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The adolescent has been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) and is taking methylphenidate. Even though the drug helps with focus and grades, the adolescent will not go to the school office at noon for his medication. Which statement best describes the result of the nurse’s evaluation?
a. The adolescent really does not need an additional dose of methylphenidate (Ritalin) at school.
b. The adolescent has developed alternative coping mechanisms to increase his focus during classes.
c. The adolescent is fearful that this drug may be a “gateway drug” and he will abuse other substances.
d. The adolescent is embarrassed about having to take medicine at school; it is a social stigma.
The nurse is planning education about smoking cigarettes and marijuana for clients who are pregnant. These activities have been linked to which of the following outcomes?
a. Infants with mental retardation.
b. SGA (small for gestational age) newborn
c. Infants with deformities
d. Digestive disorders in newborns
Which sign or symptom suggests that a 5-year-old child who does not maintain eye contact or speak may have autism spectrum disorder (ASD)?
a. The child is highly active and inattentive.
b. The child has a slight decrease in head circumference.
c. The child constantly pats his or her legs.
d. The child has a long face and prominent jaw.
A nurse is caring for a client who is in the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following findings should the nurse report to the provider?
a. Contractions occurring every 3 to 5 min
b. Contractions are strong in intensity
c. Client reports feeling contractions in lower back
d. Contractions lasting longer than 120 seconds
A nurse is educating new parents on the importance of safe sleeping habits. Which of the following statements by a parent would indicate a need for additional teaching?
a. “Our baby will sleep in my bed because I am breastfeeding".
b. “I will give my baby a pacifier during naps and at bedtime".
c. “My baby will be placed on her back when sleeping".
d. “We will remove all toys from the crib before naps and bedtime.
The nurse is explaining the difference between active and passive immunity to the student nurse. Which statement accurately describes a characteristic of the process of immunity?
a. Active immunity is produced when the immunoglobulins of one person are transferred to another.
b. Passive immunity can be obtained by injection of exogenous immunoglobulins.
c. Active immunity can be transferred from mothers to infants via colostrum or the placenta.
d. Passive immunity is acquired when a person's own immune system generates the immune response.
A nurse administers erythromycin ophthalmic ointment to a newborn. The family member asks the nurse why the client needs the medication. What response by the nurse is the most accurate?
a. The antibiotic destroys staphylococcus, that can cause infant blindness if untreated.
b. The antibiotic prevents infection of eyes that could potentially be acquired from the birth canal.
c. The ointment prevents exudate from invading the tear ducts, leading to systemic infection and blindness.
d. The ointment prevents optic neuritis caused by syphilis if not treated.
The nurse receives report on a G5P4 39 week client in labor. The nurse is told that the client is in the active (transition) phase of labor. When the nurse goes in to assess the client, what would be the expected findings?
a. Contractions every 7-8 minutes,2-3cm dilated, 25% effaced.
b. Contractions every 4-5 minutes, 4 cm dilated, 35% effaced
c. Contractions every 2-3 minutes, 9 cm dilated, 90% effaced
d. Contractions every 5-6 minutes, 5 cm dilated, 50% effaced
Which of the following is the best way to maintain cultural awareness when educating family and promoting healthy lifestyles?
a. Find out what culture they are and read articles related to those cultural practices.
b. Ask them if there are any cultural beliefs or practices they would like you to be aware of.
c Practice ethnocentrism.
d. Promoting healthy lifestyles can be done without an assessment of culture.
A parent brings a 12-month-old child diagnosed with congenital cerebral palsy to the clinic. The nurse completes an assessment. Which assessment finding requires immediate intervention by the nurse?
a. spastic movements of the extremities
b. suspected failure to thrive
c. sits with assistance
d. babbling speech
A newborn is 72 hours old and has began experiencing yellowing of the skin. What nursing action is the most appropriate based on these findings?
a. Begin phototherapy with Bili-lights
b. Encourage early and frequent feedings
c. Begin an exchange blood transfusion
d. Collect direct and indirect serum bilirubin levels
The nurse has received an order for epidural anesthesia for a client in labor. What additional intervention would the nurse expect the provider to order for this client to prevent a common adverse reaction to epidural anesthesia?
a. Observe fetal heart rate variability
b. Hydrate the client with 500 mL of intravenous fluids before epidural placement
c. Place the client in the semi-Fowler's position before epidural placement
d. Teach the client appropriate breathing techniques
The nurse knows the goal of immunizations is to:
a. Create a herd immunity41%31%63%
b. Prevent Illness50%62%25%
c. Eradicate diseases such as measles7%8%6%
d. Protect infants and at risk people who are immunocompromised
A premature infant is admitted to the neonatal intensive care unit with respiratory distress syndrome and requires assisted ventilation. The parents asks the nurse, "Why won't our baby breath on its own?" What is the nurse's best response?
