exam rationalization

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1. The mother of a 9 month old infant is concerned that the head circumference of her baby is greater than the chest circumference. The best response by the nurse is: a. “These circumferences normally are the same, but in some babies this just differs.” b. ”perhaps your baby was small gestational age or premature.” c. “This is normal until the age of 1 year, when the chest will be greater.” d. “Let me ask you few questions, and perhaps we can figure.”

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Exam Rationalization

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Page 1: Exam Rationalization

1. The mother of a 9 month old infant is concerned that the head circumference of her baby is greater than the chest circumference. The best response by the nurse is:

a.“These circumferences normally are the same, but in some babies this just differs.”

b.”perhaps your baby was small gestational age or premature.”

c.“This is normal until the age of 1 year, when the chest will be greater.”

d.“Let me ask you few questions, and perhaps we can figure.”

Page 2: Exam Rationalization

2. Preschoolers are able to see things from which of the following perspectives?

a.Their peers’b.Their own and their caregivers’c.Their own and their mother’sd.Only their own

Page 3: Exam Rationalization

3. A parent calls you and frantically reports that that her child has gotten into her ferrous sulfate pills and ingested number of these pills. Her child is now vomiting has bloody diarrhea and is complaining abdominal pain. You will tell the mother to:

a.Call emergency medical services (EMS) and get the child to the emergency room

b.Relax because these symptoms will pass and the child will be fine

c.Administer syrup of ipecacd.Call the poison control center

Page 4: Exam Rationalization

4. The nurse is working with an adolescent who complains of being lonely and having a lack of fulfillment in her life. This adolescent shies away from intimate relationships at times yet at other times she appears promiscuous. The nurse will likely work with this adolescent in which of the following areas?

a.Isolation

b.Loneliness

c.Lack of fulfillment

d.Identity

Page 5: Exam Rationalization

5. A child suffers a head injury in a tumbling accident in a gym class. The nurse’s best course of action is to:

a.Get the child up walking and make he she stays awake

b.Leave the child and go get helpc.Leave the child in the care of an older child

and go get help d.Stay with the child keep assessing and

someone call the caregivers

Page 6: Exam Rationalization

6. Which of the following arrangements is generally considered to the best for the parents of a hospitalized infant or young child?

a.Rooming- inb.Separate caregiver sleeping room on the unitc.Day visits and sleeping at homed.Staying at a nearby hotel or motel

Page 7: Exam Rationalization

Situation: Nurse Michelle works with the Family

Nursing Team in Calbayog Province specifically handling a UNICEF Project for children. The following conditions pertain to CARE OF THE FAMILIES WITH PRESCHOOLERS

Page 8: Exam Rationalization

7. Ronnie asks constant questions. How uestions does a typical 3- year old ask in day’s time?

a.300- 400b.100- 200c.1,200 or mored.Less than 50

Page 9: Exam Rationalization

8. Ronnie will need to change to a new bed because his baby sister will need Ronnie’s old crib. What measure would you suggest that his parents take to help decrease sibling rivalry between Ronnie and his new sister?

a.Tell him he will have to share with the new babyb.Ask him to get his crib ready for the new babyc.Move him to the new bed before the baby

arrivesd.Explain the new sisters grow up to become best

friends

Page 10: Exam Rationalization

9. How many words does a typical 12 months old infant use?

a.20 or moreb.2 plus “mama” and “dada”c.About 50 wordsd.About 12 words

Page 11: Exam Rationalization

10. Which of the following would watched on the baby?

a.APGAR scores and congenital defectsb.Birthmark and pigmentationc.Foot and hand markd.Measurement of length

Page 12: Exam Rationalization

SITUATION: Mark Foster a 10-month old infant with a

cleft lip and palate, is admitted to the pediatric unit for the first stage of surgical correction on his lip. Primarily breast-fed, he occasionally receives a supplemental bottle.

