40 Questions
What is the concern of the nurse in Mrs. Parker's preoperative care?
Orienting Mrs. Parker to the room safely.
What does the nurse expect to find when palpating a 19-month-old toddler's fontanels?
Closed anterior fontanel and open posterior fontanel.
What is a characteristic of a child with celiac disease?
Dietary restrictions for life.
What is the goal of total parental nutrition (TPN) administered through a peripheral I.V. line?
To provide supplemental nutrition.
What is the nurse's role in educating parents of a child with celiac disease?
Educating on lifelong dietary restrictions.
Why is reading routine preoperative education materials important for Mrs. Parker?
To educate her on preoperative care.
At what age is it important for a child to maintain dietary restrictions for celiac disease?
For life.
What is a developmental milestone achieved by a 19-month-old toddler?
Eating at a small table and chair by herself.
What topic should the nurse include in the teaching session for the parents of an infant recovering from gastroenteritis and dehydration?
Dietary and fluid requirements
What indicates that the nurse's teaching on AIDS transmission has been effective for the client?
The client verbalizes the role of sexual activity in the spread of the disorder.
At what age should Nurse Betina begin screening for lead poisoning?
6 months
What would the nurse expect to see in an 11-month-old infant with dehydration and metabolic acidosis?
Tachypnea
Which question is least useful in the assessment of a client with AIDS?
Are you a drug user?
What is an important topic to cover in the teaching session for the parents of an infant recovering from gastroenteritis and dehydration?
Dietary and fluid requirements
What should the nurse prioritize in the care of an 11-month-old infant with dehydration and metabolic acidosis?
Administering IV fluids
What is a key aspect of teaching a client with newly diagnosed AIDS?
Prevention of AIDS transmission
When should gloves be worn?
When in contact with nonintact skin, mucous membranes, or soiled items
What should the nurse do after removing the dirty dressing?
Don a new pair of sterile gloves
What is the most appropriate action for the charge nurse?
Congratulate the nurse on the use of good technique
What is a necessary precaution when in contact with nonintact skin, mucous membranes, or soiled items?
Wearing gloves
When should a mask be worn?
When changing a dressing on a surgical wound
What should the nurse instruct auxiliary personnel in?
The correct procedures for blood and body fluid isolation
What indicates the best understanding of the correct protocol for blood and body fluid isolation?
Gloves should be worn for contact with nonintact skin, mucous membranes, or soiled items
What should the nurse do before donning sterile gloves?
Wash her hands
What is the most significant concern when monitoring Patrick's fluid intake?
Fluid overload
What is the primary goal of monitoring fluid intake in a patient with meningitis?
Preventing fluid overload
What is the most appropriate nursing action for an infant with nonorganic failure to thrive?
Encouraging the infant to hold a bottle
What is the indication of pain relief in a 15-month-old post-surgical patient?
Increased interest in play
What is the highest concentration of glucose considered safe for small veins in a school-age child?
17% glucose
What is the primary concern when administering TPN to a school-age child?
Preventing caustic effects on small veins
What is the characteristic of an infant with open anterior and fontanel?
Born prematurely
What should the nurse consider when planning care for a 8-year-old boy with Down syndrome?
The need for individualized care
What is an important consideration when planning interventions for a 7-year-old child?
The child's developmental level
Why is it important to maintain a consistent, structured environment for a child with spina bifida?
To reduce anxiety and confusion
What should the nurse suspect when a child has an allergic reaction to kiwifruit and bananas?
An allergy to certain fruits
Why is rotating caregivers not an effective intervention for a child with spina bifida?
It may cause confusion and anxiety
What should take priority when teaching the parents of a school-age child?
Preventing accidents
Why is it important to assess the child's current developmental level when planning care?
To plan care accordingly
What is not an effective way to promote learning in a child with spina bifida?
Keeping the child on bed rest
What should the nurse direct teaching to when working with a child with spina bifida?
The child's parents
Study Notes
Nursing Care and Assessment
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Effective teaching for a child with celiac disease is indicated when the parents understand that the child must maintain dietary restrictions lifelong.
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Preoperative goals for a 70-year-old woman with severe macular degeneration include independently ambulating around the unit, reading the routine preoperative education materials, and maneuvering safely after orientation to the room.
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When palpating the fontanels of a 19-month-old toddler, the nurse expects to find a closed anterior fontanel and open posterior fontanel.
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Isolation gowns are not needed for contact with nonintact skin, mucous membranes, or soiled items.
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Sterile gloves are not needed to remove an old dressing, but a new pair is necessary for cleaning and redressing the wound.
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Blood and body fluid isolation protocol requires masks to be worn with all client contact, gloves for contact with nonintact skin, mucous membranes, or soiled items, and isolation gowns are not needed.
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When teaching a parent about dietary and fluid requirements for an infant recovering from gastroenteritis and dehydration, the nurse should include safety guidelines in the teaching session.
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Toilet training is not a relevant topic for teaching a parent about an infant's dietary and fluid requirements.
Infection Control and Prevention
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Effective teaching regarding prevention of AIDS transmission has occurred when the client verbalizes the role of sexual activity in spreading the disorder and acknowledges the need to avoid close contact with others.
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Questions about a client's sexual activity, such as "Do you have many sex partners?" or "What is your method of birth control?" are relevant in the assessment of a client with AIDS.
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The nurse should not ask a client with AIDS if they are a drug user, as this is not a relevant question in assessing the client's understanding of AIDS transmission.
Pediatric Care
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When caring for an 11-month-old infant with dehydration and metabolic acidosis, the nurse expects to see tachypnea.
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The smallest amount of glucose that is considered safe and not caustic to small veins, while also providing adequate TPN, is 10% glucose.
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Monitoring fluid intake is essential for a healthy adolescent with meningitis to prevent fluid overload, which may cause cerebral edema, heart failure, or hypovolemic shock.
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In an infant with nonorganic failure to thrive, maintaining a consistent, structured environment is the most appropriate nursing action.
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A child with spina bifida may have an allergy to latex, which is indicated by sneezing and getting a rash when playing with brightly colored balloons and having an allergic reaction after eating kiwifruit and bananas.
Developmental Care
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When planning care for a 15-month-old child recovering from surgery to remove Wilms' tumor, the nurse should assess for signs of pain, such as decreased appetite, increased heart rate, or decreased urine output.
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A child with Down syndrome may have developmental delays, and the nurse should plan interventions according to the child's current developmental level.
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When teaching the parents of a school-age child, the nurse should prioritize teaching about preventing accidents.
This quiz assesses knowledge of nursing and health assessment, including patient communication, disease management, and reproductive health.
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