School-aged child
A youngster with diabetes insipidus is given desmopressin acetate (DDAVP).
When assessing therapeutic efficacy, which finding would the nurse interpret as
a positive reaction to this medication?
1. Decreased urine production.
2. Increased urine glucose levels
3. Reduced blood pressure.
4. Relief from nausea - Correct answer: 1
RATIONALES: DDAVP's primary activity is to stimulate water reabsorption
by the kidneys, reducing urine output. DDAVP does not affect glucose, blood
pressure, or nausea.
Intrapartum period.
When the nurse examines a client who has just given birth to a newborn, she
notices that the fundus is swampy and deviated to the right. What should the
nurse do?
1. Have the client void.
2. Assess the client's vital signs.
3. Evaluate lochia qualities.
4. Massage the fundus. - The correct answer is 1.
,RATIONALES: By having the client void, we may evaluate whether the boggy,
distorted fundus is caused by a full bladder, which is the most prevalent source
of these fundal abnormalities. Unless the nurse detects hemorrhage as a result of
delayed involution, vital sign evaluation is unnecessary. The lochia is evaluated
to detect any potential bleeding. If the uterus remains swampy after the client
urinates, or if hemorrhage is suspected, the nurse should massage the fundus.
Basic Physical Care.
Which data collecting finding in a client who underwent major surgery 5 days
ago would be the best indicator of a wound infection?
1. Complaints about severe, acute incisional pain
2. Evidence of uneven wound margins.
3. Purulent wound leakage.
4. ANSWER: Oral temperature of 100.6°F (38.1°C)
When collecting information on a neonate, the nurse notices a vaguely defined
area of scalp edema. Which term should the nurse use to document this
observation?
1. Cephalhematoma
2. Petechiae
3. Subdural hematoma.
4. Caput succedaneum - Answer #4.
RATIONALES: Caput succedaneum is a broadly defined patch of scalp edema
that crosses the suture line and usually resolves within a few days after birth.
Cephalhematoma is a swelling of the head caused by subcutaneous bleeding
caused by pressure applied to the soft tissues during delivery; it is distinguished
,by strongly defined boundaries that do not cross the suture lines. Petechiae are
small, confined hemorrhage spots on the skin. A subdural hematoma is an
accumulation of blood between the dura and the brain.
Psychotic disorders.
A 50-year-old male client is admitted to a psychiatric ward for treatment of an
acute phase of paranoid schizophrenia with delusions about persecution. At the
end of her shift, a licensed practical nurse reports the client's condition to a
registered nurse. Which observation made by the licensed practical nurse
suggests that the client's condition is improving?
1. The client sits for several hours, staring at the television.
2. After shaving and showering, the client notes that the voices have been quiet
for several days.
3. The client reports that the television sends thoughts to his mind less
frequently than it did previously.
4. The customer looks around his room for hidden transmitters. - ANSWER
Preschooler
For a child hospitalized to the emergency department with a severe asthma
episode, nursing data collection will most likely reveal:
1. Apneic phases.
2. Expiratory wheeze.
3. Inspiratory stridor.
4. Breathing sounds are absent. - The answer is two.
, RATIONALES: Expiratory wheezing is prevalent during an acute asthma
episode and is caused by constriction of the airway due to edema. Apnea is
rarely caused by acute asthma. Inspiratory stridor is more usually associated
with croup. Acute asthma is more likely to create adventitious breath sounds
than absent breath sounds, yet adventitious noises are a warning indication since
the client is unable to exchange air.
Preschooler
A physician diagnoses leukemia in a 4-year-old child who complains of
exhaustion and sleeps the majority of the day. Which nursing diagnostic
represents the nurse's knowledge of the pathophysiology of leukemia?
1. Ineffective airway clearing due to fatigue
2. Activity intolerance due to anemia
3. Imbalanced nutrition: Exceeding body requirements due to lack of activity
4. Ineffective cerebral tissue perfusion due to central nervous system invasion
by leukemic cells - ANSWER Correct Answer: 2
RATIONALES: A kid with leukemia may develop anemia due to bone marrow
depression caused by chemotherapy or the replacement of normal bone marrow
elements with immature white blood cells. Anemia causes weariness, a lack of
energy, and activity intolerance. The information provided in the inquiry does
not support the other diagnoses.
Neurosensory Disorders
The nurse is gathering information about a 38-year-old client who has been
diagnosed with Multiple Sclerosis. Which of the following signs does the nurse
expect to see?
