out- put are signs of dehydration, which is a life-threatening complication of diarrhea; therefore, this child should be assessed first.

11. In the majority culture of America, coughing, sweating, and diarrhea are symptoms of an illness. For some individuals of Mexican-American origin, however, these symptoms are a normal part of living. The nurse recognizes that this is true, probably because Mexican-Americans:

A) have less efficient immune systems and are often ill.

B) consider these symptoms a part of normal living, not symptoms of ill health.

C) come from Mexico and coughing is normal and healthy there.

D) are usually in a lower socioeconomic group and are more likely to be sick.

B) consider these symptoms a part of normal living, not symptoms of ill health.

Page: 27 The nurse needs to identify the meaning of health to the patient, remembering that concepts are derived, in part, from the way in which members of the cultural group define health.

12. The pediatric clinic nurse is triaging telephone calls. Which client's parent should the nurse call first?

1. The 4-month-old child who had immunizations yesterday and the parent is report- ing a high-pitched cry and a 103°F fever.

2. The 8-month-old whose parent is reporting the child is pulling on the right ear and has a fever.

3. The 2-year-old child who has patent ductus arteriosis whose parent reports running out of digoxin.

4. The 3-year-old child whose mother called and reported her daughter may have chickenpox.

Rationale

Correct 1-A high fever and high-pitched crying may indicate a reaction to the immunizations; therefore, this parent needs to be called first to bring the child to the clinic.

12. Among many Asians there is a belief in the yin/yang theory, rooted in the ancient Chinese philosophy of Tao. The nurse recognizes which statement that most accurately reflects "health" in an Asian with this belief?

A) A person is able to work and produce.

B) A person is happy, stable, and feels good.

C) All aspects of the person are in perfect balance.

D) A person is able to care for others and function socially.

C) All aspects of the person are in perfect balance.

Page: 21 Many Asians believe in the yin/yang theory, in which health is believed to exist when all aspects of the person are in perfect balance. The other statements do not describe this theory.

13. The parent of a 12-year-old male child with a left below-the-knee cast calls the pedi- atric clinic nurse and tells the nurse, "My son's foot is cold and he told me it feels like his foot is asleep." Which action should the nurse implement first?

1. Prepare to bifurcate the left below-the-knee cast.

2. Tell the parent to bring the child to the office.

3. Instruct the parent to elevate the left leg on two pillows.

4. Notify the child's orthopedist of the situation.

Rationale

Correct - 3. The nurse should first take care of the client's body by having the parent elevate the left leg.

13. An individual who takes the magicoreligious perspective of illness and disease is likely to believe that his or her illness was caused by:

A) germs and viruses.

B) supernatural forces.

C) eating imbalanced foods.

D) an imbalance within his or her spiritual nature.

B) supernatural forces.

Page: 21 The basic premise of the magicoreligious perspective is that the world is seen as an arena in which supernatural forces dominate. The fate of the world and those in it depends on the actions of supernatural forces for good or evil. The other answers do not reflect the magicoreligious perspective.

14. If an American Indian has come to the clinic to seek help with regulating her diabetes, the nurse can expect that she:

A) will comply with the treatment prescribed.

B) has obviously given up her beliefs in naturalistic causes of disease.

C) may also be seeking the assistance of a shaman or medicine man.

D) will need extra help in dealing with her illness and may be experiencing a crisis of faith.

C) may also be seeking the assistance of a shaman or medicine man.

Page: 23 When self-treatment is unsuccessful, the individual may turn to the lay or folk healing systems, to spiritual or religious healing, or to scientific biomedicine. In addition to seeking help from a biomedical or scientific health care provider, patients may also seek help from folk or religious healers.

14. Which child requires the nurse to notify the healthcare provider?

1. The 1-year-old child with iron deficiency anemia who has dark-colored stool.

2. The 3-year-old child with phenylketonuria (PKU) whose parent does not feed the

child any meat or milk products.

3. The 5-year-old child with rheumatic heart fever who is having difficulty breathing.

4. The 7-year-old child diagnosed with acute glomerulonephritis who has dark

"tea"-colored urine.

Rationale

Correct - 3-A complication of rheumatic heart disease is valvular disorders that may be mani- fested by respiratory problems; therefore, the nurse should notify the child's health- care provider.

15. The pediatric nurse on the surgical unit has just received a.m. shift report. Which client should the nurse assess first?

1. The 3-week-old child 1 day postoperative with surgical repair of a myelomeningo-

cele who has bulging fontanels.

2. The 3-month-old child 2 days postoperative temporary colostomy secondary to

Hirschsprung's disease who has a moist, pink stoma.

3. The 9-month-old child with a cleft palate repair who is spitting up formula and

refusing to eat.

4. The 4-year-old child 1 day postoperative for repair of hypospadias who has clear

amber urine draining from indwelling catheter.

Rationale

Correct - 1-Bulging fontanels is a sign of increased intracranial pressure, which is a compli- cation of neurological surgery; therefore, this child should be assessed first.

16. The charge nurse has assigned a staff nurse to care for an 8-year-old client diagnosed with cerebral palsy. Which nursing action by the staff nurse would warrant immediate intervention by the charge nurse?

1. The staff nurse performs gentle range-of-motion (ROM) exercises to extremities. 2. The staff nurse puts the client's bed in the lowest position possible.

3. The staff nurse takes the client in a wheelchair to the activity room.

4. The staff nurse places the child in semi-Fowler's position to eat lunch.

Rationale

Correct - 4-The child should be positioned upright to prevent aspiration during meals; there- fore, this action would require the charge nurse to intervene.

17. The nurse and the unlicensed assistive personnel (UAP) are caring for clients on the pediatric unit. Which action by the nurse indicates appropriate delegation?

1. The nurse requests the UAP to check the circulation on the child with a cast.

2. The nurse asks the UAP to feed an infant who has just had a cleft palate repair.

3. The nurse has the UAP demonstrate a catheterization for a child with a neurogenic

bladder.

4. The nurse checks to make sure the UAP's delegated tasks have been completed.

Rationale

Correct - 4. The last step of delegating to a UAP is for the nurse to evaluate and determine whether the delegated tasks have been completed and performed correctly. This indicates the nurse has delegated appropriately.

17. The nurse recognizes that working with children with a different cultural perspective may be especially difficult because:

A) children have spiritual needs that are influenced by their stages of development.

B) children have spiritual needs that are direct reflections of what is occurring in their homes.

C) religious beliefs rarely affect the parents' perceptions of the illness.

D) parents are often the decision makers, and they have no knowledge of their children's spiritual needs.

A) children have spiritual needs that are influenced by their stages of development.

Page: 20. Illness during childhood may be an especially difficult clinical situation. Children, as well as adults, have spiritual needs that vary according to the child's developmental level and the religious climate that exists in the family. The other statements are not correct.

18. The nurse on a pediatric unit has received the a.m. shift report and tells the unli- censed assistive personnel (UAP) to keep the 2-year-old child NPO for a procedure. At 0830, the nurse observes the mother feeding the child. Which action should the nurse implement first?

1. Determine what the UAP did not understand about the instruction.

2. Tell the HCP the UAP did not follow the nurse's direction.

3. Ask the mother why she was feeding her child if the child was NPO.

4. Notify the dietary department to hold the child's meal trays.

Rationale

Correct - 1.Communication to the UAP must be clear, concise, correct, and complete. The nurse must determine why there was a lack of communication, which resulted in the child receiving food; therefore, this action should be implemented first.

19. The charge nurse on the six-bed pediatric burn unit is making shift assignments and has one registered nurse (RN), one scrub technician, one unlicensed assistive personnel (UAP), and a unit secretary. Which client care assignment indicates the best use of the hospital personnel?

