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PNLE II Nursing Practice (PM)
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Question 1
A community health nurse is caring for a group of flood victims in Marikina area. In planning for the potential needs of this group, which is the most immediate concern?
A
Peer support through structured groups
B
Meeting the basic needs to ensure that adequate food, shelter and clothing are available
C
Setting up a 24-hour crisis center and hotline
D
Finding affordable housing for the group
Question 1 Explanation:
The question asks about the immediate concern. The ABCs of community health care are always attending to people’s basic needs of food, shelter, and clothing.
Question 2
The physician prescribed gentamicin (Garamycin) to a child who is also receiving chemotherapy. Before administering the drug, the nurse should check the results of the child’s:
A
Abdominal and chest x-rays
B
Renal Function tests
C
Auditory tests
D
CBC and platelet count
Question 2 Explanation:
Both gentamicin and chemotherapeutic agents can cause renal impairment and acute renal failure; thus baseline renal function must be evaluated before initiating either medication.
Question 3
A mother brought her child in the health center for hepatitis B vaccination in a series. The mother informs the nurse that the child missed an appointment last month to have the third hepatitis B vaccination. Which of the following statements is the appropriate nursing response to the mother?
A
“Your child will have a hepatitis titer done to determine if immunization has taken place.”
B
“Your child will start the series again”
C
“Your child will get the next dose as soon as possible”
D
“I will examine the child for symptoms of hepatitis B”
Question 3 Explanation:
Continuity is essential to promote active immunity and give hepatitis B lifelong prophylaxis. Optimally, the third vaccination is given 6 months after the first.
Question 4
The mother brings her daughter to the health care clinic. The child was diagnosed with conjunctivitis. The nurse provides health teaching to the mother about the proper care of her daughter while at home. Which statement by the mother indicates a need for additional information?
A
“I should apply warm compresses before instilling antibiotic drops if purulent discharge is present in my daughter’s eye”
B
“I should perform a saline eye irrigation before instilling, the antibiotic drops into my daughter’s eye if purulent discharge is present"
C
“I do not need to be concerned about the spreading of this infection to others in my family”
D
“I can use an ophthalmic analgesic ointment at nighttime if I have eye discomfort”
Question 4 Explanation:
Conjunctivitis is highly contagious. Antibiotic drops are usually administered four times a day. When purulent discharge is present, saline eye irrigations or eye applications of warm compresses may be necessary before instilling the medication. Ophthalmic analgesic ointment or drops may be instilled, especially at bedtime, because discomfort becomes more noticeable when the eyelids are closed.
Question 5
A nurse is planning a home visit program to a new mother who is 2 weeks postpartum and breastfeeding, the nurse includes in her health teaching about the resumption of fertility, contraception and sexual activity. Which of the following statement indicates that the mother has understood the teaching?
A
“After birth, you have to have a period before you can get pregnant again’
B
“Breastfeeding protects me from pregnancy because it keeps my hormones down, so I don’t need any contraception until I stop breastfeeding”
C
“Because breastfeeding speeds the healing process after birth, I can have sex right away and not worry about infection”
D
“Because I am breastfeeding and my hormones are decreased, I may need to use a vaginal lubricant when I have sex”
Question 5 Explanation:
Prolactin suppresses estrogen, which is needed to stimulate vaginal lubrication during arousal.
Question 6
The nurse is providing health teaching about the breastfeeding and family planning to the client who gave birth to a healthy baby girl. Which of the following statement would alert the nurse that the client needs further teaching?
A
“I understand that the hormones for breastfeeding may affect when my periods come”
B
“Breastfeeding causes my womb to tighten and bleed less after birth”
C
“I can get pregnant as early as one month after my baby was born”
D
“I may not have periods while I am breastfeeding, so I don’t need family planning”
Question 6 Explanation:
It is common misconception that breastfeeding may prevent pregnancy.
Question 7
An 8-year-old boy with asthma is brought to the clinic for check up. The mother asks the nurse if the treatment given to her son is effective. What would be the appropriate response of the nurse?
A
I will review first the child’s height on a growth chart to know if the treatment is working
B
I will review first the number of prescriptions refills the child has required over the last 6 months to give you an accurate answer
C
I will review first the child’s weight on a growth chart to know if the treatment is working
D
I will review first the number of times the child has seen the pediatrician during the last 6 months to give you an accurate answer
Question 7 Explanation:
Reviewing the number of prescription refills the child has required over the last 6 months would be the best indicator of how well controlled and thus how effective the child’s asthma treatment is. Breakthrough wheezing, shortness of breath, and upper respiratory infections would require that the child take additional medication. This would be reflected in the number of prescription refills.
Question 8
The community nurse is providing an instruction to the clients in the health center about the use of diaphragm for family planning. To evaluate the understanding of the woman, the nurse asks her to demonstrate the use of the diaphragm. Which of following statement indicates a need for further health teaching?
A
“I really need to use the diaphragm and jelly most during the middle of my menstrual cycle
B
“I may need a different size diaphragm if I gain or lose more than 20 pounds”
C
“The diaphragm must be left in place for at least 6 hours after intercourse.”
D
“I should check the diaphragm carefully for holes every time I use it.”
Question 8 Explanation:
The woman must understand that, although the “fertile” period is approximately midcycle, hormonal variations do occur and can result in early or late ovulations. To be effective, the diaphragm should be inserted before every intercourse.
Question 9
The nurse is planning to conduct a home visit in a small community. Which of the following is the most important factor when planning the best time for a home care visit?
A
Length of time of the visit will take
B
Location of the patient’s home
C
Purpose of the home visit
D
Preference of the patient’s family
Question 9 Explanation:
The purpose of the visit takes priority.
Question 10
An 8-year-old girl is in second grade and the parents decided to enroll her to a new school. While the child is focusing on adjusting to new environment and peers, her grades suffer. The child’s father severely punishes the child and forces her daughter to study after school. The father does not allow also her daughter to play with other children. These data indicate to the nurse that this child is deprived of forming which normal phase of development?
A
Close relationship with peers
B
Heterosexual relationships
C
A dependency relationship with the father
D
A love relationship with the father
Question 10 Explanation:
In second grade a child needs to form a close relationships with peers.
Question 11
The health nurse is conducting health teaching about “safe” sex to a group of high school students. Which of the following statement about the use of condoms should the nurse avoid making?
A
“Condoms should be used even if you have recently tested negative for HIV”
B
“Condoms should be used every time you have sex because condoms prevent all forms of sexually transmitted diseases”
C
“Condoms should be used every time you have sex even if you are taking the pill because condoms can prevent the spread of HIV and gonorrhea”
D
“Condoms should be used because they can prevent infection and because they may prevent pregnancy”
Question 11 Explanation:
Condoms do not prevent ALL forms of sexually transmitted diseases.
Question 12
The nurse in the health center is providing immunization to the children. The nurse is carefully assessing the condition of the children before giving the vaccines. Which of the following would the nurse note to withhold the infant’s scheduled immunizations?
A
a runny nose
B
a skin rash
C
a low-grade fever
D
a dry cough
Question 12 Explanation:
A skin rash could indicate a concurrent infectious disease process in the infant. The scheduled immunizations should be withheld until the status of the infant’s health can be determined. Fevers above 38.5 degrees Celsius, alteration in skin integrity, and infectious-appearing secretions are indications to withhold immunizations.
Question 13
The Department of Health is alarmed that almost 33 million people suffer from food poisoning every year. Salmonella enteritis is responsible for almost 4 million cases of food poisoning. One of the major goals is to promote proper food preparation. The community health nurse is tasks to conduct health teaching about the prevention of food poisoning to a group of mother everyday. The nurse can help identify signs and symptoms of specific organisms to help patients get appropriate treatment. Typical symptoms of salmonella include:
A
Bloody diarrhea
B
Diarrhea and abdominal cramps
C
Nausea, vomiting and headache
D
Nausea, vomiting and paralysis
Question 13 Explanation:
Salmonella organisms cause lower GI symptoms
Question 14
The nurse assigned in the health center is counseling a 30-year-old client requesting oral contraceptives. The client tells the nurse that she has an active yeast infection that has recurred several times in the past year. Which statement by the nurse is inaccurate concerning health promotion actions to prevent recurring yeast infection?
A
“Wear loose-fitting cotton underwear”
B
“Douche once a day with a mild vinegar and water solution”
C
“During treatment for yeast, avoid vaginal intercourse for one week”
D
“Avoid eating large amounts of sugar or sugar-bingeing”
Question 14 Explanation:
Frequent douching interferes with the natural protective barriers in the vagina that resist yeast infection and should be avoided.
Question 15
A 5-year-old boy client is scheduled for hernia surgery. The nurse is preparing to do preoperative teaching with the child. The nurse should knows that the 5-year-old would:
A
Asks many questions regarding the condition and the procedure
B
Expect a simple yet logical explanation regarding the surgery
C
Worry over the impending surgery
D
Be uninterested in the upcoming surgery
Question 15 Explanation:
A 5-year-old is highly concerned with body integrity. The preschool-age child normally asks many questions and in a situation such as this, could be expected to ask even more.
Question 16
The mother brought her child to the clinic for follow-up check up. The mother tells the nurse that 14 days after starting an oral iron supplement, her child’s stools are black. Which of the following is the best nursing response to the mother?
A
“This is a normal side effect and means the medication is working”
B
“You sound quite concerned. Would you like to talk about this further?”
C
“I will need a specimen to check the stool for possible bleeding”
D
“I will notify the physician, who will probably decrease the dosage slightly”
Question 16 Explanation:
When oral iron preparations are given correctly, the stools normally turn dark green or black. Parents of children receiving this medication should be advised that this side effect indicates the medication is being absorbed and is working well.
Question 17
The mother brings a child to the health care clinic because of severe headache and vomiting. During the assessment of the health care nurse, the temperature of the child is 40 degree Celsius, and the nurse notes the presence of nuchal rigidity. The nurse is suspecting that the child might be suffering from bacterial meningitis. The nurse continues to assess the child for the presence of Kernig’s sign. Which finding would indicate the presence of this sign?
A
Flexion of the hips when the neck is flexed from a lying position
B
Inability of the child to extend the legs fully when lying supine
C
Pain when the chin is pulled down to the chest
D
Calf pain when the foot is dorsiflexed
Question 17 Explanation:
Kernig’s sign is the inability of the child to extend the legs fully when lying supine. This sign is frequently present in bacterial meningitis. Nuchal rigidity is also present in bacterial meningitis and occurs when pain prevents the child from touching the chin to the chest.
Question 18
The student nurse is assigned to take the vital signs of the clients in the pediatric ward. The student nurse reports to the staff nurse that the parent of a toddler who is 2 days postoperative after a cleft palate repair has given the toddler a pacifier. What would be the best immediate action of the nurse?
