Angelite Nurses

answers and rationale

1. The correct answer is B: Place the child on the side
Protecting the airway is the top priority in a seizure. If a child is actively convulsing, a patent airway and oxygenation must be assured.

2. The correct answer is B: Suction excessive tracheobronchial secretions
Suctioning the copious tracheobronchial secretions present in post-thoracic surgery clients maintains an open airway which is always the priority nursing intervention.

3 The correct answer is C: Prolonged hypoxemia
Most often, the cause of cardiac arrest in the pediatric population is prolonged hypoxemia. Children usually have both cardiac and respiratory arrest.

4. The correct answer is D: Observe a return demonstration
Since this is a psychomotor skill, this is the best way to know if the client has learned the proper technique.

5. The correct answer is C: Takes frequent rest periods while playing
Children with heart disease tend to have exercise intolerance. The child self-limits activity, which is consistent with manifestations of congenital heart disease in children.

6. The correct answer is A: An 18 month-old who ate an undetermined amount of crystal drain cleaner. Drain cleaner is very alkaline. The orange juice is acidic and will help to neutralize this substance.

7. The correct answer is C: Anticipation of the birth
Directing activities toward preparation for the newborn''s needs and personal adjustment are indicators of appropriate emotional response in the third trimester.

8. The correct answer is B: Excessive fluoride intake
The described findings are indicative of fluorosis, a condition characterized by an increase in the extent and degree of the enamel''s porosity. This problem can be associated with repeated swallowing of toothpaste with fluoride or drinking water with high levels of fluoride.

9. The correct answer is A: Avoid direct sunlight
Phenothiazine increases sensitivity to the sun, making clients especially susceptible to sunburn.

10. The correct answer is A: "Eat a balanced diet for your age."
A diet for a teenager with acne should be a well balanced diet for their age. There are no recommended additions and subtractions from the diet.

11. The correct answer is D: Observe swallowing patterns
The nurse should observe for increased swallowing frequency to check for hemorrhage.

12The correct answer is A: Cough and deep breathe every 2 hours
Respiratory infections are common because of fluid in the retro peritoneum pushing up against the diaphragm causing shallow respirations. Encouraging the client to cough and deep breathe every 2 hours will diminish the occurrence of this complication.
The correct answer is A: Offer small meals of high calorie soft food
If the client is losing weight because of poor appetite due to the pain, assist in selecting foods that are high in calories and nutrients, to provide more nourishment with less chewing. Suggest that frequent, small meals be eaten instead of three large ones. To minimize jaw movements when eating, suggest that foods be pureed.

14The correct answer is A: Notify the health care provider immediately
The health care provider must be contacted immediately as the client is a danger to self and others. Hospitalization is indicated.

15. The correct answer is A: "You think that someone wants to poison you?"
This response acknowledges perception through a reflective question which presents opportunity for discussion, clarification of meaning, and expressing doubt.

16. The correct answer is B: Potential complication hemorrhage
Esophageal varices are dilated and tortuous vessels of the esophagus that are at high risk for rupture if portal circulation pressures rise.

17The correct answer is D: A 30 month-old only drinking from a sippy cup
A 30 month-old should be able to drink from a cup without a cover.

18. The correct answer is C: Glaucoma, prostatic hypertrophy
Glaucoma and prostatic hypertrophy are contraindications to the use of benztropine (Cogentin) as the drug is an anticholinergic agent.

19. The correct answer is C: Dependence
The client role fosters dependency. Adolescents may react to dependency with rejection, uncooperativeness, or withdrawal.

20 The correct answer is B: The client should alternate ambulation with bed rest with legs elevated. Encourage alternating periods ambulation and bed rest with legs elevated to mobilize edema and ascites. Encourage and assist the client with gradually increasing periods of ambulation.

21 The correct answer is B: Looking different from their peers
Conformity to peer influences peaks at around age 14. Since many persons view any disability as deviant, the client will need help in learning how to deal with reactions of others. Treatment of scoliosis is long-term and involves bracing and/or surgery.