Page 13: Exam Rationalization

11. Feeding an infant with a cleft lip or palate offers a special challenge to the nurse because;a. Bottle-feeding disrupts the maternal-infant

bondb. The infant has difficulty maintaining suction

around a nipplec. The nurse must discourage the infant from

trying to suckd. The infant has no desire to suck

Page 14: Exam Rationalization

12. Immediate post-operative complications for Mark may include:a. Hemorrhage and respiratory distressb. Fever and coagulation difficultiesc. Infection and hemorrhaged. Irritability and difficulty swallowing

Page 15: Exam Rationalization

13. The physician orders elbow restraints postoperatively. the nurse should:a. Put the restraints on Mark’s dominant handb. Use the restraints only when Mark is awakec. Use the restraints only when Mark is asleepd. Release the restraints every 2-4 hours

Page 16: Exam Rationalization

14. Mrs. Foster is concerned about Mark’s dental development. The nurse knows that an infant’s first teeth, which usually erupt between ages 6 and 8 months are the:a. Upper lateral incisorsb. Lower central incisorsc. Lower lateral incisorsd. Upper central incisors

Page 17: Exam Rationalization

15. After cleft palate repair, Mark should be fed with:a. Soup spoonb. Dessert forkc. Plastic syringed. Infant spoon

Page 18: Exam Rationalization

SITUATION: Mrs. Smith reveals to the visiting nurse that

Nicholas, aged 2 weeks, has been vomiting 3 tablespoons of previously ingested food daily for the past 3 days. The vomitus contains neither blood nor bile. Mrs. Smith tells the nurse that she feeds Nicholas 4 oz. (120ml) of a soy-based, iron-fortified formula ( SIMILAC 20 with Iron) every 4 hours and that the vomiting occurs effortlessly regardless of the neonates position. Nicholas growth parameters have remained unchanged since birth. The physician suspects Gastro esophageal reflux.

Page 19: Exam Rationalization

16. To prevent Nicholas from aspirating during or after feeding, Mrs. Smith should,a. Keep Nicholas prone at a 15-degree angle

after feedingb. Thicken the morning and evening feedings

with cerealc. Administer large-volume feedings every 6

hours.d. Maintain Nicholas in an upright position, at a

60-degree angle with an infant seat.

v

Page 20: Exam Rationalization

17. To evaluate the effectiveness of Nicholas’ home care program, the nurse should consider which of the following as most important?a. Absence of spitting upb. Weight gainc. Ability to tolerate clear liquids between

feedingsd. Tolerance of feedings scheduled every 6

hours

Page 21: Exam Rationalization

SITUATION: Jenifer, a full-term neonate, is transferred to

the neonatal intensive care unit after x-ray reveal that her esophagus ends in a blind pouch. She has had problems with feeding and is now on NPO status. Her diagnosis is Esophageal Atresia: Surgery is schedule for the next morning.

Page 22: Exam Rationalization

18. Which physical findings are commonly associated with esophageal Atresia?a. Decrease bowel soundsb. Choking, coughing and cyanosisc. Visible gastric peristaltic wavesd. Jaundice and drooling

Page 23: Exam Rationalization

19. Which position is best for Jenifer preoperatively?a. Prone on her abdomenb. Right side-lyingc. Supine, with her head and chest elevated 30

degreesd. Left side-lying

Page 24: Exam Rationalization

20. To prevent aspiration of secretions, the nurse must suction Jennifer every 2 – 4 hours as needed. Prolonged and vigorous suctioning of a neonate can cause:a. Pallorb. Tachycardiac. Laryngospasmd. Pneumonia

Page 25: Exam Rationalization

SITUATION: Sonja Manthis, age 13 months, has a history

of repeated upper respiratory tract infections and poor weight gain. She was admitted to the hospital with pneumonia 3 days ago; today she is diagnosed with Cystic Fibrosis.