A
Ask the student nurse to remove the pacifier from the toddler’s mouth
B
Reassure the student that this is an acceptable action on the parent’s part
C
Discuss this action with the parents
D
Notify the pediatrician of this finding
Question 18 Explanation:
Nothing must be placed in the mouth of a toddler who just undergone a cleft palate repair until the suture line has completely healed. It is the nurse’s responsibility to inform the parent of the client. Spoon, forks, straws, and tongue blades are other unacceptable items to place in the mouth of a toddler who just undergone cleft palate repair. The general principle of care is that nothing should enter the mouth until the suture line has completely healed.
Question 19
Which of the following is the suited size of the needle would the nurse select to administer the IM injection to a preschool child?
A
21 G, 1 inch
B
18 G, 1inch
C
25 G, 5/8 inch
D
18 G, 1-1/2 inch
Question 19 Explanation:
In selecting the correct needle to administer an IM injection to a preschooler, the nurse should always look at the child and use judgment in evaluating muscle mass and amount of subcutaneous fat. In this case, in the absence of further data, the nurse would be most correct in selecting a needle gauge and length appropriate for the “average’ preschool child. A medium-gauge needle (21G) that is 1 inch long would be most appropriate.
Question 20
A community health nurse makes a home visit to an elderly person living alone in a small house. Which of the following observation would be a great concern?
A
Scattered and unwashed dishes in the sink
B
Big mirror in a wall
C
Brightly lit rooms
D
Shiny floors with scattered rugs
Question 20 Explanation:
It is a safety hazard to have shiny floors and scattered rugs because they can cause falls and rugs should be removed.
Question 21
A community health nurse makes a home visit to a child with an infectious and communicable disease. In planning care for the child, the nurse must determine that the primary goal is that the:
A
Child will not spread the infection to others
B
Public health department will be notified
C
Child will experience only minor complications
D
Child will experience mild discomfort
Question 21 Explanation:
The primary goal is to prevent the spread of the disease to others. The child should experience no complication. Although the health department may need to be notified at some point, it is no the primary goal. It is also important to prevent discomfort as much as possible.
Question 22
The community nurse is conducting a health teaching in the group of married women. When teaching a woman about fertility awareness, the nurse should emphasize that the basal body temperature:
A
Should be recorded each morning before any activity
B
Is the average temperature taken each morning
C
Can be done with a mercury thermometer but not a digital one
D
Has a lower degree of accuracy in predicting ovulation than the cervical mucus test
Question 22 Explanation:
The basal body temperature (BBT) is the lowest body temperature of a healthy person that is taken immediately after waking and before getting out of bed. The BBT usually varies from 36.2 – 36.3 degree Celsius during menses and for about 5-7 days afterward. About the time of ovulation, a slight drop approximately 0.05 degree Celsius in temperature may be seen; after ovulation, in concert with the increasing progesterone levels of the early luteal phase, the BBT rises 0.2-0.4 degree Celsius. This elevation remains until 2-3 days before menstruation, or if pregnancy has occurred.
Question 23
The physician decided to schedule the 4-year-old client for repair of left undescended testicle. The Injection of a hormone, HCG finds it less successful for treatment. To administer a pentobarbital sodium (Nembutal) suppository preoperatively to this client, in which position should the nurse place him?
A
Side-lying with upper leg flexed
B
Prone with legs abducted
C
Sitting with foot of bed elevated
D
Supine with foot of bed elevated
Question 23 Explanation:
The recommended position to administer rectal medications to children is side-lying with the upper leg flexed. This position allows the nurse to safely and effectively administer the medication while promoting comfort for the child.
Question 24
The client visits the clinic for prenatal check-up. While waiting for the physician, the nurse decided to conduct health teaching to the client. The nurse informed the client that primigravida mother should go to the hospital when which patter is evident?
A
Contractions are 5-10 minutes apart, lasting 30 seconds, and are felt as strong menstrual cramps
B
Contractions are 3-5 minutes apart, accompanied by rectal pressure and bloody show
C
Contractions are 2-3 minutes apart, lasting 90 seconds, and membranes have ruptured
D
Contractions are 5 minutes apart, lasting 60 seconds, and increasing in intensity
Question 24 Explanation:
Although instructions vary among birth centers, primigravidas should seek care when regular contractions are felt about 5 minutes apart, becoming longer and stronger.
Question 25
The community health nurse implemented a new program about effective breast cancer screening technique for the female personnel of the health department of Valenzuela. Which of the following technique should the nurse consider to be of the lowest priority?
A
Detailed health history to identify women at risk
B
Yearly breast exam by a trained professional
C
Screening mammogram every year for women over age 50
D
Screening mammogram every 1-2 years for women over age of 40.
Question 25 Explanation:
Because of the high incidence of breast cancer, all women are considered to be at risk regardless of health history.
Question 26
A 14 day-old infant with a cyanotic heart defects and mild congestive heart failure is brought to the emergency department. During assessment, the nurse checks the apical pulse rate of the infant. The apical pulse rate is 130 beats per minute. Which of the following is the appropriate nursing action?
A
Retake the apical pulse in 15 minutes
B
Administer the medication as scheduled
C
Retake the apical pulse in 30 minutes
D
Notify the pediatrician immediately
Question 26 Explanation:
The normal heart rate of an infant is 120-160 beats per minute.
Question 27
Which of the following technique is considered an aseptic practice during the home visit of the community health nurse?
A
Wrapping used dressing in a plastic bag before placing them in the nursing bag
B
Placing the contaminated needles and syringes in a labeled container inside the nursing bag
C
Using the client’s soap and cloth towel for hand washing
D
Washing hands before removing equipment from the nursing bag
Question 27 Explanation:
Handwashing is the best way to prevent the spread of infection.
Question 28
An 8-year-old client with cystic fibrosis is admitted to the hospital and will undergo a chest physiotherapy treatment. The therapy should be properly coordinated by the nurse with the respiratory therapy department so that treatments occur during:
A
Between meals
B
After meals
C
Around the child’s play schedule
D
After medication
Question 28 Explanation:
Chest physiotherapy treatments are scheduled between meals to prevent aspiration of stomach contents, because the child is placed in a variety of positions during the treatment process.
Question 29
The nurse is caring to a child client who is receiving tetracycline. The nurse is aware that in taking this medication, it is very important to:
A
Keep the child out of the sunlight
B
Monitor the child’s hearing
C
Give the drug through a straw
D
Administer the drug between meals
Question 29 Explanation:
Tetracycline may cause a phototoxic reaction.
Question 30
The nurse is caring to a 24-month-old child diagnosed with congenital heart defect. The physician prescribed digoxin (Lanoxin) to the client. Before the administration of the drug, the nurse checks the apical pulse rate to be 110 beats per minute and regular. What would be the next nursing action?
A
Withhold the digoxin and notify the physician
B
Give the digoxin as prescribed
C
Check the apical and radial simultaneously, and if they are the same, give the digoxin.
D
Check the other vital signs and level of consciousness
Question 30 Explanation:
For a 12month-old child, 110 apical pulse rate is normal and therefore it is safe to give the digoxin. A toddler’s normal pulse rate is slightly lower than an infant’s (120).
Question 31
A toddler is brought to the hospital because of severe diarrhea and vomiting. The nurse assigned to the client enters the client’s room and finds out that the client is using a soiled blanket brought in from home. The nurse attempts to remove the blanket and replace it with a new and clean blanket. The toddler refuses to give the soiled blanket. The nurse realizes that the best explanation for the toddler’s behavior is:
A
The toddler is resistive to nursing interventions
B
The blanket is an important transitional object
C
The toddler is anxious about the hospital experience
D
The toddler did not bond well with the maternal figure
Question 31 Explanation:
The “security blanket” is an important transitional object for the toddler. It provides a feeling of comfort and safety when the maternal figure is not present or when in a new situation for which the toddler was not prepared. Virtually any object (stuffed animal, doll, book etc) can become a security blanket for the toddler.
Question 32
A woman with active tuberculosis (TB) and has visited the health center for regular therapy for five months wants to become pregnant. The nurse knows that further information is necessary when the woman states:
A
“I can get pregnant after I have been free of TB for 6 months”
B
“Spontaneous abortion may occur in one out of five women who are infected”
C
“Pulmonary TB may jeopardize my pregnancy”
D
“I know that I may not be able to have close contact with my baby until contagious is no longer a problem
Question 32 Explanation:
Intervention is needed when the woman thinks that she needs to wait only 6 months after being free of TB before she can get pregnant. She needs to wait 1.5-2 years after she is declared to be free of TB before she should attempt pregnancy.
Question 33
The parent of a 16-year-old boy tells the nurse that his son is driving a motorbike very fast and with one hand. “It is making me crazy!” What would be the best explanation of the nurse to the behavior of the boy?
A
The adolescent feels indestructible
B
The adolescent has found a way to act out hostility toward the parent
C
The adolescent lacks life experience to realize how dangerous the behavior is
D
The adolescent might have an unconscious death wish
Question 33 Explanation:
Adolescents do feel indestructible, and this is reflected in many risk-taking behaviors.
Question 34
An 8-month-old infant is admitted to the hospital due to diarrhea. The nurse caring for the client tells the mother to stay beside the infant while making assessment. Which of the following developmental milestones the infant has reached?
A
Stands alone
B
Has a three-word vocabulary
C
Interacts with other infants
D
Recognizes but is fearful of strangers
Question 34 Explanation:
An 8-month-old infant both recognizes and is fearful of strangers. This developmental milestone is known as “stranger anxiety”.
Question 35
Which of the following clients is at high risk for developmental problem?
A
A preschooler with tonsillitis
B
A toddler with acute Glomerulonephritis on antihypertensive and antibiotics
C
A 2 1/2 –year old boy with cystic fibrosis
D
A 5-year-old with asthma on cromolyn sodium
Question 35 Explanation:
It is the developmental task of an 18-month-old toddler to explore and learn about the environment. The respiratory complications associated with cystic fibrosis (which are present in almost all children with cystic fibrosis) could prevent this development task from occurring.
Question 36
The nurse in the health center is making an assessment to the infant client. The nurse notes some rashes and small fluid-filled bumps in the skin. The nurse suspects that the infant has eczema. Which of the following is the most important nursing goal:
A
Preventing infection
B
Providing for adequate nutrition
C
Maintaining the comfort level
D
Decreasing the itching
Question 36 Explanation:
Preventing infection in the infant with eczema is the nurse’s most important goal. The infant with eczema is at high risk for infection due to numerous breaks in the skin’s integrity. Intact skin is always the infant’s first line of defense against infection.