22. The correct answer is C: Auscultate heart and lungs
The nurse should auscultate the heart and lungs during the first quiet moment with the infant so as to be able to hear sounds clearly. Other assessments may follow in any order.

23. The correct answer is C: A serving size at this age is about 2 tablespoons
In children, a general guide to serving sizes is 1 tablespoon of solid food per year of age. Understanding this, the nurse can assess adequacy of intake.

24. The correct answer is C: Long term steroid usage
Steroid dependency tends to delay wound healing. If the client also smokes, the risk is increased.

25 The correct answer is D: Hyperpyrexia, severe muscle rigidity, malignant hypertension, hyperpyrexia, sever muscle rigidity, and malignant hypertension are assessment signs indicative of NMS (neuroleptic malignant syndrome).

26. The correct answer is A: Immunosuppression
The decreased immunity leads to frequent secondary infections. Herpes simplex virus type 1 is an opportunistic infection. The other options may result in HSV-1. However they are not the most likely cause in clients with HIV.

27. The correct answer is D: Record these normal findings
The question is D. The rate of increase in head circumference slows by the end of infancy, and the head circumference is usually equal to chest circumference at 1 to 2 years of age.

28. The correct answer is B: "How long has this been occurring?"
Nighttime control should be present by this age, but may not occur until age 5. Involuntary voiding may occur due to infectious, anatomical and/or physiological reasons.

29. The correct answer is D: Toileting the client more frequently with supervision
With altered thought processes the most appropriate nursing approach to alter the behavior is by attending to the physical need.

30. The correct answer is B: Opening the bottom of the pouch, allowing the flatus to be expelled. The only correct way to vent the flatus from a 1 piece drainable ostomy pouch is to instruct the client to obtain privacy (the release of the flatus will cause odor), and to open the bottom of the pouch, release the flatus and dose the bottom of the pouch.

31. The correct answer is B: Cereal
Cereal is usually introduced first because it is well tolerated, easy to digest, and contains iron.

32. The correct answer is D: There is a 25% chance a daughter will be a carrier
Hemophilia A is a sex-linked recessive trait seen almost exclusively in males. With a normal father and carrier mother, affected individuals are male. There is a 25% chance of having an affected male, 25% chance of having a carrier female, 25% chance of having a normal female and 25% chance of having a normal male.

33The correct answer is A: Avoid smoking near the client
Since oxygen supports combustion, there is a risk of fire if anyone smokes near the oxygen equipment.

34The correct answer is D: Determine the client''s understanding of her colostomy. One of the greatest fears of colostomy clients is the fear that sexual intimacy is no longer possible. However, the specific concern of the client needs to be assessed before specific suggestions for dealing with the sexual concerns are given.


35. The correct answer is D: Engages in meaningful and understandable verbal communication. Data support impaired verbal communication deficit. The outcome must be related to the diagnosis and supporting data. No data is presented related to feelings or to thinking processes.

36. The correct answer is D: Spare protein catabolism to meet metabolic needs
Because of the burn injury, the child has increased metabolism and catabolism. By providing a high carbohydrate diet, the breakdown of protein for energy is avoided. Proteins are then used to restore tissue.

37. The correct answer is A: The ethical sense and feelings of justice are developing. The child is developing a sense of justice and a desire to do what is right. At seven, the child is increasingly aware of family roles and responsibilities. They also do what is right because of parental direction or to avoid punishment.

38. The correct answer is A: Maintaining good nutrition
Nurses can serve a pivotal role in providing nutritional education and case management interventions. Weight gain during pregnancy is one of the strongest predictors of infant birth weight. Specifically, teens need to increase their intake of protein, vitamins, and minerals including iron. Pregnant teens who gain between 26 and 35 pounds have the lowest incidence of low-birth-weight babies.

39. The correct answer is C: Echolalic
Echolalic - repeating words heard.

40. The correct answer is A: Low hemoglobin
Although hemodialysis improves or corrects electrolyte imbalances it has not effect on improving anemia.

41. The correct answer is A: Report a persistent cough to the health care provider. Persistent coughing should be reported to the health care provider as this may indicate bleeding.

