Introduction to Maternity and Pediatric Nursing Test Bank

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Blood and fluid loss from frequent diarrhea may cause hypovolemia and you can quickly assess volume depletion in Miss CC by:

  • A. Measuring the quantity and specific gravity of her urine output
  • B. Taking her blood pressure
  • C. Comparing the patient's present weight with her last weight
  • D. Administering the oral water test
Correct Answer: C

Rationale: Comparing the patient's present weight with her last weight is the best way to quickly assess volume depletion in Miss CC. As she has been experiencing frequent diarrhea leading to blood and fluid loss, changes in weight are a reliable indicator of changes in the body's fluid status. A significant decrease in weight would suggest a loss of fluid and potential hypovolemia due to the diarrhea. This method is simple, immediate, and directly reflects the impact of the fluid loss on the body's volume status. Measuring the quantity and specific gravity of her urine output could provide information on her kidney function but may not be as quick and direct in evaluating volume depletion as comparing her current weight with her last recorded weight. Taking her blood pressure is important in assessing overall cardiovascular status but may not be as immediate in reflecting the impact of fluid loss on volume status. Administering the oral water test is not a standard method for quickly assessing volume depletion in this scenario.

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What is the best age for solid food to be introduced into the infant's diet?

  • A. 2 to 3 months
  • B. 4 to 6 months
  • C. When birth weight has tripled
  • D. When tooth eruption has started
Correct Answer: B

Rationale: The American Academy of Pediatrics recommends introducing solid foods into an infant's diet between 4 to 6 months of age. At this stage, most infants have developed the necessary motor skills to start eating solid foods, such as being able to sit up and hold their head steady. Additionally, their digestive system has matured enough to handle solid foods. Introducing solid foods too early, such as at 2 to 3 months (Option A), can increase the risk of digestive issues and allergies. Waiting for tooth eruption (Option D) is not a reliable indicator as some infants may begin teething earlier or later than others. Waiting for the birth weight to triple (Option C) is not necessary as infants can start on solid foods once they reach the appropriate developmental stage around 4 to 6 months.

The nurse should plan to teach the client with pancytopenia caused by a chemotherapy to;

  • A. Begin a program of aggressive, strict mouth care
  • B. Avoid traumatic injuries and exposure to any infection
  • C. increase oral fluid intake to a minimum of 3000 ml daily
  • D. Report any unusual muscle cramps or tingling sensations in the extremities
Correct Answer: B

Rationale: The correct action for the nurse to teach a client with pancytopenia caused by chemotherapy is to avoid traumatic injuries and exposure to any infection. Pancytopenia is a condition characterized by low levels of all blood cell types - red blood cells, white blood cells, and platelets. This leaves the individual vulnerable to infections, easy bruising, and bleeding. By advising the client to avoid traumatic injuries and exposure to infection, the nurse is helping to reduce the risk of further complications that can arise from low blood cell counts. This includes advising the client on taking precautions such as gentle handling to prevent skin injury, using a soft toothbrush for oral care, and avoiding contact with individuals who are sick to minimize the risk of infection.

is softening of the bones as result of nutritional deficiencies or limited exposure to sunlight :

  • A. COXA
  • B. scoliosis
  • C. Rickets
  • D. Talipes
Correct Answer: C

Rationale: Rickets is a condition that involves softening and weakening of the bones in children, usually due to a vitamin D deficiency, inadequate calcium intake, or lack of exposure to sunlight. Vitamin D is essential for the absorption of calcium and phosphorus in the body, which are important for bone health. Without sufficient vitamin D, the body is unable to properly mineralize the bones, leading to softening and deformities. Common symptoms of rickets include bowed legs, delayed growth, and muscle weakness. Treatment typically involves vitamin D supplementation, dietary changes, and adequate exposure to sunlight.

Which intervention should the nurse implement to maintain the skin integrity of the preterm newborn?

  • A. Cleanse skin with a gentle alkaline-based soap and water.
  • B. Cleanse skin with a neutral pH solution only when necessary.
  • C. Thoroughly rinse skin with plain water after bathing in a mild hexachlorophene solution.
  • D. Avoid cleaning skin.
Correct Answer: B

Rationale: Preterm newborns have delicate skin that is more susceptible to damage and irritation. Using a neutral pH solution for cleansing helps to maintain the skin's natural acidity and prevent disruption of the skin barrier. It is important to avoid over-bathing or using harsh alkaline-based soaps that can strip the skin of its natural oils and cause dryness or irritation. Cleansing the skin only when necessary helps to protect the fragile skin of preterm newborns and reduce the risk of skin breakdown or injury.

What should a male client over age 50 do to help ensure early identification of prostate cancer?

  • A. Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly
  • B. Have a transrectal ultrasound every 5 years
  • C. Perform monthly testicular self-examinations, especially after age 50
  • D. Have a complete blood count (CBC) and blood urea nitrogen (BUN) and creatinine levels
Correct Answer: A

Rationale: For male clients over age 50, early identification of prostate cancer involves a combination of regular digital rectal examination and PSA test. The digital rectal examination allows a healthcare provider to manually assess the size, shape, and consistency of the prostate gland, looking for any abnormalities such as nodules or hard areas that may indicate prostate cancer. The PSA test measures the level of prostate-specific antigen in the blood, with elevated levels potentially signaling the presence of prostate cancer. Yearly screening using both these methods increases the chances of early detection and optimal management of prostate cancer in older male clients. Regular monitoring helps in identifying the disease at an earlier, more treatable stage, improving outcomes and prognosis.

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