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The student nurse reports to the staff nurse that the parent of a toddler who is 2 days postoperative after a cleft palate repair has given the toddler a pacifier. What would be the best immediate action of the nurse?
A) Notify the pediatrician of this finding B) Reassure the student that this is an acceptable action on the parent’s part C) Discuss this action with the parents D) Ask the student nurse to remove the pacifier from the toddler’s mouth
2. The nurse is providing a health teaching to the mother of an 8-year-old child with cystic fibrosis. Which of the following statement if made by the mother would indicate to the nurse the need for further teaching about the medication regimen of the child?
A) “My child might need an extra capsule if the meal is high in fat” B) “I’ll give the enzyme capsule before every snack” C) “I’ll give the enzyme capsule before every meal” D) “My child hates to take pills, so I’ll mix the capsule into a cup of hot chocolate
3. The mother brought her child to the clinic for follow-up check up. The mother tells the nurse that 14 days after starting an oral iron supplement, her child’s stools are black. Which of the following is the best nursing response to the mother?
A) “I will notify the physician, who will probably decrease the dosage slightly” B) “This is a normal side effect and means the medication is working” C) “You sound quite concerned. Would you like to talk about this further?” D) “I will need a specimen to check the stool for possible bleeding”
The nurse is caring to a child client who is receiving tetracycline. A 14 day-old infant with a cyanotic heart defects and mild congestive heart failure is brought to the emergency department. the nurse checks the apical pulse rate of the infant. An 8-year-old boy with asthma is brought to the clinic for check up. Which of the following is the appropriate nursing action? A) Retake the apical pulse in 15 minutes B) Retake the apical pulse in 30 minutes . The nurse is aware that in taking this medication. What would be the appropriate response of the nurse? A) I will review first the child’s height on a growth chart to know if the treatment is working B) I will review first the child’s weight on a growth chart to know if the treatment is working C) I will review first the number of prescriptions refills the child has required over the last 6 months to give you an accurate answer D) I will review first the number of times the child has seen the pediatrician during the last 6 months to give you an accurate answer 5. The apical pulse rate is 130 beats per minute. it is very important to: A) Administer the drug between meals B) Monitor the child’s hearing C) Give the drug through a straw D) Keep the child out of the sunlight 6. The mother asks the nurse if the treatment given to her son is effective.4. During assessment.
The physician prescribed gentamicin (Garamycin) to a child who is also receiving chemotherapy. 1 inch D) 18 G. 5/8 inch C) 21 G. Which of the following is the suited size of the needle would the nurse select to administer the IM injection to a preschool child? A) 18 G.C) Notify the pediatrician immediately D) Administer the medication as scheduled 7. 1inch 9. Which of the following activities performed by the child would give a best sign that the medication is effective? A) Listening to story of his mother . The boy is being treated with salicylates for the migratory polyarthritis accompanying the diagnosis of rheumatic fever. A 9-year-old boy is admitted to the hospital. the nurse should check the results of the child’s: A) CBC and platelet count B) Auditory tests C) Renal Function tests D) Abdominal and chest x-rays 8. 1-1/2 inch B) 25 G. Before administering the drug.
An 8-year-old client with cystic fibrosis is admitted to the hospital and will undergo a chest physiotherapy treatment. The therapy should be properly coordinated by the nurse with the respiratory therapy department so that treatments occur during: . The physician decided to schedule the 4-year-old client for repair of left undescended testicle. The physician prescribed digoxin (Lanoxin) to the client.B) Listening to the music in the radio C) Playing mini piano D) Watching movie in the dvd mini player 10. The Injection of a hormone. The nurse is caring to a 24-month-old child diagnosed with congenital heart defect. HCG finds it less successful for treatment. 12. give the digoxin. Before the administration of the drug. the nurse checks the apical pulse rate to be 110 beats per minute and regular. What would be the next nursing action? A) Check the other vital signs and level of consciousness B) Withhold the digoxin and notify the physician C) Give the digoxin as prescribed D) Check the apical and radial simultaneously. and if they are the same. in which position should the nurse place him? A) Supine with foot of bed elevated B) Prone with legs abducted C) Sitting with foot of bed elevated D) Side-lying with upper leg flexed 11. To administer a pentobarbital sodium (Nembutal) suppository preoperatively to this client.
