Which client would be at risk for acquiring rheumatic endocarditis?

child with streptococcal pharyngitis

Which action should nurse take for a 2 year old with a heart defect and is scheduled for a heart cath?

check for iodine or shellfish allergies prior to procedure

Which info should the nurse NOT about safety during the school-age years to parents?

gating stairs at the top and bottom

Which info should the nurse include to a group of parents to promote nutrition in preschool age children?

average calorie intake should be 1800 calories per day

Which action should the nurse take when caring for a client who has superficial partial thickness burns?

apply cool, wet compresses to the affected area

Client has complete heart block, HR 34, BP 83/48, is lethargic and unable to complete sentences. Which action first?

apply transcutaneous pacemaker pads

Which statement by the client indicates understanding of the discharge teaching about permanent pacemakers?

I will notify the airport screeners about my pacemaker

Which action should the nurse take first for a client who has heart failure and reports increased shortness of breath?

assist the client into high fowler's position

Which question should the nurse ask to determine if there is a contraindication to administering the varicella vaccine?

are you currently taking corticosteroid medication?

Which action should the nurse NOT take when preparing a toddler for an IV catheter insertion?

ask the parents to leave during the procedure

Which action should the nurse take for a client who has a moderate burn?

initiate a high protein high calorie diet

Which finding will help the nurse distinguish between an MI and angina?

angina can be relieved with rest and nitroglycerin

Which parent statement indicates understanding of expected changes during puberty of adolescent girls?

girls usually stop growing aout 2 years after menarche

Which of the following findings is NOT an indication of hearing loss?

overly attentive to the surroundings

Which statement should nurse give when a client asks how to restrict his fluid intake to 2,000ml/day?

pour fluid you drink into an empty 2 L bottle to keep track

Which statement by the client indicates understanding of discharge teaching about having a mechanical heart valve?

I will have my prothrombin time checked on a regular basis

Which action should nurse implement for a client who has major pains and is experiencing severe pain?

adminsiter morphine sulfate IV via continuous infusion

Which response should the nurse make when a client asks why her provider prescribed a daily aspirin?

aspirin reduces formation of blood clots that could cause a heart attack

Which finding is immediate threat for a client following a peripheral bypass graft surgery of the left lower extremity?

capillary refill of affected limb of 6 seconds and looks mottled

Which guidance should the nurse NOT provide to the parents of a toddler?

annual screenings for phenylketonuria are important

Which statement should the nurse include in the teaching about parallel play in children?

the child plays independently when in an group

Which of the following is NOT a behavior a toddler shows as an effect of hospitalization?

believes the experience is a punishment

Which action is appropriate when administering immunizations to a 4 month old?

provide sucrose solution on the pacifier

Which statement by client indicates understanding of teaching for the use of metoprolol for angina?

I will call my doctor if my pulse is less than 60

Which statement by the parents indicates understanding of the teaching about an infant with Down syndrome?

i should place a cool mist humidifier in his room

Which finding should the nurse report on a 2.5 year old toddler?

head circumference exceeds chest circumference

Which of the following behaviors is expected of a preschool age child?

relating fears to magical thinking

Which statement indicates understanding of the teaching for age appropriate activities for a 2 year old?

i will send my childs favorite stuffed animal when napping away from home

Which information should the nurse include about separation anxiety?

kicking a stranger is an example

Which info should nurse include about prepubescence and preadolescence with parents of school age children?

