Question 1

Which nursing diagnosis would a nurse use to best address a suicidal patient's feelings of despair?

Accepted Answer

Nursing diagnosis that a nurse would use to best address the suicidal patient's feelings of despair is anxiety. A nursing diagnosis of spiritual distress is appropriate for the suicidal patient who is experiencing a lack of hope for the future and a feeling of despair.

Question 2

During a family therapy, the nurse notes that the patient's mother is sitting with the patient's father with her arms and legs crossed and her body turned away from her husband. This non-verbal behavior is an example of:

Accepted Answer

This non-verbal behavior is an example of distancing. Crossed arms and legs and turning away from a person are nonverbal behavioral signs that convey an unwillingness to communicate with another. This is indicative that the patient's mother is distancing herself from a meaningful conversation.

Question 3

The most accurate method of documenting the physical growth of a three-year-old patient is:

Accepted Answer

The most accurate method of documenting the physical growth of a three-year-old patient is to use growth charts over time. Because growth is a continuous but uneven process, the most reliable evaluation lies in comparing growth measurements over a prolonged period of time.

Question 4

Which of the following behaviors by a three-year-old patient supports a nursing diagnosis of delayed growth and development?

Accepted Answer

Behavior by a three-year-old patient that supports a nursing diagnosis of delayed growth and development is walking while holding onto furniture. Toddlers can walk alone at the age of twelve to thirteen months. The patient who needs support while ambulating is considered to have a delay in growth and development.

Question 5

The physician writes "DNAR" on the chart of a four-year-old patient. The nurse should understand that DNAR stands for:

Accepted Answer

The nurse should understand that DNAR stands "for do not attempt resuscitation." This order is written by the physician after discussions with the patient and the family regarding withholding resuscitative measures such as CPR, defibrillation, and intubation in the event of a terminal illness.

Question 6

Jimmy, a ten-year-old patient, was admitted to the unit. The nurse learns that the patient has a phobia. Considering the phobia, what nursing diagnosis would be appropriate for Jimmy?

Accepted Answer

Considering the phobia, a nursing diagnosis that would be appropriate for Jimmy is fear related to a specific stimulus. The essential feature of a phobia is a marked, persistent, and excessive or unreasonable fear when in the presence of, or when anticipating an encounter with, a specific object or stimulus.

Question 7

When Nurse Janine is assessing a patient, she notes pallor and mottling of the skin, decline in blood pressure, and dyspnea with periods of apnea. These manifestations are indicative of:

Accepted Answer

These manifestations are indicative of imminent death. Signs of impending death include mottling and cyanosis of extremities, changes in patterns of respirations, and slowing of the circulation.

Question 8

A thirteen-year-old patient who is scheduled for an abdominal cholecystectomy is given a preoperative teaching by a nurse. Which of the following statements by the patient is indicative that further teaching is required?

Accepted Answer

The statement by the patient that is indicative that further teaching is required is, "I will need to move my body like a log when I turn." Abdominal cholecystectomy involves removal of the gallbladder through a midline abdominal or right subcostal incision. The technique mentioned by the patient is only necessary for patients who have had a lumbar disc-not abdominal-surgery to prevent twisting the spine during movement.

Question 9

The physician ordered an analgesic per orem every four hours PRN for breakthrough pain for a seventeen-year-old patient who is receiving an epidural narcotic. The nurse should be aware that the best time to administer the analgesic is:

Accepted Answer

The nurse should be aware that the best time to administer the analgesic is when the patient states that he is experiencing a sudden increase in pain. The statement by the patient is a breakthrough pain. The nurse caring for the patient should instruct the patient to request the PRN medication before the pain becomes severe.

Question 10

A pediatric patient has a nasogastric tube that has been in place for five days. Thirty minutes after the nurse removes the tube, the patient experiences epistaxis. To control the bleeding, the nurse should:

Accepted Answer

To control the bleeding, the nurse should apply pressure by pinching the anterior portion of the nose for five to ten minutes. Pressure should be applied to the nose for five to ten minutes. Patients require coaching in mouth breathing while pressure is applied.