1. The RN performs daily whirlpool dressing changes.

2. The unit secretary transcribes the HCP's orders.

3. The scrub technician medicates the client prior to dressing changes. 4. The UAP places the current laboratory results on the chart.

1-The scrub technician is assigned to perform daily whirlpool dressing changes, which is a lengthy procedure. Therefore, assigning the one RN to this task would be inappropriate because he or she cannot be unavailable for an extended period of time.

**2-One of the responsibilities of the unit secretary is to transcribe the HCP's orders, but the licensed nurse retains total responsibility for the correctness and accuracy of the transcribed orders.

3-The scrub technician cannot administer medications.

4-The unit secretary and laboratory personnel are responsible for posting laboratory data into the client's charts. The UAP should be on the unit taking care of the clients.

20. The RN and the UAP are caring for clients on a pediatric surgical unit. Which tasks would be most appropriate to delegate to the UAP? Select all that apply.

1. Pass dietary trays to the clients.

2. Obtain routine vital signs on the clients.

3. Complete the preoperative checklist.

4. Change linens on the clients' beds.

5. Document the clients' intake and output.

1, 2, 4, and 5 are correct.

1. The UAP can pass the dietary trays to

the clients because it does not require

judgment.

2. One of the responsibilities of the UAP is

taking routine vital signs on clients.

3. The nurse must complete the preoperative checklist because it requires nursing judg- ment to determine whether the client is ready for surgery.

4. One of the responsibilities of the UAP is changing bed linens.

5. The UAP can document the client's in- take and output, but the UAP cannot evaluate the numbers.

21. Which client should the charge nurse on the pediatric unit assign to the most experienced nurse?

1. The 4-year-old child diagnosed with hemophilia receiving factor VIII.

2. The 8-year-old child with headaches who is scheduled for a CT scan.

3. The 6-year-old child recovering from a sickle cell crisis.

4. The 11-year-old child newly diagnosed with rheumatoid arthritis.

1-The administration of blood products does not require the most experienced nurse.

2-Preparing a child for a routine procedure does not require the most experienced nurse.

3-The child recovering from a sickle cell crisis would not require the most experienced nurse.

**4-The child newly diagnosed with a chronic disease, which will have acute exacerba- tions, requires extensive teaching; there- fore, the most experienced nurse should be assigned to this child and family.

21. In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate?

A. Patient denies usual childhood illnesses.

B. Patient states he was a "very healthy" child.

C. Patient states sister had measles, but he didn't.

D. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.

D. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.

Page: 51. Childhood illnesses include measles, mumps, rubella, chickenpox, pertussis, and strep throat. Avoid recording "usual childhood illnesses" because an illness common in the person's childhood may be unusual today (e.g., measles).

22. The charge nurse is making shift assignments on a pediatric oncology unit. Which delegation/assignment would be most appropriate?

1. Delegate the unlicensed assistive personnel (UAP) to obtain routine blood work

from the central line.

2. Instruct the licensed practical nurse (LPN) to contact the leukemia support group.

3. Assign the chemotherapy-certified RN to administer chemotherapeutic medication.

4. Have the dietitian check the meal trays for the amount eaten.

1-Only an RN can withdraw blood from a

central line.

2. The social worker or case manager is respon-

sible for referring clients to support groups. This is not an expected responsibility of a floor nurse/LPN.

**3. Only chemotherapy-certified RNs can administer antineoplastic, chemothera- peutic medications. This is a national minimal standard of care according to the Oncology Nursing Society.

4. The dietician is responsible for ensuring that the proper food is provided along with evalu- ating the child's nutritional intake, not checking the amount of food eaten—this is the responsibility of the nursing staff.

22. The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What would be an appropriate response?

A. "Maybe she is just teething."

B. "I will check her ear for an ear infection."

C. "Are you sure she is really having pain?"

D. "Please describe what she is doing to indicate she is having pain."

D. "Please describe what she is doing to indicate she is having pain."

Page: 60. With a very young child, ask the parent, "How do you know the child is in pain?" Pulling at ears alerts parent to ear pain. The statements about teething and questioning whether the child is really having pain do not explore the symptoms, which should be done before a physical examination.

23. The nurse observes the unlicensed assistive personnel (UAP) bringing a cartoon video to a 6-year-old female child on bed rest so that she can watch it on the television. Which action should the nurse take?

1. Tell the UAP that the child should not be watching videos.

2. Explain that this is the responsibility of the child life therapist.

3. Praise the UAP for providing the child with an appropriate activity. 4. Notify the charge nurse that the UAP gave the child videos to watch.

1. A 6 year old child on best rest needs an appropriate activity to help with distraction; a cartoon video would be an age appropriate activity.

2. The child life therapist is responsible for

recreational and developmental activity for the hospitalized child, but any staff member should address the child's psychosocial needs.

**3. Part of the delegation process is to evaluate the UAP's performance of duties, and the nurse should praise any initiative on the part of the UAP in being a client advocate.

4. Videos are one of the few age-appropriate activities to occupy a 6-year-old on bed rest; therefore, there is no reason to notify the charge nurse.

24. Which newborn should the nurse in the neonatal intensive care unit (NICU) assign to a new graduate who has just completed an NICU internship?

1. The 1-day-old infant diagnosed with a myelomeningocele.

2. The 2-week-old infant who was born 6 weeks premature.

3. The 3-hour-old infant who is being evaluated for esophageal atresia. 4. The 1-week-old infant diagnosed with tetralogy of Fallot.

1-The newborn with the myelomeningocele has a portion of the spinal cord and mem- branes protruding through the back and is at risk for hydrocephalus and meningitis; this client should be assigned to a more experi- enced nurse.

**2-The new graduate who has completed the NICU internship should be able to care for a premature infant because care is primarily supportive.

3-Esophageal atresia, a congenital anomaly in which the esophagus does not completely develop, is a clinical and surgical emergency. It puts the newborn at risk for aspiration be- cause the upper esophagus ends in a blind pouch with the lower part of the esophagus connected to the trachea. This newborn should be assigned to a more experienced nurse.

4-Tetralogy of Fallot is a cyanotic, congenital anomaly. It includes a combination of four defects of the heart, all of which result in unoxygenated blood being pumped into the systemic circulation. This newborn must be assigned to an experienced nurse.

24. The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment?

A. It assesses how the individual is coping with life at home.

B. It determines how children are meeting developmental milestones.

C. It can identify any problems with memory the individual may be experiencing.

D. It helps to determine how a person is managing day-to-day activities.

D. It helps to determine how a person is managing day-to-day activities.

Page: 67. The functional assessment measures how a person manages day-to-day activities. The other answers do not reflect the purpose of a functional assessment.

25. The newly hired nurse is working on a pediatric unit and needs the unlicensed assistive personnel (UAP) to obtain a urine specimen on an 11-month-old infant. Which statement made to the UAP indicates the nurse understands the delegation process?

1. "Be sure to weigh the diaper when obtaining the urine specimen."

2. "Do you know how to apply the urine collection bag?"

3. "Use a small indwelling catheter when obtaining the urine specimen." 4. "I need for you to get a urine specimen on the infant."

1-Weighing the diaper is the procedure for de- termining the infant's urinary output and is not part of the procedure for obtaining a urine specimen.

**2-The NCSBN position paper in 1995 defined delegation as transferring to a competent individual the authority to perform a selected nursing task in a se- lected situation. The nurse retains the accountability for the delegation. The nurse must determine whether the UAP has the ability and knowledge to perform a task. This question clarifies whether the UAP has the ability to obtain a urine specimen.

3-Obtaining a urine specimen with an in- dwelling catheter on an 11-month-old infant would require more expertise than a UAP would have on the pediatric unit.

