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.
Which of these parents' comments for a newborn would most likely reveal an initial
finding of a suspected pyloric stenosis?
. Mild vomiting that progressed to vomiting shooting across the room.
The nurse is assessing a child for clinical manifestations of iron deficiency anemia.
Which factor would the nurse recognize as the cause for the findings?
.Tissue hypoxia
The nurse would expect the cystic fibrosis client to receive supplemental pancreatic
enzymes along with a diet
. High in carbohydrates and proteins
In evaluating the growth of a 12 month-old child, which of these findings would the
nurse expect to be present in the infant?
. Tripled the birth weight
A Hispanic client in the postpartum period refuses the hospital food because it is
"cold." The best initial action by the nurse is to
.Ask the client what foods are acceptable or bad
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The father of an 8 month-old infant asks the nurse if his infant's vocalizations are
normal for his age. Which of the following would the nurse expect at this age?
.Imitation of sounds
The nurse should recognize that physical dependence is accompanied by what
findings when alcohol consumption is first reduced or ended?
.Withdrawal
Immediately following an acute battering incident in a violent relationship, the
batterer may respond to the partner's injuries by
.Minimizing the episode and underestimating the victim's injuries
A client with pneumococcal pneumonia was started on antibiotics 16 hours
ago.During the nurse's initial evening rounds, the nurse notices a foul smell in the
room. The client makes all of these statements during their conversation. Which
statement would alert the nurse to a complication?
"."I have been coughing up foul-tasting, brown, thick sputum.
The nurse is assessing a client in congestive heart failure. Auscultation of the heart
is most likely to reveal
. S3 ventricular gallop
A nurse has just received a medication order which is not legible. Which statement
best reflects assertive communication?
"Would you please clarify what you have written so I am sure I am reading it
correctly?"
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What is the most important consideration when teaching parents how to reduce
risks in the home?
Age of children in the home
A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the
nurse enters the room to request something for pain. The nurse should
Administer the prescribed analgesia
While caring for a toddler with croup, which initial sign of croup requires the nurse's
immediate attention?
Respiratory rate of 42
A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial
assessment, the nurse would anticipate which of the following assessment findings?
Lethargy
The emergency room nurse admits a child who experienced a seizure at school. The
father comments that this is the first occurrence, and denies any family history of
epilepsy. What is the best response by the nurse?
"The seizure may or may not mean your child has epilepsy."
Alcohol and drug abuse impairs judgment and increases risk taking behavior. What
nursing diagnosis best applies?