Page 26: Exam Rationalization

21. The nursing care for Sonja should involve all of the following except:a. Preventing infectionb. Maintaining nutritional needsc. Assisting with Oxygenationd. Preventing disease transmission

Page 27: Exam Rationalization

22. Which nursing intervention should the nurse include in Sonja’s care plana. Monitoring Sonja’s blood glucose level 4

times a dayb. Performing postural drainage with

percussion 3 times a dayc. Accompanying Sonja to physical therapy dailyd. Placing Sonja in protective ( reverse)

isolation

Page 28: Exam Rationalization

23. The Physician prescribes pancrelipase (Pancrease) for Sonja to:a. Soften stools and prevent constipationb. Prevent an allergic reaction to milkc. Supply needed enzymes to digest foodd. Prevent upper respiratory tract infection

Page 29: Exam Rationalization

SITUATION: Karen, age 18 months is admitted to the

pediatric unit with the diagnosis of Bronchiolitis. She has an elevated temperature, is pale, and looks tired. She also appears to be mildly dyspneic. The physician prescribe administration of 30 % oxygen with mist.

Page 30: Exam Rationalization

24. The admitting nurse should ensure that Karen’s room includes:a. Tracheotomy setb. Croup tentc. A sign indicating the need for respiratory

isolationd. A portable chest X-ray Machine

Page 31: Exam Rationalization

25. While Karen is receiving humidified oxygen the nurse must be concern with:a. Keeping the mist level low enough so that her

pajamas and bedding remain dry.b. Caring for the areas of skin under the nasal

cannulac. Preventing oxygen toxicity in the tentd. Frequent changes of linens/ bedding

Page 32: Exam Rationalization

26. At age 3, what level of personality will start to develop?a. Egob. Superegoc. IDd. Consciousness

Page 33: Exam Rationalization

27. In assessing a 5-month-old infant of the following assessment findings will cause you an alarm?a. (+) Moro reflexb. (+) Swimming reflexc. Absent Babinski reflexd. (+) Rooting reflex

Page 34: Exam Rationalization

28. Toilet training should start at what age:a. 1 ½b. 2c. 2 ½d. 5

Page 35: Exam Rationalization

29. In Piaget’s cognitive development, what stage does abstract thinking develop?

a.Sensorimotorb.Concrete thinkingc.Formal operationd.Pre operationale.sensorimotor

s

Page 36: Exam Rationalization

30. At what stage of growth and development does the boy compete with the father for mother attention?

a.Phallicb.Genitalc.Latencyd.Anal

Page 37: Exam Rationalization

31. According to Piaget’s theory of cognitive development, which of the following is true about school-age children?

a.They remain egocentricb.They are able to reason abstracted to predict

outcomesc.They are able to make judgments based only

on what they seed.They are able to classify or group objects

shared characteristics

Page 38: Exam Rationalization

32. Which of the following play activities would most likely be appropriate for a healthy 6-year-old girl?

a.Sitting quickly with books, crayons, and puzzles

b.Playing “house” with the 6-year-old boy who lives next door

c.Playing only with her imaginary friendd.Baking a cake from a mix with her parent’s

assistance

Page 39: Exam Rationalization

33. Play has been described as the work of children. Which preschool of the following best described the play behaviours of a prescribed child?

a.Preschooler generally prefer to sit alone quietly and play with blocks and crayons

b.The attraction span of preschoolers is long enough to watch full-length video movies without interruption

c.Preschooler’s play is associative. Group is common and rules are minimal

d.Preschooler children will always choose same-gender playmate

Page 40: Exam Rationalization

34. Elizabeth is 3 years old. Which of the following skills would you expect her to able to demonstrate proficiently?

a. Able to build a tower of 8 and 10 cubesb. Able to add 3 parts to – figurec. Able to tie her shoesd. Able to walk down stairs using alternate footing

Page 41: Exam Rationalization

35. Mrs. Lauro is worried that her 2 ½ -year-old child Irish is not getting enough to eat. She tells the nurse, “She’s such a picky eater.” The first nursing action is to:

a. Encourage the mother to feed the child’s smaller and more frequent meals

b. Provide teaching pamphlets on nutrition’s snacksc. Review the basic food group requirements with

the motherd. Assess the daily eating pattern of the child

Page 42: Exam Rationalization

36. 2-year-old Ron weighs 27 lbs and 34 inches tall; at birth, he weighed 7 lbs 2 oz.. And at 1-year-old, he weighed 22 lbs, the nurse graphing the child’s growth interpret this as:

a. Failure to thriveb. Below-normal growthc. Normal growthd. Above-normal growth

Page 43: Exam Rationalization

37. A mother voices frustration that her 2 ½ -year-old daughter takes her favorite blanket to day care every day. The best response for the nurse is:

a. “You need to discourage this because it is overly dependent behavior.”

b. “Don’t worry, all children do this.”c. “This is normal behavior and helps to prevent fear

and loneliness.”d. “You need to stop this because your daughter will

be teased by other children.”

