FUNDAMENTALS Flashcards
The prenatal client is 7 months pregnant and wants to start an exercise program. The nurse should suggest which of the following exercises to the patient?
A. Bike riding
B. Circuit training
C. Aerial yoga
D. Swimming
Explanation
NCSBN client need | Topic: Health Pr0motion and Maintenance,
Rationale:
The correct answer is D. Swimming is the best exercise at this point in the mother’s pregnancy. Swimming is low impact and requires no balance, which can be troublesome with the weight a woman carries in her third trimester.
Choices A, B, and C are incorrect. These activities are too high intensity for a woman who is just starting an exercise regimen and require careful steadiness.
Reference:
Beckmann C. Obstetrics And Gynecology. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2014
The RN is delegating a task. After evaluating the patient’s condition. the RN determines that the task should not be delegated to the LPN/LVN who is working on the team. The RN should:
A. Consult the RN working on another team
B. Complete the task him/herself
C. Quickly instruct the LVN/LPN in how to perform the task
D. Contact the Charge nurse for direction
Explanation
Correct Answer: B.
If the RN determines that the patient’s condition is such that a task should not be delegated to the LPN/LVN, the patient is too sick for anyone other than the RN to care for him. There is no need to consult another RN or charge nurse. The RN should not provide quick instruction to the LPN/LVN. This type of training is not appropriate when the patient is very ill.
NCSBN Client Need
Topic: Management of Care
Sub-topic: Assignment and Delegation
Subject: Leadership and Management
Lesson: Assignment/Delegation
Reference: National Council of State Boards of Nursing. National Guidelines for Nursing Delegation. Journal of Nursing Regulation. Accessed online on February 11, 2020, at https://www.ncsbn.org/NCSBN_Delegation_Guidelines.pdf.
Which of the following statements regarding Reye’s Syndrome are true? Select all that apply.
A. The definitive diagnosis is made by serum amylase levels.
B. It is characterized by cerebral edema and fatty changes in the liver.
C. It is associated with ibuprofen administration during a viral illness.
D. It commonly follows a viral illness such as varicella or influenza.
Explanation
Answer: B and D
A is incorrect. The definitive diagnosis for Reye’s Syndrome is made with a liver biopsy. Amylase is an enzyme produced by the kidneys and can be elevated in acute pancreatitis. This lab has nothing to do with Reye’s Syndrome.
B is correct. Defining characteristics of Reye’s Syndrome are cerebral edema and fatty changes in the liver.
C is incorrect. Reye’s syndrome can be associated with aspirin administration during a viral illness, not ibuprofen. It is not recommended to administer aspirin or aspirin-containing products to a child with a febrile illness due to this risk, but ibuprofen is safe.
D is correct. Reye’s Syndrome commonly follows a viral illness such as varicella or influenza.
NCSBN Client Need:
Topic: Physiological Integrity
Subtopic: Physiological Adaptation
Subject: Child Health
Lesson: Neurology
Reference: McKinney E, James S, Murray S, Ashwill J: Maternal-child nursing, ed 4, St. Louis, 2013, Saunders.
Which is an intrinsic risk factor that increases the risk of patients developing pressure ulcers?
A. Shearing
B. Friction
C. Impaired tissue perfusion
D. Pressure
Explanation
Intrinsic refers to anything essential or belonging naturally.
The correct answer is C. Impaired tissue perfusion is an internal risk factor. Other intrinsic risk factors associated with skin breakdown include:
Poor nutritional status Incontinence Alterations in fluid balance Altered neurological functioning
A, B, and D are incorrect. Shearing, friction, and pressure are extrinsic (external) factors that increase the risk of impaired tissue performance that causes pressure sores.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Reduction of Risk Potential
Chapter 35: Skin Integrity and Wound Healing
Lesson: Types of Wounds
Fundamentals of Nursing (Wilkinson/Barnett)
Which nursing actions are appropriate when irrigating a nasogastric tube connected to suction? Select All That Apply.