Furthermore, it does not determine whether the UAP understands how to do the procedure.

4. This statement does not determine whether the UAP understands how to perform the procedure of obtaining a urine specimen from an 11-month-old infant.

26. Which task is most appropriate for the pediatric nurse to delegate to the unlicensed assistive personnel (UAP)?

1. Ask the UAP to orient the parents and child to the room.

2. Tell the UAP to prepare the child for an endoscopy.

3. Request the UAP to log roll the client who had a spinal surgery. 4. Instruct the UAP to assess the child's developmental level.

**1-The UAP can orient the parents and child to the room, and demonstrate how to use the call light, how the bed works, or how the television works.

2-The UAP cannot prepare a child for en- doscopy; this requires assessment and evaluation to determine if the child is ready for the procedure.

3-There must be at least two people to log roll a child, and the UAP cannot do this procedure alone.

4-The nurse cannot delegate assessment to the UAP.

27. Which behavior by the unlicensed assistive personnel (UAP) warrants intervention by the nurse?

1. The UAP weighs the child's diaper on a scale and records the urine output on the intake & output (I&O) sheet.

2. The UAP sits with the child while the parent goes down to the cafeteria to get something to eat.

3. The UAP bathes the child with congenital dislocated hip with the Pavlik harness on the child.

4. The UAP applies wrist restraints on the 7-month-old who is 1 day postoperative cleft palate repair.

1-The UAP can weigh the diapers and obtain urine output. The nurse must evaluate the output.

2-A child under 12 years of age cannot be left alone in the room, and the UAP could stay with the child while the parent gets some- thing to eat.

3-The Pavlik harness should not be removed, so bathing the child in the harness is appro- priate and does not warrant intervention.

**4- The 7-month-old should have elbow restraints, not wrist restraints. Elbow restraints prevent the child from putting fingers into the mouth, but allow the child to move the arms.

27. During an examination, the nurse can assess mental status by which activity?

A) Examining the patient's electroencephalogram

B) Observing the patient as he or she performs an IQ test

C) Observing the patient and inferring health or dysfunction

D) Examining the patient's response to a specific set of questions

C) Observing the patient and inferring health or dysfunction

Page: 71. Mental status cannot be scrutinized directly like the characteristics of skin or heart sounds. Its functioning is inferred through assessment of an individual's behaviors, such as consciousness, language, mood and affect, and other aspects.

28. The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this patient:

A) will have no decrease in any of his abilities, including response time.

B) will have difficulty on tests of remote memory because this typically decreases with age.

C) may take a little longer to respond, but his general knowledge and abilities should not have declined.

D) will have had a decrease in his response time because of language loss and a decrease in general knowledge.

C) may take a little longer to respond, but his general knowledge and abilities should not have declined.

Page: 72. The aging process leaves the parameters of mental status mostly intact. There is no decrease in general knowledge and little or no loss in vocabulary. Response time is slower than in youth. It takes a bit longer for the brain to process information and to react to it. Recent memory, which requires some processing is somewhat decreased with aging, but remote memory is not affected.

28. The nurse is caring for pediatric clients. Which tasks are most appropriate to assign to an unlicensed assistive personnel (UAP) and/or a licensed vocational nurse (LPN)? Select all that apply.

1. Instruct the LPN to teach the parent of a child new diagnosed with type

1 diabetes.

2. Tell the UAP to apply an ice collar to the child who is 1 day postoperative

tonsillectomy.

3. Ask the UAP to place ointment on a child's diaper rash around the anal area.

4. Request the LPN to double-check the medication dose for the child receiving an

antibiotic.

5. Tell the LPN to transcribe the healthcare provider's orders for the child with

cystic fibrosis.

2, 3, 4, and 5 are correct.

1. The nurse cannot assign teaching to the LPN.

2. The UAP can apply an ice collar since the

client is stable.

3. The UAP can apply ointment to a diaper

rash—it is a medication but it can be

applied by the UAP.

4. The LPN can double-check a dose of

medication. The nurse can assign med-

ication administration to an LPN.

5. The LPN can transcribe a healthcare

provider's orders.

29. The nurse is discharging a 4-month-old child with a temporary colostomy. Which intervention should the nurse implement?

1. Request the UAP to complete the discharge written documentation.

2. Tell the LPN to show the parent how to irrigate the colostomy.

3. Ask the UAP to remove the child's intravenous catheter. 4. Request the UAP to escort the parent and child to the car.

1-The nurse cannot delegate teaching to the UAP.

2-The LPN could teach a client how to irrigate a colostomy, but a 4-month-old is inconti- nent of stool; therefore, irrigating the colostomy is not done.

3-The LPN or nurse should remove the IV catheter of a 4-month-old child, not the UAP.

**4-The UAP can escort the child and parents to the car.

30. The unlicensed assistive personnel (UAP) tells the nurse the child with Down syndrome who is 2 days postoperative appendectomy is having pain. Which intervention should the nurse implement first?

1. Tell the UAP to check the child's vital signs.

2. Assess the child's abdominal dressing and pain immediately.

3. Notify the healthcare provider.

4. Check the MAR for last time pain medication was administered.

1-The UAP can take vital signs but the nurse should assess the child to determine whether this is routine postoperative pain (expected), or whether a complication is occurring.

**2. A rule of thumb—if anyone else gives the nurse information about a client, the nurse should first assess the client before

taking any further action.

3. The nurse may need to notify the HCP, but not before assessing the child.

4. The nurse may need to administer pain med- ication but not prior to assessing the child.

30. During a mental status examination, the nurse wants to assess a patient's affect. The nurse should ask the patient which question?

A) "How do you feel today?"

B) "Would you please repeat the following words?"

C) "Have these medications had any effect on your pain?"

D) "Has this pain affected your ability to get dressed by yourself?"

A) "How do you feel today?"

Page: 74. Judge mood and affect by body language and facial expression and by asking directly, "How do you feel today?" or "How do you usually feel?" The mood should be appropriate to the person's place and condition and should change appropriately with topics.

31. The 8-year-old male child in the pediatric unit is refusing to ambulate postopera- tively. Which intervention would be most appropriate?

1. Give the child the option to ambulate now or after lunch.

2. Ask the parents to insist the child ambulate in the hall.

3. Refer the child to the child developmental therapist.

4. Tell the child he can watch a video game if he cooperates.

**1.The nurse should offer the child choices that ensure cooperation with the thera- peutic regimen. The choices are when the child will ambulate, not whether the child will ambulate.

2. The nurse could ask the parents for help in making sure the client ambulates, but this may cause a rift in the nurse/parent/child re- lationship. This is not the most appropriate intervention.

3. The child development therapist could assist with activities that would encourage the client to ambulate, but the nurse should take control of the situation and ensure the client ambulates. This is not the most appropriate intervention.

4. This is bribery, and the nurse should not use this technique to ensure cooperation with the therapeutic regimen.

32. The clinic nurse overhears a mother in the waiting room tell her 6-year-old son, "If you don't sit down and be quiet, I am going to get the nurse to give you a shot." Which action should the nurse implement?

1. Do not take any action because the mother is attempting to discipline her son. 2. Tell the child the nurse would not give him a shot because the mother said to.

3. Report this verbally abusive behavior to Child Protective Services.

4. Tell the mother this behavior will cause her son to be afraid of the nurses.

1. The nurse must take action or the child will

be afraid of the nurse.

2. The nurse should discuss the inappropriate

comment with the mother, not with the child.

3. If every nurse who overheard this type of comment reported it to Child Protective

Services, it would only unnecessarily increase the workload in an already overloaded system. Furthermore, reporting perceived potential abuse to Child Protective Services is a very serious accusation.