growth differences between boys and girls are evident

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Process 2 Exam 4

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Answers

1
Which med should nurse anticipate for a client who had an allergic reaction to a bee sting?
diphenhydramine sub-q
albuterol inhaler
methylprednisolone IV bolus
epinephrine IV
2
Which statement should the nurse give to a client who asks what causes an aneurysm to rupture?
this happens when the wall of an artery becomes thin and flexible
it is due to abdominal enlargement
it is due to hypertension
this happens when there is turbulence in blood flow in an artery
3
Which client would be at risk for acquiring rheumatic endocarditis?
child with streptococcal pharyngitis
middle-age adult who has lupus
older adult who has crhonic obstructive pulmonary disease (COPD)
young adult who recently got a tattoo
4
Which immunization would the nurse NOT administer to a 5 year old?
Hib
inactivated poliovirus
DTaP
MMR
5
Which of the following vaccines is NOT given to a 2month old?
PCV13
DTaP
rotavirus
Hepatitis A
6
Which finding should you expect for a client who has pericarditis?
murmur
rash
friction rub
petechiae
7
Which is NOT a sign of infection for a client who has a skin graft?
unstable body temp
subeschar hemorrhage
pink color to subcutaneous fat
change in skin color around affected area
8
Which action should nurse take for a 2 year old with a heart defect and is scheduled for a heart cath?
limit fluid intake following procedure
elevate affected extremity following the procedure
check for iodine or shellfish allergies prior to procedure
place on NPO for 12 hours prior to procedure
9
Which info should the nurse NOT about safety during the school-age years to parents?
gating stairs at the top and bottom
wearing safety belts
implementing firearm safety
wearing helmets when riding bikes
10
Which info should the nurse include to a group of parents to promote nutrition in preschool age children?
daily intake of fruits and veggies should total 2 servings
healthy diets include a total of 8 g protein each day
average calorie intake should be 1800 calories per day
saturated fats should equal 20% of total daily caloric intake
11
Which of the following findings would NOT be a sign of coarctation of the aorta in infants?
cool skin of lower extremities
severe cyanosis
weak femoral pulses
heart failure
12
Which action should the nurse take when caring for a client who has superficial partial thickness burns?
clean the affected area using a soft bristle brush
administer morphine sulfate
administer IV infusion of 0.9% sodium chloride
apply cool, wet compresses to the affected area
13
Client has complete heart block, HR 34, BP 83/48, is lethargic and unable to complete sentences. Which action first?
obtain a signed informed consent form for a pacemaker
prepare the client for insertion of a permanent pacemaker
apply transcutaneous pacemaker pads
transport client to the cardiovascular laboratory
14
Which statement by the client indicates understanding of the discharge teaching about permanent pacemakers?
I will expect to have occasional hiccups
I will take my pulse every 2-3 days
I will have to disconnect my garage door opener
I will notify the airport screeners about my pacemaker
15
Which action should the nurse take first for a client who has heart failure and reports increased shortness of breath?
assist the client into high fowler's position
check oxygen saturation with pulse oximeter
obtain client's weight
ausculate lung sounds
16
Which question should the nurse ask to determine if there is a contraindication to administering the varicella vaccine?
do you have an allergy to eggs?
are you currently taking corticosteroid medication?
have you ever had encephalopathy following immunizations?
have you ever had an anaphylactic reaction to yeast?
17
Which action should the nurse NOT take when preparing a toddler for an IV catheter insertion?
allow the child to make one choice during the procedure
explain procedure using child's favorite toy
apply lidocaine and prilocaine to three potential sites
ask the parents to leave during the procedure
18
Which cardiac enzyme would confirm the MI occured 14 days ago?
troponin T
myoglobin
CK-MB
troponin I
19
Which action should the nurse take for a client who has a moderate burn?
implement contact isolation
maintain immobilization of the affected area
initiate a high protein high calorie diet
expose affected area to the air
20
Which is the first manifestation of sexual maturation in boys?
facial hair growth
vocal changes
pubic hair growth
testicular enlargement
21
Which finding will help the nurse distinguish between an MI and angina?
the pain of an MI resolves in less than 15 minutes
angina can occur for longer than 30 minutes
the type of activity that causes an MI can be identified
angina can be relieved with rest and nitroglycerin
22
Which parent statement indicates understanding of expected changes during puberty of adolescent girls?
girls experience menstruation prior to breast development
girls are expected to gain about 65 lbs during puberty
girls typically grow more than 10 inches during puberty
girls usually stop growing aout 2 years after menarche
23
Which of the following findings is NOT an indication of hearing loss?
appears shy
overly attentive to the surroundings
speaks loudly
uses monotone speech
24
Which statement should nurse give when a client asks how to restrict his fluid intake to 2,000ml/day?
pour fluid you drink into an empty 2 L bottle to keep track
each glass is 8 oz, there are 30 ml per oz, so you can have 8 glasses a day
