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CPNRE MOSBY 3 EXAM WITH COMPLETE SOLUTIONS
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Developmentally, a gross motor skill the nurse should expect a 3-year-old to perform is: a. Riding alone on a small bicycle b. Skipping and hopping on alternate feet c. Standing on one foot for a few seconds d. Jumping rope by lifting both feet simultaneously c. Standing on one foot for a few seconds
At 36 months (3 years) a Gross Motor skill that can be accomplished by this age group is balancing on one foot; jumps in place; pedals tricycles knowledge ----You will be asked quite a few questions re: growth and development of a normal infant, toddler, child
Which of the following responses by the nurse would be most helpful in establishing a trusting relationship with a patient? a. Begin with interaction with sensitive topics to get them out of the way quickly b. Discuss the medications the patient has been taking at home c. Encourage the patient to talk about his concerns d. Reassure the patient that the staff is very competent. c. Encourage the patient to talk about his concerns Before interacting, discussing or reassuring, a relationship built on trust must be established.
What should the PN do initially when a client with a urinary catheter reports lower
abdominal and perineal discomfort?
- Report to the nurse-in-charge immediately
- Check for patency of the drainage system
- Reposition the client and irrigate the catheter
- Obtain a urine specimen for analysis
- Check for patency of the drainage system : improperly positioned drainage system or any kinks in the tubing that prevent drainage will cause discomfort Assessment is first priority
Alyson Hope, mother of five-month-old Isabelle asks the nurse when Isabelle will be able to pull herself to a standing position. What should the nurse tell her? a. "It should be any time now." b. "Infants generally pull themselves up onto furniture at about six to seven months." c. "Isabelle will probably stand holding onto a table by about eight to nine months." d. I don't think you should expect Isabelle to stand until about 11 to 12 months."
c. "Isabelle will probably stand holding onto a table by about eight to nine months."
The nurse has been working in palliative care for several years and is surprised when he feels tremendous sadness at Mrs. Haliburton's death. What should the nurse initially do to cope with these emotions? a. Examine his patterns of dealing with grief b. Arrange for time off or a vacation c. Reflect on the need to change to another specialty in nursing d. Make an appointment with a psychiatrist who specializes in palliative care a. Examine his patterns of dealing with grief The nurse's initial action should be to reflect on the coping mechanisms for grief and
Clients with AIDS are at special risk for fungal and protozoan infections primarily because of the : a. Autoimmune nature of the disease b. Destruction of T4 cells by the AIDS virus c. High risk sexual behaviours and practices d. Invasion of the vital organs by the AIDS virus b. Destruction of T4 cells by the AIDS virus This is the manner in which the AIDS virus interferes with the individual's immunity to other infections. Option d-is not related to opportunistic infections that result from immune deficiency caused by HIV infection. Knowledge
low Apgar score at 5 minutes after birth correlates with the occurrence of: a. Cerebral palsy b. Genetic defects c. Mental retardation d. Neonatal mobidity d. Neonatal mobidity Application: Here is an example of an Apgar score taken at 1 minute and 5 minutes. There should be improvement from one to the other. A score of 0-3 is critical, 4-6 fairly low, 7-10 normal
The physician orders daily sputum specimens to be collected from a client. It is most appropriate for the nurse to collect this specimen from the client: a. After activity b. Before meals c. On awakening
d. Before a respiratory treatment c. On awakening Best practice recommends obtaining sputum specimens upon awakening. Knowledge
A client has a total hip arthroplasty. After surgery the nurse should: a. Log roll the client when turning b. Elevate the affected limb on a pillow c. Place a trochanter roll along the entire extremity d. Keep an abduction pillow between the legs at all times. d. Keep an abduction pillow between the legs at all times. Nurse cannot adduct as this may cause the hip to fracture, or head of femur to pop out of the acetabulum. Extremities must be kept abducted!!! ie. Abduction pillow Application
A patient is receiving fluid boluses to treat hypovolemic shock. For which of the following assessment findings should the nurse stop the fluid boluses and notify the physician? a. Tachycardia and hypotension b. Crackles throughout the lung fields c. Increased oxygen saturation percentages d. Peripheral cyanosis b. Crackles throughout the lung fields Application: Since the patient is receiving fluid boluses, there is a concern for overhydration "fluid volume excess." These fluid boluses are usually administered at high rates, so it is important for the nurse to monitor the client's response to the therapy. Strict I and O's, daily weights. A, C and D would not be an outcome or result from fluid replacement therapy.