A. Draw up 30mL of saline solution into the syringe
B. Unclamp the suction tubing near the connection site to instill solution
C. Place the tip of the syringe in the tube to gently insert saline solution
D. Place syringe in the blue air vent of a Salem sump or double-lumen tube
E. After instilling irrigant. hold the end of the NG tube over an irrigation tray
F. Observe for return of NG drainage into an available container
Explanation
Answer and Rationale
The correct answers are A, C, E and F.
A: The nurse irrigating a nasogastric tube connected to suction should draw up 30 ml of saline (or amount indicated on the order or per policy) into the syringe,
C: The nurse should place the tip of the syringe in the tube to gently insert the saline solution.
E and F: After instilling irrigant, the nurse should hold the end of the NG tube over an irrigation tray or emesis basin and observe for return flow of NG drainage into an available container.
B and D are incorrect.
B: The tubing should be clamped near the connection site to protect the patient from leakage of NG drainage.
D: then place the syringe in the drainage port, not in the blue air vent of a Salem sump or double-lumen tube. The blue air vent acts to decrease pressure built up in the stomach when the Salem sump is attached to suction.
NCSBN Client Need
Topic: Physiological integrity
Subtopic: Basic Care and Comfort
Resource: Fundamentals of Nursing 8th Edition (Wolters/Klewer)
Chapter 37: Bowel Elimination
Lesson: Nasogastric Tubes
A 34-year old female arrives at the emergency department after developing pain in her left calf. What are the important questions to ask this patient while assessing her? Select all that apply
A. Is your left calf bigger than your right calf?
B. Are you pregnant?
C. Have you been on any long car or plane rides recently?
D. Do you take any birth control?
E. Do you take any antidepressants?
Explanation
The correct answers are A, B, C, and D. This patient needs to be assessed for a deep vein thrombosis because of her risk factors like age, possible birth control use, and long travel. Asking these questions can be crucial in diagnosing the patient and obtaining further ultrasound imaging.
E is incorrect. This question is not pertinent related to deep vein thrombosis.
NCSBN Client Needs
Topic: Reduction of Risk Potential
Sub-Topic: Potential for Alterations in Body Systems
Subject: Adult Health
Lesson: Hematologic System
Reference: Lewis, Dirksen, Heitkemper, Bucher, 2013
Which of the following educational points would be helpful for optimizing feedings in an infant with heart failure? Select all that apply.
A. Small frequent feedings
B. Feeding q5 hours
C. Feed for a maximum of 30 minutes
D. Increased calorie formula
Explanation
Answer: A, C, and D
A is correct. It is appropriate advice to feed an infant with heart failure in small, frequent feedings. These infants will have a difficult time feeding and be working very hard during their feeds. They will need to be paced so that they conserve their energy and do not burn too many calories while feeding. Small, frequent feeds are the best way to optimize their nutrition.
B is incorrect. Feeding an infant with heart failure every 5 hours is not frequent enough. Small, frequent feedings should be initiated to maximize caloric intake and conserve energy. A baby with heart failure should be fed on a schedule every 3 hours.
C is correct. It is appropriate advice to feed an infant with heart failure for only 30 minutes at a time. After 30 minutes of feeding, the infant is using too much energy to gain calories and grow due to the feeding. Conserving energy is very important for infants experiencing heart failure.
D is correct. It is appropriate advice to feed an infant with heart failure an increased calorie formula. This will allow them to get a maximum amount of calories for growth in as little work as possible. Infants who are breastfed may require additional supplementation to grow.
NCSBN Client Need:
Topic: Physiological Integrity
Subtopic: Physiological adaptation
Subject: Pediatrics
Lesson: Cardiac
Reference: Ricci, S. S., & Kyle, T. (2009). Maternity and pediatric nursing. Lippincott Williams & Wilkins.
The mean arterial pressure necessary for adequate end-organ perfusion in the average adult patient is ________.