this is the same as 2 quarts, or same as 2 pots of coffee
take sips of water or ice chips so you will not take in too much fluid
25
Which statement by the client indicates understanding of discharge teaching about having a mechanical heart valve?
I will be glad to get back to my exericse routine right away
I will continue to limit my intake of foods containing potassium
I will talk to my dentist about no longer neding antibiotics before exams
I will have my prothrombin time checked on a regular basis
26
Which action should nurse implement for a client who has major pains and is experiencing severe pain?
administer acetaminophen PO every 4 hours
adminsiter morphine sulfate IV via continuous infusion
administer meperidine IM as needed
administer hydrocodone PO every 6 hours
27
Which response should the nurse make when a client asks why her provider prescribed a daily aspirin?
aspirin relieves headaches that are caused by other meds
aspirin relieves the pain due to myocardial ischemia
aspirin reduces formation of blood clots that could cause a heart attack
aspirin dissolves clots that are forming in your coronary arteries
28
Which condition should nurse inform mother about for an adolescent sleeping such long hours?
rapid growth
slowed metabolism
sleep terrors
elevated zinc levels
29
Which lab finding should nurse report for a client who has been on long term NSAID therapy to treat myocarditis?
creatinine 0.7
serum glucose 110
ALT 30
platelets 100,000
30
Which finding is immediate threat for a client following a peripheral bypass graft surgery of the left lower extremity?
trace of bloody drainage on dressing
pulse of 2+ in affected limb
capillary refill of affected limb of 6 seconds and looks mottled
throbbing pain of affected limb that is decreased following analgesic
31
Which guidance should the nurse NOT provide to the parents of a toddler?
expression of bedtime fears is common
annual screenings for phenylketonuria are important
develop food habits that will prevent dental carries
expect behaviors associated with negativism and ritualism
32
Which statement should the nurse include in the teaching about parallel play in children?
the child plays independently when in an group
the child plays alone
children sit and observe others playing
children exhibit organized play when in a group
33
Which finding should nurse suspect for a client following a angioplasty in femoral artery who has blood under his back?
retroperitoneal bleeding
bleeding from incisional site
heart failure
cardiac tamponade
34
Which of the following is NOT a manifestation of down syndrome?
protruding abdomen
larger ears that are set back
hypotonia
broad, short feet and hands
35
Which of the following is NOT a behavior a toddler shows as an effect of hospitalization?
displays intense emotions
experiences separation anxiety
exhibits regressive behavior
believes the experience is a punishment
36
Preschooler says she needs to leave hospital because her doll is scared to be home alone. Which per-operational thought?
egocentrism
centration
magical thinking
animism
37
Which lab test confirm rheumatic endocarditis?
arterial blood gases
liver enzymes
serum albumin
throat culture
38
Which action is appropriate when administering immunizations to a 4 month old?
ask the parents to leave the room during the injection
provide sucrose solution on the pacifier
administer 81 mg of aspirin
use the z-track method when injecting
39
Which action should the nurse take first for a client who has septic shock?
maintain adequate fluid volume with IV infusions
administer antibiotic therapy
administer vasopressor medication
monitor hemodynamic status
40
Which statement by client indicates understanding of teaching for the use of metoprolol for angina?
I should have my clotting time checked weekly
I will report any ringing in my ears
I should place the tablet under my tongue
I will call my doctor if my pulse is less than 60
41
Which statement by the parents indicates understanding of the teaching about an infant with Down syndrome?
i should expect him to have frequent diarrhea
i should avoid the use of lotion on his skin
i should place a cool mist humidifier in his room
i should expect him to grow faster in length than other infants
42
What condition would this be: a client who has splinter hemorrhages in her nail bed and reports a fever?
infective endocarditis
myocarditis
pericarditis
rheumatic endocarditis
43
Which finding should the nurse report on a 2.5 year old toddler?
anterior and posterior fontanels closed
current weight equals four times the birth weight
head circumference exceeds chest circumference
heat increased by 3 inches in the past year
44
Which of the following is a risk factor for heart disease?
HDL 90 mg
triglycerides 125 mg
troponin I 0.02 ng
cholesterol total 245 mg
45
Which of the following behaviors is expected of a preschool age child?
understanding cause of illness
awareness of body functioning
relating fears to magical thinking
describing manifestations of illness
46
Which statement indicates understanding of the teaching for age appropriate activities for a 2 year old?
the soccer team my child will be playing on starts practicing next week
i will send my childs favorite stuffed animal when napping away from home
i should expect my child to be able to draw circles
my child should be able to stand on one foot or a second
47
Which of the following is NOT a finding of right sided valvular heart disease?
peripheral edema
bradycardia
client report of fatigue
dyspnea
48
Which of the following would NOT be a sign of shock?
increased urine output
seizure activity
weak, thready pulse
respiratory rate of 42
49