Individual feels there are no solutions to their problems. Knowledge
An approach that would be most therapeutic in dealing with a client with a major depression shortly after admission to the hospital would be: a. Setting up a routine of therapy sessions b. Introducing the client to one other client on the unit c. Encouraging interaction with others in small groups d. Employing an attitude of concern that is not intrusive d. Employing an attitude of concern that is not intrusive This approach allows the client to control the pace of development of the nurse-client relationship. Application
A hospitalized client comments to the nurse, "Well I guess my sex life is over." The most appropriate response by the nurse would be: a. "I am sorry to hear that." b. "Why do you say that?" c. "Oh, you have a lot of good years left." d. "Have you asked your doctor about that?" b. "Why do you say that?" Option d -passes the responsibility over and blocks any further communication.Option a demonstrates the nurse is agreeing with the response that may not be true. Option c is a cliché statement.Application
Three days after surgery for cancer of the colon, the client is able to look at the colostomy. The nurse introduces care of the colostomy. The nurse should teach the client to care for the skin around the stoma by: a. Applying liberal amounts of Vaseline for 3 inches around the stoma
b. Rinsing the area with peroxide and applying fresh gauze bandages c. Washing with soap and water and then applying a protective ointment or paste d. Pouring saline over the stoma and rubbing vigorously to remove hard fecal matter. c. Washing with soap and water and then applying a protective ointment or paste Best practice for cleansing of stoma.The other options are incorrect.Application
A young child is to receive a liquid iron preparation. The nurse should teach the mother to: a. Administer this at least an hour before meals b. Explain that loose stools are common with iron c. Have the child take the diluted iron preparation through a straw. d. Avoid giving the child orange or other citric juices with the iron preparation. c. Have the child take the diluted iron preparation through a straw. Liquid preparation of iron stains the teeth, therefore, dilute and drink through straw. Option d-vitamin C enhances absorption of iron. Application
Preoperative teaching for a client who is to have cataract surgery should include the importance of: a. Remaining in bed for 6 hours b. Breathing and coughing deeply c. Avoiding bending from the waist d. Lying in the supine position for 3 hours c. Avoiding bending from the waist Any bending, heavy lifting, pushing or pulling will cause an increase in intraocular pressure, therefore, routine post-op instructions should include this. Knowledge
d. The admitting office should not have put a client with a history of combativeness in a two-bedded room. c. Knowing that the client was frequently combative, close observation by the nursing staff was indicated Option c -demonstrates the guidelines necessary for the above client's behavior, and addresses any legal concerns. Critical Thinking
While the nurse is talking to a hypermanic client, the client's conversation becomes embarrassingly vulgar. The nurse should respond to the client's behavior by: a. Tactfully teasing the client about the use of such vulgarity b. Restricting the client's contact with staff until this symptom passes c. Asking the client to limit the use of vulgarity while continuing the conversation d. Discreetly refusing to talk to the client when the client is speaking in this manner. c. Asking the client to limit the use of vulgarity while continuing the conversation Best response initially. This may need to be reassessed and readdressed. Application
Following a cholecystectomy the client should be assessed for signs of bleeding or hemorrhage. These observations are made because: a. Prostaglandins are released at the surgical site b. The inflammatory process interferes with platelet formation c. Diaphragmatic excursion places pressure on the suture line d. Blood clotting may be hindered by lack of vitamin K absorption. d. Blood clotting may be hindered by lack of vitamin K absorption. Knowledge -providing rationale for bleeding post cholecystectomy. Recall, bile is necessary for the breakdown of fat. This occurs in the small intestine. Post-op the common bile duct and surrounding area will be swollen, therefore bile is temporarily obstructed from reaching the small intestine. Vitamin ADE AND K are "fat soluble" vitamins. They require bile for absorption. Lack of vitamin K leads to bleeding.