Explanation
Answer: 60
Mean arterial pressure is a calculation that takes into account the importance of diastole in the cardiac cycle. In the normal cardiac cycle, the heart is in systole for â…“ of the time and diastole for â…” of the time. When looking only at blood pressure, one does not account for the greater length of time the heart spends in diastole. A MAP of 60 is needed for adequate perfusion to the brain and kidneys in the average adult.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Physiological Adaptation
Reference: Brorsen, A. & Roglet, K. (2011). Pediatric Critical Care. Burlington, MA: Jones & Bartlett Learning.
Subject: Adult Health
Lesson: Cardiovascular
What is the priority nursing assessment for a 76-year-old patient with pneumonia?
A. Airway patency
B. Percussion sounds
C. Breath sounds
D. Respiratory rate
Explanation
Impaired mobility in older adults creates risk for airway collapse, reduced air exchange, hypoxia, hypercapnia, and acidosis. Reduced gag and cough reflexes can place older people at risk for aspiration of secretions and, potentially, aspiration pneumonia. There is a possibility of postoperative respiratory complications because of impaired cough reflex, weaker muscles, and decreased inspiratory capacity.
Older adults are at increased risk of respiratory complications during stress. The nurse should pay attention to maintaining adequate ventilation, keeping lung volumes high, clearing secretions, and positioning to prevent aspiration.
Answer and Rationale:
The correct answer is A. B, C, and D are incorrect. Airway always assumes priority in an assessment.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Physiological Adaptation
Resource: Nursing Health Assessment: A Best Practice Approach (Walters Kluwer)
Chapter 16: Thorax and Lung Assessment
Lesson: Objective Data
High-quality CPR for an adult consists of the following: (Select all that apply)
A. Compression rate of 100 to 120 per minute.
B. Compression depth of 1.5 inches.
C. Allow full chest recoil between compressions.
D. Rotate compressor at least every 2 minutes.
Explanation
Correct answer: Responses A, C, and D are correct. The purpose of CPR is to move blood through the heart and to the cells of the body to prevent cell death. According to the American Heart Association (AHA), high-quality CPR includes a compression rate of 100-120 per minute to a depth of 2-2.4 inches. Therefore, response B (compression depth of 1.5 inches) is not correct. The provider must allow full chest recoil between each compressor. Full chest recoil allows the heart chambers to fill with blood between compressions. When the ventricles fill, more oxygenated blood will be available to the cells. Fatigue will result in less effective compressions, so the AHA recommends that the compressors rotate every 2 minutes or five cycles of compressions to prevent fatigue.
NCSBN Client Need
Topic: Physiological Adaptation
Sub-Topic: Medical Emergencies
Subject: Critical Care
Lesson: Cardiovascular; Prioritization
Reference: American Heart Association. Advanced Cardiovascular Life Support: Provider Manual. March 2016 eBook edition.
A 28-year-old female presents to the OB-GYN office, suspecting she may be pregnant. Which would the nurse recognize as a possible sign of pregnancy?
A. Amenorrhea
B. Positive cardiac activity on ultrasound
C. Enlarged uterus
D. Auscultation of fetal heart tones
Explanation
A is correct. Presumptive signs of pregnancy are symptoms that are experienced by the patient. Of the options listed, amenorrhea is the only likely sign of fertility.
B is incorrect. Positive cardiac activity on ultrasound would be a positive sign of pregnancy.
C is incorrect. An enlarged uterus would be detected by the examiner and would be a probable sign of pregnancy.
D is incorrect. Auscultation of fetal heart tones would be a positive sign of pregnancy.
Subject: Adult health
Lesson: Reproductive
Topic: Antepartum care, system-specific assessments
Reference: (Jarvis, 2012, p. 796)
The nurse is providing discharge teaching to a patient receiving sulfamethoxazole. Which of the following instructions should be given during this teaching?
A. Discontinue taking this medication when symptoms are alleviated
B. Restrict fluid intake to prevent hypertension
C. Drink plenty of fluids
D. Go to the emergency department if the urine turns a dark brown or yellow
Explanation
NCSBN client need | Topic: Physiological Integrity, Pharmacological and Parenteral therapies
Rationale:
The correct answer is C. Sulfamethoxazole is used to treat urinary tract infections and should be taken with plenty of water. Each dose should be taken with a full glass of water.
