Integumentary
Genitourinary
Hematology
Hodgepodge
Hodge podge
100
A nurse is teaching the parent of an infant who has seborrheic dermatitis of the scalp. Which of the following instructions should the nurse include in the teaching?
A. You can use petrolatum to help soften and remove patches from your infants scalp.
B. When patches are present, you should keep your infant away from others.
C. You should avoid washing your infant's hair while patches are present on the scalp.
D. When patches are present, it indicates that your infant has a systemic infection.
A
100
A child is diagnosed with Wilms’ tumor. During assessment, the nurse in charge expects to detect:
a. gross hematuria
b. dysuria
c. abdominal mass
d. nausea and vomiting
c. The most common sign of Wilms’ tumor is a painless, palpable abdominal mass, sometimes accompanied by an increase in abdominal girth. Gross hematuria is uncommon, although microscopic hematuria may be present. Dysuria is not associated with Wilms’ tumor. Nausea and vomiting are rare in children with Wilms’ tumor.
100
"The most common signs and symptoms of leukemia related to bone marrow involvement are which of the following?
"a. Petechiae, fever, fatigue
b. Headache, papilledema, irritability
c. Muscle wasting, weight loss, fatigue
d. Decreased intracranial pressure, psychosis, confusion"
A
Signs of infiltration of the bone marrow are petechiae from lowered platelet count, fever related to infection from the depressed number of effective leukocytes, and fatigue from the anemia.
The other options are not signs of bone marrow involvement."
100
Immunity obtained as a result of experiencing an illness is known as:
a. active natural immunity
b. active acquired immunity
c. passive natural immunity
d. passive acquired immunity
a.
100
Which of the following factors should the nurse recognize as predisposing the urinary tract to infections in males or females?
a. Increased fluid intake
b. Short urethra in young females
c. Ingestion of highly acidic juices
d. Frequent emptying od the bladder
b. Short urethra in young females
200
When planning care for a male client with burns on the upper torso, which nursing diagnosis should take the highest priority?
a. Ineffective airway clearance related to edema of the respiratory passages
b. Impaired physical mobility related to the disease process
c. Disturbed sleep pattern related to facility environment
d. Risk for infection related to breaks in the skin
A.
When caring for a client with upper torso burns, the nurse’s primary goal is to maintain respiratory integrity. Therefore, option A should take the highest priority. Option B isn’t appropriate because burns aren’t a disease. Option C and D may be appropriate, but don’t command a higher priority than option A because they don’t reflect immediately life-threatening problems.
200
A child diagnosed acute glomerulonephritis will most likely have a history of which of the following?
a) Recent illness such as strep throat
b) Hemorrhage or history of bruising easily
c) Sibling diagnosed with the same disease
d) Hearing loss with impaired speech development
a. Symptoms of acute glomerulonephritis often appear one to three weeks after the onset of a streptococcal infection such as strep throat.
200
What are the needs of the patient with acute lymphocytic leukemia and thrombocytopenia?
"(A) to a private room so she will not infect other patients and health care workers
(B) to a private room so she will not be infected by other patients and
health care workers
(C) to a semiprivate room so she will have stimulation during her hospitalization
(D to a semiprivate room so she will have the opportunity to express her feelings about her illness
B(CORRECT:)- protects patient from exogenous bacteria,
risk for developing infection from others due to depressed WBC count,
alters ability to fight infection
200
Which of the following children has an increased risk of sudden infant death syndrome (SIDS)
a) Premature infant with low birth weight
b) A healthy 2-year-old
c) Infant hospitalized for fever
d) Firstborn child.
a.
200
Which of the following interventions is most appropriate for helping parents to cope with a child newly diagnosed with bronchopulmonary dysplasia?
a. Teach cardiopulmonary resuscitation
b. Refer them to support groups
c. Help parents identify necessary lifestyle changes
d. Evaluate and assess parents; stress and anxiety levels
a.
300
A 2 year old with impetigo is ordered topical antibiotic ointment. You're teaching the child's mother how to apply the ointment. Which action by the mother during application of the ointment requires you to re-educate the parent?
- A. The mother washes her hands before and after the application of the ointment.
- B. The mother applies a layer of ointment directly over the crust of the lesion.
- C. The mother uses warm water and antibacterial soap to cleanse the lesions prior to application of ointment.