On admission of a client to the labor and delivery unit the nurse asks the client about the marital status. The client refuses to answer and becomes very agitated, telling the nurse to leave. The nurse should: a. Have this information to complete the client's history b. Refer the client to a social service organization for help c. Question the family about the marital status of the client d. Have restricted questions to those relevant to the situation d. Have restricted questions to those relevant to the situation Marital status is not considered a relevant question required for the nurse to obtain for an admission history. Application
A 5-week-old infant is admitted to the hospital with a tentative diagnosis of congenital heart defect. The infant tires easily and has difficulty breathing and feeding. The best position in which to place the infant would be: a. Supine with the knees flexed b. Orthopneic with pillows for support c. Prone with the head supported by pillows d. Side-lying with the head and chest elevated. d. Side-lying with the head and chest elevated. d — best response for age and condtion. This position allows for chest expansion. Pillows are contraindicated and may be dangerous with infants. Normally, babies should be placed on their backs to reduce risk of SIDS for sleeping, therefore, prone would be contraindicated. Application
A client is admitted to the recovery unit after an abdominal hysterectomy. The observation that should be reported to the physician immediately is: a. An apical pulse of 90 b. A decreased urinary output
An elderly individual is hospitalized for weight loss and dehydration because of nutritional deficits. The nurse recognizes that in the elderly: a. Daily fluid intake must be markedly increased b. Financial resources are usually unrelated to nutritional status c. The individual's diet should be high in carbohydrates and low in proteins d. Except for decreased caloric needs, the nutritional needs are unchanged. a. Daily fluid intake must be markedly increased C is incorrect, as the diet should not be high in carbohydrates. Metabolism is lower in the elderly, therefore, calories need to be reduced. Nutritional needs do differ making d incorrect. Fluids need to be encouraged. Application
During an 8-month prenatal visit a client complains of discomfort with Braxton-Hicks contractions. The nurse should instruct her to: a. Lie down until they stop b. Time them for at least one hour c. Walk around until they subside d. Take 2 aspirins for discomfort c. Walk around until they subside Braxton-Hicks are painless, intermittent "practice" contractions of pregnancy. They become more frequent and can sometimes cause discomfort closer to labor. These irregular, false labor pains usually decrease in intensity with walking and position changes. Application Best Practice — walking
The nurse should be aware that the transitional phase of labor has probably begun when the client: a. Complains of pain in the back
b. Assumes the lithotomy position c. Perspires and has a flushed face d. States that her pains have lessened c. Perspires and has a flushed face During the transitional phase of labor- mother will be restless, and irritable. She may tremble, vomit, or cry. There may be an increase in the amount of bloody show and a strong urge to push if fetal station is low. Important to watch for hyperventilation during this phase. ----Knowledge
A baby is Rh positive and the mother is Rh negative. The baby is to receive an exchange transfusion. The nurse knows that the baby will receive Rh-negative blood because: a. It is the same as the mother's blood b. It is neutral and will not react with the baby's blood c. It eliminates the possibility of a transfusion reaction occurring d. It's RBCs will not be destroyed by maternal anti-Rh antibodies d. It's RBCs will not be destroyed by maternal anti-Rh antibodies Knowledge question — If a woman who is Rh negative carries a fetus with Rh-positive blood, the antibodies readily cross the placenta and attack the fetus' blood cells, and the fetus can develop hemolytic anemia. To prevent this, the fetus often receives an exchange transfusion. Option d-provides the rationale why the baby receives Rh-negative blood. Application
An elderly man with dementia is admitted to a nursing home. His wife appears frail, tired, and angry when she first visits her husband. She remarks to the unit nurse in a sarcastic tone, "Let's see what you can do with him." The nurse's most therapeutic response to this comment would be: a. "It must have been very difficult to care for him." b. "I don't understand what you mean by that comment." c. "We know how to care for clients such as your husband."