Choice A is incorrect. Antibiotics should not be discontinued until the entire prescribed course is completed. I am stopping this medication when symptoms may contribute to antibiotic resistance.
Choice B is incorrect. This medication should be taken with plenty of fluids to prevent adverse effects.
Choice D is incorrect. Dark brown urine is a common side effect of using sulfamethoxazole and does not warrant a visit to the emergency department.
Reference:
Lilley L, Savoca D, Lilley L. Pharmacology And The Nursing Process. Maryland Heights, MO: Mosby; 2011
You are the nursing supervisor in a long-term care facility. One of the major considerations that you apply into your practice is strict infection control prevention measures because you are knowledgeable about the fact that the normal aging process is associated with the deterioration of the body’s normal defenses. Which theory of aging supports your belief that strict infection control prevention measures are necessary?
A. The Programmed Longevity Theory
B. The Immunological Theory of Aging
C. The Endocrine Theory
D. The Rate of Living Theory
planation
Important Fact:
Programmed theories assert that the human body is designed to age and there is a certain biological timeline that bodies follow. All of these theories share the idea that aging is natural and “programmed” into the body.
Error theories, such as the Rate of Living Theory, assert that aging is caused by environmental damage to the body’s systems, which accumulates over time.
Answer & Rationale:
The correct answer is B. The theory of aging that supports your belief that strict infection control prevention measures are necessary is the Immunological Theory of Aging. The Immunological Theory of Aging states that aging leads to the decline of the person’s defensive immune system and the decreased ability of the antibodies to protect us against infection. A, C and D are incorrect. The Programmed Longevity theory of aging states that genetic instability and changes occur such as some genes turning on and off lead to the aging process; the Endocrine Theory of aging states that aging results from hormonal changes and the biological clock’s ticking; and Rate of Living Theory states that one’s longevity is the result of one’s rate of oxygen basal metabolism.
Resource
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Physiological Adaptation
Chapter 10: Lifespan of Older Adults
Lesson: Theories of Aging
Reference: Fundamentals of Nursing (Wilkinson/Barnett/Smith)
In labor and delivery, you are taking care of a patient experiencing placenta previa. You expect her to have _______ bleeding on your assessment.
Explanation
Answer: painless
“Painless bleeding” is a buzzword for placenta previa on the NCLEX. It is essential to know that the bleeding with placenta previa is expected to be painless, whereas, with an abruption, it will be excruciating, massive dark red bleeding. Distinguishing between these two labor and delivery complications is very important.
NCSBN Client Need:
Topic: Physiological Integrity
Subtopic: Physiological adaptation
Subject: Maternal and Newborn Health
Lesson: Labor and Delivery
Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care. Elsevier Health Sciences.
Which of the following activities can be delegated to unlicensed assistive personnel (UAPs)? Select All That Apply.
A. Performing initial patient assessments
B. Making patient beds
C. Giving patients bed baths
D. Administering patient medications
E. Ambulating clients
F. Assisting clients with meals
Explanation
Because of the pressure to reduce health care costs and the increasing demand for nursing services amid a critical shortage of professional nurses, many employers of nurses have increased their use of unlicensed assistive personnel (UAP). UAPs are people who are trained to function in an assistive role to the nurse in the provision of patient activities as delegated by and under the supervision of the nurse.
The correct answers are B, C, E, and F. In most cases, patient hygiene, bed-making, ambulating patients, and helping to feed patients can be delegated to a UAP.
A and D are incorrect.
A: Performing the initial patient assessment is the responsibility of the registered nurse.
D: The administration of medications is carried out by registered nurses and licensed vocational/practical nurses.