A toddler is brought to the hospital because of severe diarrhea and vomiting. The toddler refuses to give the soiled blanket.A) After meals B) Between meals C) After medication D) Around the child’s play schedule 13. The nurse assigned to the client enters the client’s room and finds out that the client is using a soiled blanket brought in from home. The nurse is providing health teaching about the breastfeeding and family planning to the client who gave birth to a healthy baby girl. Which of the following statement would alert the nurse that the client needs further teaching? A) “I understand that the hormones for breastfeeding may affect when my periods come” B) “Breastfeeding causes my womb to tighten and bleed less after birth” C) “I may not have periods while I am breastfeeding. The nurse realizes that the best explanation for the toddler’s behavior is: A) The toddler did not bond well with the maternal figure B) The blanket is an important transitional object C) The toddler is anxious about the hospital experience D) The toddler is resistive to nursing interventions . The nurse attempts to remove the blanket and replace it with a new and clean blanket. so I don’t need family planning” D) “I can get pregnant as early as one month after my baby was born” 14.
15. the nurse knows that the suited developmental task of this child is to: A) Learn to play with other children B) Able to trust others C) Express all needs through speaking D) Explore and manipulate the environment 16. and doesn’t need Mommy as much” B) The older daughter not have interaction with the baby at the hospital. Which of the following is an appropriate toy would the nurse select for the child: A) Puzzle B) Musical automobile . In caring a 3-year-old-client. A 2-year-old client with cystic fibrosis is confined to bed and is not allowed to go to the playroom. A mother who gave birth to her second daughter is so concerned about her 2-year old daughter. “I am afraid that my 2-year-old daughter may not accept her newly born sister”. She tells the nurse. It is appropriate to the nurse to response that: A) The older daughter be given more responsibility and assure her “that she is a big girl now. because she may harm her new sibling C) The older daughter stay with her grandmother for a few days until the parents and new baby are settled at home D) The mother spend time alone with her older daughter when the baby is sleeping 17. The nurse has knowledge about the developmental task of the child.
Which of the following clients is at high risk for developmental problem? A) A toddler with acute Glomerulonephritis on antihypertensive and antibiotics B) A 5-year-old with asthma on cromolyn sodium C) A preschooler with tonsillitis D) A 2 1/2 –year old boy with cystic fibrosis 19. Which of the following will the nurse includes in the instructions? A) Plugging all electrical outlets in the house B) Installing a gate at the top and bottom of any stairs in the home .C) Arranging stickers in the album D) Pounding board and hammer 18. A nurse is providing safety instructions to the parents of the 11-month-old child. Which of the following would be the best divesionary activity for the nurse to select for a 2 weeks hospitalized 3-year-old girl? A) Crayons and coloring books B) doll C) xylophone toy D) puzzles 20.
While the child is focusing on adjusting to new environment and peers. A 5-year-old boy client is scheduled for hernia surgery. What activity selected by the nurse would the child most likely find stimulating? . An 8-year-old girl is in second grade and the parents decided to enroll her to a new school. The nurse is preparing to do preoperative teaching with the child. The child complains of being bored and it seems tiresome to stay on bed and doing nothing. The father does not allow also her daughter to play with other children. The nine-year-old client is admitted in the hospital for almost 1 week and is on bed rest. The child’s father severely punishes the child and forces her daughter to study after school. her grades suffer. These data indicate to the nurse that this child is deprived of forming which normal phase of development? A) Heterosexual relationships B) A love relationship with the father C) A dependency relationship with the father D) Close relationship with peers 22.C) Purchasing an infant car seat as soon as possible D) Begin to teach the child not to place small objects in the mouth 21. The nurse should knows that the 5-year-old would: A) Expect a simple yet logical explanation regarding the surgery B) Asks many questions regarding the condition and the procedure C) Worry over the impending surgery D) Be uninterested in the upcoming surgery 23.
The nurse caring for the client tells the mother to stay beside the infant while making assessment. “It is making me crazy!” What would be the best explanation of the nurse to the behavior of the boy? A) The adolescent might have an unconscious death wish B) The adolescent feels indestructible C) The adolescent lacks life experience to realize how dangerous the behavior is D) The adolescent has found a way to act out hostility toward the parent 25. Which of the following developmental milestones the infant has reached? A) Has a three-word vocabulary B) Interacts with other infants C) Stands alone D) Recognizes but is fearful of strangers .A) Watching a video B) Putting together a puzzle C) Assembling handouts with the nurse for an upcoming staff development meeting D) Listening to a compact disc 24. The parent of a 16-year-old boy tells the nurse that his son is driving a motorbike very fast and with one hand. An 8-month-old infant is admitted to the hospital due to diarrhea.