**4. The nurse should explain to the mother that threatening the child with a shot will cause the child to be frightened of healthcare professionals. This type of comment is inappropriate and should not be used to discipline a child.

32. The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status?

A) Mental status assessment diagnoses specific psychiatric disorders.

B) Mental disorders occur in response to everyday life stressors.

C) Mental status functioning is inferred through assessment of an individual's behaviors.

D) Mental status can be assessed directly, just like other systems of the body (e.g., cardiac and breath sounds).

C) Mental status functioning is inferred through assessment of an individual's behaviors.

Page: 71. Mental status functioning is inferred through assessment of an individual's behaviors. It cannot be assessed directly like characteristics of the skin or heart sounds.

33. The parents of an infant born with Down syndrome are holding their infant and crying. The father asks, "I have heard children like this are hard to take care of at home." Which referral would be most appropriate for the parents?

1. The Web site for the National Association for Down Syndrome.

2. The hospital chaplain.

3. A Down syndrome support group. 4. A geneticist.

1. There is a Web site to obtain information about Down syndrome, but this type of re- ferral would not be the most appropriate for parents who need to deal with emotional as- pects of having a child with special needs.

2. The hospital chaplain is an important part of the multidisciplinary healthcare team but would not have specialized knowledge re- garding caring for a special needs child.

**3. According to the NCLEX-RN® test plan, referrals are included in management of care. The most appropriate referral would be to a support group where other parents who have special needs children can share their feelings and provide ad- vice on how to care for their child in the home.

4. Although Down syndrome results from a trisomy chromosome 21, it is primarily associated with maternal age over 35 years. Furthermore, a geneticist would not have specialized knowledge regarding caring for a special needs child.

34. The charge nurse on the pediatric unit hears the overhead announcement of Code Pink (infant abduction), newborn nursery. Which action should the charge nurse implement?

1. Send a staff member to the newborn nursery.

2. Explain the situation to the clients and visitors.

3. Continue with the charge nurse's responsibilities. 4. Station a staff member at all the unit exits.

1. The newborn nursery does not need any more people in the area. Personnel are needed to monitor any and all exits.

2. The purpose of using code names to alert hospital personnel of emergency situations is to avoid panic among the clients and visitors; therefore, the nurse should not explain the situation to the clients and visitors.

3. Any time there is an overhead emergency an- nouncement, the charge nurse is responsible for following the hospital emergency plan.

**4. Code Pink means an infant has been abducted from the newborn nursery. The priority intervention is to prevent the ab- ductor from taking the child from the hospital, which can be prevented by plac- ing a staff member at all of the unit exits.

34. The nurse is assessing a patient's skin during an office visit. What is the best technique to use to best assess the patient's skin temperature? Use the:

A) fingertips because they're more sensitive to small changes in temperature.

B) dorsal surface of the hand because the skin is thinner than on the palms.

C) ulnar portion of the hand because there is increased blood supply that enhances temperature sensitivity.

D) palmar surface of the hand because it is most sensitive to temperature variations because of increased nerve supply in this area.

B) dorsal surface of the hand because the skin is thinner than on the palms.

The dorsa (backs) of hands and fingers are best for determining temperature because the skin there is thinner than on the palms. Fingertips are best for fine, tactile discrimination; the other responses are not useful for palpation.

35. The mother of a 4-year-old child diagnosed with Duchenne's muscular dystrophy is overwhelmed and asks the nurse, "I have been told a case manager will come and talk to me. What will they do for me?" Which statement indicates the nurse understands the role of the case manager?

1. "You will have a case manager so that the hospital can save money."

2. "She will make sure your child gets the right medication for muscular dystrophy." 3. "She will help you find the resources you need to care for your child."

4. "The case manager helps your child to have a normal life expectancy."

1.Even though case management is a strategy to ensure coordination of care while reduc- ing costs, the nurse should not share this with the mother.

2. The case manager is not responsible for ensuring that the client receives the correct medication; it is the responsibility of the HCP.

**3. According to the NCLEX-RN® test blueprint, questions on case management are included. The case manager will coordinate the care for a client with a chronic illness with other members of the multidisciplinary healthcare team. This attempts to prevent duplication of ser- vices and allows the mother to have a specific individual to coordinate services to meet the child's needs.

4. The life expectancy of a child with Duchenne's muscular dystrophy is approximately 25 years. The case manager is not responsible for help- ing the child have a normal life expectancy.

36. The nurse is assigned to the pediatric unit performance improvement committee. The unit is concerned with IV infection rates. Which action should the nurse implement first when investigating the problem?

1. Contact central supply for samples of IV start kits.

2. Obtain research to determine the best length for IV dwell time. 3. Identify how many IV infections have occurred in the last year. 4. Audit the charts to determine if hospital policy is being followed.

1 .Although this would not be the first step in investigating a problem, this action may be initiated if it is determined to be the cause for the increase in infection rates.

2. The nurse should utilize evidenced-based practice research when proposing changes because it is part of the performance im- provement process, but it is not the first in- tervention when investigating the problem.

**3. The first intervention is to determine the extent of the problem and who owns the problem. The NCLEX-RN® test blue- print includes performance improvement (quality improvement) in the manage- ment of care content.

4. This action may need to be implemented once it is determined whether there is a problem with IV infection rates. However, this would be the second step in the process.

36. The nurse would use bimanual palpation technique in which situation?

A) Palpating the thorax of an infant

B) Palpating the kidneys and uterus

C) Assessing pulsations and vibrations

D) Assessing the presence of tenderness and pain

B) Palpating the kidneys and uterus

Pages: 115-116. Bimanual palpation requires the use of both hands to envelop or capture certain body parts or organs such as the kidneys, uterus, or adnexa. The other situations are not appropriate for bimanual palpation.

37. The clinic nurse is discussing a tubal ligation with a 17-year-old adolescent with Down syndrome. The adolescent does not want the surgery, but her parents (who are also in the room) are telling her she must have it. Which statement by the nurse would be an example of the ethical principle of justice?

1. "I think this requires further discussion before scheduling this procedure." 2. "You will not be able to have children after you have this procedure."

3. "You should have this procedure because you could not care for a child." 4. "You can refuse this procedure and your parents can't make you have it."

**1. The ethical principle of justice is to treat all clients fairly, without regard to age, socioeconomic status, or any other vari- able, including clients with special needs. This statement supports the adolescent's right to her opinion even though she has Down syndrome.

2.If the adolescent needs clarification of the procedure, this would be an appropriate re- sponse, which is an example of the ethical principle of veracity or truth telling.

3.This statement is an example of the ethical principle of paternalism, in which the nurse knows what is best for the client.

4.This is an example of autonomy, in which the client has the right to self-determination. The Nuremburg Code of ethics specifically supports the rights of individuals with special needs against being forced to participate in procedures they do not want.

37. When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should:

A) consider this a normal finding.

B) palpate this area for an underlying mass.

C) reposition the hands and attempt to percuss in this area again.

D) consider this an abnormal finding and refer the patient for additional treatment.

A) consider this a normal finding.

Pages: 116-117. Percussion over relatively dense organs, such as the liver or spleen, will produce a dull sound. The other responses are not correct.

38. The school nurse has referred an 8-year-old student for further evaluation of vision. The single mother has told the school nurse she does not have the money for the eval- uation or glasses. Which action by the nurse would be an example of client advocacy? 1. Tell the mother the child cannot read the board.

2. Refer the mother to a local service organization. 3. Ask the mother if the family is on Medicaid.

4. Loan the mother money for the examination.

1.Although this may be the case, this is not client advocacy, and doing so may make the mother feel guilty about not being able to afford glasses for her child.