NCSBN Client Need
Topic: Safe and Effective Care Environment
Subtopic: Coordinated Care
Resource: The Art and Science of Person-Centered Nursing Care
Chapter 14: Implementing
Lesson: Delegation and the Unlicensed Assistive Personnel
The school nurse is attending to a student who has gotten a chemical cleaner in their eyes. In which order should the following actions be performed? Document the occurrence Check the pH of the eye Irrigate the eye Call the child’s parent Assess Visual acuity
Correct Answer is: Irrigate the eye Check the pH of the eye Assess Visual acuity Document the occurrence Call the child’s parent
Explanation
When a chemical injury is sustained, the school nurse should irrigate the student’s eye, check the pH of the eye, assess the child’s visual acuity, document the occurrence, and call the child’s parents to inform them of the occurrence, actions taken, and outcome.
NCSBN client need |Topic: Physiological integrity, physiological adaptation
Reference:
Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby
The nurse is caring for a patient with a diagnosis of prediabetes, which is not appropriate teaching for preventing progression from typing two diabetes diagnosis.
A. Maintain healthy weight
B. Perform moderate exercise regularly
C. Discuss dietary recommendations
D. Test daily blood glucose via fingerstick
Explanation
D is correct. Testing blood glucose daily may be appropriate to monitor the patient’s response to specific interventions, but is not typically indicated for prediabetes. This option pertains to monitoring/assessment, not prevention measures.
A is incorrect. Weight is a significant risk factor in developing type 2 diabetes. There is no information about the patient’s current weight status, so losing weight would not necessarily be indicated, but maintaining a healthy weight would be appropriate to reduce the patient’s risk for disease progression.
B is incorrect. Regular, moderate exercise reduces the risk of developing diabetes because it can help control both weight and blood sugar. Average levels of activity cause the body to use glucose, reducing serum levels. The American Diabetes Association recommends 30 minutes of exercise at least five times per week.
C is incorrect. The nurse should provide teaching about general dietary recommendations/modifications to reduce the patient’s risk of developing type 2 diabetes. If it is determined that the patient would benefit from further education, the nurse should schedule a patient for a meeting with the unit diabetes educator before discharge.
Subject: Adult health
Lesson: Endocrine
Topic: health screening, lifestyle choices, the potential for alterations in body systems, illness management
Reference: (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011, p. 1221)
You are caring for a 17-year-old patient who has been taking isotretinoin (Accutane) for the past three months. The most critical assessment for this patient is:
A. Improvement in the appearance of the skin
B. Dry skin on the face
C. Mood changes
D. Problems remembering to take medication
Explanation
Correct answer: C. Mood changes. Accutane is a synthetic retinoid that is frequently prescribed for severe acne that does not respond to other topical and oral treatments. This medication is usually given for 4 to 6 months or until significant improvement is noticed. Effects can include dry skin and development in the appearance of the skin. However, there are also severe side effects that can develop. The FDA required that labeling of Accutane be changed to add that there is a possible connection between Accutane and critical mood changes. Depression, irritability, altered sleep patterns, and suicidal ideation should be reviewed with the patient during every visit. Family members should be aware of the possibility of these problems. They should be instructed to watch for these symptoms and should call the physician immediately if issues are noted.
NCSBN Client Need
Topic: Pharmacological and Parenteral Therapies
Sub-Topic: Adverse Effects/Contraindications/Side effects/Interactions
Subject: Adult Health
Lesson: Integumentary; Neurologic
Reference: United States Food and Drug Administration. https://www.fda.gov/consumers/consumer-updates/facing-facts-about-acne. Facing Facts about Acne. Accessed online October 8, 2019.
Which statement should the nurse use during client education regarding a vasectomy as a permanent method of contraception?
A. If you change your mind in the future. it’s simple to reverse the procedure.
B. You will need to return for an annual follow-up visit and sperm count.
C. If you have a history of cardiac disease. we won’t be able to do the vasectomy.
D. You’ll need to use another type of birth control until your sperm count is zero.
Explanation
A vasectomy is a form of male birth control that cuts the supply of sperm to your semen. It’s done by cutting and sealing the tubes that carry sperm. Vasectomy has a low risk of problems and can usually be performed in an outpatient setting under local anesthesia. Although vasectomy reversals are possible, vasectomy should be considered a permanent form of male birth control.