1. Vision changes.
A youngster with diabetes insipidus is given desmopressin acetate (DDAVP).
When assessing therapeutic efficacy, which finding would the nurse interpret as
a positive reaction to this medication?
1. Decreased urine production.
2. Increased urine glucose levels
3. Reduced blood pressure.
4. Relief from nausea - Correct answer: 1
RATIONALES: DDAVP's primary activity is to stimulate water reabsorption
by the kidneys, reducing urine output. DDAVP does not affect glucose, blood
pressure, or nausea.
Intrapartum period.
When the nurse examines a client who has just given birth to a newborn, she
notices that the fundus is swampy and deviated to the right. What should the
nurse do?
1. Have the client void.
2. Assess the client's vital signs.
3. Evaluate lochia qualities.
4. Massage the fundus. - The correct answer is 1.
,RATIONALES: By having the client void, we may evaluate whether the boggy,
distorted fundus is caused by a full bladder, which is the most prevalent source
of these fundal abnormalities. Unless the nurse detects hemorrhage as a result of
delayed involution, vital sign evaluation is unnecessary. The lochia is evaluated
to detect any potential bleeding. If the uterus remains swampy after the client
urinates, or if hemorrhage is suspected, the nurse should massage the fundus.
Basic Physical Care.
Which data collecting finding in a client who underwent major surgery 5 days
ago would be the best indicator of a wound infection?
1. Complaints about severe, acute incisional pain
2. Evidence of uneven wound margins.
3. Purulent wound leakage.
4. ANSWER: Oral temperature of 100.6°F (38.1°C)
When collecting information on a neonate, the nurse notices a vaguely defined
area of scalp edema. Which term should the nurse use to document this
observation?
1. Cephalhematoma
2. Petechiae
3. Subdural hematoma.
4. Caput succedaneum - Answer #4.
RATIONALES: Caput succedaneum is a broadly defined patch of scalp edema
that crosses the suture line and usually resolves within a few days after birth.
Cephalhematoma is a swelling of the head caused by subcutaneous bleeding
caused by pressure applied to the soft tissues during delivery; it is distinguished
,by strongly defined boundaries that do not cross the suture lines. Petechiae are
small, confined hemorrhage spots on the skin. A subdural hematoma is an
accumulation of blood between the dura and the brain.
Psychotic disorders.
A 50-year-old male client is admitted to a psychiatric ward for treatment of an
acute phase of paranoid schizophrenia with delusions about persecution. At the
end of her shift, a licensed practical nurse reports the client's condition to a
registered nurse. Which observation made by the licensed practical nurse
suggests that the client's condition is improving?
1. The client sits for several hours, staring at the television.
2. After shaving and showering, the client notes that the voices have been quiet
for several days.
3. The client reports that the television sends thoughts to his mind less
frequently than it did previously.
4. The customer looks around his room for hidden transmitters. - ANSWER
Preschooler
For a child hospitalized to the emergency department with a severe asthma
episode, nursing data collection will most likely reveal:
1. Apneic phases.
2. Expiratory wheeze.
3. Inspiratory stridor.
4. Breathing sounds are absent. - The answer is two.
, RATIONALES: Expiratory wheezing is prevalent during an acute asthma
episode and is caused by constriction of the airway due to edema. Apnea is
rarely caused by acute asthma. Inspiratory stridor is more usually associated
with croup. Acute asthma is more likely to create adventitious breath sounds
than absent breath sounds, yet adventitious noises are a warning indication since
the client is unable to exchange air.
Preschooler
A physician diagnoses leukemia in a 4-year-old child who complains of
exhaustion and sleeps the majority of the day. Which nursing diagnostic
represents the nurse's knowledge of the pathophysiology of leukemia?
1. Ineffective airway clearing due to fatigue
2. Activity intolerance due to anemia
3. Imbalanced nutrition: Exceeding body requirements due to lack of activity
4. Ineffective cerebral tissue perfusion due to central nervous system invasion
by leukemic cells - ANSWER Correct Answer: 2
RATIONALES: A kid with leukemia may develop anemia due to bone marrow
depression caused by chemotherapy or the replacement of normal bone marrow
elements with immature white blood cells. Anemia causes weariness, a lack of
energy, and activity intolerance. The information provided in the inquiry does
not support the other diagnoses.
Neurosensory Disorders
The nurse is gathering information about a 38-year-old client who has been
diagnosed with Multiple Sclerosis. Which of the following signs does the nurse
expect to see?
1. Vision changes.