Nursing management for a client with an acute episode of bronchial asthma should be directed toward: a. Curing the condition permanently b. Raising mucus secretions from the chest c. Limiting pulmonary secretions by decreasing fluid intake d. Convincing the client that the condition is emotionally based. b. Raising mucus secretions from the chest Bronchial asthma has edema, mucous, and swelling, spasm and constriction. Therefore treatment should be aimed at reducing the edema, bringing up the mucous and clearing it, and opening the airway. There is no permanent cure for asthma. Decreasing fluid intake, will cause the secretions to thicken. Asthma is not emotionally based. Anxiety/Fear intensifies the episode. Application
We have an expert-written solution to this problem! The nurse arrives on the nursing unit and is receiving shift report. The Emergency Department nurse is requesting an immediate transfer of a 65-year-old client. A visitor in room 212 states, "My mother just fell." A physician arrives requesting immediate help with a dressing. How should the nurse proceed? a. Accept the 65-year-old client to the unit b. Complete the dressing with the physician c. Attend to the client who fell d. Finish the nursing unit shift report c. Attend to the client who fell Priority is to attend to the client who fell first!! You do not know the status of that client-she may have suffered a heart attack, stroke etc. Critical Thinking
A mother brings her 3-month-old female infant into the Well Baby Clinic stating, "She has not been feeding well." On examination of the baby, the nurse notes bruising on
extremities and buttocks. What should the nurse do first? a. Report this suspected case of child abuse to the local authorities and the physician b. Ask the mother about the child's bruises and gather further data about the situation c. Inform the physician of the bruises and complete an incident report d. Notify social work and request a home assessment b. Ask the mother about the child's bruises and gather further data about the situation An important role of the health care team is to identify abusive or potentially abusive situations as early as possible. When a child is brought to a physician or hospital, the caregiver may attribute the injury to some action of the child or action of a sibling. When a child's symptoms do not match the injury the caregiver describes, be alert for possible abuse. However, do not accuse the caregiver before a complete investigation takes place. Laws require health care personnel to report suspected abuse. This requirement overrides the concern for confidentiality. If the nurse does not report suspected child abuse, the penalty for the nurse can be loss of nursing license. Critical Thinking
The nurse obtains a temperature of 35.8 degrees C when assessing the vital signs of a 1-day-old newborn. The nurse takes the temperature again and obtains the same result. What should the nurse do next? a. Record the temperature and proceed with the assessment b. Warm the infant and take the temperature in 15 minutes c. Press the emergency bell for assistance d. Contact the physician and report the temperature b. Warm the infant and take the temperature in 15 minutes Less than 36 degrees C is considered hypothermic. Baby needs to be warmed up, then reassessed. Critical Thinking
When taking the history of a client with right ventricular heart failure, the nurse would expect the client to complain of: a. Enlarging abdomen, edema, fatigue
d. Reassure Ms. Fleisher that she has never been a bother b. Discuss with Ms. Fleisher ways to address these feelings ANSWER: therapeutic: displays empathy and promotes dialogue and expression of feelings
Mr. Stanley, 83 years old, has just been admitted to a nursing home. He shouts, "Let me out of here! I want to go home!" Which response by the nurse best demonstrates respect for Mr. Stanley? a. "I'm sorry, but you can't go home Mr. Stanley." b. "It must be hard for you to leave your home." c. "Do not be upset Mr. Stanley. We will take good care of you." d. "Would you like me to call your family?" b. "It must be hard for you to leave your home."--demonstrates respect as it includes reflection in order to understand the client's feelings
Which statement by the practical nurse would provide the most empathetic response to a 92-year-old client's request to see his mother? a. "It must be difficult for you to be alone." b. "I am so sorry that your mother is away." c. "I can try to locate your mother." d. "Perhaps there is someone else I can contact." a. “ It must be difficult for you to be alone. ”— empathetic, indicates that the nurse has listened to the client and understands how he feels
Mrs. Roman, 77, has heart failure and a history of angina. The nurse must apply a transdermal patch of nitroglycerine at 0800 hours. Which of the following statements
about transdermal medications is correct? a. They may be applied to any area of the body regardless of hair distribution as this does not interfere with absorption b. Transdermal medications are applied to the skin by patch or disc and stay in place for seven days. c. Removal of the old patch or disc prior to applying the new medication is recommended but not mandatory as all the medication has been absorbed from the old patch d. Transdermal medications can be absorbed through the skin of the nurse's hands in the process of applying the medication to Mrs. Roman d. Transdermal medications can be absorbed through the skin of the nurse's hands in the process of applying the medication to Mrs. Roman Nurses must wear gloves during the administration of the transdermal medications as prevention. Application
A nurse works in a long-term care facility. In a rush to complete the 1000 hour medications, the nurse gives Mr. Smith the wrong medication. What is the nurse's first responsibility? a. Disclose the incident to Mr. Smith and his family b. Inform the unit manager and prescriber of the medication error c. Complete an incident report for the agency about the details of the incident d. Assess Mr. Smith to ensure that he is not in immediate danger. d. Assess Mr. Smith to ensure that he is not in immediate danger. While other interventions may be required, the first responsibility is the safety of the client. Application
Post-caesarian section, Ms. Urquhart has her urinary catheter removed. Six hours later, she has not voided. What should be the nurse's first action? a. Provide her with a bedpan and provide privacy