Page 44: Exam Rationalization

Situation: Kikay, 16 years old is called in the guidance

because of failing grades. She spend more time playing computer games and surfing in the internet than studying her lessons. She is late referred to the school clinic for her health problems.

Page 45: Exam Rationalization

38. At age 16, which of the following is the following is the normal developmental task of Kikay?

a. Identity

b. Indus c. Intimacy d.Initiative

Page 46: Exam Rationalization

39. The first and most important need of the newborn is to:

a. Maintain adequate nutritionb. Maintain adequate oxygen supplyc. Prevent eye infectiond. Maintain normal temperature

Page 47: Exam Rationalization

40. The change from fetal to adult circulation is triggered by:

a. Obstruction of the umbilical vesselsb. Pressure on the baby’s head incurred during

birth processc. Higher oxygen content of the blood resulting

from pulmonary circulationd. Pressure changes associated with expansion

of the lungs and closure of foramen ovale

Page 48: Exam Rationalization

41. During the first few days following birth the neonate is expected to lose weight. It is estimated that the loss will be appropriately between:a. 1%-2% c. 8%-15%b.5%-10% d. 2%-6%

Page 49: Exam Rationalization

42. Which of the following would be signs of dehydration exhibited by an infant?

a. Pallor, periorbital edema, fever, rapid pulseb. Sunken fontanel, poor skin turgor, oliguriac. Fever, anuria, slow pulse, edemad. Poor skin turgor, weight loss, bulging

fontanel

Page 50: Exam Rationalization

43. The normal time of the closure of the anterior fontanels expected to bea. At the end of the second monthb. At the end of the sixth monthc. Six to ten of aged. Twelve to eighteen months of age

Page 51: Exam Rationalization

44. The stool of the breast fed five day old baby would be most likely

a. Meconiumb. Scambled eggc. Putty-liked. Black Tarry

Page 52: Exam Rationalization

45. The Normal time for the closure of the posterior fontanel is expected to be:

a. At the end of sixth monthb. Twelve to eighteen months of agec. At the end of the second monthd. At the beginning of the second year of life

Page 53: Exam Rationalization

46. The infant had an APGAR score of nine at birth. An APGAR score of nine indicate that the baby is:

a. In good condition and no special care is necessary

b. In fair condition and may require treatment for validity

c. In severe distress and immediate measures will have to be taken

d. Immature and need to be placed in an incubator

Page 54: Exam Rationalization

47. An infant was admitted to the nursery after a very difficult labor and a forceps delivery. His original APGAR score was five. After 5 minutes was seven. An APGAR score of five indicates that the baby is:

a. In excellent condition and no special care is necessary.

b. In fair condition and need to be watchc. In severe distress and drastic measures have

to be takend. Immature and need to be placed in an

incubator

Page 55: Exam Rationalization

48. According to APGAR scoring, which is the most valuable index concerning the condition if the newborn?a. Respirations

b. Reflex Irritability c. Heart Rate d. Muscle Tone e. Color

irregular

least

Page 56: Exam Rationalization

49. Which of the following reflex responses indicate brain damage?a. Positive retrusion of the tongue reflexb. Positive rooting reflexc. Negative moro reflexd. Positive grasp reflex

Page 57: Exam Rationalization

50. A six month old baby is attending the Well Baby Clinic. At sixth months the baby had all of the abilities, which developed last.

a. Sitting for a short period without supportb. Laughing aloud when hold and cuddledc. Following a rolling object with his eyesd. Recognizing his mother

3 mos.