the nurse should emphasize that the basal body temperature: A) Should be recorded each morning before any activity B) Is the average temperature taken each morning C) Can be done with a mercury thermometer but not a digital one D) Has a lower degree of accuracy in predicting ovulation than the cervical mucus test 27. the nurse decided to conduct health teaching to the client. The client visits the clinic for prenatal check-up. The nurse informed the client that primigravida mother should go to the hospital when which patter is evident? A) Contractions are 2-3 minutes apart. accompanied by rectal pressure and bloody show .26. and membranes have ruptured B) Contractions are 5-10 minutes apart. Which of following statement indicates a need for further health teaching? A) “I should check the diaphragm carefully for holes every time I use it. lasting 30 seconds. To evaluate the understanding of the woman. While waiting for the physician. The community nurse is providing an instruction to the clients in the health center about the use of diaphragm for family planning. the nurse asks her to demonstrate the use of the diaphragm. lasting 90 seconds.” B) “The diaphragm must be left in place for at least 6 hours after intercourse. When teaching a woman about fertility awareness. and are felt as strong menstrual cramps C) Contractions are 3-5 minutes apart.” C) “I really need to use the diaphragm and jelly most during the middle of my menstrual cycle D) “I may need a different size diaphragm if I gain or lose more than 20 pounds” 28. The community nurse is conducting a health teaching in the group of married women.
Which of the following is the most important nursing goal: . A nurse is planning a home visit program to a new mother who is 2 weeks postpartum and breastfeeding. and increasing in intensity 29. The nurse in the health center is making an assessment to the infant client.D) Contractions are 5 minutes apart. you have to have a period before you can get pregnant again’ D) “Breastfeeding protects me from pregnancy because it keeps my hormones down. A community nurse enters the home of the client for follow-up visit. the nurse includes in her health teaching about the resumption of fertility. I may need to use a vaginal lubricant when I have sex” C) “After birth. Which of the following statement indicates that the mother has understood the teaching? A) “Because breastfeeding speeds the healing process after birth. The nurse suspects that the infant has eczema. The nurse notes some rashes and small fluid-filled bumps in the skin. lasting 60 seconds. contraception and sexual activity. so I don’t need any contraception until I stop breastfeeding” 30. Which of the following is the most appropriate area to place the nursing bag of the nurse when conducting a home visit? A) cushioned footstool B) bedside wood table C) kitchen countertop D) living room sofa 31. I can have sex right away and not worry about infection” B) “Because I am breastfeeding and my hormones are decreased.
” . The nurse is carefully assessing the condition of the children before giving the vaccines. The mother informs the nurse that the child missed an appointment last month to have the third hepatitis B vaccination. Which of the following statements is the appropriate nursing response to the mother? A) “I will examine the child for symptoms of hepatitis B” B) “Your child will start the series again” C) “Your child will get the next dose as soon as possible” D) “Your child will have a hepatitis titer done to determine if immunization has taken place.A) Preventing infection B) Providing for adequate nutrition C) Decreasing the itching D) Maintaining the comfort level 32. The nurse in the health center is providing immunization to the children. A mother brought her child in the health center for hepatitis B vaccination in a series. Which of the following would the nurse note to withhold the infant’s scheduled immunizations? A) a dry cough B) a skin rash C) a low-grade fever D) a runny nose 33.
The nurse is planning to conduct a home visit in a small community. Which of the following technique is considered an aseptic practice during the home visit of the community health nurse? A) Wrapping used dressing in a plastic bag before placing them in the nursing bag B) Washing hands before removing equipment from the nursing bag C) Using the client’s soap and cloth towel for hand washing D) Placing the contaminated needles and syringes in a labeled container inside the nursing bag 36. 35. Which of the following technique should the nurse consider to be of the lowest priority? A) Yearly breast exam by a trained professional B) Detailed health history to identify women at risk C) Screening mammogram every year for women over age 50 D) Screening mammogram every 1-2 years for women over age of 40.34. Which of the following is the most important factor when planning the best time for a home care visit? A) Purpose of the home visit B) Preference of the patient’s family C) Location of the patient’s home D) Length of time of the visit will take . The community health nurse implemented a new program about effective breast cancer screening technique for the female personnel of the health department of Valenzuela.
” B) “You need to ask the physician” C) “The number of immunizations your baby will receive is determined by your baby’s health history and age” D) “It is easier on your baby to receive several immunizations rather than one at a time” 39.37. and fish for protein and calcium needs plus prenatal vitamins and iron supplements . The community health nurse is conducting a health teaching about nutrition to a group of pregnant women who are anemic and are lactose intolerant. The nurse assigned in the health center is counseling a 30-year-old client requesting oral contraceptives. During immunization week in the health center. “Why is our baby going to receive so many immunizations over a long time period?” The best nursing response would be: A) “The number of immunizations your baby will receive shows how many pediatric communicable and infectious diseases can now be prevented. The client tells the nurse that she has an active yeast infection that has recurred several times in the past year. yogurt. Which statement by the nurse is inaccurate concerning health promotion actions to prevent recurring yeast infection? A) “During treatment for yeast. the parent of a 6-month-old infant asks the health nurse. avoid vaginal intercourse for one week” B) “Wear loose-fitting cotton underwear” C) “Avoid eating large amounts of sugar or sugar-bingeing” D) “Douche once a day with a mild vinegar and water solution” 38. Which of the following foods should the nurse especially encourage during the third trimester? A) Cheese.