**2.This is an example of client advocacy because many local service organizations, such as the Lions Club or the Rotary Club, will subsidize the cost of the vision test and glasses.

3.Medicaid does not pay for glasses, and it is not the school nurse's business whether the family is on Medicaid.

4.The nurse should not loan the mother money because this crosses professional boundaries.

38. The nurse is unable to palpate the right radial pulse on a patient. The best action would be to:

A) auscultate over the area with a fetoscope.

B) use a goniometer to measure the pulsations.

C) use a Doppler device to check for pulsations over the area.

D) check for the presence of pulsations with a stethoscope.

C) use a Doppler device to check for pulsations over the area.

Page: 120. Doppler devices are used to augment pulse or blood pressure measurements. Goniometers measure joint range of motion. A fetoscope is used to auscultate fetal heart tones. Stethoscopes are used to auscultate breath, bowel, and heart sounds.

39. The emergency department (ED) nurse is scheduling the 16-year-old client for an emergency appendectomy. Which intervention should the nurse implement when obtaining permission for the surgery?

1. Withhold the narcotic pain medication until the client signs the permit.

2. Have the client's parent or legal guardian sign the operative permit.

3. Explain the procedure to the client and the parents in simple terms.

4. Get a visitor from the ED waiting area to witness the parent's signature.

1. The 16-year-old client is not old enough to sign the permit; therefore, pain medication would not be withheld.

**2. Legally, a child under the age of 18 must have a parent or legal guardian sign for informed consent. The nurse should de- termine whether the child is aware of the situation and assents to the procedure.

3. The surgeon is responsible for explaining the procedure; the nurse is responsible for witnessing the signature on the operative permit.

4. The nurse is responsible for witnessing the signature. Having a visitor sign the operative permit is a violation of HIPAA.

39. When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination?

A) There is no need to wash one's hands after removing gloves, as long as the gloves are still intact.

B) Wash hands before and after every physical patient encounter.

C) Wash hands between the examination of each body system to prevent the spread of bacteria from one part of the body to another.

D) Wear gloves throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases.

B) Wash hands before and after every physical patient encounter.

Page: 120. The nurse should wash his or her hands before and after every physical patient encounter; after contact with blood, body fluids, secretions, and excretions; after contact with any equipment contaminated with body fluids; and after removing gloves. Hands should be washed after gloves have been removed, even if the gloves appear to be intact. Gloves should be worn when there is potential contact with any body fluids.

40. The unit manager has been notified by central supply that many client items are missing from stock and have not been charged to the client. Which action should the nurse manager implement regarding the lost charges?

1. Send out a memo telling the staff to follow the charge procedures.

2. Form a performance improvement committee to study the problem.

3. Determine whether the items in question are being restocked daily.

4. Schedule a staff meeting to discuss how to prevent further lost charges.

1. A written memo does not allow the staff to have input into how to correct the problem. This memo might lead to blaming and arguments among the staff.

2. The performance improvement committee is designed to improve client care, not to address management issues.

3. This is implying that the unit manager does not believe the central supply lost charges. If the unit manager has this concern, it should be addressed directly with the central supply supervisor.

**4. Because the staff is responsible for following the hospital procedure for charging for items used in client care, the unit manager should discuss this with staff to determine what should be done to correct the problem.

40. The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination?

A) When the infant is sleeping

B) At the end of the examination

C) Before auscultation of the thorax

D) Halfway through the examination

B) At the end of the examination

Page: 123. Elicit the Moro or "startle" reflex at the end of the examination because it may cause the infant to cry.

41. Which child's behavior warrants notifying the child developmental specialist? 1. The 1-year-old child who cries when the parent leaves the room.

2. The 2-year-old child who can talk in two- or three-word sentences.

3. The 3-year-old child who is toilet trained for bowel and bladder.

4. The 4-year-old child who throws frequent temper tantrums.

1. A 1 yr old child who cries when the parent leaves the room is developmentally on target

2. The 2-year-old who can speak in two- or

three-word sentences is developmentally on

target.

3. The 3-year-old should be toilet trained by

this age.

**4. The toddler (age 1-3) is expected to throw temper tantrums, but a 4-year-old child should not be doing this; therefore, the child is not developmentally on target and the child developmental specialist should be notified.

42. Which child should the nurse assign to the new graduate who has just completed orientation to the pediatric unit?

1. The 5-year-old child admitted in a sickle cell crisis whose patient-controlled

analgesia (PCA) pump is not controlling the child's pain.

2. The 6-year-old child in Russell's traction for a fractured femur who has insertion

pin sites that are inflamed and infected.

3. The 12-year-old child who is newly diagnosed with type 1 diabetes who needs

medication teaching.

4. The 16-year-old female diagnosed with scoliosis who is being admitted for inser-

tion of a spinal rod in the morning.

42. 1. The child with uncontrolled pain would require a more experienced nurse.

2. Infected skeletal pin sites can lead to osteomyelitis, which would require a more experienced nurse.

3. This child and parents require extensive teaching and should be assigned to a more experienced nurse.

**4. The new graduate should be able to com- plete preoperative teaching and prepare the young client for surgery. This client is stable.

42. The nurse is assessing an 80-year-old male patient. Which assessment findings would be considered normal?

A) An increase in body weight from younger years

B) Additional deposits of fat on the thighs and lower legs

C) The presence of kyphosis and flexion in the knees and hips

D) A change in overall body proportion, a longer trunk, and shorter extremities

C) The presence of kyphosis and flexion in the knees and hips

Page: 149. Changes that occur in the aging person include more prominent bony landmarks, decreased body weight (especially in males), a decrease in subcutaneous fat from the face and periphery, and additional fat deposited on the abdomen and hips. Postural changes of kyphosis and slight flexion in the knees and hips also occur.

43. Which action by the emergency department (ED) nurse warrants intervention by the charge nurse?

1. The nurse is elevating the right arm of a child who appears to have fractured the wrist.

2. The nurse is notifying Child Protective Services for a child who is suspected of being sexually abused.

3. The nurse is assessing the tonsils on a 4-year-old child who has a sore throat and is drooling.

4. The nurse is obtaining a midstream urine specimen for the child who is complain- ing of burning upon urination.

1. Elevating the arm to help decrease edema is an appropriate intervention and does not warrant intervention.

2. The nurse is legally obligated to notify CPS for any suspected child abuse.

**3. A child who is drooling may have epiglot- titis and opening the mouth may lead to respiratory distress. This action warrants intervention by the charge nurse.

4. The nurse needs to confirm a urinary tract

infection by obtaining a urine specimen.

43. When assessing the force, or strength, of a pulse, the nurse recalls that it:

A) is usually recorded on a 0- to 2-point scale.

B) demonstrates elasticity of the vessel wall.

C) is a reflection of the heart's stroke volume.

D) reflects the blood volume in the arteries during diastole.

C) is a reflection of the heart's stroke volume.

Page: 134. The heart pumps an amount of blood (the stroke volume) into the aorta. The force flares the arterial walls and generates a pressure wave, which is felt in the periphery as the pulse.

45. Which interventions should the nurse implement to help establish a nurse/parent relationship? Select all that apply.

1. Include the parents when developing the plan of care for their child.

2. Encourage the parents to hold their child as much as possible.

3. Allow the parents to verbalize their feelings of fear and anxiety. 4. Tell the parents to never leave while the child is hospitalized.

5. Request the parents to bring toys from home the child will enjoy.

1 and 3 are correct.

1. Including the parents in developing the

plan of care will help establish a positive

relationship.