42. The correct answer is B: 1 in 4 risk for each child to have the disease
Cystic Fibrosis is an autosomal recessive transmission pattern. In this situation, both parents must be carriers of the trait for the disease since neither one of them has the disease. Therefore, for each pregnancy, there is a 25% chance of the child having the disease, 50% chance of carrying the trait and a 25% chance of having neither the trait or the disease.

43 The correct answer is A: Bronchial breath sounds in outer lung fields
Pneumonia causes a marked increase in interstitial and alveolar fluid. Consolidated lung tissue transmits bronchial breath sounds to outer lung fields.

44. The correct answer is A: Protect the client from injury
It is a priority to note, and then record, what movements are seen during a seizure because the diagnosis and subsequent treatment often rests solely on the seizure description.

45. The correct answer is B: Myelination of the spinal cord is completed by this age. Voluntary control of the sphincter muscles can be gradually achieved due to the complete myelination of the spinal cord, sometime between the ages of 18 to 24 months of age.

46 The correct answer is D: Administer oxygen
When dealing with a medical emergency, the rule is airway first, then breathing, and then circulation. Starting oxygen is a priority.

47. The correct answer is C: Frequent urination
Clients with Benign Prostatic Hypertrophy have overflow incontinence with frequent urination in small amounts day and night.

48. The correct answer is A: "When a child asks a question, give a simple answer." During discussions related to sexuality, honesty is very important. However, honesty does not mean imparting every fact of life associated with the question. When children ask 1 question, they are looking for 1 answer. When they are ready, they will ask about the other pieces.

49. The correct answer is C: Check the mouth and radial pulse
The first step in treatment of a toxic exposure or ingestion is to assess the airway, breathing and circulation; then stabilize the client. The other nursing actions will follow.

50. The correct answer is D: To reduce the tendency of the client to hide objects under his or her clothing. The client may conceal weights on their body to increase weight gain.

51. The correct answer is A: Avoid overheating
Fluid loss caused by overheating and dehydration can trigger a crisis.

52. The correct answer is B: Helplessness
The battered individual internalizes appropriate anger at the batterer’s unfairness and instead feels depressed with a sense of helplessness, when the partner explodes in spite of best efforts to please the batterer.

53The correct answer is A: 50% increase in birth weight
Birth weight should be doubled at 6 months of age, tripled at 1 year, and quadrupled by 18 months.

54. The correct answer is C: Tension pneumothorax with slight tracheal deviation to the right. Tracheal deviation indicates a significant volume of air being trapped in the chest cavity with a mediastinal shift. In tension pneumothorax the tracheal deviation is away from the affected side. The affected side is the side where the air leak is in the lung. This situation also results in sudden air hunger, agitation, hypotension, pain in the affected side, and cyanosis with a high risk of cardiac tamponade and cardiac arrest.

55. The correct answer is D: Characteristic limp
Developmental dysplasia produces a characteristic limp in children who are walking.

56. The correct answer is A: Allow the child to continue their normal activities Physical activity is important in a two year-old who is developing autonomy. Physical activity is a valuable adjunct to chest physical therapy. Exercise tends to stimulate mucous secretion and help develop normal breathing patterns.

57. The correct answer is A: Ileostomy
Ileostomy output contains gastric and enzymatic agents that when present on skin can denuded skin in several hours. Because of the caustic nature of this stoma output adequate peristomal skin protection must be delivered to prevent skin breakdown.

58. The correct answer is C: Place the client in a side-lying position
Place the client in a side-lying position to maintain an open airway, drain secretions, and prevent aspiration if vomiting occurs.

59. The correct answer is D: Do not cross legs
Hip flexion should not exceed 60 degrees.

60. The correct answer is A: The state nurse practice act in which the assignment is made. The state nurse practice act is the governing document of what can be done in the assigned state.

61 The correct answer is D: Explain that this rash is not contagious and does not require isolation. Fifth Disease is a viral illness with an uncertain period of communicability (perhaps 1 week prior to and 1 week after onset). Isolation of the child with Fifth Disease is not necessary except in cases of hospitalized children who are immunosuppressed or having aplastic crises. The parents may need written confirmation of this from the health care provider.