Question 37
During immunization week in the health center, the parent of a 6-month-old infant asks the health nurse, “Why is our baby going to receive so many immunizations over a long time period?” The best nursing response would be:
A
“You need to ask the physician”
B
“It is easier on your baby to receive several immunizations rather than one at a time”
C
“The number of immunizations your baby will receive shows how many pediatric communicable and infectious diseases can now be prevented.”
D
“The number of immunizations your baby will receive is determined by your baby’s health history and age”
Question 37 Explanation:
Completion for the recommended schedule of infant immunizations does not require a large number of immunizations, but it also provides protection against multiple pediatric communicable and infectious diseases.
Question 38
A community nurse enters the home of the client for follow-up visit. Which of the following is the most appropriate area to place the nursing bag of the nurse when conducting a home visit?
A
living room sofa
B
kitchen countertop
C
cushioned footstool
D
bedside wood table
Question 38 Explanation:
A wood surface provides the least chance for organisms to be present.
Question 39
Which of the following would be the best divesionary activity for the nurse to select for a 2 weeks hospitalized 3-year-old girl?
A
Crayons and coloring books
B
puzzles
C
xylophone toy
D
doll
Question 39 Explanation:
The best diversion for a hospitalized child aged 2-3 years old would be anything that makes noise or makes a mess; xylophone which certainly makes noise or music would be the best choice.
Question 40
The mother brought her daughter to the health center. The child has head lice. The nurse anticipates that the nursing diagnosis most closely correlated with this is:
A
Altered body image related to alopecia
B
Fluid volume deficit related to vomiting
C
Altered comfort related to itching
D
Diversional activity deficit related to hospitalization
Question 40 Explanation:
Severe itching of the scalp is the classic sign and symptom of head lice in a child. In turn, this would lead to the nursing diagnosis of “altered comfort”.
Question 41
The nurse is providing a health teaching to the mother of an 8-year-old child with cystic fibrosis. Which of the following statement if made by the mother would indicate to the nurse the need for further teaching about the medication regimen of the child?
A
“I’ll give the enzyme capsule before every snack”
B
“My child hates to take pills, so I’ll mix the capsule into a cup of hot chocolate
C
“My child might need an extra capsule if the meal is high in fat”
D
“I’ll give the enzyme capsule before every meal”
Question 41 Explanation:
The pancreatic capsules contain pancreatic enzyme that should be administered in a cold, not a hot, medium (example: chilled applesauce versus hot chocolate) to maintain the medication’s integrity.
Question 42
The City health department conducted a medical mission in Barangay Marulas. Majority of the children in the Barangay Marulas were diagnosed with pinworms. The community health nurse should anticipate that the children’s chief complaint would be:
A
Lack of appetite
B
Severe itching of the scalp
C
Severe abdominal pain
D
Perianal itching
Question 42 Explanation:
Perianal itching is the child’s chief complaint associated with the diagnosis of pinworms. The itching, in this instance, is often described as being “intense” in nature. Pinworms infestation usually occurs because the child is in the anus-to-mouth stage of development (child uses the toilet, does not wash hands, places hands and pinworm eggs in mouth). Teaching the child hand washing before eating and after using the toilet can assist in breaking the cycle.
Question 43
The department of health is promoting the breastfeeding program to all newly mothers. The nurse is formulating a plan of care to a woman who gave birth to a baby girl. The nursing care plan for a breast-feeding mother takes into account that breast-feeding is contraindicated when the woman:
A
Is pregnant
B
Has genital herpes infection
C
Develops mastitis
D
Has inverted nipples
Question 43 Explanation:
Pregnancy is one contraindication to breast-feeding. Milk secretion is inhibited and the baby’s sucking may stimulate uterine contractions.
Question 44
A 2-year-old client with cystic fibrosis is confined to bed and is not allowed to go to the playroom. Which of the following is an appropriate toy would the nurse select for the child:
A
Puzzle
B
Pounding board and hammer
C
Arranging stickers in the album
D
Musical automobile
Question 44 Explanation:
The autonomous toddler would be frustrated by being confined to be. The pounding board and hammer is developmentally appropriate and an excellent way for the toddler to release frustration.
Question 45
A 9-year-old boy is admitted to the hospital. The boy is being treated with salicylates for the migratory polyarthritis accompanying the diagnosis of rheumatic fever. Which of the following activities performed by the child would give a best sign that the medication is effective?
A
Listening to the music in the radio
B
Listening to story of his mother
C
Watching movie in the dvd mini player
D
Playing mini piano
Question 45 Explanation:
The purpose of the salicylate therapy is to relieve the pain associated with the migratory polyarthritis accompanying the rheumatic fever. Playing mini piano would require movement of the child’s joints and would provide the nurse with a means of evaluating the child’s level of pain.
Question 46
The nine-year-old client is admitted in the hospital for almost 1 week and is on bed rest. The child complains of being bored and it seems tiresome to stay on bed and doing nothing. What activity selected by the nurse would the child most likely find stimulating?
A
Assembling handouts with the nurse for an upcoming staff development meeting
B
Putting together a puzzle
C
Listening to a compact disc
D
Watching a video
Question 46 Explanation:
A 9-year-old enjoys working and feeling a sense of accomplishment. The school-age child also enjoys “showing off,” and doing something with the nurse on the pediatric unit would allow this. This activity also provides the school-age child a needed opportunity to interact with others in the absence of school and personal friends.
Question 47
A nurse is providing safety instructions to the parents of the 11-month-old child. Which of the following will the nurse includes in the instructions?
A
Begin to teach the child not to place small objects in the mouth
B
Installing a gate at the top and bottom of any stairs in the home
C
Purchasing an infant car seat as soon as possible
D
Plugging all electrical outlets in the house
Question 47 Explanation:
An 11-month-old child stands alone and can walk holding onto people or objects. Therefore the installation of a gate at the top and bottom of any stairs in the house is crucial for the child’s safety.
Question 48
A mother who gave birth to her second daughter is so concerned about her 2-year old daughter. She tells the nurse, “I am afraid that my 2-year-old daughter may not accept her newly born sister”. It is appropriate to the nurse to response that:
A
The older daughter not have interaction with the baby at the hospital, because she may harm her new sibling
B
The older daughter be given more responsibility and assure her “that she is a big girl now, and doesn’t need Mommy as much”
C
The older daughter stay with her grandmother for a few days until the parents and new baby are settled at home
D
The mother spend time alone with her older daughter when the baby is sleeping
Question 48 Explanation:
The introduction of a baby into a family with one or more children challenges parent to promote acceptance of the baby by siblings. The parent’s attitudes toward the arrival of the baby can set the stage for the other children’s reaction. Spending time with the older siblings alone will also reassure them of their place in the family, even though the older children will have to eventually assume new positions within the family hierarchy.
Question 49
The nurse has knowledge about the developmental task of the child. In caring a 3-year-old-client, the nurse knows that the suited developmental task of this child is to:
A
Learn to play with other children
B
Explore and manipulate the environment
C
Express all needs through speaking
D
Able to trust others
Question 49 Explanation:
Toddlers need to meet the developmental milestone of autonomy versus shame and doubt. In order to accomplish this, the toddler must be able to explore and manipulate the environment.
Question 50
The community health nurse is conducting a health teaching about nutrition to a group of pregnant women who are anemic and are lactose intolerant. Which of the following foods should the nurse especially encourage during the third trimester?
A
Red beans, green leafy vegetables, and fish for iron and calcium needs plus prenatal vitamins and iron supplements
B
Prenatal iron and calcium supplements plus a regular adult diet
C
Cheese, yogurt, and fish for protein and calcium needs plus prenatal vitamins and iron supplements
D
Red meat, milk and eggs for iron and calcium needs plus prenatal vitamins and iron supplements
Question 50 Explanation:
This is appropriate foods that are high in iron and calcium but would not affect lactose intolerance.
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PNLE II Nursing Practice (EM)
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Question 1
A community health nurse makes a home visit to a child with an infectious and communicable disease. In planning care for the child, the nurse must determine that the primary goal is that the:
A
Public health department will be notified
B
Child will experience only minor complications
C
Child will not spread the infection to others
D
Child will experience mild discomfort
Question 1 Explanation:
The primary goal is to prevent the spread of the disease to others. The child should experience no complication. Although the health department may need to be notified at some point, it is no the primary goal. It is also important to prevent discomfort as much as possible.
Question 2
Which of the following is the suited size of the needle would the nurse select to administer the IM injection to a preschool child?
A
18 G, 1inch
B
21 G, 1 inch
C
25 G, 5/8 inch
D
18 G, 1-1/2 inch
Question 2 Explanation:
In selecting the correct needle to administer an IM injection to a preschooler, the nurse should always look at the child and use judgment in evaluating muscle mass and amount of subcutaneous fat. In this case, in the absence of further data, the nurse would be most correct in selecting a needle gauge and length appropriate for the “average’ preschool child. A medium-gauge needle (21G) that is 1 inch long would be most appropriate.
Question 3
The physician decided to schedule the 4-year-old client for repair of left undescended testicle. The Injection of a hormone, HCG finds it less successful for treatment. To administer a pentobarbital sodium (Nembutal) suppository preoperatively to this client, in which position should the nurse place him?
A
Supine with foot of bed elevated
B
Prone with legs abducted
C
Side-lying with upper leg flexed
D
Sitting with foot of bed elevated
Question 3 Explanation:
The recommended position to administer rectal medications to children is side-lying with the upper leg flexed. This position allows the nurse to safely and effectively administer the medication while promoting comfort for the child.
Question 4
A woman with active tuberculosis (TB) and has visited the health center for regular therapy for five months wants to become pregnant. The nurse knows that further information is necessary when the woman states:
A
“Pulmonary TB may jeopardize my pregnancy”
B
“Spontaneous abortion may occur in one out of five women who are infected”
C
“I can get pregnant after I have been free of TB for 6 months”
D
“I know that I may not be able to have close contact with my baby until contagious is no longer a problem
Question 4 Explanation:
Intervention is needed when the woman thinks that she needs to wait only 6 months after being free of TB before she can get pregnant. She needs to wait 1.5-2 years after she is declared to be free of TB before she should attempt pregnancy.
Question 5
A toddler is brought to the hospital because of severe diarrhea and vomiting. The nurse assigned to the client enters the client’s room and finds out that the client is using a soiled blanket brought in from home. The nurse attempts to remove the blanket and replace it with a new and clean blanket. The toddler refuses to give the soiled blanket. The nurse realizes that the best explanation for the toddler’s behavior is:
A
The blanket is an important transitional object
B
The toddler did not bond well with the maternal figure
C
The toddler is anxious about the hospital experience
D
The toddler is resistive to nursing interventions
Question 5 Explanation:
The “security blanket” is an important transitional object for the toddler. It provides a feeling of comfort and safety when the maternal figure is not present or when in a new situation for which the toddler was not prepared. Virtually any object (stuffed animal, doll, book etc) can become a security blanket for the toddler.
