Description

The correct answer is A: Reduce the environmental stimuli 43. A hospitalized child suddenly has a seizure while his family is visiting. The nursenotes whole body rigidity followed by general jerking movements. The child vomits immediately after the seizure. A priority nursing diagnosis for the child is A) High risk for infection related to vomiting B) Altered family processes related to chronic illness C) Fluid volume deficit related to vomiting D) Risk for aspiration related to loss of consciousness The correct answer is D: Risk for aspiration related to loss of consciousness 44.A 4 month-old child taking digoxin (Lanoxin) has a blood pressure of 92/78; resting pulse of 78; respirations 28 and a potassium level of 4.8 mEq/L. The client is irritable andhas vomited twice since the morning dose of digoxin. Which finding is most indicative ofdigoxin toxicity? * A) Bradycardia B) Lethargy C) Irritability D) Vomiting The correct answer is A: Bradycardia 45. A Hispanic client confides in the nurse that she is concerned that staff may give hernewborn the "evil eye." The nurse should communicate to other personnel that the appropriate approach is to A) Touch the baby after looking at him B) Talk very slowly while speaking to him C) Avoid touching the child D) Look only at the parents The correct answer is A: Touch the baby after looking at him 46.A client is admitted for COPD. Which finding would require the nurse's immediateattention? A) Nausea and vomiting B) Restlessness and confusion C) Low-grade fever and cough D) Irritating cough and liquefied sputum The correct answer is B: Restlessness and confusion 47.A young adult male has been diagnosed with testicular cancer. Which of these statements by this client would need to be explored by the nurse to clarify information? A) This surgical procedure involves removing one or both testicles through a cut in the groin. My lymph nodes in my lower belly also may be removed. B) I have a good chance to regain my fertility later. However if I am concerned, I can have my sperm frozen and preserved (cryopreserved) before chemotherapy. C) If I have cancer at stage 3 it means I have less involvement of the cancer. D) After the surgical removal of a testicle, I can have an artificial testicle (prosthesis) placed inside my scrotum. This artificial implant has the weight and feel of a normal testicle. The correct answer is C: If I have cancer at stage 3 it means I have less involvement of the cancer. 48.A newly appointed nurse manager is having difficulties with time management.Which advice from an experienced manager should the new manager do initially? A) Set daily goals and establish priorities for each hour and each day. B) Ask for additional assistance when you feel overwhelmed. C) Keep a time log of your day in hourly blocks for at least 1 week. D) Complete each task before beginning another activity in selected instances. The correct answer is C: Keep a time log of your day in hourly blocks for at least 1 week. 49. The nurse and a student nurse are discussing the specific points about infants born toHBsAg-positive mothers. Which of these comments by the student indicates a need for clarification of information? A) "The infant will get the hepititis B vaccine (HepB) and the hepatitis B immune globulin within 12 hours at birth at separate injection sites." B) "The second dose can be given at 1 to 2 months of age." C) "The third dose should be given at least 16 weeks from the second dose." D) "The last dose in the series is not to be given before age 24 weeks." The correct answer is C: "The third dose should be given at least 16 weeks from the second dose." 50.A 74 year-old male is admitted due to inability to void. He has a history of an enlarged prostate and has not voided in 14 hours. When assessing for bladder distention,the best method for the nurse to use is to assess for A) Rebound tenderness B) Left lower quadrant dullness C) Rounded swelling above the pubis D) Urinary discharge The correct answer is C: Rounded swelling above the pubis