62The correct answer is B: The infant is very susceptible to infections
HIV infected children are susceptible to opportunistic infections due to a compromised immune system.

63. The correct answer is C: 2 weeks
Lithium is started immediately to treat bipolar disorder because it is quite effective in controlling mania. Lithium takes approximately 2 weeks to effect change in a client’s symptoms.

64 The correct answer is B: Visitation is helpful for both
Contact with the ill child helps siblings understand the reasons for hospitalization and maintains the relationship.

65 The correct answer is B: Crashing
Following cocaine use, the intense pleasure is replaced by an equally unpleasant feeling referred to as crashing.

66 The correct answer is B: There is typically a series of minor, vague complaints. Signs of abuse may not be clearly manifested and a series a minor complaints such as headache, abdominal pain, insomnia, back pain, and dizziness may be covert indications of abuse undetected. Complaints may be vague.

67. The correct answer is C: Ask for a log of urinary output
The nurse must monitor the urine output as a priority because it is the best indictor of renal function. The other options would be done after an evaluation of the urine output.

68. The correct answer is B: Place the client on their side
This position keeps the airway patent and prevents aspiration.

69 The correct answer is D: SA node, AV node, Bundle of His, Purkinje fibers
The pathway of a normal electrical impulse through the heart is: SA node, AV node, Bundle of His, Purkinje fibers.

70 The correct answer is A: Pulmonary circulation
Congestion occurs in the pulmonary circulation due to the inefficient emptying of the left ventricle and the lack of a competent valve to prevent back flow into the pulmonary vein.

71. The correct answer is C: Reddened tissue
As the wound granulates, redness indicates healing.

72. The correct answer is D: Consistent limit-setting enforced 24 hours per day
Treatment approaches that include restructuring the personality, assisting the person with developmental level and setting limits for maladaptive behavior such as acting out.

73. The correct answer is A: Have respiratory support equipment available
Persons receiving neuroleptic medication experiencing torticollis and involuntary muscle movement are demonstrating side effects that could lead to respiratory failure.

74. The correct answer is D: Rationalization
Rationalization is justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfies the teller as well as the listener.

75. The correct answer is B: There is a relationship between smoking and low birth weight. Nicotine reduces placental blood flow, and may contribute to fetal hypoxia or placenta previa, decreasing the growth potential of the fetus.

76. The correct answer is C: Palpate for a thrill over the fistula
To assess for patency in a fistula or graft, the nurse auscultates for a bruit and palpates for a thrill. Other options are not related to evaluation for patency.

77. The correct answer is D: Active listening
Use of therapeutic communication skills such as silence and active listening encourages verbalization of feelings.

78. The correct answer is C: Establish that the client is unresponsive
The first step in CPR is to establish unresponsiveness. Second is to call for help. Third is opening the airway.

79. The correct answer is B: Allow an opportunity for the teen to express feelings
Adolescents need to express their feelings. Generally, they talk freely when given an opportunity and some privacy to do so.

80. The correct answer is C: Autocratic or authoritarian
Autocratic leadership style is suggested in this situation. It is appropriate for groups with little education and experience and who need strong direction, while participative or democratic style is usually more successful on nursing units.

81. The correct answer is A: Give the medication as ordered
Amoxicillin continues to be the drug of choice in the treatment of acute otitis media. The dose range is 20-40 mg/kg/day divided every 8 hours. 15kg x 40mg = 600mg, divided by 3 = 200 mg per dose. The prescribed dose is correct and should be given as ordered.

82. The correct answer is D: Falls forward when sitting
Sitting without support is expected at this age.

83 The correct answer is C: Conducting any health assessment
A mental status assessment is a critical part of baseline information, and should be a part of every examination.

84. The correct answer is B: Often take part in active sports
Establish an age-appropriate safe environment. Adolescent hemophiliacs should be aware that contact sports may trigger bleeding. However, developmental characteristics of this age group such as impulsivity, inexperience and peer pressure, place adolescents in unsafe environments.