- D. The mother uses a cotton swab to apply the ointment.
The answer is B. It is very important to REMOVE any crust from the lesion BEFORE applying antibiotic ointment to the lesion. This allows the ointment to come into contact with the skin, which is where the bacteria reside. To remove the crust, use warm water and antibacterial soap. All the other options are correct.
300
In caring for a child with nephrotic syndrome, which of the following interventions will be included in the child's plan of care?
a) Ambulating three to four times a day
b) Testing the urine for glucose levels regularly
c) Increasing fluid intake by 50 cc an hour
d) Weighing on the same scale each day
D. The child with nephrotic syndrome is weighed every day using the same scale to accurately monitor the child's fluid gain and loss.
300
A 16-year-old girl is in the clinic for a follow-up for a fever. She has been having prolonged fever accompanied by fatigue, night sweats, and loss of appetite. On physical examination, she has a temperature of 38°C with an enlarged cervical lymph node on the right that is painless, rubbery, and firm. There is no hepatosplenomegaly. She is then referred for excisional biopsy of the enlarged lymph node that shows Reed-Sternberg cells. What is the most likely diagnosis?
Hodgkins lymphoma
300
When assessing a patient with a head injury, the nurse recognizes that the earliest indication of increased intracranial pressure (ICP) is
a. vomiting.
b. headache.
c. change in level of consciousness (LOC).
d. sluggish pupil response to light.
c.
LOC is the most sensitive indicator of the patient's neurologic status and possible changes in ICP. Vomiting and sluggish pupil response to light are later signs of increased ICP. A headache can be caused by compression of intracranial structures as the brain swells, but it is not unexpected after a head injury.
300
When a child with nephrotic syndrome is confined to bed, what is an appropriate nursing intervention?
A. Restrain the child as necessary.
B. Discourage parents from holding the child.
C. Adjust activities to child's tolerance level.
D. Perform passive range-of-motion exercises daily.
c.
400
Nurse Tamara discovers scabies when assessing a client who has just been transferred to the medical-surgical unit from the day surgery unit. To prevent scabies infection in other clients, the nurse's priority should be:
a. wash hands, apply a pediculicide to the client’s scalp, and remove any observable mites.
b. isolate the client’s bed linens until the client is no longer infectious.
c. notify the nurse in the day surgery unit of a potential scabies outbreak.
d. place the client on enteric precautions.
B.
To prevent the spread of scabies in other hospitalized clients, the nurse should isolate the client’s bed linens until the client is no longer infectious — usually 24 hours after treatment begins. Other required precautions include using good hand-washing technique and wearing gloves when applying the pediculicide and during all contact with the client. Although the nurse should notify the nurse in the day surgery unit of the client’s condition, a scabies epidemic is unlikely because scabies is spread through skin or sexual contact. This client doesn’t require enteric precautions because the mites aren’t found on feces.
400
A child has been diagnosed with acute glomerular nephritis. Which of the following changes would the nurse expect to see in the child’s laboratory reports?
a. Urine red blood cell count: elevated
b. Urine specific gravity: decreased
c. Urine creatinine clearance: decreased
d. Urine white blood cell count: elevated
A.
The number of red blood cells in the urine increases dramatically. The nurse would expect to see white blood cells in the urine if the child had a UTI. Because of the hematuria and proteinuria, the nurse would expect to see an increase in the child’s urinary specific gravity. Because the child’s kidney function is compromised, the nurse would expect to see reduced creatinine clearance in the urine, but a concurrent rise in the serum creatinine.
400
A 3-year-old girl is brought in after her mother noticed a rash and bruising over her trunk and extremities. She also has intermittent epistaxis over the past few days. She had an upper respiratory illness two weeks ago but otherwise is well. Examination reveals a well-appearing child with scattered petechiae. Hemoglobin is 12 g/dL, WBC 8,000, INR 1.0, and platelets 8,000. Which of the following is the most likely diagnosis?
Idiopathic thrombocytic purpura (ITP)
400
The Foley Family is caring for their youngest child, Justin, who is suffering from tetralogy of Fallot. Which of the following are defects associated with this congenital heart condition?