Question 6
The nine-year-old client is admitted in the hospital for almost 1 week and is on bed rest. The child complains of being bored and it seems tiresome to stay on bed and doing nothing. What activity selected by the nurse would the child most likely find stimulating?
A
Listening to a compact disc
B
Putting together a puzzle
C
Assembling handouts with the nurse for an upcoming staff development meeting
D
Watching a video
Question 6 Explanation:
A 9-year-old enjoys working and feeling a sense of accomplishment. The school-age child also enjoys “showing off,” and doing something with the nurse on the pediatric unit would allow this. This activity also provides the school-age child a needed opportunity to interact with others in the absence of school and personal friends.
Question 7
The parent of a 16-year-old boy tells the nurse that his son is driving a motorbike very fast and with one hand. “It is making me crazy!” What would be the best explanation of the nurse to the behavior of the boy?
A
The adolescent lacks life experience to realize how dangerous the behavior is
B
The adolescent feels indestructible
C
The adolescent might have an unconscious death wish
D
The adolescent has found a way to act out hostility toward the parent
Question 7 Explanation:
Adolescents do feel indestructible, and this is reflected in many risk-taking behaviors.
Question 8
The community nurse is conducting a health teaching in the group of married women. When teaching a woman about fertility awareness, the nurse should emphasize that the basal body temperature:
A
Should be recorded each morning before any activity
B
Can be done with a mercury thermometer but not a digital one
C
Has a lower degree of accuracy in predicting ovulation than the cervical mucus test
D
Is the average temperature taken each morning
Question 8 Explanation:
The basal body temperature (BBT) is the lowest body temperature of a healthy person that is taken immediately after waking and before getting out of bed. The BBT usually varies from 36.2 – 36.3 degree Celsius during menses and for about 5-7 days afterward. About the time of ovulation, a slight drop approximately 0.05 degree Celsius in temperature may be seen; after ovulation, in concert with the increasing progesterone levels of the early luteal phase, the BBT rises 0.2-0.4 degree Celsius. This elevation remains until 2-3 days before menstruation, or if pregnancy has occurred.
Question 9
The City health department conducted a medical mission in Barangay Marulas. Majority of the children in the Barangay Marulas were diagnosed with pinworms. The community health nurse should anticipate that the children’s chief complaint would be:
A
Severe abdominal pain
B
Severe itching of the scalp
C
Perianal itching
D
Lack of appetite
Question 9 Explanation:
Perianal itching is the child’s chief complaint associated with the diagnosis of pinworms. The itching, in this instance, is often described as being “intense” in nature. Pinworms infestation usually occurs because the child is in the anus-to-mouth stage of development (child uses the toilet, does not wash hands, places hands and pinworm eggs in mouth). Teaching the child hand washing before eating and after using the toilet can assist in breaking the cycle.
Question 10
A 5-year-old boy client is scheduled for hernia surgery. The nurse is preparing to do preoperative teaching with the child. The nurse should knows that the 5-year-old would:
A
Expect a simple yet logical explanation regarding the surgery
B
Be uninterested in the upcoming surgery
C
Worry over the impending surgery
D
Asks many questions regarding the condition and the procedure
Question 10 Explanation:
A 5-year-old is highly concerned with body integrity. The preschool-age child normally asks many questions and in a situation such as this, could be expected to ask even more.
Question 11
A community nurse enters the home of the client for follow-up visit. Which of the following is the most appropriate area to place the nursing bag of the nurse when conducting a home visit?
A
living room sofa
B
cushioned footstool
C
kitchen countertop
D
bedside wood table
Question 11 Explanation:
A wood surface provides the least chance for organisms to be present.
Question 12
A 9-year-old boy is admitted to the hospital. The boy is being treated with salicylates for the migratory polyarthritis accompanying the diagnosis of rheumatic fever. Which of the following activities performed by the child would give a best sign that the medication is effective?
A
Playing mini piano
B
Watching movie in the dvd mini player
C
Listening to story of his mother
D
Listening to the music in the radio
Question 12 Explanation:
The purpose of the salicylate therapy is to relieve the pain associated with the migratory polyarthritis accompanying the rheumatic fever. Playing mini piano would require movement of the child’s joints and would provide the nurse with a means of evaluating the child’s level of pain.
Question 13
A community health nurse is caring for a group of flood victims in Marikina area. In planning for the potential needs of this group, which is the most immediate concern?
A
Setting up a 24-hour crisis center and hotline
B
Peer support through structured groups
C
Finding affordable housing for the group
D
Meeting the basic needs to ensure that adequate food, shelter and clothing are available
Question 13 Explanation:
The question asks about the immediate concern. The ABCs of community health care are always attending to people’s basic needs of food, shelter, and clothing.
Question 14
The mother brings her daughter to the health care clinic. The child was diagnosed with conjunctivitis. The nurse provides health teaching to the mother about the proper care of her daughter while at home. Which statement by the mother indicates a need for additional information?
A
“I can use an ophthalmic analgesic ointment at nighttime if I have eye discomfort”
B
“I should perform a saline eye irrigation before instilling, the antibiotic drops into my daughter’s eye if purulent discharge is present"
C
“I should apply warm compresses before instilling antibiotic drops if purulent discharge is present in my daughter’s eye”
D
“I do not need to be concerned about the spreading of this infection to others in my family”
Question 14 Explanation:
Conjunctivitis is highly contagious. Antibiotic drops are usually administered four times a day. When purulent discharge is present, saline eye irrigations or eye applications of warm compresses may be necessary before instilling the medication. Ophthalmic analgesic ointment or drops may be instilled, especially at bedtime, because discomfort becomes more noticeable when the eyelids are closed.
Question 15
A mother brought her child in the health center for hepatitis B vaccination in a series. The mother informs the nurse that the child missed an appointment last month to have the third hepatitis B vaccination. Which of the following statements is the appropriate nursing response to the mother?
A
“Your child will have a hepatitis titer done to determine if immunization has taken place.”
B
“Your child will start the series again”
C
“I will examine the child for symptoms of hepatitis B”
D
“Your child will get the next dose as soon as possible”
Question 15 Explanation:
Continuity is essential to promote active immunity and give hepatitis B lifelong prophylaxis. Optimally, the third vaccination is given 6 months after the first.
Question 16
An 8-year-old client with cystic fibrosis is admitted to the hospital and will undergo a chest physiotherapy treatment. The therapy should be properly coordinated by the nurse with the respiratory therapy department so that treatments occur during:
A
Around the child’s play schedule
B
After meals
C
Between meals
D
After medication
Question 16 Explanation:
Chest physiotherapy treatments are scheduled between meals to prevent aspiration of stomach contents, because the child is placed in a variety of positions during the treatment process.
Question 17
A mother who gave birth to her second daughter is so concerned about her 2-year old daughter. She tells the nurse, “I am afraid that my 2-year-old daughter may not accept her newly born sister”. It is appropriate to the nurse to response that:
A
The older daughter stay with her grandmother for a few days until the parents and new baby are settled at home
B
The mother spend time alone with her older daughter when the baby is sleeping
C
The older daughter not have interaction with the baby at the hospital, because she may harm her new sibling
D
The older daughter be given more responsibility and assure her “that she is a big girl now, and doesn’t need Mommy as much”
Question 17 Explanation:
The introduction of a baby into a family with one or more children challenges parent to promote acceptance of the baby by siblings. The parent’s attitudes toward the arrival of the baby can set the stage for the other children’s reaction. Spending time with the older siblings alone will also reassure them of their place in the family, even though the older children will have to eventually assume new positions within the family hierarchy.
Question 18
A community health nurse makes a home visit to an elderly person living alone in a small house. Which of the following observation would be a great concern?
A
Scattered and unwashed dishes in the sink
B
Big mirror in a wall
C
Shiny floors with scattered rugs
D
Brightly lit rooms
Question 18 Explanation:
It is a safety hazard to have shiny floors and scattered rugs because they can cause falls and rugs should be removed.
Question 19
A nurse is providing safety instructions to the parents of the 11-month-old child. Which of the following will the nurse includes in the instructions?
A
Purchasing an infant car seat as soon as possible
B
Installing a gate at the top and bottom of any stairs in the home
C
Plugging all electrical outlets in the house
D
Begin to teach the child not to place small objects in the mouth
Question 19 Explanation:
An 11-month-old child stands alone and can walk holding onto people or objects. Therefore the installation of a gate at the top and bottom of any stairs in the house is crucial for the child’s safety.
Question 20
An 8-month-old infant is admitted to the hospital due to diarrhea. The nurse caring for the client tells the mother to stay beside the infant while making assessment. Which of the following developmental milestones the infant has reached?
A
Recognizes but is fearful of strangers
B
Stands alone
C
Interacts with other infants
D
Has a three-word vocabulary
Question 20 Explanation:
An 8-month-old infant both recognizes and is fearful of strangers. This developmental milestone is known as “stranger anxiety”.
Question 21
The department of health is promoting the breastfeeding program to all newly mothers. The nurse is formulating a plan of care to a woman who gave birth to a baby girl. The nursing care plan for a breast-feeding mother takes into account that breast-feeding is contraindicated when the woman:
A
Has genital herpes infection
B
Develops mastitis
C
Is pregnant
D
Has inverted nipples
Question 21 Explanation:
Pregnancy is one contraindication to breast-feeding. Milk secretion is inhibited and the baby’s sucking may stimulate uterine contractions.
Question 22
During immunization week in the health center, the parent of a 6-month-old infant asks the health nurse, “Why is our baby going to receive so many immunizations over a long time period?” The best nursing response would be:
A
“The number of immunizations your baby will receive is determined by your baby’s health history and age”
B
“You need to ask the physician”
C
“It is easier on your baby to receive several immunizations rather than one at a time”
D
“The number of immunizations your baby will receive shows how many pediatric communicable and infectious diseases can now be prevented.”
Question 22 Explanation:
Completion for the recommended schedule of infant immunizations does not require a large number of immunizations, but it also provides protection against multiple pediatric communicable and infectious diseases.
Question 23
The community health nurse is conducting a health teaching about nutrition to a group of pregnant women who are anemic and are lactose intolerant. Which of the following foods should the nurse especially encourage during the third trimester?