2. Holding their child will help with the child/parent relationship, but not with the nurse/parent relationship.

3. Allowing the parents to vent their feel- ings will help form a positive nurse/ parent relationship.

4. The nurse must not make the parents feel guilty if they have to work while the child is hospitalized. A relative can stay with the child if parents have to work.

5. This will help the child/parent relationship not the nurse/parent relationship.

46. The nurse is caring for clients on the pediatric unit. Which child would warrant a referral to the early childhood development specialist?

1. The 9-month-old child who says only "mama" or "dada."

2. The 11-month-old child who walks hanging onto furniture.

3. The 8-month-old child who sits by leaning forward on both hands. 4. The 4-month-old infant who turns from the abdomen to the back.

1.The 9-month-old infant's language and cog- nitive skills include imitating sounds, saying single syllables, and beginning to put sylla- bles together. Using "mama" and "dada" indicates this child is developmentally on target.

2. The 10- to 12-month-old infant can walk with one hand held or cruise the furniture, but will usually crawl to get places more rapidly. This behavior indicates the child is developmentally on target.

**3.The 8-month-old infant should be able to sit steadily unsupported; therefore, this child is developmentally delayed and warrants a referral to the early childhood development specialist. Leaning forward on both hands to sit is normal for a 6-month-old.

4.The 4-month-old infant should be able to turn from the abdomen to back; there- fore, this child is developmentally on target.

45. The nurse is providing care for a 68-year-old woman who is complaining of constipation. What concern exists regarding her nutritional status?

A) The absorption of nutrients may be impaired.

B) The constipation may represent a food allergy.

C) She may need emergency surgery for the problem.

D) The gastrointestinal problem will increase her caloric demand.

A) The absorption of nutrients may be impaired.

Page: 182. Gastrointestinal symptoms such as vomiting, diarrhea, or constipation may interfere with nutrient intake or absorption. The other responses are not correct.

47. The 10-year-old child diagnosed with leukemia is scheduled for a bone marrow aspiration. Which intervention is most important when obtaining informed consent for the procedure?

1. Obtain assent from the child.

2. Have the parent sign the permit.

3. Refer any questions to the HCP.

4. Witness the signature on the permit.

**1.The most important intervention for this child is to make sure the child has some control and input into the decision mak- ing. It is customary to obtain assent from children 7 years of age and older. Assent means the child has been fully informed about the procedure and concurs with those giving the informed consent.

2.The parents must sign the permit because the child is under age 18, but the most im- portant intervention is to make sure the child is included and aware of decisions being made about his or her body.

3.The nurse may be able to clarify some of the child's or parent's questions and does not need to refer all questions to the HCP.

4.Witnessing the signature on the permit is required prior to the child's having surgery, but it is not the most important intervention.

46. During a nutritional assessment, why is it important for the nurse to ask a patient what medications he or she is taking?

A) Certain drugs can affect the metabolism of nutrients.

B) The nurse needs to assess the patient for allergic reactions.

C) Medications need to be documented on the record for the physician's review.

D) Medications can affect one's memory and ability to identify food eaten in the last 24 hours.

A) Certain drugs can affect the metabolism of nutrients.

Page: 183

Analgesics, antacids, anticonvulsants, antibiotics, diuretics, laxatives, antineoplastic drugs, steroids, and oral contraceptives are drugs that can interact with nutrients, impairing their digestion, absorption, metabolism, or use. The other responses are not correct.

48. The 13-year-old client has just delivered a 4-pound baby boy. The stepfather of the client becomes verbally abusive to the nurse when he is asked to leave the room. The client is withdrawn and silent. Which legal action should the nurse implement?

1. Call hospital security to come to the room.

2. Contact Child Protective Services.

3. Refer the child to the social worker.

4. Ask the client whether she feels safe at home.

1.The nurse should call hospital security when a client or visitor is being abusive, but this is not a legal action.

**2.Legally, the nurse is required to report any suspected child abuse. A 13-year-old child who is having a baby and is with- drawn and silent along with a potential abuser who is trying to control access to the child should make the nurse suspect child abuse.

3.Referring the client to a social worker is not a legal action.

4.Asking the client whether she feels safe at home is an appropriate assessment question, but it is not a legal action.

47. The nurse is reviewing the nutritional assessment of an 82-year-old patient. Which of these factors is most likely to affect the nutritional status of an elderly person?

A) Increase in taste and smell

B) Living alone on a fixed income

C) Change in cardiovascular status

D) Increase in gastrointestinal motility and absorption

B) Living alone on a fixed income

Page: 176. Socioeconomic conditions frequently affect the nutritional status of the aging adult; these factors should be closely evaluated. Physical limitations, income, and social isolation are frequent problems that interfere with the acquisition of a balanced diet. A decrease in taste and smell and decreased gastrointestinal motility and absorption occur with aging. Cardiovascular status is not a factor that affects an elderly person's nutritional status.

49. The fire alarm on the pediatric unit has just started sounding. Which action should the charge nurse implement first?

1. Call the hospital operator to find out the location of the fire.

2. Ensure that all visitors and clients are in the room with the door closed.

3. Prepare to evacuate the clients and visitors down the stairs. 4. Make a list of which clients are not currently on the unit.

1.The charge nurse must first make sure that clients and visitors are safe. Someone will notify the charge nurse about the location of the fire.

**2.Safety of the clients and visitors is prior- ity; therefore, ensuring that they are in a room with the door closed is the first intervention.

3.The charge nurse may need to prepare for evacuation, but it is not the first intervention.

4. Although making a list of clients not cur- rently on the unit is an appropriate interven- tion, the charge nurse must first ensure the safety of the clients and visitors who are on the pediatric unit.

48. When the mid-upper arm circumference and triceps skinfold of an 82-year-old man are evaluated, which is important for the nurse to remember?

A) These measurements are no longer necessary for the elderly.

B) Derived weight measures may be difficult to interpret because of wide ranges of normal.

C) These measurements may not be accurate because of changes in skin and fat distribution.

D) Measurements may be difficult to obtain if the patient is unable to flex his elbow to at least 90 degrees.

C) These measurements may not be accurate because of changes in skin and fat distribution.

Page: 191

Accurate mid-upper arm circumference and triceps skinfold measurements are difficult to obtain and interpret in older adults because of sagging skin, changes in fat distribution, and declining muscle mass. Body mass index and waist-to-hip ratio are better indicators of obesity in the elderly.

50. A nurse overhears two other nurses talking about a client in the hospital dining room. Which action should the nurse implement first?

1. Notify the HIPAA officer about the breach of confidentiality.

2. Immediately report the two nurses to their clinical manager.

3. Document the situation in writing and submit to the Chief Nursing Officer (CNO). 4. Tell the two nurses they are violating the client's confidentiality.

1. .The HIPAA officer can be notified of the breach of confidentiality, but the nurse must first confront the two nurses and correct the behavior.

2. The nurses can be reported to their clinical manager, but the nurse must first confront the two nurses and correct the behavior.

3. The situation can be documented in writing and turned into the HIPAA officer (not the CNO), but the nurse must first confront the two nurses and correct the behavior.

**4. This is a violation of HIPAA; therefore, the nurse must first confront the two nurses and correct the behavior.

49. The nurse needs to perform anthropometric measures of an 80-year-old man who is confined to a wheelchair. Which of the following is true in this situation?

A) Changes in fat distribution will affect the waist-to-hip ratio.

B) Height measurements may not be accurate because of changes in bone.

C) Declining muscle mass will affect the triceps skinfold measure.

D) Mid-arm circumference is difficult to obtain because of loss of skin elasticity.

B) Height measurements may not be accurate because of changes in bone.

Page: 191. Height measures may not be accurate in individuals confined to a bed or wheelchair or those over 60 years of age because of osteoporotic changes.