85. The correct answer is D: 4. Continue to monitor respirations
12 respirations per minute is tolerated post-operatively. A range from 8 to 10 gives cause for concern. At that point pulse oximetry is taken, as that rate could be tolerated. Vigorous stimulation is not indicated beyond deep breathing and coughing. It is not necessary to ask the RN to check findings.

86
The correct answer is A: Learning relaxation techniques
The only factor that can enhance the client''s response to pain medication for angina is reducing anxiety through relaxation methods. Anxiety can be great enough to make the pain medication totally ineffective.

87. The correct answer is C: Cardiac output altered: decreased
All nursing interventions should be focused on improving cardiac output. Increasing cardiac output is the primary goal of therapy. Comfort will improve as the client improves and the respiratory status will improve as cardiac output increases.

88. The correct answer is D: "In early recovery, it’s quite common to have mixed feelings. Let’s discuss the benefits of sobriety for you." This response gives the client the opportunity to decrease ambivalent feelings by focusing on the benefits of sobriety. Dependence issues are great for the client fostering ambivalence.

89. The correct answer is A: Steroids
Adverse medication effects can cause a syndrome that may or may not remit when the medication is discontinued. Examples include: phenothiazines, steroids, and reserpine.

90. The correct answer is D: "Have you thought about how you would do it?"
This response provides an opening to discuss intent and means of committing suicide.

91. The correct answer is A: Check for subcutaneous emphysema in the upper torso. Continuous bubbling in the water seal chamber is an abnormal finding 2 hours after a lobectomy. Further assessment of appropriate factors was done by the nurse to rule out an air leak in the sytem. Thus the conclusion is that the problem is one of an air leak in the lung. This client may need to be returned to surgery to deal with the sustained air leak. Action by the health care provider is required to prevent further complications.

92. The correct answer is D: Surgery will be performed in stages
Hypospadias, a condition in which the urethral opening is located on the ventral surface or below the penis, is corrected in stages as soon as the infant can tolerate surgery.

93 The correct answer is D: Have blood lithium levels drawn during the summer months. Clients taking lithium therapy need to be aware that hot weather may cause excessive perspiration, a loss of sodium and consequently an increase in serum lithium concentration.

94. The correct answer is A: Placing the spoon in the client’s hand and stating "Use the spoon to eat your food." This response identifies adaptive behavior with instruction and verbal expectation.

95The correct answer is A: Auscultation of an S3 heart sound
Auscultation of an S3 heart sound. This is an early sign of volume overload (or CHF) because during the first phase of diastole, when blood enters the ventricles, an extra sound is produced due to the presence of fluid left in the ventricles.

96 The correct answer is B: Assess for neonatal withdrawl syndrome
Neonatal withdrawl syndrome is a cluster of findings that signal the withdrawal of the infant from the opiates. The findings seen in methadone withdrawal are often more severe than for other substances. Initial signs are central nervous system hyper irritability and gastro-intestinal symptoms. If withdrawal signs are severe, there is an increased mortality risk. Scoring the infant ensures proper treatment during the period of withdrawal.

97. The correct answer is B: Expressing shame
Erikson describes the stage of the preschool child as being the time when there is normally an increase in initiative. The child should have resolved the sense of shame and doubt in the toddler stage.

98. The correct answer is B: "Are you thinking about killing yourself?"
Sudden mood elevation and energy may signal increased risk of suicide. The nurse must validate suicide ideation as a beginning step in evaluating seriousness of risk.

99. The correct answer is D: Ventricular septal defect
While assessments for conduction disturbance should be included following repair of any defect, it is a priority for this condition. A ventricular septal defect is an abnormal opening between the right and left ventricles. The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening. Either method involves manipulation of the ventricular septum, thereby increasing risk of interrupting the conduction pathway. Consequently, postoperative complications include conduction disturbances.

100. The correct answer is C: Decreased cardiac output
Cardiac output and urinary output are directly correlated. The nurse should suspect a drop in cardiac output if the urinary output drops.