A
Prenatal iron and calcium supplements plus a regular adult diet
B
Red beans, green leafy vegetables, and fish for iron and calcium needs plus prenatal vitamins and iron supplements
C
Red meat, milk and eggs for iron and calcium needs plus prenatal vitamins and iron supplements
D
Cheese, yogurt, and fish for protein and calcium needs plus prenatal vitamins and iron supplements
Question 23 Explanation:
This is appropriate foods that are high in iron and calcium but would not affect lactose intolerance.
Question 24
The nurse is caring to a 24-month-old child diagnosed with congenital heart defect. The physician prescribed digoxin (Lanoxin) to the client. Before the administration of the drug, the nurse checks the apical pulse rate to be 110 beats per minute and regular. What would be the next nursing action?
A
Withhold the digoxin and notify the physician
B
Check the other vital signs and level of consciousness
C
Check the apical and radial simultaneously, and if they are the same, give the digoxin.
D
Give the digoxin as prescribed
Question 24 Explanation:
For a 12month-old child, 110 apical pulse rate is normal and therefore it is safe to give the digoxin. A toddler’s normal pulse rate is slightly lower than an infant’s (120).
Question 25
The nurse assigned in the health center is counseling a 30-year-old client requesting oral contraceptives. The client tells the nurse that she has an active yeast infection that has recurred several times in the past year. Which statement by the nurse is inaccurate concerning health promotion actions to prevent recurring yeast infection?
A
“Wear loose-fitting cotton underwear”
B
“During treatment for yeast, avoid vaginal intercourse for one week”
C
“Avoid eating large amounts of sugar or sugar-bingeing”
D
“Douche once a day with a mild vinegar and water solution”
Question 25 Explanation:
Frequent douching interferes with the natural protective barriers in the vagina that resist yeast infection and should be avoided.
Question 26
The community health nurse implemented a new program about effective breast cancer screening technique for the female personnel of the health department of Valenzuela. Which of the following technique should the nurse consider to be of the lowest priority?
A
Yearly breast exam by a trained professional
B
Detailed health history to identify women at risk
C
Screening mammogram every year for women over age 50
D
Screening mammogram every 1-2 years for women over age of 40.
Question 26 Explanation:
Because of the high incidence of breast cancer, all women are considered to be at risk regardless of health history.
Question 27
The nurse has knowledge about the developmental task of the child. In caring a 3-year-old-client, the nurse knows that the suited developmental task of this child is to:
A
Express all needs through speaking
B
Explore and manipulate the environment
C
Able to trust others
D
Learn to play with other children
Question 27 Explanation:
Toddlers need to meet the developmental milestone of autonomy versus shame and doubt. In order to accomplish this, the toddler must be able to explore and manipulate the environment.
Question 28
Which of the following clients is at high risk for developmental problem?
A
A 5-year-old with asthma on cromolyn sodium
B
A 2 1/2 –year old boy with cystic fibrosis
C
A preschooler with tonsillitis
D
A toddler with acute Glomerulonephritis on antihypertensive and antibiotics
Question 28 Explanation:
It is the developmental task of an 18-month-old toddler to explore and learn about the environment. The respiratory complications associated with cystic fibrosis (which are present in almost all children with cystic fibrosis) could prevent this development task from occurring.
Question 29
The nurse in the health center is making an assessment to the infant client. The nurse notes some rashes and small fluid-filled bumps in the skin. The nurse suspects that the infant has eczema. Which of the following is the most important nursing goal:
A
Decreasing the itching
B
Preventing infection
C
Maintaining the comfort level
D
Providing for adequate nutrition
Question 29 Explanation:
Preventing infection in the infant with eczema is the nurse’s most important goal. The infant with eczema is at high risk for infection due to numerous breaks in the skin’s integrity. Intact skin is always the infant’s first line of defense against infection.
Question 30
The student nurse is assigned to take the vital signs of the clients in the pediatric ward. The student nurse reports to the staff nurse that the parent of a toddler who is 2 days postoperative after a cleft palate repair has given the toddler a pacifier. What would be the best immediate action of the nurse?
A
Reassure the student that this is an acceptable action on the parent’s part
B
Notify the pediatrician of this finding
C
Ask the student nurse to remove the pacifier from the toddler’s mouth
D
Discuss this action with the parents
Question 30 Explanation:
Nothing must be placed in the mouth of a toddler who just undergone a cleft palate repair until the suture line has completely healed. It is the nurse’s responsibility to inform the parent of the client. Spoon, forks, straws, and tongue blades are other unacceptable items to place in the mouth of a toddler who just undergone cleft palate repair. The general principle of care is that nothing should enter the mouth until the suture line has completely healed.
Question 31
An 8-year-old boy with asthma is brought to the clinic for check up. The mother asks the nurse if the treatment given to her son is effective. What would be the appropriate response of the nurse?
A
I will review first the child’s weight on a growth chart to know if the treatment is working
B
I will review first the number of times the child has seen the pediatrician during the last 6 months to give you an accurate answer
C
I will review first the number of prescriptions refills the child has required over the last 6 months to give you an accurate answer
D
I will review first the child’s height on a growth chart to know if the treatment is working
Question 31 Explanation:
Reviewing the number of prescription refills the child has required over the last 6 months would be the best indicator of how well controlled and thus how effective the child’s asthma treatment is. Breakthrough wheezing, shortness of breath, and upper respiratory infections would require that the child take additional medication. This would be reflected in the number of prescription refills.
Question 32
An 8-year-old girl is in second grade and the parents decided to enroll her to a new school. While the child is focusing on adjusting to new environment and peers, her grades suffer. The child’s father severely punishes the child and forces her daughter to study after school. The father does not allow also her daughter to play with other children. These data indicate to the nurse that this child is deprived of forming which normal phase of development?
A
Heterosexual relationships
B
A love relationship with the father
C
A dependency relationship with the father
D
Close relationship with peers
Question 32 Explanation:
In second grade a child needs to form a close relationships with peers.
Question 33
Which of the following technique is considered an aseptic practice during the home visit of the community health nurse?
A
Wrapping used dressing in a plastic bag before placing them in the nursing bag
B
Washing hands before removing equipment from the nursing bag
C
Using the client’s soap and cloth towel for hand washing
D
Placing the contaminated needles and syringes in a labeled container inside the nursing bag
Question 33 Explanation:
Handwashing is the best way to prevent the spread of infection.
Question 34
The client visits the clinic for prenatal check-up. While waiting for the physician, the nurse decided to conduct health teaching to the client. The nurse informed the client that primigravida mother should go to the hospital when which patter is evident?
A
Contractions are 3-5 minutes apart, accompanied by rectal pressure and bloody show
B
Contractions are 2-3 minutes apart, lasting 90 seconds, and membranes have ruptured
C
Contractions are 5-10 minutes apart, lasting 30 seconds, and are felt as strong menstrual cramps
D
Contractions are 5 minutes apart, lasting 60 seconds, and increasing in intensity
Question 34 Explanation:
Although instructions vary among birth centers, primigravidas should seek care when regular contractions are felt about 5 minutes apart, becoming longer and stronger.
Question 35
The nurse is planning to conduct a home visit in a small community. Which of the following is the most important factor when planning the best time for a home care visit?
A
Location of the patient’s home
B
Length of time of the visit will take
C
Preference of the patient’s family
D
Purpose of the home visit
Question 35 Explanation:
The purpose of the visit takes priority.
Question 36
The nurse is providing a health teaching to the mother of an 8-year-old child with cystic fibrosis. Which of the following statement if made by the mother would indicate to the nurse the need for further teaching about the medication regimen of the child?
A
“I’ll give the enzyme capsule before every meal”
B
“My child hates to take pills, so I’ll mix the capsule into a cup of hot chocolate
C
“My child might need an extra capsule if the meal is high in fat”
D
“I’ll give the enzyme capsule before every snack”
Question 36 Explanation:
The pancreatic capsules contain pancreatic enzyme that should be administered in a cold, not a hot, medium (example: chilled applesauce versus hot chocolate) to maintain the medication’s integrity.
Question 37
The community nurse is providing an instruction to the clients in the health center about the use of diaphragm for family planning. To evaluate the understanding of the woman, the nurse asks her to demonstrate the use of the diaphragm. Which of following statement indicates a need for further health teaching?
A
“I should check the diaphragm carefully for holes every time I use it.”
B
“I really need to use the diaphragm and jelly most during the middle of my menstrual cycle
C
“I may need a different size diaphragm if I gain or lose more than 20 pounds”
D
“The diaphragm must be left in place for at least 6 hours after intercourse.”
Question 37 Explanation:
The woman must understand that, although the “fertile” period is approximately midcycle, hormonal variations do occur and can result in early or late ovulations. To be effective, the diaphragm should be inserted before every intercourse.
Question 38
A nurse is planning a home visit program to a new mother who is 2 weeks postpartum and breastfeeding, the nurse includes in her health teaching about the resumption of fertility, contraception and sexual activity. Which of the following statement indicates that the mother has understood the teaching?
A
“Because breastfeeding speeds the healing process after birth, I can have sex right away and not worry about infection”
B
“Because I am breastfeeding and my hormones are decreased, I may need to use a vaginal lubricant when I have sex”
C
“Breastfeeding protects me from pregnancy because it keeps my hormones down, so I don’t need any contraception until I stop breastfeeding”
D
“After birth, you have to have a period before you can get pregnant again’
Question 38 Explanation:
Prolactin suppresses estrogen, which is needed to stimulate vaginal lubrication during arousal.
Question 39
The health nurse is conducting health teaching about “safe” sex to a group of high school students. Which of the following statement about the use of condoms should the nurse avoid making?
A
“Condoms should be used even if you have recently tested negative for HIV”
B
“Condoms should be used every time you have sex because condoms prevent all forms of sexually transmitted diseases”
C
“Condoms should be used because they can prevent infection and because they may prevent pregnancy”
D
“Condoms should be used every time you have sex even if you are taking the pill because condoms can prevent the spread of HIV and gonorrhea”
Question 39 Explanation:
Condoms do not prevent ALL forms of sexually transmitted diseases.
Question 40
A 2-year-old client with cystic fibrosis is confined to bed and is not allowed to go to the playroom. Which of the following is an appropriate toy would the nurse select for the child:
A
Musical automobile
B
Arranging stickers in the album
C
Puzzle
D
Pounding board and hammer
Question 40 Explanation:
The autonomous toddler would be frustrated by being confined to be. The pounding board and hammer is developmentally appropriate and an excellent way for the toddler to release frustration.