Vasectomy offers no protection from sexually transmitted infections. Vasectomy is a safe and effective birth control choice for men who are sure they don’t want to father a child in the future.
Vasectomy is nearly 100 percent effective in preventing pregnancy. Vasectomy is an outpatient surgery with a low risk of complications or side effects. The cost of a vasectomy is far less than the price of female sterilization (tubal ligation) or the long-term value of birth control medications for women. The correct answer is D. The second method of birth control is necessary until the sperm count is zero. A is incorrect. Although reversal is possible, it is often difficult, requiring microsurgery. Also, results may be unsuccessful. B is incorrect. Once the sperm count is zero, there is no need for follow-up exams. C is incorrect. There is no correlation between having a vasectomy and cardiac disease.
NCSBN Client Need
Topic: Health Promotion and Maintenance
Chapter 40: Sexuality
Lesson: Altered Sexual Function
Reference: Fundamentals of Nursing (Kozier and Erb)
The nurse taking care of a malnourished patient notes that their lab results are in and that the patient is currently hypokalemic. The nurse knows that given this condition. The patient should be monitored for which changes in their EKG?
A. U wave and a flat T wave
B. An inverted QRS complex
C. Absence of a U wave
D. Exaggerated QRS complex
Explanation
NCSBN client need | Topic: Physiologic Adaptation: Fluid and Electrolyte Imbalances
Rationale:
The correct answer is A. This patient is experiencing hypokalemia, also known as a deficiency in potassium or a blood serum potassium level of less than 3.5 mmol/L. Low potassium affects the heart’s ability to repolarize, which is reflected in an EKG with a flat T wave and, occasionally, the presence of a U wave. Choices B, C, and D are incorrect.
Reference:
Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby
Which of the following opportunistic infections are a sign that a patient with HIV now has AIDS? Select all that apply.
A. Stomach Ulcers
B. Symptomatic Tuberculosis
C. Toxoplasmosis of the brain
D. Osteoporosis
E. Pneumocystis carinii pneumonia
Explanation
NCSBN client need | Topic: Physiological Integrity, Illness Management
Rationale:
The correct answers are B, C, and E. Generally, tuberculosis, or TB, does not affect those with healthy CD4 levels. Symptomatic TB is a sign of AIDS. An infection with Toxoplasmosis of the brain indicates a serious infection directly related to the condition. Affecting the lung, pneumocystis carinii pneumonia is typical of patients with AIDS and a serious sign of low CD4 counts.
Choice A is incorrect. While some people with HIV or AIDS may have stomach ulcers, they are not indicative of an AIDS diagnosis.
Choice D is incorrect. Osteoporosis, a condition where a reduction in bone strength increases a person’s risk of bone breakage. This is not a sign of AIDS.
Reference:
Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby
Which of the following alternative therapies are not considered a low-risk treatment? Select all that apply.
A. St. John’s Wort
B. Meditation
C. Acupuncture
D. Relaxation Techniques
E. Guided Imagery
Explanation
NCSBN client need | Topic: Psychosocial Integrity: Cultural awareness
Rationale:
The correct answers are A and C. St. John’s Wort, an herbal remedy for depression, may interfere with specific medical treatments and should not be taken without medical supervision. Acupuncture, while generally safe, is not always well-tolerated and should also be approved and supervised by a health care provider.
Reference:
Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby
nurse is teaching a patient relaxation techniques. Which of the following statements by the patient indicate he understands the instruction he has been provided? Select all that apply.
A. “I must breathe in and out in rhythm.”
B. “I should check my pulse and expect it to be faster.”
C. “I can expect my muscles to feel less tense.”
D. “I will be more relaxed and less aware.”
Explanation
Relaxation techniques are useful in many situations, including childbirth and consist of rhythmic breathing and progressive muscle relaxation. When these techniques are implemented, many people see a reduction in the need for pharmacologic measures to relieve stress and anxiety.
