NCLEX PassPoint - PN

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Chapter 32: Metabolic Conditions P...

34 terms murrayb4Preview NUR 102 Exam 3 73 terms McKenzie_Rose10 Preview Toddle 52 terms alex A nurse is reinforcing education with a parent on how to reduce the baby's risk of developing otitis media. Which instruction should the nurse be sure is included in the teaching plan?Administer antibiotics whenever the baby has a cold.Place the baby in an upright position when giving a bottle.Avoid getting the ears wet while bathing or swimming.Clean the external ear canal daily.Place the baby in an upright position when giving a bottle.

Explanation:

Feeding a baby in an upright position reduces the pooling of formula in the nasopharynx. Formula provides a good medium for the growth of bacteria, which can travel easily through the short, horizontal Eustachian tubes. The other interventions do not reduce the risk of a baby developing otitis media.During the first formula feeding, a client has difficulty getting her neonate to take the artificial nipple into his or her mouth. Which of the following actions would enhance latching on to the nipple?Tilt the bottle so that the nipple fills with formula.Stroke the neonate's lips gently with the nipple.Use a nipple with the largest possible opening.Squeeze the baby's lower jaw to open the mouth.Stroke the neonate's lips gently with the nipple.

Explanation:

Stroking the neonate's lips gently with the nipple usually causes the mouth to open wide enough for nipple insertion. Tilting the bottle or pushing the tip of the nipple into the neonate's mouth may cause continued difficulty. Using a nipple with larger openings wouldn't help resolve the problem and may allow too much formula to enter the mouth once the neonate starts to suck. To suck effectively, the neonate needs to compress the entire nipple, not just the tip.A client has a serum calcium level of 7.2 mg/dl. During the

physical examination, the nurse expects to assess:

Trousseau's sign.Homans' sign.Hegar's sign.Goodell's sign Trousseau's sign.

Explanation:

This client's serum calcium level indicates hypocalcemia, an electrolyte imbalance that causes Trousseau's sign (carpopedal spasm induced by inflating the blood pressure cuff above systolic pressure). Homans' sign (pain on dorsiflexion of the foot) indicates deep vein thrombosis. Hegar's sign (softening of the uterine isthmus) and Goodell's sign (cervical softening) are probable signs of pregnancy.

A nurse obtaining data from a client observes jugular vein distention (JVD). Which condition does the nurse suspect this client to have?abdominal aortic aneurysm heart failure myocardial infarction (MI) deep vein thrombosis heart failure

Explanation:

Elevated venous pressure, exhibited as JVD, indicates the heart's failure to pump.JVD is not a sign of abdominal aortic aneurysm or deep vein thrombosis. An MI, if severe enough, can progress to heart failure; however, in and of itself, an MI does not cause JVD.A client exhibits signs of dementia. Which condition, that can cause a dementia similar to Alzheimer's disease (AD), is reversible?multiple sclerosis electrolyte imbalance multiple small brain infarctions human immunodeficiency virus infection (HIV) electrolyte imbalance

Explanation:

Electrolyte imbalance is a correctable metabolic abnormality that may present with dementia type symptomology. Multiple sclerosis presents with neuromuscular changes, not dementia. Small brain infarctions do not present with dementia-like symptoms. HIV does not present with dementia.A client comes to the emergency department complaining of sudden onset of sharp, severe pain in the lumbar region, which radiates around the side and toward the bladder. The client also reports nausea and vomiting and appears pale, diaphoretic, and anxious. The physician tentatively diagnoses renal calculi and orders flat-plate abdominal X-rays. Renal calculi can form anywhere in the urinary tract. The nursing instructor asks the student where is the common formation site? How should the student reply?"The most common renal calculi formation site is the kidney." "The most common renal calculi formation site is the ureter." "The most common renal calculi formation site is the bladder." "The most common renal calculi formation site is the urethra." "The most common renal calculi formation site is the kidney."

Explanation:

The most common site of renal calculi formation is the kidney. Calculi may travel down the urinary tract with or without causing damage and may lodge anywhere along the tract or may stay within the kidney. The ureter, bladder, and urethra are less common sites of renal calculi formation.Which therapeutic strategy is used to reduce anxiety in a client diagnosed with illness anxiety disorder?suicide precautions relaxation exercises electroconvulsive therapy pharmacological intervention relaxation exercises

Explanation:

A nurse can initiate relaxation exercises to decrease anxiety without an order from the physician. In illness anxiety disorder, there is a very low risk of suicide. Medical intervention would include electroconvulsive therapy and pharmacological intervention.A 3-year-old child has a positive culture for streptococcus organisms. Which intervention is most appropriate?Give the client aspirin.Give the client antibiotics.Give the client corticosteroids.Encourage fluid intake.Give the client antibiotics.

Explanation:

Infection caused by streptococcus organisms is treated with antibiotics, mainly penicillin. Antipyretics, such as acetaminophen, may be given for fever. Aspirin isn't recommended. Corticosteroids are not indicated. Fluid intake is encouraged to prevent dehydration from decreased oral intake due to a sore throat or to replace fluids lost due to possible diarrhea from the antibiotics.