a. "Your infant's cardiovascular system is not developed yet in order to sustain respiration."
b. "Most preterm infants require additional oxygen through ventilation to sustain respiration."
c. "Premature infants have a respiratory system that takes time to adjust to extrauterine life."
d. "Your infant cannot sustain respirations yet due to the lack of assistance from surfac
The nurse educates a client who is in her third trimester on signs/symptoms that should be reported to the healthcare provider. Which statement by the client indicates further teaching is required? “I will call if I have:
a. "frequent urination, even if it’s clear and odorless”
b. "noticed my baby doesn't move as much the bigger he/she gets"
c. "a severe headache, blurred vision or epigastric pain"
d. "vaginal leaking or spotting"
The nurse receives report on four gravid clients. Which client should the nurse assess first?
a. G5 P2, 38 weeks, history of marginal placenta previa, current Hgb 11.6 g/dL
b. G1 P0, 40.2 weeks, Rh-negative, current Hct 31% and in active labor
c. G2 P1, 38 weeks, gestational diabetes, current blood glucose 89 mg/dL
d. G1 P0, 32 weeks, abdominal tenderness, increased fundal height, fetal heart rate 125 bpm
The nurse cares for a client who returns to the clinic for her two-week follow-up appointment postpartum. Her husband says she isn’t sleeping or eating much. Her mother says there were times in the past when she had depression and took antidepressant medications. She did not take any medication during pregnancy. Which client statement should the nurse respond to first?
a. “Stop talking about me like I’m not here!”
b. "Of course, I don't sleep; I am breastfeeding."
c. “I didn’t want to hurt my baby by taking medications.”
d. “I have felt so overwhelmed over the last 2 weeks.”
A client has experienced a spontaneous abortion at 10 weeks and asks the nurse why this happened. Which of the following would the nurse state is the most common cause of miscarriage?
a. Chromosomal abnormalities or other possible birth defects.
b. Environmental teratogens
c. Excessive activity
d. Drinking caffeine.
A newborn is exhibiting signs of neonatal abstinence syndrome (withdrawal). The neonate’s mother abused opiates during the pregnancy. Which medical intervention is contraindicated for this neonate?
a. morphine hydrochloride
b. swaddling
c. naloxone hydrochloride
d. low stimulation environment
The nurse notes moderate variability when assessing the internal electronic fetal monitor (EFM) strip for a term client in labor. The nurse makes which of the following interpretations in relation to this finding?
a. The fetus is in a sleep cycle.
b. The fetus is becoming hypoxic.
c. The fetus has a healthy central nervous system.
D. The fetus is experiencing cord compression.
A nurse is providing care to a pediatric client. What techniques would increase effective communication with this client population? (Select all that apply).
a. Stand at a distance of 10 feet or more until the client is calm.
b. Sitting at the client's eye level during the assessment.
c. Allow the client more time to communicate their thoughts
d. Wait until the client is asleep to listen to heart and lung sounds.
e. Communicate only with the client's guardian about health care procedures.
A 5-year-old client presents to the pediatric unit with a diagnosis of failure to thrive (FTT). What risk factors are most likely the cause of this client experiencing FTT? (Select all that apply).
a. Low socioeconomic status
b. Neglect
c. Malabsorption disorder
d. Being exclusively breastfed
e. Both parents work outside the home
The nurse cares for a client with severe preeclampsia. Which actions should the nurse take to prevent injury from eclampsia? (Select all that apply).
a. Use low volume and calm voice to keep the client informed.
b. Have oxygen and suction equipment set up and ready to use.
c. Pad side rails and keep the client on complete bed rest.
d. Keep all family members out of the room in a nearby waiting area.
e. Emergency medications should be easily accessible.
The nurse will record what information about each vaccine after immunizing a child? Select all that apply.
a. lot number and expiration date of vaccine
b. whether bacterial or viral
c. site and route of vaccine administration
d. manufacturer of vaccine
e. how vaccine was stored
The nurse is developing a presentation for a group of young adult women about premenstrual syndrome. Which treatment options should the nurse point out as most appropriate? Select all that apply.
a. Antipsychotic medications
b. Reduction of caffeine intake
c. Vitamin and mineral supplements
d. Decrease in water intake
e. NSAIDs