Page 58: Exam Rationalization

Situation 10: Boy Rocco, two-month-old infant is brought

to the pediatrician for well-baby check-up.

Page 59: Exam Rationalization

51. Upon assessment, the nurse noticed that two reflexes of Baby Rocco have faded out which include?

a.Rooting and suckingb.Moro and tonic neckc.Mora and Babinskid.Rooting and landau

Page 60: Exam Rationalization

52. Which of the following situations would alert you are to a potentially development problem with a child?

a.Saying “mama” and “papa” for the first time at 13 months of age

b.Cooling at 3 monthsc.Using gestures to communicate at 18 months

oldd.Pointing to body parts at 15 months age

Page 61: Exam Rationalization

53. Which of the following is most important factor of successful toilet training?

a.Readiness of the child based on developmental stage

b.Age of the childc.Toilet-sitting at definite scheduled timesd.Mother’s willingness to be flexible

Page 62: Exam Rationalization

54. She asks why her baby’s hands and feet are bluish. Which of the following refers to this condition?

a.Port-win stainb.Acrocyanosisc.Tetralogy or fallotd.Mongolian spots

Page 63: Exam Rationalization

55. Angeli, a 6-month-old infant has a delayed development. Upon assessment, Abby expects her infant to:

a.sits upright for long periodb.reach out for her toyc.be able to hold a piece of cheese curls with

her finger and thumbd.hold her feeding bottle for a short while

Page 64: Exam Rationalization

56. Mrs. Simon asks Abby what attachment behaviors she will expect her 4-month-old son Gabby to demonstrate. Which of the following is NOT included by Abby in her teaching?

a.greets his mother when she returnsb.recognizes and responds to his mother’s

voicec.follows his mother as she movesd.friendly to strangers

Page 65: Exam Rationalization

57. She encourages Mrs. Perez to talk to her child, a 9-month-old girl, who at her age should be:

a.obeying simple commandsb.vocalizing single syllablesc.copying when talked tod.saying “Dada”

Page 66: Exam Rationalization

58. A neonate demonstrate the tonic neck reflex by:a. Extending the leg on the same side to which

his head is trunedb. Flexing the leg on the same side to which his

head is turnedc. Extending the leg on the opposite side to

which is head is turned d. Abducting the leg on the same side to which

his head is turned

Page 67: Exam Rationalization

59. The best way for the nurse to examine a small child is by proceeding:a. Cephallocuadally (head to toe)b. Proximally to distallyc. From the intrusive area to the least intrusive

aread. From the least intrusive area to the most

intrusive area

Page 68: Exam Rationalization

60. Blood pressure that varies among extremities is common finding in children with:a. Aortic stenosisb. Coarctation of the aortac. Patent ductus arteriosusd. Atrial septal defect

Page 69: Exam Rationalization

61. Which congenital cardiac anomaly is associated with tetralogy of Fallot (TOF)

a. Origination of the aorta from the right ventricle and origination of the pulmonary artery from the left ventricle

b. A hole in the ventricular septum allowing the communication between ventricles

c. Pulmonary stenosis, right ventricular hypertrophy, ventricular septal defect, and dextroposition of the aorta

d. Narrowing of the aorta, which restricts left ventricular outflow

a. 

Page 70: Exam Rationalization

62. A neonate receiving double volume exchange transfusion is at increased risk of all of the following complications except:a. Academiab. Hypokalemiac. Hyperkalemiad. Hypoglycemia

Page 71: Exam Rationalization

63. A neonate with sickle cell anemia is protected from initial morbidity because of:a. Maternal antibodiesb. Persistent fetal circulationc. Fetal hemoglobind. Maternal hemoglobin

Page 72: Exam Rationalization

64. An enlarged scrotum in an infant younger than age 4 months indicates:a. Hypospadiasb. Phimosisc. Inguinal herniad. Hydrocele

Page 73: Exam Rationalization

65. A low grade fever, barky cough, inspiratory stridor and retractions in a child under age 3 may indicate:a. Allergiesb. Asthmac. Bronchitisd. Croup