51. The nurse is caring for newborns in the nursery. Which newborn warrants immediate intervention by the nurse?

1. The 8-hour-old newborn who has not passed meconium.

2. The 15-hour-old newborn who is slightly jaundiced.

3. The 4-hour-old newborn who is jittery and irritable. 4. The 10-hour-old newborn who will not stop crying.

1.The nurse would not be concerned about not passing meconium until at least 24 hours after delivery.

2. The nurse would not be concerned about a newborn who is slightly jaundiced until after 24 hours after delivery, at which point the HCP would investigate to determine whether the jaundice is pathological.

**3. A newborn who is jittery and irritable needs to be assessed first for possible hypoglycemia. The nurse could feed the newborn glucose water or provide more frequent, regular feedings.

4. Although the nurse should determine why the newborn will not stop crying, the new- born who is showing signs of hypoglycemia warrants immediate intervention.

50. The nurse is performing a nutritional assessment on an 80-year-old patient. The nurse knows that physiological changes that directly affect the nutritional status of the elderly include:

A) slowed gastrointestinal motility.

B) hyperstimulation of the salivary glands.

C) an increased sensitivity to spicy and aromatic foods.

D) decreased gastrointestinal absorption causing esophageal reflux.

A) slowed gastrointestinal motility.

Page: 176. Normal physiological changes in aging adults that affect nutritional status include slowed gastrointestinal motility, decreased gastrointestinal absorption, diminished olfactory and taste sensitivity, decreased saliva production, decreased visual acuity, and poor dentition.

53. The nurse who has never worked on the maternity ward has been pulled from the surgical unit to work in the newborn nursery. Which assignment would be most appropriate for the nurse to accept?

1. Perform an assessment on the newborn.

2. Assist the pediatrician with a circumcision. 3. Gavage feed a newborn who is 8 hours old. 4. Transport newborns to the mothers' room.

1.The nurse should not accept any assign- ment for which he or she is unqualified.

A newborn assessment requires specialized knowledge and skills to detect potential complications.

2. The nurse who is not familiar with the pro- cedure or the unit should not be assigned to assist a pediatrician to perform a procedure.

3. This is a dangerous procedure because the nurse must insert a tube into the newborn's stomach. A nurse who is not familiar with this procedure should refuse the assignment.

**4. Any nurse can take an infant to the mother's room and check the bands to ensure the right infant is with the right mother. This is an appropriate task for a nurse who has never worked in the nursery.

51. The nurse keeps in mind that a thorough skin assessment is very important because the skin holds information about a person's:

A) support systems.

B) circulatory status.

C) socioeconomic status.

D) psychological wellness.

B) circulatory status.

Page: 211. The skin holds information about the body's circulation, nutritional status, and signs of systemic diseases as well as topical data on the integument itself.

54. The nurse is instructing the unlicensed assistive personnel (UAP) on gross motor skill activity that is appropriate for a developmentally delayed 9-month-old infant. Which activity should the nurse delegate to the UAP?

1. Help the child to sit without support.

2. Teach the child to catch the beach ball. 3. Reward the child with food for sitting up. 4. Teach the child to blow a kiss.

**1. The 9-month-old infant should be able to sit without support. Therefore, the nurse should instruct the UAP to perform the developmental task of helping the child sit without support.

2. Teaching a child to catch a beach ball would be appropriate for a 15- to 18-month-old child, so the nurse should not instruct the UAP to perform this task.

3. The UAP should not use food as a reward or comfort measure because it may lead to childhood obesity.

4. Teaching a child how to blow a kiss is a language/cognitive activity and will not help the child's gross motor development.

52. A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse would pay special attention to the danger signs for pigmented lesions and would be concerned with which additional finding?

A) Color variation

B) Border regularity

C) Symmetry of lesions

D) Diameter less than 6 mm

A) Color variation

Pages: 212-213. Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, color variation, and diameter greater than 6 mm.

55. Which incident should the primary nurse report to the clinical manager concerning a violation of information technology guidelines?

1. The nurse keeps the computer screen turned away from public view.

2. The nurse researches medications using the online formulary.

3. The nurse shares the computer access code with another nurse. 4. The nurse logs off the computer when leaving the terminal.

1. Making sure no one can view the screen is an appropriate information technology guideline.

2. Researching medication online is ensuring safe and effective nursing care and shows that the nurse is keeping abreast of new medications.

**3. According to the NCLEX-RN® test blueprint, the nurse must be knowledge- able of information technology. Giving another nurse his or her access code is a very serious violation of information technology guidelines and should be reported.

4. Logging off the computer is an appropriate information technology guideline.

53. An elderly woman is brought to the emergency department after being found lying on the kitchen floor 2 days, and she is extremely dehydrated. What would the nurse expect to see upon examination?

A) Smooth mucous membranes and lips

B) Dry mucous membranes and cracked lips

C) Pale mucous membranes

D) White patches on the mucous membranes

B) Dry mucous membranes and cracked lips

Page: 215. With dehydration, mucous membranes look dry and lips look parched and cracked. The other responses are not found in dehydration.

56. The nurse is caring for clients in a pediatric emergency department (ED). Which client should the nurse assess first?

1. The child with a dog bite on the left hand who is bleeding.

2. The child who has a laceration on the right side of the forehead.

3. The child with a fractured tibia who will not move the foot. 4. The child who has ingested a bottle of prenatal vitamins.

1. A dog bite is an emergency, but it is not life threatening; therefore, this child would not be assessed first.

2. The child with a head laceration must be assessed, but not before a child who might die of medication poisoning.

3. The child with a fractured tibia would not be expected to move the foot.

**4. A child who ingested a bottle of prenatal vitamins presents a medication poisoning that is a potentially life-threatening situa- tion. This child must be assessed first

to determine how many vitamins were taken, how long ago they were taken, and whether or not the vitamins contained iron. The child's neurological status must also be assessed.

54. A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which assessment finding?

A) Anasarca

B) Scleroderma

C) Pedal erythema

D) Clubbing of the nails

D) Clubbing of the nails

Pages: 217-218. Clubbing of the nails occurs with congenital cyanotic heart disease, neoplastic, and pulmonary diseases. The other responses are assessment findings not associated with pulmonary diseases.

57. The nurse is caring for a client in a children's medical center. Which behavior indicates the nurse understands the pediatric client's rights?

1. The nurse administers an injection without talking to the child.

2. The nurse covers the 5-year-old child's genitalia during a code.

3. The nurse discusses the child's condition with the grandparents. 4. The nurse leaves an uncapped needle at the client's bedside.

1. The pediatric client has the right to an explanation of procedures being done to his or her body.

**2. The pediatric client has a right to be treated with dignity and respect. Just because the child is being coded does not mean the nurse should allow the child's body to be exposed to everyone in the room.

3. The pediatric client has a right to confiden- tiality, and the parents/legal guardians are the only individuals who have a right to the child's health information. Talking to the grandparents is a violation of HIPAA unless the parents have approved.

4. The nurse is responsible and accountable to protect the health, safety, and rights of the pediatric client. Leaving an uncapped needle at the bedside could cause serious harm to the child.

55. The nurse has discovered decreased skin turgor in a patient and knows that this is an expected finding in which of these conditions?

A) Severe obesity

B) Childhood growth spurts

C) Severe dehydration

D) Connective tissue disorders such as scleroderma

C) Severe dehydration

Page: 215. Decreased skin turgor is associated with severe dehydration or extreme weight loss.

58. The home health nurse is planning the care of a 14-year-old client diagnosed with leukemia who is receiving chemotherapy. Which psychosocial problem is priority for this client?