Answer and Rationale:
The correct answers are A, C, and D. B is incorrect. When relaxation techniques are properly implemented, the patient should experience a decreased pulse rate.
NCSBN Client Need
Topic: Health Promotion and Maintenance
Resource: Fundamentals of Nursing 8th Edition (Wolters and Klewer)
Chapter 41: Stress and Adaptation
Lesson: Stress Management Techniques
An elderly client is in the clinic for a yearly check-up. The nurse notes several large bruises of varying stages on her back. Stomach. And upper arms. When asked about these bruises. The client states that her son. Who cares for her. Sometimes hits her when he is angry. She asks the nurse to keep this information a secret. How should the nurse respond?
A. “I’d like to discuss some strategies we can use to prevent your son from hitting you.”
B. “The next time you are struck by your son. you should bring yourself to the emergency department.”
C. “I have a legal obligation to report your bruises and abuse.”
D. “I promise to keep this a secret.”
Explanation
Choice C is correct. Nurses have a legal obligation to report child and elder abuse, as well as other forms of violence, some of which vary state to state. In this situation, the nurse should report the violation to the nurse supervisor and initiate a report.
Choice A is incorrect. The nurse in this situation needs to report the abuse. Encouraging the client to find ways to avoid being struck puts the patient in harm’s way and delays finding a solution.
Choice B is incorrect. Waiting until the next time the patient is struck might be too late and could lead to more severe injury.
Choice D is incorrect. The nurse in this situation may not keep this situation a secret. They are legally obligated to report this incident.
NCSBN client need | Topic: Coordinated Care / Legal Responsibilities
Reference: Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis.
In pediatrics, monitoring development is incredibly important. Development that moves from the head downward through the body and towards the feet is _________________ development.
Explanation
Answer: cephalocaudal
Cephalocaudal development moves from the head down through the body and towards the feet. Suppose you break down the word, ‘cephalic’ from cephalic means relating to or located near the head. Next, ‘caudal’ refers to the tail, or towards the rear. So, cephalocaudal means from the head towards the tail. In human growth and development, cephalocaudal development is considered normal. For example, infants are born with heads that are proportionally much larger than their trunk. Their trunk grows later.
NCSBN Client Need:
Topic: Health promotion and maintenance
Subject: Pediatrics
Lesson: Development
Reference: Ricci, S. S., & Kyle, T. (2009). Maternity and pediatric nursing. Lippincott Williams & Wilkins.
Aging adult clients may have variations in pulse rates with:
A. Food intake
B. Heat
C. Respirations
D. Exercise
xplanation
Aging adults have a normal pulse range of 60-100 beats/minute. Variation in rhythm may develop with age and increased activity, such as with exercise. The radial artery may stiffen from peripheral vascular disease. However, a rigid highway does not indicate vascular disease elsewhere in the body. The pulse rate of older adults takes longer to rise to meet sudden increases in demand, takes longer to return to resting state, and tends to be lower than that of younger adults.
Answer and Rationale:
The correct answer is D. Exercise increases the heart rate because of increased metabolic demands. A and B are incorrect. Certain types of food may cause changes within the body (such as salty foods can increase blood pressure and affect heart rate). Also, internal temperature changes may cause an increase in heart rate. However, overall food intake and heat are not causes for variations in pulse rate. C is incorrect. Sinus arrhythmia, a variation in pulse with respiration, is common among children.
NCSBN Client Need
Topic: Health Promotion and Maintenance
Resource: Nursing Health Assessment: A Best Practice Approach (Wolters/Klewer)
Chapter 5: Vital Signs and General Survey
Lesson: Pulse
In pediatrics, monitoring development is incredibly important. Development that moves from the center of the body outward to the extremities is _________________ development.