A. Aorta exits from the right ventricle, pulmonary artery exits from the left ventricle, and two noncommunicating circulations
B.Ventricular septal defect, overriding aorta, pulmonic stenosis (PS), and right ventricular hypertrophy
C. Coarctation of aorta, aortic valve stenosis, mitral valve stenosis, and patent ductus arteriosus
D. Tricuspid valve atresia, atrial septal defect, ventricular septal defect, and hypoplastic right ventricle
B. Ventricular septal defect, overriding aorta, pulmonic stenosis (PS), and right ventricular hypertrophy
400
All of the following are true statements regarding impetigo EXCEPT:
a. The child's school should be notified of the diagnosis
b. Scarring may occur if the child picks off the scar prematurely
c. Most common during the dry winter months
d. Commonly diagnosed by the appearance of the pustluar or crusty lesions
c. Most common during the dry winter months
500
A patient is being discharged after treatment for a scald burn that caused a superficial burn over one hand and a superficial partial-thickness burn on several fingers. What should be included in this patient's discharge instructions?
(Select all that apply)
1. Report any fever to your healthcare provider.
2. Report development of purulent drainage to your healthcare provider.
3. Use only sterile dressings on the fingers.
4. Cleanse the areas every hour with alcohol to prevent infection.
5. Apply the topical antimicrobial agent as instructed.
Correct Answer: 1,2,3, 5
Rationale: Fever or purulent drainage are indicative of development of infection and should be reported to the healthcare provider. Sterile dressings only should be used on the areas of the superficial partial-thickness burns where the skin is not intact. Cleansing is necessary no more often than daily to the intact skin areas and only soap and water should be used, not alcohol. Topical agents may be ordered by the health care provider and the patient should follow directions for applying to help prevent infection of the areas.
500
The clinical manifestations of nephrotic syndrome are due to which of the following?
a. Obstruction of the capillaries of the glomeruli.
b. Loss of the kidney’s ability to excrete waste and concentrate urine.
c. Chemical changes in the composition of albumin.
d. Increased permeability of the glomeruli.
D.
Increased permeability of the glomeruli in nephrotic syndrome allows large substances such as protein to pass through and be excreted in the urine.
500
3. Which of the following is TRUE about sickle cell disease (SCD)? Select all that apply.
a. Sickle cell anemia (SCD) is an inherited disorder of the hemoglobin in blood.
b. Sickle cell anemia requires the inheritance of two sickle cell genes.
c. Sickle cell trait, which is the inheritance of one sickle gene, also frequently causes problems.
d. Virtually all of the major symptoms of sickle cell anemia are the direct result of the abnormally shaped sickled red blood cells obstructing the flow of blood.
e. The contemporary treatment of sickle cell anemia is focused primarily toward managing the individual features of the illness as they occur.
Options A, B, D, and E: Sickle cell anemia (SCD) is an inherited disorder of the hemoglobin in blood. It requires the inheritance of two sickle cell genes. Sickle cell trait, which is the inheritance of one sickle gene, almost never causes problems. Virtually all of the major symptoms of sickle cell anemia are the direct result of the abnormally shaped sickled red blood cells blocking the flow of blood. The contemporary treatment of sickle cell anemia is focused primarily toward managing the individual features of the illness as they occur
500
The nurse recognizes the presence of Cushing's triad in the patient with
a. Increased pulse, irregular respiration, increased BP
b. decreased pulse, irregular respiration, increased pulse pressure
c. increased pulse, decreased respiration, increased pulse pressure
d. decreased pulse, increased respiration, decreased systolic BP
B. Cushing's triad consists of three vital sign measures that reflect ICP and its effect on the medulla, the hypothalamus, the pons, and the thalamus. Because these structures are very deep, Cushing's triad is usually a late sign of ICP. The signs include an increasing systolic BP with a widening pulse pressure, a bradycardia with a full and bounding pulse, and irregular respirations
500
A child diagnosed with attention deficit hyperactivity disorder had this nursing diagnosis: impaired social interaction related to excessive neuronal activity as evidenced by aggression and demanding behavior with others. Which finding indicates the plan of care was effective? The child:
a. has an improved ability to identify anxiety and use self-control strategies.
b. has increased expressiveness in communication with others.
c. shows increased responsiveness to authority figures.
d. engages in cooperative play with other children.
ANS: D
The goal should be directly related to the defining characteristics of the nursing diagnosis, in this case, improvement in the child's aggressiveness and play. The distracters are more relevant for a child with autism spectrum or anxiety disorder.