Which information should the nurse include about separation anxiety?
detachment is the stage exhibited in the hospital
it is often observed in the school age child
kicking a stranger is an example
it results in prolonged issues of adaptability
50
Which immunization should should the nurse NOT administer for a 11-12 year old?
pneumococcal
influenza
meningococcal
Tdap
51
Which info should nurse include about prepubescence and preadolescence with parents of school age children?
growth differences between boys and girls are evident
changes in height and weight occur slowly during this period
initial physiologic changes appear during early childhood
signs of sexual maturation become highly visible in boys
52
Which of the following is NOT a sign of a thoracic aortic aneurysm?
cough
altered swallowing
upper chest pain
SOB
53
Which skill should the 18 month old toddler be able to perform?
walk up and down the stairs
draw circles
throw a ball overhand
build a tower with six blocks
54
Which is a risk factor for ADHD?
child of a single parent
history of post-term birth
history of head trauma
formula feeding infant
55
Which of the following vaccines would you NOT administer to a 4 month old?
inactivated poliovirus
DTaP
Hepatitis B
MMR
56
Which assessment finding should nurse expect of a client who is to undergo peripheral bypass graft surgery on left leg?
thin, peeling toenails of left foot
3+ dorsal pedal pulse in left foot
report of intermittent claudication in affected leg
rubor of affected leg when elevated
57
Which skill should the nurse expect the 3 year old child to perform?
ride a tricycle
throw a ball overhead
hop on one foot
jump rope
58
Which of the following findings would the nurse NOT expect for a child who has myopia?
difficulty reading/seeing the board
headaches
difficulty focusing on close objects
poor school performance
59
Which activity should nurse include that is appropriate for a 6 year old?
jumping rope
playing card games
joining competitive sports
solving jigsaw puzzles
60
Which finding should nurse report for a client following a temporary venous pacemaker via femoral artery set at 70/min?
persistent hiccups
BP 104/62
observed pacing spike followed by a QRS complex
heart rate 84
61
Which of the following is NOT a sign of pulmonary edema?
orthopnea
tachypnea
persistent cough
increased urinary output
62
Which of the following should the nurse NOT include in classroom strategies for a child who has ADHD for the teacher?
establish consistent classroom rules
allow for regular breaks
combine verbal instruction with visual cues
eliminate testing
63
Which of the following is NOT a risk factor for valvular heart disease?
measles infection during childhood
diastolic murmur present
hypertension for 5 years
surgical repair of an atrial septal defect at age 2
64
Which lifestyle change should the nurse recommend to prevent angina and MI?
relaxation exercises
diet modifcation
taking omega 3
smoking cessation
65
Which finding should the nurse expect for a client who has mitral valve insufficiency?
petechiae
S4 heart sound
splenomegaly
crackles in lung bases
66
Which lab findings should the nurse monitor for an adolescent who has acne and is starting isotretinoin?
serum sodium
serum potassium
cholesterol and triglycerides
BUN and creatinine
67
The student should understand that the purpose of "stand clear" during cardioversion is what?
they should initiate CPR due to pulseless electrical activity
a time-out is being called to verify correct protocols
the cardioverter is being charged to the appropriate setting
they cannot be in contact with equipment connected to the client
68
Which food selection would be high in potassium for a client who is encouraged to increase potassium in his diet?
1 medium baked potato
1 medium apple
1 slice toast with 1 tbsp peanut butter
1 large scrambled egg
69
The clients HR is 46 who is on telemetry. The nurse should anticipate which of the following management strategies?
administration of IV lidocaine
synchronized cardioversion
defibrillation
pacemaker insertion
70
Which screening should the nurse NOT perform for a 13 year old adolescent?
scolosis
weight
BMI
blood lead level
71
Which of the following clients is NOT at risk for developing dysrhythmia?
client who has a potassium level of 4.3
client who has COPD
client who underwent stent placement in a coronary artery
client who has metabolic alkalosis
72
Which information should the nurse include to parents about acetaminophen poisoning?
nausea begins 24 hours after ingestion
children can have 4g/day of acetaminophen
pallor can appear as early as 2 hour after ingestion
jaundice will appear in 12 hour if the child is toxic
73
Which action is the priority when taking care of a client who has a possible dissecting abdominal aortic aneurysm?
administer IV fluid as prescribed
provide a warm environment
administer pain medication as prescribed
initiate a 12-lead ECG
74
Which action should the nurse take for a child who swallowed paint thinner and is lethargic, gagging, and cyanotic?
prepare for intubation with a cuffed endotracheal tube
administer chelation therapy using deferoxamine mesylate
insert a nasogastric tube, and administer activated charcoal
induce vomiting with syrup of ipecac
75
Which statement indicates understanding about what parents should do to promote sleeping in preschooler children?
I will my child stay up an additional 2 hours on weekend nights
i will keep a dim lamp on in my child's room during the night
I will sleep in the bed with my childd if she wakes up during the night
i will let my child watch tv for 30 minutes just before bedtime each night

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