Question 11

Carrie is a clinical nurse specialist who is caring for a five-year-old patient for the first time. Carrie should utilize which nursing strategy to promote communication?

Accepted Answer

Carrie should explain care when it is given. Preschool children need to have care interventions explained in simple terms before, during, and after all nursing procedures.

Question 12

A four-year-old patient who has celiac disease is being assessed in the pediatric unit. Which of the following nursing diagnosis would a nurse give priority in the patient's long-term care plan?

Accepted Answer

The nursing diagnosis that a nurse would give priority in the patient's long-term care plan is high risk for ineffective family coping. Because of the prolonged onset of celiac disease, the parents' ability to cope with the situation may be severely altered.

Question 13

Andrea, a clinical nurse specialist, is caring for a patient who sustained serious facial and neck burns. To which nursing diagnosis would Andrea give first priority in caring for this patient?

Accepted Answer

The nursing diagnosis that Andrea would give first priority in caring for this patient is ineffective airway clearance. A patient with facial and neck burns is at high risk for ineffective airway clearance related to possible upper airway edema, secondary to inhalation of superheated air, smoke, or noxious chemicals.

Question 14

A twenty-year-old patient with a terminal illness is rapidly deteriorating, but remains alert, oriented, and verbally responsive. She states, "I am tired of being ill. I wish this could end now." The nurse should properly document this information using which of the following statements?

Accepted Answer

The nurse should properly document this information using the patient's statement, "I am tired of being ill. I wish this could end now." All information should be documented exactly as the patient stated. When recording subjective data, the patient's exact words are included within quotation marks.

Question 15

While orienting a newly hired nurse to the unit, the charge nurse stresses the importance of accurate documentation. The primary reason for a nurse to document care accurately is to:

Accepted Answer

The primary reason for a nurse to document care accurately is to demonstrate responsibility and accountability. Effective documentation reflects the quality of care and provides evidence of each healthcare team member's accountability in giving care.

Question 16

A three-year-old patient underwent a tonsillectomy. As the nurse is giving discharge instructions, which comment by the child's parents suggests that they understand the care
Requirements?

Accepted Answer

A comment by the child's parents that suggests that they understand the care
requirements is "We have bought fruit popsicles to give her later today." Clear liquids are a good choice during the first twenty-four hours after surgery. Popsicles are appealing to children, while providing fluids. They are less likely to irritate the surgical site than juices.

Question 17

A nurse is caring for a seventeen-year-old patient who had a subtotal thyroidectomy. When discussing drug therapy, the nurse should tell the patient and the parents:

Accepted Answer

When discussing drug therapy, the nurse should tell the patient and the parents to report palpitations, tremors, or loss of weight, which may indicate overdosage. Excessive thyroid hormone replacement may lead to the signs and symptoms of hyperthyroidism.

Question 18

An eighteen-year-old patient is scheduled for a thyroidectomy. She is concerned that the surgery will interfere with her ability to become pregnant. The nurse bases the response on the knowledge that:

Accepted Answer

The nurse bases the response on the knowledge that as long as medication is taken as ordered, ovulation will occur. Medication is regulated to maintain the usual blood levels of thyroxine; therefore, ovulation is not affected and future pregnancy is possible.

Question 19

A twenty-year-old patient with diabetes mellitus tells the nurse that she takes Guaifenesin cough syrup when she has a cold. The nurse should teach her that she:

Accepted Answer

The nurse should teach her that she must calculate the glucose in her daily carbohydrate allowance. Cough syrup contains a glucose base. The patient should use a glucose-free product or account for the glucose.

Question 20

The nurse on the pediatric unit does not administer sufficient, ordered, opiod medication to relieve the intractable pain of a patient because the nurse fears the patient will become addicted. In this scenario, the nurse is adhering to the ethical principle of:

Accepted Answer

In this scenario, the nurse is adhering to the ethical principle of beneficence. This ethical principle is commonly known as "doing good." It is related to the nurse's duty to help patients further their legitimate interest within the boundaries of safety.

Quiz 3: Pediatrics