1. Diversional activity deficit.

2. High risk for infection. 3. Social isolation.

4. Hopelessness.

1. Diversional activity deficit would be appro- priate if the client did not have sufficient activities to keep him or her occupied. Most children of this age will watch television, play video games, or read books.

2. The client has leukemia and is receiving chemotherapy, which leads to an increased risk of infection; however, this is a physiolog- ical problem, not a psychosocial problem.

**3. The client will be isolated from peers and schools because of the high risk of infec- tion resulting from the immunosuppres- sion secondary to chemotherapy and the disease process. At this stage, the child needs to be developing peer relationships and independence from parents. There- fore, social isolation is the priority psy- chosocial problem for this client.

4. The nurse should not identify hopelessness because childhood leukemia has a good prognosis.

56. A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would:

A) tell the patient to watch the lesion and report back in 2 months.

B) refer the patient because of the suspicion of melanoma on the basis of her symptoms.

C) ask additional questions regarding environmental irritants that may have caused this condition.

D) suspect that this is a compound nevus, which is very common in young to middle-aged adults.

B) refer the patient because of the suspicion of melanoma on the basis of her symptoms.

The ABCD danger signs of melanoma are asymmetry, border irregularity, color variation, and diameter. In addition, individuals may report a change in size, development of itching, burning, bleeding, or a new-pigmented lesion. Any of these signs raise suspicion of malignant melanoma and warrant immediate referral.

59. The nurse is administering IV fluids to a 3-year-old client. Which action by the nurse would warrant intervention by the charge nurse?

1. The nurse places the IV on an infusion pump.

2. The nurse does not use a volume-controlled chamber.

3. The nurse checks the child's IV site every hour.

4. The nurse labels the IV tubing with date and time.

1.Placing the IV line on an infusion pump helps to make sure the client does not receive an overload of IV fluid. Most facilities require an IV pump and volume-controlled chamber when administering fluids in a pediatric clinic.

**2.A volume-controlled chamber (Buretrol) is a device that is used with children when administering IV fluids. The cham- ber is filled with 1 hour's amount of fluid so that the child will not inadvertently re- ceive an overload of fluid. Fluid volume overload is a potentially life-threatening situation in children.

3. The site should be checked frequently to en- sure that the IV does not infiltrate; therefore, this does not warrant intervention.

4. The IV tubing should not be used longer than 72 hours; therefore, labeling the tubing with the date and time would not warrant intervention.

57. The nurse is assessing for clubbing of the fingernails and would expect to find:

A) a nail base that is firm and slightly tender.

B) curved nails with a convex profile and ridges across the nail.

C) a nail base that feels spongy with an angle of the nail base of 150 degrees.

D) an angle of the nail base of 180 degrees or greater with a nail base that feels spongy.

D) an angle of the nail base of 180 degrees or greater with a nail base that feels spongy.

Pages: 217-218. The normal nail is firm at its base and has an angle of 160 degrees. In clubbing, the angle straightens to 180 degrees or greater and the nail base feels spongy.

60. The nurse is caring for clients on a psychiatric pediatric unit. Which action by the nurse is reportable to the state board of nursing?

1. The nurse leaves for lunch and does not return to complete the shift.

2. The nurse fails to check the ID band when administering medications.

3. The nurse has had three documented medication errors in the last 3 months. 4. The nurse has admitted to having an affair with another staff member.

**1. Abandonment is a reportable offense to the state board of nursing in every state. Reportable offenses could result in stipulations made to the nurse's license.

2. This is failure to follow the five rights of medication administration, but it is not a reportable offense.

3. Multiple medication errors are a manage- ment issue, not a reportable offense.

4.Having an affair with a fellow employee is not a reportable offense.

58. A patient has been admitted for severe psoriasis. The nurse can expect to see what finding in the patient's fingernails?

A) Splinter hemorrhages

B) Paronychia

C) Pitting

D) Beau lines

C) Pitting

Pages: 248-250. Pitting nails are characterized by sharply defined pitting and crumbling of the nails with distal detachment, and they are associated with psoriasis. See Table 12-13 for descriptions of the other terms.

61. The nurse is working in a free healthcare clinic. Which client situation warrants further investigation?

1. The child diagnosed with rheumatoid arthritis who is wearing a copper bracelet.

2. The mother of a child with a sunburn who is using juice from an aloe vera plant on

the burn.

3. The grandmother who reports rubbing Vick's Vapo-Rub on the child's chest for

a cold.

4. The father who tells the nurse that the child receives a variety of herbs every day.

1. A copper bracelet may or may not help the child with rheumatoid arthritis, but because it will not hurt the child, it does not warrant further investigation.

2. Aloe vera is used in many topical burn prepa- rations; therefore, this practice would not warrant further investigation.

3. Vick's VapoRub may or may not help the child's cold, but, because it will not hurt the child, it does not warrant further investigation.

**4. Herbal products are not regulated by the Food and Drug Administration, and there is very little (if any) research on herbal use with children. The nurse should at least investigate which herbs the child is receiving before taking further action.

59. The nurse suspects that a patient has hyperthyroidism and laboratory data indicate that the patient's thyroxine and tri-iodothyronine hormone levels are elevated. Which of these findings would the nurse most likely find on examination?

A) Tachycardia

B) Constipation

C) Rapid dyspnea

D) Atrophied nodular thyroid

A) Tachycardia

Thyroxine and tri-iodothyronine are thyroid hormones that stimulate the rate of cellular metabolism, resulting in tachycardia. With an enlarged thyroid as in hyperthyroidism, the nurse might expect to find diffuse enlargement (goiter) or a nodular lump, but not an atrophied gland. Dyspnea and constipation are not findings associated with hyperthyroidism.

62. The unlicensed assistive personnel (UAP) tells the primary nurse that the 4-year-old child is alone in the room because the mother went to the cafeteria to get something to eat. Which action should the nurse implement first?

1. Arrange for the mother to have a tray sent to the room.

2. Go to the cafeteria and ask the mother to return to the room. 3. Tell the UAP to stay with the child until the mother returns. 4. Notify social services that the mother left the child alone.

1.This is an appropriate nursing intervention so that the mother will not have to leave her child, but it is not the first intervention. The child's safety is priority.

2. The nurse could go to the cafeteria and tell the mother to return to the room, but during this time the UAP should stay with the child.

**3. The child's safety is priority; therefore, the nurse should have the UAP stay with the child until the mother returns.

4. Social services would not need to be notified at this time. If the mother continually leaves the child alone, then this would be an appropriate action.

60. During an examination, the nurse knows that Paget's disease would be indicated by which of these assessment findings?

A) Positive Macewen sign

B) Premature closure of the sagittal suture

C) Headache, vertigo, tinnitus, and deafness

D) Elongated head with heavy eyebrow ridge

C) Headache, vertigo, tinnitus, and deafness

Paget's disease occurs more often in males and is characterized by bowed long bones, sudden fractures, and enlarging skull bones that press on cranial nerves causing symptoms of headache, vertigo, tinnitus, and progressive deafness.

63. The nurse is evaluating an 18-month-old child in the pediatric clinic. Which data would indicate to the nurse that the child is not meeting tasks according to Erikson's Stages of Psychosocial Development?

1. The child stamps his or her foot and says "no" frequently.

2. The child does not interact with the mother.

3. The child cries when the mother leaves the room. 4. The child responds when called by name.

1.An 18-month-old child should be throwing temper tantrums. This indicates the child is developing a sense of autonomy.

**2.An 18-month-old child should cling to the mother and interact continuously with the primary caregiver. A child not interacting with the mother is not meeting the task of developing a sense of autonomy.

3.The child has met the task of trust when he or she cries if the mother leaves the room.

4.When a child responds to his or her name, it indicates a sense of identity; therefore, the task is met.