milk and eggs for iron and calcium needs plus prenatal vitamins and iron supplements 40. Salmonella enteritis is responsible for almost 4 million cases of food poisoning. One of the major goals is to promote proper food preparation.B) Prenatal iron and calcium supplements plus a regular adult diet C) Red beans. green leafy vegetables. Typical symptoms of salmonella include: A) Nausea. The community health nurse is tasks to conduct health teaching about the prevention of food poisoning to a group of mother everyday. vomiting and headache . The Department of Health is alarmed that almost 33 million people suffer from food poisoning every year. vomiting and paralysis B) Bloody diarrhea C) Diarrhea and abdominal cramps D) Nausea. The nurse can help identify signs and symptoms of specific organisms to help patients get appropriate treatment. and fish for iron and calcium needs plus prenatal vitamins and iron supplements D) Red meat. The nurse knows that further information is necessary when the woman states: A) “Spontaneous abortion may occur in one out of five women who are infected” B) “Pulmonary TB may jeopardize my pregnancy” C) “I know that I may not be able to have close contact with my baby until contagious is no longer a problem D) “I can get pregnant after I have been free of TB for 6 months” 41. A woman with active tuberculosis (TB) and has visited the health center for regular therapy for five months wants to become pregnant.
The nurse is formulating a plan of care to a woman who gave birth to a baby girl.42. The health nurse is conducting health teaching about “safe” sex to a group of high school students. The department of health is promoting the breastfeeding program to all newly mothers. Which of the following observation would be a great concern? A) Big mirror in a wall B) Scattered and unwashed dishes in the sink C) Shiny floors with scattered rugs D) Brightly lit rooms 43. A community health nurse makes a home visit to an elderly person living alone in a small house. The nursing care plan for a breastfeeding mother takes into account that breast-feeding is contraindicated when the woman: A) Is pregnant B) Has genital herpes infection . Which of the following statement about the use of condoms should the nurse avoid making? A) “Condoms should be used because they can prevent infection and because they may prevent pregnancy” B) “Condoms should be used even if you have recently tested negative for HIV” C) “Condoms should be used every time you have sex because condoms prevent all forms of sexually transmitted diseases” D) “Condoms should be used every time you have sex even if you are taking the pill because condoms can prevent the spread of HIV and gonorrhea” 44.
The nurse continues to assess the child for the presence of Kernig’s sign. The City health department conducted a medical mission in Barangay Marulas. The mother brings a child to the health care clinic because of severe headache and vomiting. During the assessment of the health care nurse. Majority of the children in the Barangay Marulas were diagnosed with pinworms. The nurse is suspecting that the child might be suffering from bacterial meningitis. The mother brought her daughter to the health center. The community health nurse should anticipate that the children’s chief complaint would be: A) Lack of appetite B) Severe itching of the scalp C) Perianal itching D) Severe abdominal pain 46. The nurse anticipates that the nursing diagnosis most closely correlated with this is: A) Fluid volume deficit related to vomiting B) Altered body image related to alopecia C) Altered comfort related to itching D) Diversional activity deficit related to hospitalization 47.C) Develops mastitis D) Has inverted nipples 45. The child has head lice. and the nurse notes the presence of nuchal rigidity. Which finding would indicate the presence of this sign? . the temperature of the child is 40 degree Celsius.
A) Flexion of the hips when the neck is flexed from a lying position B) Calf pain when the foot is dorsiflexed C) Inability of the child to extend the legs fully when lying supine D) Pain when the chin is pulled down to the chest 48. the nurse must determine that the primary goal is that the: A) Child will experience mild discomfort B) Child will experience only minor complications C) Child will not spread the infection to others D) Public health department will be notified 49. A community health nurse makes a home visit to a child with an infectious and communicable disease. the antibiotic drops into my daughter’s eye if purulent discharge is present" . The child was diagnosed with conjunctivitis. In planning care for the child. The nurse provides health teaching to the mother about the proper care of her daughter while at home. The mother brings her daughter to the health care clinic. Which statement by the mother indicates a need for additional information? A) “I do not need to be concerned about the spreading of this infection to others in my family” B) “I should apply warm compresses before instilling antibiotic drops if purulent discharge is present in my daughter’s eye” C) “I can use an ophthalmic analgesic ointment at nighttime if I have eye discomfort” D) “I should perform a saline eye irrigation before instilling.
shelter and clothing are available . A community health nurse is caring for a group of flood victims in Marikina area. In planning for the potential needs of this group.50. which is the most immediate concern? A) Finding affordable housing for the group B) Peer support through structured groups C) Setting up a 24-hour crisis center and hotline D) Meeting the basic needs to ensure that adequate food.
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