An anxious client is brought to the walk in clinic with difficulty breathing following a bee sting. Which of the following is the nurse's priority action?assist the client to lie down monitor the client's airway administer 100% oxygen via mask assess the site to remove the stinger monitor the client's airway

Explanation:

The initial priority action with any client having difficulty breathing is to assess and maintain the airway. All other actions may be completed following the assessment of the airway.The nurse is collecting data on a 6-year old child. The child reports dysuria and urgency. The parent reports that the child has recently had some enuresis. The nurse recognizes these as signs and symptoms of which condition?nephrotic syndrome urinary tract infection acute glomerulonephritis obstructive uropathy urinary tract infection

Explanation:

Frequency and urgency can lead to enuresis. All are symptoms of urinary tract infection.A client's blood glucose level is 45 mg/dl. The nurse should be alert for which signs and symptoms?Coma, anxiety, confusion, headache, and cool, moist skin Kussmaul's respirations, dry skin, hypotension, and bradycardia Polyuria, polydipsia, polyphagia, and weight loss Polyuria, polydipsia, hypotension, and hypernatremia Coma, anxiety, confusion, headache, and cool, moist skin

Explanation:

Signs and symptoms of hypoglycemia include anxiety, restlessness, headache, irritability, confusion, diaphoresis, cool skin, tremors, coma, and seizures.Kussmaul's respirations, dry skin, hypotension, and bradycardia are signs of diabetic ketoacidosis. Excessive thirst, hunger, hypotension, and hypernatremia are symptoms of diabetes insipidus. Polyuria, polydipsia, polyphagia, and weight loss are classic signs and symptoms of diabetes mellitus.A nurse is reinforce educating the parents of a 5-year-old child admitted to the pediatric unit with cystic fibrosis.Which statement concerning steatorrheaic stools is most accurate?They're frothy, foul-smelling, and fatty.They're clay-colored.They're orange or green.They're black and tarry.They're frothy, foul-smelling, and fatty.

Explanation:

Children with cystic fibrosis have an abnormal electrolyte transport system in the cells that eventually blocks the pancreas, preventing the secretion of enzymes that digest certain foods such as protein and fats. This results in foul-smelling, fatty stool. Black, tarry stool is observed in clients who have upper GI bleeding, are on iron medications, or who consume diets high in red meat and dark-green vegetables. Clay-colored stool indicates possible bile obstruction. Orange or green stool may indicate intestinal infection.The nurse caring for an infant with pyloric stenosis should be alert for which classic sign or symptom?chronic diarrhea excessive drooling loss of appetite projectile vomiting projectile vomiting

Explanation:

The obstruction seen in pyloric stenosis doesn't allow food to pass through to the duodenum. The classic sign of projectile vomiting occurs when the stomach becomes full, and the infant vomits for relief. Drooling would not be a finding in a child with pyloric stenosis but rather in a child with tracheoesophageal fistula.Chronic hunger is commonly seen. There's no diarrhea because food doesn't pass the stomach.

A nurse is caring for a client who recently underwent a total hip replacement. The client is progressing well and expects to be discharged the following day. When returning to bed after ambulating, the client reports severe pain in the surgical wound. Which action should the nurse take?Assume the client anxious about being discharged, and administer pain medication.Suspect a wound infection, and monitor the client's temperature and vital signs.Inspect the surgical site and affected extremity.Reassure the client that pain is a direct result of increased activity.Inspect the surgical site and affected extremity.

Explanation:

Worsening pain after a total hip replacement may indicate dislocation of the prosthesis. Evaluation of pain should include inspection of the wound and the affected extremity. Assuming that the client is anxious about discharge and administering pain medication does not locate the cause of the pain. Sudden severe pain is not normal after hip replacement. Wound infections are usually distinguished by purulent drainage.The nurse is caring for a child with a diagnosis of croup.What advice should the nurse give to the parent when concern is expressed about the child waking at night due to the cough?Hold child in the bathroom with a hot shower running, allowing steam to fill room.Call 911 for assistance.Administer another dose of medication.Immediately take the child to an ambulatory care center.Hold child in the bathroom with a hot shower running, allowing steam to fill room.

Explanation:

Steam from the shower will decrease laryngeal spasms, so taking the child to the bathroom and turning on a hot shower should help. It is not necessary to call 911 each time a child has a coughing episode with croup. Driving the child to a patient care center would be dangerous if something more serious happened on the way.If the child is coughing he would not be able to do a breathing treatment successfully.The nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. When describing a healthy stoma, which statement should the nurse be sure to include?"The stoma should appear dark and have a bluish hue." "At first, the stoma may bleed slightly when touched." "A burning sensation under the stoma faceplate is normal." "The stoma should remain swollen distal to the abdomen." "At first, the stoma may bleed slightly when touched."

Explanation:

For the first few days to a week after a client receives a colostomy, slight bleeding normally occurs when the stoma is touched because the surgical site is still fresh.However, profuse bleeding should be reported immediately. A dark stoma with a bluish hue indicates impaired circulation; a normal stoma should appear red, similar to the buccal mucosa. Swelling should decrease in 6 weeks, leaving a stoma that protrudes slightly from the abdomen; continued swelling suggests a blockage. A burning sensation under the faceplate is abnormal and indicates skin breakdown.The nurse is caring for an 18-month-old child admitted to the pediatric unit with a diagnosis of celiac disease.Which finding would the nurse expect to observe in this child?bulges in the groin area a protuberant abdomen a palpable abdominal mass a concave abdomen a protuberant abdomen

Explanation:

A child with celiac disease would have a protuberant abdomen due to the presence of fat, bulky stools, undigested food, and flatus. A concave abdomen, bulges in the groin area, and a palpable abdominal mass are not associated with celiac disease.During a senior citizen health screening, the nurse observes a 75-year-old female with a severely increased thoracic curve, or "humpback". What is this condition called?Scoliosis Kyphosis Genus varum Lordosis Kyphosis

Explanation:

Kyphosis refers to an increased thoracic curvature of the spine, or "humpback." Lordosis is an increase in the lumbar curve or swayback. Scoliosis is a lateral deformity of the spine. Genus varum is a bow-legged appearance of the legs.