Explanation
Answer: proximodistal
Development that moves from the center of the body outward to the extremities is proximodistal. The terms proximal and distal are both essential in anatomy. Proximal refers to a body part that is “situated nearer to the center of the body or the point of attachment.” and distal refers to a body part that is “situated away from the center of the body or the point of attachment.” For example, the elbow is proximal to the wrist, and the ankle is distal to the knee. In development, proximodistal development is healthy. The proximal parts of the body, like the trunk, develop sooner than the distal portions. This is why infants can hold their head up or roll over before they develop excellent motor skills like a pincer grasp. Proximodistal development means that the most distal parts of the body, like fingers and toes, are some of the last to develop, which explains why it takes much longer for infants to do things like hold a crayon and color than it does to raise their arms.
NCSBN Client Need:
Topic: Health promotion and maintenance
Subject: Pediatrics
Lesson: Development
Reference: Ricci, S. S., & Kyle, T. (2009). Maternity and pediatric nursing. Lippincott Williams & Wilkins.
___________’s sign is positive if you inflate a BP cuff past the systolic blood pressure and observe a carpopedal spasm.
Explanation
Answer: Trousseau
This is a sign of hypocalcemia.
NCSBN Client Need:
Topic: Physiological Integrity
Subtopic: Physiological Adaptation
Subject: Adult Health
Lesson: Endocrine
Reference: Fong, J., & Khan, A. (2012). Hypocalcemia: updates in diagnosis and management for primary care. Canadian family physician Medecin de Famille Canadien, 58(2), 158–162.
THe ICU nurse is caring for a patient who is receiving intermittent bolus feeds via a PEG tube. The nurse checks gastric residual volume (GRV) and finds 200mL. Which nursing action is appropriate?
A. Administer Reglan and reassess GRV in 30 minutes.
B. Decrease rate of bolus feeds.
C. Administer bolus as ordered.
D. Hold feeding and assess patient for signs of bloating. pain. or distention.
Explanation
C is correct. The normal range for GRV is less than or equal to 250-300mL for ICU patients. This patient’s GRV would be within the normal range, so the nurse should continue to administer the bolus feeding as ordered.
A is incorrect. The nurse would expect to administer Reglan and continue to assess the patient’s residual volume if the patient’s GRV was higher than 250mL for two consecutive checks.
B is incorrect. The patient’s GRV is within the normal range for an ICU patient, so decreasing the rate would not be indicated.
D is incorrect. The patient’s GRV is within the normal range for an ICU patient, so holding the bolus would not be indicated.
Subject: Critical Care
Lesson: Critical Care Concepts
Topic: nutrition and oral hydration, system-specific assessments, alterations in body systems
Reference: (Jones & Fix, 2015, p. 26-28)
Which of the following images shows the correct location to assess for McEwan’s sign?
A. junction of the frontal and sagittal sutures
B. junction of the parietal, temporal, and occipital bones
C. junction of the sagittal and lambdoid sutures
D. junction of the frontal, temporal, and parietal bones
30-05-2020
Last Updated
Explanation
Answer: D
A is incorrect. This is not the location to assess for McEwan’s sign. This is the junction of the frontal and sagittal sutures. To assess for McEwan’s sign, percussion the junction of the frontal, temporal, and parietal bones
B is incorrect. This is not the location to assess for McEwan’s sign. This is the junction of the parietal, temporal, and occipital bones. To assess for McEwan’s sign, percussion the junction of the frontal, temporal, and parietal bones
C is incorrect. This is not the location to assess for McEwan’s sign. This is the junction of the sagittal and lambdoid sutures. To assess for McEwan’s sign, percussion the junction of the frontal, temporal, and parietal bones
D is correct. McEwan’s sign is a sign used to detect hydrocephalus. The examiner percusses on the skull at the junction of the frontal, temporal, and parietal bones and can auscultate a “cracked pot”, or hyper resonant sound if hydrocephalus is present. Macewen’s sign is not related to congestive heart failure or chronic hypoxia.
NCSBN Client Need:
Topic: Psychosocial Integrity
Subject: Pediatrics
Lesson: Neurology
Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s Essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.