Question 41
The Department of Health is alarmed that almost 33 million people suffer from food poisoning every year. Salmonella enteritis is responsible for almost 4 million cases of food poisoning. One of the major goals is to promote proper food preparation. The community health nurse is tasks to conduct health teaching about the prevention of food poisoning to a group of mother everyday. The nurse can help identify signs and symptoms of specific organisms to help patients get appropriate treatment. Typical symptoms of salmonella include:
A
Bloody diarrhea
B
Nausea, vomiting and headache
C
Nausea, vomiting and paralysis
D
Diarrhea and abdominal cramps
Question 41 Explanation:
Salmonella organisms cause lower GI symptoms
Question 42
The mother brought her daughter to the health center. The child has head lice. The nurse anticipates that the nursing diagnosis most closely correlated with this is:
A
Fluid volume deficit related to vomiting
B
Altered comfort related to itching
C
Altered body image related to alopecia
D
Diversional activity deficit related to hospitalization
Question 42 Explanation:
Severe itching of the scalp is the classic sign and symptom of head lice in a child. In turn, this would lead to the nursing diagnosis of “altered comfort”.
Question 43
The nurse is caring to a child client who is receiving tetracycline. The nurse is aware that in taking this medication, it is very important to:
A
Monitor the child’s hearing
B
Give the drug through a straw
C
Administer the drug between meals
D
Keep the child out of the sunlight
Question 43 Explanation:
Tetracycline may cause a phototoxic reaction.
Question 44
The mother brought her child to the clinic for follow-up check up. The mother tells the nurse that 14 days after starting an oral iron supplement, her child’s stools are black. Which of the following is the best nursing response to the mother?
A
“This is a normal side effect and means the medication is working”
B
“You sound quite concerned. Would you like to talk about this further?”
C
“I will need a specimen to check the stool for possible bleeding”
D
“I will notify the physician, who will probably decrease the dosage slightly”
Question 44 Explanation:
When oral iron preparations are given correctly, the stools normally turn dark green or black. Parents of children receiving this medication should be advised that this side effect indicates the medication is being absorbed and is working well.
Question 45
A 14 day-old infant with a cyanotic heart defects and mild congestive heart failure is brought to the emergency department. During assessment, the nurse checks the apical pulse rate of the infant. The apical pulse rate is 130 beats per minute. Which of the following is the appropriate nursing action?
A
Retake the apical pulse in 15 minutes
B
Administer the medication as scheduled
C
Notify the pediatrician immediately
D
Retake the apical pulse in 30 minutes
Question 45 Explanation:
The normal heart rate of an infant is 120-160 beats per minute.
Question 46
The mother brings a child to the health care clinic because of severe headache and vomiting. During the assessment of the health care nurse, the temperature of the child is 40 degree Celsius, and the nurse notes the presence of nuchal rigidity. The nurse is suspecting that the child might be suffering from bacterial meningitis. The nurse continues to assess the child for the presence of Kernig’s sign. Which finding would indicate the presence of this sign?
A
Calf pain when the foot is dorsiflexed
B
Inability of the child to extend the legs fully when lying supine
C
Pain when the chin is pulled down to the chest
D
Flexion of the hips when the neck is flexed from a lying position
Question 46 Explanation:
Kernig’s sign is the inability of the child to extend the legs fully when lying supine. This sign is frequently present in bacterial meningitis. Nuchal rigidity is also present in bacterial meningitis and occurs when pain prevents the child from touching the chin to the chest.
Question 47
The nurse in the health center is providing immunization to the children. The nurse is carefully assessing the condition of the children before giving the vaccines. Which of the following would the nurse note to withhold the infant’s scheduled immunizations?
A
a dry cough
B
a skin rash
C
a low-grade fever
D
a runny nose
Question 47 Explanation:
A skin rash could indicate a concurrent infectious disease process in the infant. The scheduled immunizations should be withheld until the status of the infant’s health can be determined. Fevers above 38.5 degrees Celsius, alteration in skin integrity, and infectious-appearing secretions are indications to withhold immunizations.
Question 48
The physician prescribed gentamicin (Garamycin) to a child who is also receiving chemotherapy. Before administering the drug, the nurse should check the results of the child’s:
A
Auditory tests
B
Renal Function tests
C
CBC and platelet count
D
Abdominal and chest x-rays
Question 48 Explanation:
Both gentamicin and chemotherapeutic agents can cause renal impairment and acute renal failure; thus baseline renal function must be evaluated before initiating either medication.
Question 49
Which of the following would be the best divesionary activity for the nurse to select for a 2 weeks hospitalized 3-year-old girl?
A
Crayons and coloring books
B
puzzles
C
doll
D
xylophone toy
Question 49 Explanation:
The best diversion for a hospitalized child aged 2-3 years old would be anything that makes noise or makes a mess; xylophone which certainly makes noise or music would be the best choice.
Question 50
The nurse is providing health teaching about the breastfeeding and family planning to the client who gave birth to a healthy baby girl. Which of the following statement would alert the nurse that the client needs further teaching?
A
“I can get pregnant as early as one month after my baby was born”
B
“I understand that the hormones for breastfeeding may affect when my periods come”
C
“I may not have periods while I am breastfeeding, so I don’t need family planning”
D
“Breastfeeding causes my womb to tighten and bleed less after birth”
Question 50 Explanation:
It is common misconception that breastfeeding may prevent pregnancy.
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Text Mode – Text version of the exam
The scope of this Nursing Test II is parallel to the NP2 NLE Coverage:
Maternal and Child Health
Community Health Nursing
Communicable Diseases
Integrated Management of Childhood Illness
1. The student nurse is assigned to take the vital signs of the clients in the pediatric ward. The student nurse reports to the staff nurse that the parent of a toddler who is 2 days postoperative after a cleft palate repair has given the toddler a pacifier. What would be the best immediate action of the nurse?
Notify the pediatrician of this finding
Reassure the student that this is an acceptable action on the parent’s part
Discuss this action with the parents
Ask the student nurse to remove the pacifier from the toddler’s mouth
2. The nurse is providing a health teaching to the mother of an 8-year-old child with cystic fibrosis. Which of the following statement if made by the mother would indicate to the nurse the need for further teaching about the medication regimen of the child?
“My child might need an extra capsule if the meal is high in fat”
“I’ll give the enzyme capsule before every snack”
“I’ll give the enzyme capsule before every meal”
“My child hates to take pills, so I’ll mix the capsule into a cup of hot chocolate
3. The mother brought her child to the clinic for follow-up check up. The mother tells the nurse that 14 days after starting an oral iron supplement, her child’s stools are black. Which of the following is the best nursing response to the mother?
“I will notify the physician, who will probably decrease the dosage slightly”
“This is a normal side effect and means the medication is working”
“You sound quite concerned. Would you like to talk about this further?”
“I will need a specimen to check the stool for possible bleeding”
4. An 8-year-old boy with asthma is brought to the clinic for check up. The mother asks the nurse if the treatment given to her son is effective. What would be the appropriate response of the nurse?
I will review first the child’s height on a growth chart to know if the treatment is working
I will review first the child’s weight on a growth chart to know if the treatment is working
I will review first the number of prescriptions refills the child has required over the last 6 months to give you an accurate answer
I will review first the number of times the child has seen the pediatrician during the last 6 months to give you an accurate answer
5. The nurse is caring to a child client who is receiving tetracycline. The nurse is aware that in taking this medication, it is very important to:
Administer the drug between meals
Monitor the child’s hearing
Give the drug through a straw
Keep the child out of the sunlight
6. A 14 day-old infant with a cyanotic heart defects and mild congestive heart failure is brought to the emergency department. During assessment, the nurse checks the apical pulse rate of the infant. The apical pulse rate is 130 beats per minute. Which of the following is the appropriate nursing action?
Retake the apical pulse in 15 minutes
Retake the apical pulse in 30 minutes
Notify the pediatrician immediately
Administer the medication as scheduled
7. The physician prescribed gentamicin (Garamycin) to a child who is also receiving chemotherapy. Before administering the drug, the nurse should check the results of the child’s:
CBC and platelet count
Auditory tests
Renal Function tests
Abdominal and chest x-rays
8. Which of the following is the suited size of the needle would the nurse select to administer the IM injection to a preschool child?
18 G, 1-1/2 inch
25 G, 5/8 inch
21 G, 1 inch
18 G, 1inch
9. A 9-year-old boy is admitted to the hospital. The boy is being treated with salicylates for the migratory polyarthritis accompanying the diagnosis of rheumatic fever. Which of the following activities performed by the child would give a best sign that the medication is effective?
Listening to story of his mother
Listening to the music in the radio
Playing mini piano
Watching movie in the dvd mini player
10. The physician decided to schedule the 4-year-old client for repair of left undescended testicle. The Injection of a hormone, HCG finds it less successful for treatment. To administer a pentobarbital sodium (Nembutal) suppository preoperatively to this client, in which position should the nurse place him?
Supine with foot of bed elevated
Prone with legs abducted
Sitting with foot of bed elevated
Side-lying with upper leg flexed
11. The nurse is caring to a 24-month-old child diagnosed with congenital heart defect. The physician prescribed digoxin (Lanoxin) to the client. Before the administration of the drug, the nurse checks the apical pulse rate to be 110 beats per minute and regular. What would be the next nursing action?
Check the other vital signs and level of consciousness
Withhold the digoxin and notify the physician
Give the digoxin as prescribed
Check the apical and radial simultaneously, and if they are the same, give the digoxin.
12. An 8-year-old client with cystic fibrosis is admitted to the hospital and will undergo a chest physiotherapy treatment. The therapy should be properly coordinated by the nurse with the respiratory therapy department so that treatments occur during:
After meals
Between meals
After medication
Around the child’s play schedule
13. The nurse is providing health teaching about the breastfeeding and family planning to the client who gave birth to a healthy baby girl. Which of the following statement would alert the nurse that the client needs further teaching?
“I understand that the hormones for breastfeeding may affect when my periods come”
“Breastfeeding causes my womb to tighten and bleed less after birth”
“I may not have periods while I am breastfeeding, so I don’t need family planning”
“I can get pregnant as early as one month after my baby was born”
14. A toddler is brought to the hospital because of severe diarrhea and vomiting. The nurse assigned to the client enters the client’s room and finds out that the client is using a soiled blanket brought in from home. The nurse attempts to remove the blanket and replace it with a new and clean blanket. The toddler refuses to give the soiled blanket. The nurse realizes that the best explanation for the toddler’s behavior is:
The toddler did not bond well with the maternal figure
The blanket is an important transitional object
The toddler is anxious about the hospital experience
The toddler is resistive to nursing interventions
15. The nurse has knowledge about the developmental task of the child. In caring a 3-year-old-client, the nurse knows that the suited developmental task of this child is to:
Learn to play with other children
Able to trust others
Express all needs through speaking
Explore and manipulate the environment
16. A mother who gave birth to her second daughter is so concerned about her 2-year old daughter. She tells the nurse, “I am afraid that my 2-year-old daughter may not accept her newly born sister”. It is appropriate to the nurse to response that:
The older daughter be given more responsibility and assure her “that she is a big girl now, and doesn’t need Mommy as much”
The older daughter not have interaction with the baby at the hospital, because she may harm her new sibling
The older daughter stay with her grandmother for a few days until the parents and new baby are settled at home
The mother spend time alone with her older daughter when the baby is sleeping
17. A 2-year-old client with cystic fibrosis is confined to bed and is not allowed to go to the playroom. Which of the following is an appropriate toy would the nurse select for the child:
Puzzle
Musical automobile
Arranging stickers in the album
Pounding board and hammer
18. Which of the following clients is at high risk for developmental problem?
A toddler with acute Glomerulonephritis on antihypertensive and antibiotics
A 5-year-old with asthma on cromolyn sodium
A preschooler with tonsillitis
A 2 1/2 –year old boy with cystic fibrosis
19. Which of the following would be the best divesionary activity for the nurse to select for a 2 weeks hospitalized 3-year-old girl?
Crayons and coloring books
doll
xylophone toy
puzzles
20. A nurse is providing safety instructions to the parents of the 11-month-old child. Which of the following will the nurse includes in the instructions?
Plugging all electrical outlets in the house
Installing a gate at the top and bottom of any stairs in the home
Purchasing an infant car seat as soon as possible
Begin to teach the child not to place small objects in the mouth
21. An 8-year-old girl is in second grade and the parents decided to enroll her to a new school. While the child is focusing on adjusting to new environment and peers, her grades suffer. The child’s father severely punishes the child and forces her daughter to study after school. The father does not allow also her daughter to play with other children. These data indicate to the nurse that this child is deprived of forming which normal phase of development?
Heterosexual relationships
A love relationship with the father
A dependency relationship with the father
Close relationship with peers
22. A 5-year-old boy client is scheduled for hernia surgery. The nurse is preparing to do preoperative teaching with the child. The nurse should knows that the 5-year-old would:
Expect a simple yet logical explanation regarding the surgery
Asks many questions regarding the condition and the procedure
Worry over the impending surgery
Be uninterested in the upcoming surgery
23. The nine-year-old client is admitted in the hospital for almost 1 week and is on bed rest. The child complains of being bored and it seems tiresome to stay on bed and doing nothing. What activity selected by the nurse would the child most likely find stimulating?
Watching a video
Putting together a puzzle
Assembling handouts with the nurse for an upcoming staff development meeting
Listening to a compact disc
24. The parent of a 16-year-old boy tells the nurse that his son is driving a motorbike very fast and with one hand. “It is making me crazy!” What would be the best explanation of the nurse to the behavior of the boy?
The adolescent might have an unconscious death wish
The adolescent feels indestructible
The adolescent lacks life experience to realize how dangerous the behavior is
The adolescent has found a way to act out hostility toward the parent
25. An 8-month-old infant is admitted to the hospital due to diarrhea. The nurse caring for the client tells the mother to stay beside the infant while making assessment. Which of the following developmental milestones the infant has reached?
Has a three-word vocabulary
Interacts with other infants
Stands alone
Recognizes but is fearful of strangers
26. The community nurse is conducting a health teaching in the group of married women. When teaching a woman about fertility awareness, the nurse should emphasize that the basal body temperature:
Should be recorded each morning before any activity
Is the average temperature taken each morning
Can be done with a mercury thermometer but not a digital one
Has a lower degree of accuracy in predicting ovulation than the cervical mucus test
27. The community nurse is providing an instruction to the clients in the health center about the use of diaphragm for family planning. To evaluate the understanding of the woman, the nurse asks her to demonstrate the use of the diaphragm. Which of following statement indicates a need for further health teaching?
“I should check the diaphragm carefully for holes every time I use it.”
“The diaphragm must be left in place for at least 6 hours after intercourse.”
“I really need to use the diaphragm and jelly most during the middle of my menstrual cycle
“I may need a different size diaphragm if I gain or lose more than 20 pounds”
28. The client visits the clinic for prenatal check-up. While waiting for the physician, the nurse decided to conduct health teaching to the client. The nurse informed the client that primigravida mother should go to the hospital when which patter is evident?
Contractions are 2-3 minutes apart, lasting 90 seconds, and membranes have ruptured
Contractions are 5-10 minutes apart, lasting 30 seconds, and are felt as strong menstrual cramps
Contractions are 3-5 minutes apart, accompanied by rectal pressure and bloody show
Contractions are 5 minutes apart, lasting 60 seconds, and increasing in intensity
29. A nurse is planning a home visit program to a new mother who is 2 weeks postpartum and breastfeeding, the nurse includes in her health teaching about the resumption of fertility, contraception and sexual activity. Which of the following statement indicates that the mother has understood the teaching?
“Because breastfeeding speeds the healing process after birth, I can have sex right away and not worry about infection”
“Because I am breastfeeding and my hormones are decreased, I may need to use a vaginal lubricant when I have sex”
“After birth, you have to have a period before you can get pregnant again’
“Breastfeeding protects me from pregnancy because it keeps my hormones down, so I don’t need any contraception until I stop breastfeeding”
30. A community nurse enters the home of the client for follow-up visit. Which of the following is the most appropriate area to place the nursing bag of the nurse when conducting a home visit?
cushioned footstool
bedside wood table
kitchen countertop
living room sofa
31. The nurse in the health center is making an assessment to the infant client. The nurse notes some rashes and small fluid-filled bumps in the skin. The nurse suspects that the infant has eczema. Which of the following is the most important nursing goal:
Preventing infection
Providing for adequate nutrition
Decreasing the itching
Maintaining the comfort level
32. The nurse in the health center is providing immunization to the children. The nurse is carefully assessing the condition of the children before giving the vaccines. Which of the following would the nurse note to withhold the infant’s scheduled immunizations?
a dry cough
a skin rash
a low-grade fever
a runny nose
33. A mother brought her child in the health center for hepatitis B vaccination in a series. The mother informs the nurse that the child missed an appointment last month to have the third hepatitis B vaccination. Which of the following statements is the appropriate nursing response to the mother?
“I will examine the child for symptoms of hepatitis B”
“Your child will start the series again”
“Your child will get the next dose as soon as possible”
“Your child will have a hepatitis titer done to determine if immunization has taken place.”
34. The community health nurse implemented a new program about effective breast cancer screening technique for the female personnel of the health department of Valenzuela. Which of the following technique should the nurse consider to be of the lowest priority?
Yearly breast exam by a trained professional
Detailed health history to identify women at risk
Screening mammogram every year for women over age 50
Screening mammogram every 1-2 years for women over age of 40.
35. Which of the following technique is considered an aseptic practice during the home visit of the community health nurse?
Wrapping used dressing in a plastic bag before placing them in the nursing bag
Washing hands before removing equipment from the nursing bag
Using the client’s soap and cloth towel for hand washing
Placing the contaminated needles and syringes in a labeled container inside the nursing bag
36. The nurse is planning to conduct a home visit in a small community. Which of the following is the most important factor when planning the best time for a home care visit?
Purpose of the home visit
Preference of the patient’s family
Location of the patient’s home
Length of time of the visit will take
37. The nurse assigned in the health center is counseling a 30-year-old client requesting oral contraceptives. The client tells the nurse that she has an active yeast infection that has recurred several times in the past year. Which statement by the nurse is inaccurate concerning health promotion actions to prevent recurring yeast infection?
“During treatment for yeast, avoid vaginal intercourse for one week”
“Wear loose-fitting cotton underwear”
“Avoid eating large amounts of sugar or sugar-bingeing”
“Douche once a day with a mild vinegar and water solution”
38. During immunization week in the health center, the parent of a 6-month-old infant asks the health nurse, “Why is our baby going to receive so many immunizations over a long time period?” The best nursing response would be:
“The number of immunizations your baby will receive shows how many pediatric communicable and infectious diseases can now be prevented.”
“You need to ask the physician”
“The number of immunizations your baby will receive is determined by your baby’s health history and age”
“It is easier on your baby to receive several immunizations rather than one at a time”
39. The community health nurse is conducting a health teaching about nutrition to a group of pregnant women who are anemic and are lactose intolerant. Which of the following foods should the nurse especially encourage during the third trimester?
Cheese, yogurt, and fish for protein and calcium needs plus prenatal vitamins and iron supplements
Prenatal iron and calcium supplements plus a regular adult diet
Red beans, green leafy vegetables, and fish for iron and calcium needs plus prenatal vitamins and iron supplements
Red meat, milk and eggs for iron and calcium needs plus prenatal vitamins and iron supplements
40. A woman with active tuberculosis (TB) and has visited the health center for regular therapy for five months wants to become pregnant. The nurse knows that further information is necessary when the woman states:
“Spontaneous abortion may occur in one out of five women who are infected”
“Pulmonary TB may jeopardize my pregnancy”
“I know that I may not be able to have close contact with my baby until contagious is no longer a problem
“I can get pregnant after I have been free of TB for 6 months”
41. The Department of Health is alarmed that almost 33 million people suffer from food poisoning every year. Salmonella enteritis is responsible for almost 4 million cases of food poisoning. One of the major goals is to promote proper food preparation. The community health nurse is tasks to conduct health teaching about the prevention of food poisoning to a group of mother everyday. The nurse can help identify signs and symptoms of specific organisms to help patients get appropriate treatment. Typical symptoms of salmonella include:
Nausea, vomiting and paralysis
Bloody diarrhea
Diarrhea and abdominal cramps
Nausea, vomiting and headache
42. A community health nurse makes a home visit to an elderly person living alone in a small house. Which of the following observation would be a great concern?
Big mirror in a wall
Scattered and unwashed dishes in the sink
Shiny floors with scattered rugs
Brightly lit rooms
43. The health nurse is conducting health teaching about “safe” sex to a group of high school students. Which of the following statement about the use of condoms should the nurse avoid making?
“Condoms should be used because they can prevent infection and because they may prevent pregnancy”
“Condoms should be used even if you have recently tested negative for HIV”
“Condoms should be used every time you have sex because condoms prevent all forms of sexually transmitted diseases”
“Condoms should be used every time you have sex even if you are taking the pill because condoms can prevent the spread of HIV and gonorrhea”
44. The department of health is promoting the breastfeeding program to all newly mothers. The nurse is formulating a plan of care to a woman who gave birth to a baby girl. The nursing care plan for a breast-feeding mother takes into account that breast-feeding is contraindicated when the woman:
Is pregnant
Has genital herpes infection
Develops mastitis
Has inverted nipples
45. The City health department conducted a medical mission in Barangay Marulas. Majority of the children in the Barangay Marulas were diagnosed with pinworms. The community health nurse should anticipate that the children’s chief complaint would be:
Lack of appetite
Severe itching of the scalp
Perianal itching
Severe abdominal pain
46. The mother brought her daughter to the health center. The child has head lice. The nurse anticipates that the nursing diagnosis most closely correlated with this is:
Fluid volume deficit related to vomiting
Altered body image related to alopecia
Altered comfort related to itching
Diversional activity deficit related to hospitalization
47. The mother brings a child to the health care clinic because of severe headache and vomiting. During the assessment of the health care nurse, the temperature of the child is 40 degree Celsius, and the nurse notes the presence of nuchal rigidity. The nurse is suspecting that the child might be suffering from bacterial meningitis. The nurse continues to assess the child for the presence of Kernig’s sign. Which finding would indicate the presence of this sign?
Flexion of the hips when the neck is flexed from a lying position
Calf pain when the foot is dorsiflexed
Inability of the child to extend the legs fully when lying supine
Pain when the chin is pulled down to the chest
48. A community health nurse makes a home visit to a child with an infectious and communicable disease. In planning care for the child, the nurse must determine that the primary goal is that the:
Child will experience mild discomfort
Child will experience only minor complications
Child will not spread the infection to others
Public health department will be notified
49. The mother brings her daughter to the health care clinic. The child was diagnosed with conjunctivitis. The nurse provides health teaching to the mother about the proper care of her daughter while at home. Which statement by the mother indicates a need for additional information?
“I do not need to be concerned about the spreading of this infection to others in my family”
“I should apply warm compresses before instilling antibiotic drops if purulent discharge is present in my daughter’s eye”
“I can use an ophthalmic analgesic ointment at nighttime if I have eye discomfort”
“I should perform a saline eye irrigation before instilling, the antibiotic drops into my daughter’s eye if purulent discharge is present”
50. A community health nurse is caring for a group of flood victims in Marikina area. In planning for the potential needs of this group, which is the most immediate concern?
Finding affordable housing for the group
Peer support through structured groups
Setting up a 24-hour crisis center and hotline
Meeting the basic needs to ensure that adequate food, shelter and clothing are available
Answers and Rationales
C. Nothing must be placed in the mouth of a toddler who just undergone a cleft palate repair until the suture line has completely healed. It is the nurse’s responsibility to inform the parent of the client. Spoon, forks, straws, and tongue blades are other unacceptable items to place in the mouth of a toddler who just undergone cleft palate repair. The general principle of care is that nothing should enter the mouth until the suture line has completely healed.
D. The pancreatic capsules contain pancreatic enzyme that should be administered in a cold, not a hot, medium (example: chilled applesauce versus hot chocolate) to maintain the medication’s integrity.
B. When oral iron preparations are given correctly, the stools normally turn dark green or black. Parents of children receiving this medication should be advised that this side effect indicates the medication is being absorbed and is working well.
C. Reviewing the number of prescription refills the child has required over the last 6 months would be the best indicator of how well controlled and thus how effective the child’s asthma treatment is. Breakthrough wheezing, shortness of breath, and upper respiratory infections would require that the child take additional medication. This would be reflected in the number of prescription refills.
D. Tetracycline may cause a phototoxic reaction.
D. The normal heart rate of an infant is 120-160 beats per minute.
C. Both gentamicin and chemotherapeutic agents can cause renal impairment and acute renal failure; thus baseline renal function must be evaluated before initiating either medication.
C. In selecting the correct needle to administer an IM injection to a preschooler, the nurse should always look at the child and use judgment in evaluating muscle mass and amount of subcutaneous fat. In this case, in the absence of further data, the nurse would be most correct in selecting a needle gauge and length appropriate for the “average’ preschool child. A medium-gauge needle (21G) that is 1 inch long would be most appropriate.
C. The purpose of the salicylate therapy is to relieve the pain associated with the migratory polyarthritis accompanying the rheumatic fever. Playing mini piano would require movement of the child’s joints and would provide the nurse with a means of evaluating the child’s level of pain.
D. The recommended position to administer rectal medications to children is side-lying with the upper leg flexed. This position allows the nurse to safely and effectively administer the medication while promoting comfort for the child.
C. For a 12month-old child, 110 apical pulse rate is normal and therefore it is safe to give the digoxin. A toddler’s normal pulse rate is slightly lower than an infant’s (120).
B. Chest physiotherapy treatments are scheduled between meals to prevent aspiration of stomach contents, because the child is placed in a variety of positions during the treatment process.
C. It is common misconception that breastfeeding may prevent pregnancy.
B. The “security blanket” is an important transitional object for the toddler. It provides a feeling of comfort and safety when the maternal figure is not present or when in a new situation for which the toddler was not prepared. Virtually any object (stuffed animal, doll, book etc) can become a security blanket for the toddler.
D. Toddlers need to meet the developmental milestone of autonomy versus shame and doubt. In order to accomplish this, the toddler must be able to explore and manipulate the environment.
D. The introduction of a baby into a family with one or more children challenges parent to promote acceptance of the baby by siblings. The parent’s attitudes toward the arrival of the baby can set the stage for the other children’s reaction. Spending time with the older siblings alone will also reassure them of their place in the family, even though the older children will have to eventually assume new positions within the family hierarchy.
D. The autonomous toddler would be frustrated by being confined to be. The pounding board and hammer is developmentally appropriate and an excellent way for the toddler to release frustration.
D. It is the developmental task of an 18-month-old toddler to explore and learn about the environment. The respiratory complications associated with cystic fibrosis (which are present in almost all children with cystic fibrosis) could prevent this development task from occurring.
C. The best diversion for a hospitalized child aged 2-3 years old would be anything that makes noise or makes a mess; xylophone which certainly makes noise or music would be the best choice.
B. An 11-month-old child stands alone and can walk holding onto people or objects. Therefore the installation of a gate at the top and bottom of any stairs in the house is crucial for the child’s safety.
D. In second grade a child needs to form a close relationships with peers.
B. A 5-year-old is highly concerned with body integrity. The preschool-age child normally asks many questions and in a situation such as this, could be expected to ask even more.
C. A 9-year-old enjoys working and feeling a sense of accomplishment. The school-age child also enjoys “showing off,” and doing something with the nurse on the pediatric unit would allow this. This activity also provides the school-age child a needed opportunity to interact with others in the absence of school and personal friends.
B. Adolescents do feel indestructible, and this is reflected in many risk-taking behaviors.
D. An 8-month-old infant both recognizes and is fearful of strangers. This developmental milestone is known as “stranger anxiety”.
A. The basal body temperature (BBT) is the lowest body temperature of a healthy person that is taken immediately after waking and before getting out of bed. The BBT usually varies from 36.2 – 36.3 degree Celsius during menses and for about 5-7 days afterward. About the time of ovulation, a slight drop approximately 0.05 degree Celsius in temperature may be seen; after ovulation, in concert with the increasing progesterone levels of the early luteal phase, the BBT rises 0.2-0.4 degree Celsius. This elevation remains until 2-3 days before menstruation, or if pregnancy has occurred.
C. The woman must understand that, although the “fertile” period is approximately midcycle, hormonal variations do occur and can result in early or late ovulations. To be effective, the diaphragm should be inserted before every intercourse.
D. Although instructions vary among birth centers, primigravidas should seek care when regular contractions are felt about 5 minutes apart, becoming longer and stronger.
B. Prolactin suppresses estrogen, which is needed to stimulate vaginal lubrication during arousal.
B. A wood surface provides the least chance for organisms to be present.
A. Preventing infection in the infant with eczema is the nurse’s most important goal. The infant with eczema is at high risk for infection due to numerous breaks in the skin’s integrity. Intact skin is always the infant’s first line of defense against infection.
B. A skin rash could indicate a concurrent infectious disease process in the infant. The scheduled immunizations should be withheld until the status of the infant’s health can be determined. Fevers above 38.5 degrees Celsius, alteration in skin integrity, and infectious-appearing secretions are indications to withhold immunizations.
C. Continuity is essential to promote active immunity and give hepatitis B lifelong prophylaxis. Optimally, the third vaccination is given 6 months after the first.
B. Because of the high incidence of breast cancer, all women are considered to be at risk regardless of health history.
B. Handwashing is the best way to prevent the spread of infection.
A. The purpose of the visit takes priority.
D. Frequent douching interferes with the natural protective barriers in the vagina that resist yeast infection and should be avoided.
A. Completion for the recommended schedule of infant immunizations does not require a large number of immunizations, but it also provides protection against multiple pediatric communicable and infectious diseases.
C. This is appropriate foods that are high in iron and calcium but would not affect lactose intolerance.
D. Intervention is needed when the woman thinks that she needs to wait only 6 months after being free of TB before she can get pregnant. She needs to wait 1.5-2years after she is declared to be free of TB before she should attempt pregnancy.
C. Salmonella organisms cause lower GI symptoms
C. It is a safety hazard to have shiny floors and scattered rugs because they can cause falls and rugs should be removed.
C. Condoms do not prevent ALL forms of sexually transmitted diseases.
A. Pregnancy is one contraindication to breast-feeding. Milk secretion is inhibited and the baby’s sucking may stimulate uterine contractions.
C. Perianal itching is the child’s chief complaint associated with the diagnosis of pinworms. The itching, in this instance, is often described as being “intense” in nature. Pinworms infestation usually occurs because the child is in the anus-to-mouth stage of development (child uses the toilet, does not wash hands, places hands and pinworm eggs in mouth). Teaching the child hand washing before eating and after using the toilet can assist in breaking the cycle.
C. Severe itching of the scalp is the classic sign and symptom of head lice in a child. In turn, this would lead to the nursing diagnosis of “altered comfort”.
C. Kernig’s sign is the inability of the child to extend the legs fully when lying supine. This sign is frequently present in bacterial meningitis. Nuchal rigidity is also present in bacterial meningitis and occurs when pain prevents the child from touching the chin to the chest.
C. The primary goal is to prevent the spread of the disease to others. The child should experience no complication. Although the health department may need to be notified at some point, it is no the primary goal. It is also important to prevent discomfort as much as possible.
A. Conjunctivitis is highly contagious. Antibiotic drops are usually administered four times a day. When purulent discharge is present, saline eye irrigations or eye applications of warm compresses may be necessary before instilling the medication. Ophthalmic analgesic ointment or drops may be instilled, especially at bedtime, because discomfort becomes more noticeable when the eyelids are closed.
D. The question asks about the immediate concern. The ABCs of community health care are always attending to people’s basic needs of food, shelter, and clothing